IBD, IBS, Coelaic Disease Flashcards
Features of Crohn’s
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
Features of UC
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
Presentation of IBD (4)
Diarrhoea
Abdominal pain
Passing blood
Weight loss
Testing for IBD
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
Management of Chron’s when inducing remission
First line: Steroids (e.g. oral prednisolone or IV hydrocortisone)
Azathioprine Mercaptopurine Methotrexate Infliximab Adalimumab
Management of Chron’s when maintaining remission
Reasonable not to take any medications whilst well
First line: Azathioprine
Mercaptopurine
Alternatives:
Methotrexate
Infliximab
Adalimumab
Surgical options in Chron’s
Bowel resection when only distal ileum affected (usually entire GI tract)
Can be useful in treating strictures and fistulas
Management of UC when inducing remission in mild to moderate disease
First line: aminosalicylate (e.g. mesalazine oral or rectal)
Second line: corticosteroids (e.g. prednisolone)
Management of UC when inducing remission in severe disease
First line: IV corticosteroids (e.g. hydrocortisone)
Second line: IV ciclosporin
Management of UC when maintaining remission
Aminosalicylate (e.g. mesalazine oral or rectal)
Azathioprine
Mercaptopurine
Surgery in UC
Removing the colon and rectum (panproctocolectomy) will remove the disease
Left with either:
Permanent ileostomy
ileo-anal anastomosis (J-pouch)
What is IBS?
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
Symptoms of IBS (7)
Diarrhoea
Constipation
Fluctuating bowel habit
Abdominal pain
Bloating
Worse after eating
Improved by opening bowels
How to diagnose IBS?
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
Lifestyle management in IBS (6)
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
Medical treatment of IBS
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
What is Coeliac Disease?
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
What auto-antibodies are associated with coeliac disease?
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)
Hows does coeliac disease affect the small bowel?
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
Coeliac disease
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
Genetic associations with coeliac disease
HLA-DQ2 gene (90%)
HLA-DQ8 gene
Why does IgA need to be tested?
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
How to diagnose coelaics/
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”
What autoimmune conditions is coeliac associated with? (5)
Type 1 Diabetes Thyroid disease Autoimmune hepatitis Primary biliary cirrhosis Primary sclerosing cholangitis
What are the complications of untreated coeliac disease? (7)
Vitamin deficiency
Anaemia
Osteoporosis
Ulcerative jejunitis
Enteropathy-associated T-cell lymphoma (EATL) of the intestine
Non-Hodgkin lymphoma (NHL)
Small bowel adenocarcinoma (rare)
What is the treatment for coeliac disease?
Lifelong gluten-free diet
