IBD/IBS/Coeliac Flashcards
Intestinal Features of Crohn’s disease (CD)
Diarrhoea usually non-bloody
Weight loss more prominent
Upper gastrointestinal symptoms, mouth ulcers, perianal disease
Abdominal mass palpable in the right iliac fossa
Intestinal Features of Ulcerative colitis (UC)
Bloody diarrhoea more common
Abdominal pain in the left lower quadrant
Tenesmus
Extra- Intestinal Features of Crohn’s disease (CD)
Gallstones are more common secondary to reduced bile acid reabsorption
Oxalate renal stones*
Extra - Intestinal Features of Ulcerative colitis (UC)
Primary sclerosing cholangitis more common
Complications of Crohn’s disease (CD)
Obstruction, fistula, colorectal cancer
small bowel cancer
osteoporosis
Risk of colorectal cancer high in UC than CD
true
Pathology of Crohn’s?
Lesions may be seen anywhere from the mouth to anus
Skip lesions may be present
Pathology of UC?
Inflammation always starts at rectum and never spreads beyond ileocaecal valve
Continuous disease
Histology of Crohn’s?
Inflammation in all layers from mucosa to serosa
increased goblet cells
granulomas
Histology of UC?
No inflammation beyond submucosa (unless fulminant disease) - inflammatory cell infiltrate in lamina propria
neutrophils migrate through the walls of glands to form crypt abscesses
depletion of goblet cells and mucin from gland epithelium
granulomas are infrequent
Endoscopy of Crohn’s
Deep ulcers, skip lesions - ‘cobble-stone’ appearance
Endoscopy of UC
Widespread ulceration with preservation of adjacent mucosa which has the appearance of polyps (‘pseudopolyps’)
Which enemas are used when?
Crohn’s - Small bowel enema
UC - Barium enema
Radiology finding in Crohn’s
high sensitivity and specificity for examination of the terminal ileum strictures: 'Kantor's string sign' proximal bowel dilation 'rose thorn' ulcers fistulae
Radiology in UC
loss of haustrations
superficial ulceration, ‘pseudopolyps’
long standing disease: colon is narrow and short -‘drainpipe colon’
Crohn’s disease is a form of inflammatory bowel disease. It commonly affects the
terminal ileum and colon but may be seen anywhere from the mouth to anus.
Crohn’s are prone to strictures, fistulas and adhesions because?
inflammation occurs in all layers, down to the serosa.
Crohn’s disease typically presents in
late adolescence or early adulthood
Crohn’s disease bloods?
raised inflammatory markers
increased faecal calprotectin
anaemia
low vitamin B12 and vitamin D
most common extra-intestinal feature in both CD and UC
Arthritis: pauciarticular, asymmetric
Episcleritis is more common in CD
True
Features Common to both Crohn’s disease (CD) and Ulcerative colitis (UC) AND RELATED to disease activity
Arthritis: pauciarticular, asymmetric
Erythema nodosum
Episcleritis
Osteoporosis
Features Common to both Crohn’s disease (CD) and Ulcerative colitis (UC) AND UNRELATED to disease activity
Arthritis: polyarticular, symmetric Uveitis Pyoderma gangrenosum Clubbing Primary sclerosing cholangitis
Primary sclerosing cholangitis is much more common and Uveitis is more common in UC
true
Crohn’s disease which bloods correlates well with disease activity
C-reactive protein
CD investigation of choice?
colonoscopy
Crohn’s disease patients should be strongly advised to stop smoking
true
Crohn’s disease: management - Inducing remission first line?
glucocorticoids (oral, topical or intravenous) are generally used to induce remission.
Budesonide is an alternative in a subgroup of patients
enteral feeding with an elemental diet may be used in addition to or instead of other measures to induce remission, particularly if there is concern regarding the side-effects of steroids (for example in young children)
Crohn’s disease: management - Inducing remission second line?
