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4th year passmedicine by topic > IBD/IBS/Coeliac > Flashcards

IBD/IBS/Coeliac Flashcards

1
Q

Intestinal Features of Crohn’s disease (CD)

A

Diarrhoea usually non-bloody
Weight loss more prominent
Upper gastrointestinal symptoms, mouth ulcers, perianal disease
Abdominal mass palpable in the right iliac fossa

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2
Q

Intestinal Features of Ulcerative colitis (UC)

A

Bloody diarrhoea more common
Abdominal pain in the left lower quadrant
Tenesmus

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3
Q

Extra- Intestinal Features of Crohn’s disease (CD)

A

Gallstones are more common secondary to reduced bile acid reabsorption

Oxalate renal stones*

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4
Q

Extra - Intestinal Features of Ulcerative colitis (UC)

A

Primary sclerosing cholangitis more common

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5
Q

Complications of Crohn’s disease (CD)

A

Obstruction, fistula, colorectal cancer
small bowel cancer
osteoporosis

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6
Q

Risk of colorectal cancer high in UC than CD

A

true

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7
Q

Pathology of Crohn’s?

A

Lesions may be seen anywhere from the mouth to anus

Skip lesions may be present

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8
Q

Pathology of UC?

A

Inflammation always starts at rectum and never spreads beyond ileocaecal valve

Continuous disease

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9
Q

Histology of Crohn’s?

A

Inflammation in all layers from mucosa to serosa
increased goblet cells
granulomas

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10
Q

Histology of UC?

A

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

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11
Q

Endoscopy of Crohn’s

A

Deep ulcers, skip lesions - ‘cobble-stone’ appearance

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12
Q

Endoscopy of UC

A

Widespread ulceration with preservation of adjacent mucosa which has the appearance of polyps (‘pseudopolyps’)

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13
Q

Which enemas are used when?

A

Crohn’s - Small bowel enema

UC - Barium enema

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14
Q

Radiology finding in Crohn’s

A 
high sensitivity and specificity for examination of the terminal ileum
strictures: 'Kantor's string sign'
proximal bowel dilation
'rose thorn' ulcers
fistulae
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15
Q

Radiology in UC

A

loss of haustrations
superficial ulceration, ‘pseudopolyps’
long standing disease: colon is narrow and short -‘drainpipe colon’

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16
Q

Crohn’s disease is a form of inflammatory bowel disease. It commonly affects the

A

terminal ileum and colon but may be seen anywhere from the mouth to anus.

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17
Q

Crohn’s are prone to strictures, fistulas and adhesions because?

A

inflammation occurs in all layers, down to the serosa.

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18
Q

Crohn’s disease typically presents in

A

late adolescence or early adulthood

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19
Q

Crohn’s disease bloods?

A

raised inflammatory markers
increased faecal calprotectin
anaemia
low vitamin B12 and vitamin D

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20
Q

most common extra-intestinal feature in both CD and UC

A

Arthritis: pauciarticular, asymmetric

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21
Q

Episcleritis is more common in CD

A

True

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22
Q

Features Common to both Crohn’s disease (CD) and Ulcerative colitis (UC) AND RELATED to disease activity

A

Arthritis: pauciarticular, asymmetric
Erythema nodosum
Episcleritis
Osteoporosis

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23
Q

Features Common to both Crohn’s disease (CD) and Ulcerative colitis (UC) AND UNRELATED to disease activity

A 
Arthritis: polyarticular, symmetric
Uveitis
Pyoderma gangrenosum
Clubbing
Primary sclerosing cholangitis
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24
Q

Primary sclerosing cholangitis is much more common and Uveitis is more common in UC

A

true

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25
Q

Crohn’s disease which bloods correlates well with disease activity

A

C-reactive protein

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26
Q

CD investigation of choice?

A

colonoscopy

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27
Q

Crohn’s disease patients should be strongly advised to stop smoking

A

true

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28
Q

Crohn’s disease: management - Inducing remission first line?

A

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)

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29
Q

Crohn’s disease: management - Inducing remission second line?

A

5-ASA drugs (e.g. mesalazine) are used second-line to glucocorticoids but are not as effective

Methotrexate is an alternative to azathioprine

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30
Q

Crohn’s disease: management add on medication

A

azathioprine or mercaptopurine* may be used as an add-on medication to induce remission but is not used as monotherapy

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31
Q

Crohn’s disease: management

refractory disease and fistulating Crohn’s

A

infliximab is useful in refractory disease and fistulating Crohn’s. Patients typically continue on azathioprine or methotrexate

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32
Q

Crohn’s disease: management

isolated peri-anal disease

A

metronidazole

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33
Q

Crohn’s disease: management - Maintaining remission

A

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

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34
Q

Crohn’s disease: management around ?% of patients with Crohn’s disease will eventually have surgery

A

around 80% of patients with Crohn’s disease will eventually have surgery

35
Q

The commonest disease pattern in Crohn’s is stricturing terminal ileal disease and this often culminates in an

A

ileocaecal resection

36
Q

Crohn’s disease is notorious for the developmental of i

A

intestinal fistulae

37
Q

assess thiopurine methyltransferase (TPMT) activity before offering

A

azathioprine or mercaptopurine

38
Q

Ulcerative colitis pathology

A

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

39
Q

Most ulcerative colitis flares occur without an identifiable trigger.

