IBD, IBS, Coelaic Disease

Question 1

Features of Crohn’s

Answer 1

N - No blood or mucus

E – Entire GI tract

S – “Skip lesions” on endoscopy

T – Terminal ileum most affected and Transmural (full thickness) inflammation

S – Smoking is a risk factor (don’t set the nest on fire)

Crohn’s is also associated with weight loss, strictures and fistulas

Question 2

Features of UC

Answer 2

C – Continuous inflammation

L – Limited to colon and rectum

O – Only superficial mucosa affected

S – Smoking is protective

E – Excrete blood and mucus

U – Use aminosalicylates

P – Primary Sclerosing Cholangitis

Question 3

Presentation of IBD (4)

Answer 3

Diarrhoea
Abdominal pain
Passing blood
Weight loss

Question 4

Testing for IBD

Answer 4

Routine bloods - FBC (anaemia), CRP (infection), thyroid, kidney and liver function

Faecal calprotectin (released by the intestines when inflamed) is a useful screening test (> 90% sensitive and specific to IBD in adults)

Endoscopy (OGD and colonoscopy) with biopsy is diagnostic

ultrasound, CT and MRI can be used to look for complications such as fistulas, abscesses and strictures

Question 5

Management of Chron’s when inducing remission

Answer 5

First line: Steroids (e.g. oral prednisolone or IV hydrocortisone)

Azathioprine
Mercaptopurine
Methotrexate
Infliximab
Adalimumab

Question 6

Management of Chron’s when maintaining remission

Answer 6

Reasonable not to take any medications whilst well

First line: Azathioprine
Mercaptopurine

Alternatives:
Methotrexate
Infliximab
Adalimumab

Question 7

Surgical options in Chron’s

Answer 7

Bowel resection when only distal ileum affected (usually entire GI tract)

Can be useful in treating strictures and fistulas

Question 8

Management of UC when inducing remission in mild to moderate disease

Answer 8

First line: aminosalicylate (e.g. mesalazine oral or rectal)

Second line: corticosteroids (e.g. prednisolone)

Question 9

Management of UC when inducing remission in severe disease

Answer 9

First line: IV corticosteroids (e.g. hydrocortisone)

Second line: IV ciclosporin

Question 10

Management of UC when maintaining remission

Answer 10

Aminosalicylate (e.g. mesalazine oral or rectal)

Azathioprine

Mercaptopurine

Question 11

Surgery in UC

Answer 11

Removing the colon and rectum (panproctocolectomy) will remove the disease
Left with either:

Permanent ileostomy

ileo-anal anastomosis (J-pouch)

Question 12

What is IBS?

Answer 12

Functional bowel disorder - no identifiable organic disease

Symptoms are a result of abnormal function of as otherwise normal bowel

Occurs in up to 20% of the population

Question 13

Symptoms of IBS (7)

Answer 13

Diarrhoea

Constipation

Fluctuating bowel habit

Abdominal pain

Bloating

Worse after eating

Improved by opening bowels

Question 14

How to diagnose IBS?

Answer 14

Other pathology should be excluded:

• Normal FBC, ESR and CRP blood tests
• Faecal calprotectin negative
• Coeliac disease serology (anti-TTG antibodies)
• Cancer is not suspected or excluded if suspected

Symptoms should suggest IBS:

Abdominal pain / discomfort:

• Relieved on opening bowels, or
• Associated with a change in bowel habit

AND 2 of:
-Abnormal stool passage
-Bloating
-Worse symptoms after eating
PR mucus

Question 15

Lifestyle management in IBS (6)

Answer 15

Adequate fluid intake

Regular small meals

Reduced processed foods

Limit caffeine and alcohol

Low “FODMAP” diet (ideally with dietician guidance)

Trial of probiotic supplements for 4 weeks

Question 16

Medical treatment of IBS

Answer 16

First Line:
- Loperamide for diarrhoea
- Laxatives for constipation. Avoid lactulose as it can cause bloating. Linaclotide is a specialist laxative for patients with IBS not responding to first-line laxatives
Antispasmodics for cramps e.g. hyoscine butylbromide (Buscopan)

Second Line:
- tricyclic antidepressants

Third line:
SSRIs

Question 17

What is Coeliac Disease?

Answer 17

Autoimmune

Exposure to gluten causes an autoimmune reaction - causes inflammation in the small bowel

Usually develops in early childhood but can start at any age

Question 18

What auto-antibodies are associated with coeliac disease?

Answer 18

Anti-tissue transglutaminase (anti-TTG)

Anti-endomysial (anti-EMA)

Relate to disease activity - rise with more active disease, may disappear with effective treatment

Deaminated gliadin peptides antibodies (anti-DGPs)

Question 19

Hows does coeliac disease affect the small bowel?

Answer 19

Particularly affects he jejunum

Causes atrophy of the intestinal villi (help with absorbing nutrients)

Inflammation causes malabsorption of nutrients and the symptoms of the disease

Question 20

Coeliac disease

Answer 20

Often asymptomatic

Failure to thrive in young children

Diarrhoea

Fatigue

Weight loss

Mouth ulcers

Anaemia secondary to iron, B12 or folate deficiency

Dermatitis herpetiformis (an itchy blistering skin rash typically on the abdomen)

(Rarely neuro symptomms - Peripheral neuropathy, Cerebellar ataxia, Epilepsy

Question 21

Genetic associations with coeliac disease

Answer 21

HLA-DQ2 gene (90%)

HLA-DQ8 gene

Question 22

Why does IgA need to be tested?

Answer 22

Anti-TTG and anti-EMA antibodies are IgA

Some patients have an IgA deficiency

If total IgA is low because they have an IgA deficiency then the coeliac test will be negative even when they have coeliacs

In this case test for IgG

Question 23

How to diagnose coelaics/

Answer 23

Investigations must be carried out whilst the patient remains on a diet containing gluten

Check total immunoglobulin A levels

Look for Raised anti-TTG antibodies (first choice)
Raised anti-endomysial antibodies

Endoscopy and intestinal biopsy show:
“Crypt hypertrophy”
“Villous atrophy”

Question 24

What autoimmune conditions is coeliac associated with? (5)

Answer 24

Type 1 Diabetes
Thyroid disease
Autoimmune hepatitis
Primary biliary cirrhosis
Primary sclerosing cholangitis

Question 25

What are the complications of untreated coeliac disease? (7)

Answer 25

Vitamin deficiency

Anaemia

Osteoporosis

Ulcerative jejunitis

Enteropathy-associated T-cell lymphoma (EATL) of the intestine

Non-Hodgkin lymphoma (NHL)

Small bowel adenocarcinoma (rare)

Question 26

What is the treatment for coeliac disease?

Answer 26

Lifelong gluten-free diet