5-ASA drugs (e.g. mesalazine) are used second-line to glucocorticoids but are not as effective
Methotrexate is an alternative to azathioprine
Crohn’s disease: management add on medication
azathioprine or mercaptopurine* may be used as an add-on medication to induce remission but is not used as monotherapy
Crohn’s disease: management
refractory disease and fistulating Crohn’s
infliximab is useful in refractory disease and fistulating Crohn’s. Patients typically continue on azathioprine or methotrexate
Crohn’s disease: management
isolated peri-anal disease
metronidazole
Crohn’s disease: management - Maintaining remission
as above, stopping smoking is a priority (remember: smoking makes Crohn’s worse, but may help ulcerative colitis)
azathioprine or mercaptopurine is used first-line to maintain remission
methotrexate is used second-line
5-ASA drugs (e.g. mesalazine) should be considered if a patient has had previous surgery
Crohn’s disease: management around ?% of patients with Crohn’s disease will eventually have surgery
around 80% of patients with Crohn’s disease will eventually have surgery
The commonest disease pattern in Crohn’s is stricturing terminal ileal disease and this often culminates in an
ileocaecal resection
Crohn’s disease is notorious for the developmental of i
intestinal fistulae
assess thiopurine methyltransferase (TPMT) activity before offering
azathioprine or mercaptopurine
Ulcerative colitis pathology
red, raw mucosa, bleeds easily
inflammatory cell infiltrate in lamina propria
neutrophils migrate through the walls of glands to form crypt abscesses
depletion of goblet cells and mucin from gland epithelium
Most ulcerative colitis flares occur without an identifiable trigger.
true
Ulcerative colitis: flares
f factors are often linked:
stress medications NSAIDs antibiotics cessation of smoking
Flares of ulcerative colitis are usually classified as either mild, moderate or severe:
mild
Fewer than four stools daily, with or without blood
No systemic disturbance
Normal erythrocyte sedimentation rate and C-reactive protein values
Flares of ulcerative colitis are usually classified as either mild, moderate or severe:
moderate
Four to six stools a day, with minimal systemic disturbance
Flares of ulcerative colitis are usually classified as either mild, moderate or severe:
severe
More than six stools a day, containing blood
Evidence of systemic disturbance, e.g. fever tachycardia abdominal tenderness, distension or reduced bowel sounds anaemia hypoalbuminaemia
Treating mild-to-moderate ulcerative colitis
proctitis
topical aminosalicylate - mesalazine
if remission is not achieved within 4 weeks, add an oral aminosalicylate
if remission still not achieved add topical or oral corticosteroid
Treating mild-to-moderate ulcerative colitis
proctosigmoiditis and left-sided ulcerative colitis
topical (rectal) aminosalicylate - if remission is not achieved within 4 weeks:
add a high-dose oral aminosalicylate
OR switch to a high-dose oral aminosalicylate and a topical corticosteroid
if remission still not achieved stop topical treatments and offer an oral aminosalicylate and an oral corticosteroid
Treating mild-to-moderate ulcerative colitis
extensive disease
topical (rectal) aminosalicylate and a high-dose oral aminosalicylate:
if remission is not achieved within 4 weeks, stop topical treatments and offer a high-dose oral aminosalicylate and an oral corticosteroid
Ulcerative colitis: management
Severe colitis
should be treated in hospital
intravenous steroids are usually given first-line
intravenous ciclosporin may be used if steroid are contraindicated
if after 72 hours there has been no improvement, consider adding intravenous ciclosporin to intravenous corticosteroids or consider surgery
Maintaining remission
Following a mild-to-moderate ulcerative colitis flare
proctitis and proctosigmoiditis
topical (rectal) aminosalicylate alone (daily or intermittent) or
an oral aminosalicylate plus a topical (rectal) aminosalicylate (daily or intermittent) or
an oral aminosalicylate by itself: this may not be effective as the other two options
Maintaining remission
Following a mild-to-moderate ulcerative colitis flare
left-sided and extensive ulcerative colitis
low maintenance dose of an oral aminosalicylate
Maintaining remission
Following a severe relapse or >=2 exacerbations in the past year
oral azathioprine or oral mercaptopurine
methotrexate is not recommended for the management of UC
true
probiotics may prevent relapse in patients UC with mild to moderate disease
true
The diagnosis of IBS should be considered if the patient has had the following for at least 6 months:
abdominal pain, and/or
bloating, and/or
change in bowel habit
positive diagnosis of IBS should be made if the patient has abdominal pain relieved by ?
in addition to 2 of the following 4 symptoms:
abdominal pain relieved by defecation or associated with altered bowel frequency stool form
altered stool passage (straining, urgency, incomplete evacuation) abdominal bloating (more common in women than men), distension, tension or hardness symptoms made worse by eating passage of mucus
IBS red flags
rectal bleeding
unexplained/unintentional weight loss
family history of bowel or ovarian cancer
onset after 60 years of age
IBS suggested primary care investigations are:
full blood count
ESR/CRP
coeliac disease screen (tissue transglutaminase antibodies)
IBS First-line pharmacological treatment
pain: antispasmodic agents
constipation: laxatives but avoid lactulose
diarrhoea: loperamide is first-line
IBS
For patients with constipation who are not responding to conventional laxatives linaclotide may be considered, if:
optimal or maximum tolerated doses of previous laxatives from different classes have not helped and
they have had constipation for at least 12 months
IBS Second-line pharmacological treatment
low-dose tricyclic antidepressants (e.g. amitriptyline 5-10 mg) are used in preference to selective serotonin reuptake inhibitors
IBS psychological interventions - if symptoms do not respond to pharmacological treatments after? months and who develop a continuing symptom profile (refractory IBS), consider referring for cognitive behavioural therapy, hypnotherapy or psychological therapy
psychological interventions - if symptoms do not respond to pharmacological treatments after 12 months and who develop a continuing symptom profile (refractory IBS), consider referring for cognitive behavioural therapy, hypnotherapy or psychological therapy
Irritable bowel syndrome: management General dietary advice
have regular meals and take time to eat
avoid missing meals or leaving long gaps between eating
drink at least 8 cups of fluid per day, especially water or other non-caffeinated drinks such as herbal teas
restrict tea and coffee to 3 cups per day
reduce intake of alcohol and fizzy drinks
consider limiting intake of high-fibre food (for example, wholemeal or high-fibre flour and breads, cereals high in bran, and whole grains such as brown rice)
reduce intake of ‘resistant starch’ often found in processed foods
limit fresh fruit to 3 portions per day
for diarrhoea, avoid sorbitol
for wind and bloating consider increasing intake of oats (for example, oat-based breakfast cereal or porridge) and linseeds (up to one tablespoon per day).
Coeliac disease is an autoimmune condition caused by sensitivity to the protein gluten. It is thought to affect around ?% of the UK population.
Coeliac disease is an autoimmune condition caused by sensitivity to the protein gluten. It is thought to affect around 1% of the UK population.
Coeliac disease Repeated exposure to gluten leads to?
villous atrophy which in turn causes malabsorption
Conditions associated with coeliac disease include
Autoimmune thyroid disease
Dermatitis herpetiformis
Irritable bowel syndrome
Type 1 diabetes
Genes associated with coeliac disease include
It is strongly associated with HLA-DQ2 (95% of patients) and HLA-DQ8 (80%).
Coeliac disease complications - bloods
anaemia: iron, folate and vitamin B12 deficiency (folate deficiency is more common than vitamin B12 deficiency in coeliac disease)
Coeliac disease complications - bone
osteoporosis, osteomalacia
Coeliac disease complications- malignancy
enteropathy-associated T-cell lymphoma of small intestine
rare: oesophageal cancer, other malignancies
Coeliac disease can result in subfertility
true
subfertility, unfavourable pregnancy outcomes
Coeliac disease helps lactose intolerance
false
causes it
Coeliac disease can cause hyposplenism
true
Duodenal biopsy from a patient with coeliac disease shows:
villous atrophy
crypt hyperplasia
lamina propria infiltration with lymphocytes
increase in intraepithelial lymphocytes
Coeliac disease - Diagnosis is made by
combination of immunology and jejunal biopsy
If patients are already taking a gluten-free diet they should be asked, if possible, to reintroduce gluten for at least 6 weeks prior to testing.
Coeliac disease Villous atrophy and immunology is irreversible
false
reverses on a gluten-free diet.
First choice immunology for coeliac disease?
tissue transglutaminase (TTG) antibodies (IgA)
endomyseal antibody (IgA) needed to look for selective IgA deficiency, which would give a false negative coeliac result
coeliac
anti-gliadin antibody (IgA or IgG) tests are not recommended by NICE
anti-casein antibodies are also found in some patients
true
rice contains gluten
false
The management of coeliac disease involves a gluten-free diet. Gluten-containing cereals include:
wheat: bread, pasta, pastry
barley: beer
rye
oats
The management of coeliac disease involves omitting whisky
false
whisky is made using malted barley. Proteins such as gluten are however removed during the distillation process making it safe to drink for patients with coeliac disease
Some notable foods which are gluten-free include:
rice
potatoes
corn (maize)
what may be checked to check compliance with a gluten-free diet.
Tissue transglutaminase antibodies
Why are all patients with coeliac disease are offered the pneumococcal vaccine
Patients with coeliac disease often have a degree of functional hyposplenism
Coeliac UK recommends that everyone with coeliac disease is vaccinated against pneumococcal infection and has a booster every ?
5 years