A

true

40
Q

Ulcerative colitis: flares

f factors are often linked:

A 
stress
medications
NSAIDs
antibiotics
cessation of smoking
41
Q

Flares of ulcerative colitis are usually classified as either mild, moderate or severe:
mild

A

Fewer than four stools daily, with or without blood

No systemic disturbance

Normal erythrocyte sedimentation rate and C-reactive protein values

42
Q

Flares of ulcerative colitis are usually classified as either mild, moderate or severe:
moderate

A

Four to six stools a day, with minimal systemic disturbance

43
Q

Flares of ulcerative colitis are usually classified as either mild, moderate or severe:
severe

A

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
44
Q

Treating mild-to-moderate ulcerative colitis

proctitis

A

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

45
Q

Treating mild-to-moderate ulcerative colitis

proctosigmoiditis and left-sided ulcerative colitis

A

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

46
Q

Treating mild-to-moderate ulcerative colitis

extensive disease

A

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

47
Q

Ulcerative colitis: management

Severe colitis

A

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

48
Q

Maintaining remission

Following a mild-to-moderate ulcerative colitis flare
proctitis and proctosigmoiditis

A

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

49
Q

Maintaining remission
Following a mild-to-moderate ulcerative colitis flare
left-sided and extensive ulcerative colitis

A

low maintenance dose of an oral aminosalicylate

50
Q

Maintaining remission

Following a severe relapse or >=2 exacerbations in the past year

A

oral azathioprine or oral mercaptopurine

51
Q

methotrexate is not recommended for the management of UC

A

true

52
Q

probiotics may prevent relapse in patients UC with mild to moderate disease

A

true

53
Q

The diagnosis of IBS should be considered if the patient has had the following for at least 6 months:

A

abdominal pain, and/or
bloating, and/or
change in bowel habit

54
Q

positive diagnosis of IBS should be made if the patient has abdominal pain relieved by ?

in addition to 2 of the following 4 symptoms:

A

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
55
Q

IBS red flags

A

rectal bleeding
unexplained/unintentional weight loss
family history of bowel or ovarian cancer
onset after 60 years of age

56
Q

IBS suggested primary care investigations are:

A

full blood count
ESR/CRP
coeliac disease screen (tissue transglutaminase antibodies)

57
Q

IBS First-line pharmacological treatment

A

pain: antispasmodic agents
constipation: laxatives but avoid lactulose
diarrhoea: loperamide is first-line

58
Q

IBS

For patients with constipation who are not responding to conventional laxatives linaclotide may be considered, if:

A

optimal or maximum tolerated doses of previous laxatives from different classes have not helped and
they have had constipation for at least 12 months

59
Q

IBS Second-line pharmacological treatment

A

low-dose tricyclic antidepressants (e.g. amitriptyline 5-10 mg) are used in preference to selective serotonin reuptake inhibitors

60
Q

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

A

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

61
Q

Irritable bowel syndrome: management General dietary advice

A

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).

62
Q

Coeliac disease is an autoimmune condition caused by sensitivity to the protein gluten. It is thought to affect around ?% of the UK population.

A

Coeliac disease is an autoimmune condition caused by sensitivity to the protein gluten. It is thought to affect around 1% of the UK population.

63
Q

Coeliac disease Repeated exposure to gluten leads to?

A

villous atrophy which in turn causes malabsorption

64
Q

Conditions associated with coeliac disease include

A

Autoimmune thyroid disease
Dermatitis herpetiformis
Irritable bowel syndrome
Type 1 diabetes

65
Q

Genes associated with coeliac disease include

A

It is strongly associated with HLA-DQ2 (95% of patients) and HLA-DQ8 (80%).

66
Q

Coeliac disease complications - bloods

A

anaemia: iron, folate and vitamin B12 deficiency (folate deficiency is more common than vitamin B12 deficiency in coeliac disease)

67
Q

Coeliac disease complications - bone

A

osteoporosis, osteomalacia

68
Q

Coeliac disease complications- malignancy

A

enteropathy-associated T-cell lymphoma of small intestine

rare: oesophageal cancer, other malignancies

69
Q

Coeliac disease can result in subfertility

A

true

subfertility, unfavourable pregnancy outcomes

70
Q

Coeliac disease helps lactose intolerance

A

false

causes it

71
Q

Coeliac disease can cause hyposplenism

A

true

72
Q

Duodenal biopsy from a patient with coeliac disease shows:

A

villous atrophy
crypt hyperplasia
lamina propria infiltration with lymphocytes
increase in intraepithelial lymphocytes

73
Q

Coeliac disease - Diagnosis is made by

A

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.

74
Q

Coeliac disease Villous atrophy and immunology is irreversible

A

false

reverses on a gluten-free diet.

75
Q

First choice immunology for coeliac disease?

A

tissue transglutaminase (TTG) antibodies (IgA)

endomyseal antibody (IgA)
needed to look for selective IgA deficiency, which would give a false negative coeliac result
76
Q

coeliac
anti-gliadin antibody (IgA or IgG) tests are not recommended by NICE
anti-casein antibodies are also found in some patients

A

true

77
Q

rice contains gluten

A

false

78
Q

The management of coeliac disease involves a gluten-free diet. Gluten-containing cereals include:

A

wheat: bread, pasta, pastry
barley: beer
rye
oats

79
Q

The management of coeliac disease involves omitting whisky

A

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

80
Q

Some notable foods which are gluten-free include:

A

rice
potatoes
corn (maize)

81
Q

what may be checked to check compliance with a gluten-free diet.

A

Tissue transglutaminase antibodies

82
Q

Why are all patients with coeliac disease are offered the pneumococcal vaccine

A

Patients with coeliac disease often have a degree of functional hyposplenism

83
Q

Coeliac UK recommends that everyone with coeliac disease is vaccinated against pneumococcal infection and has a booster every ?

A

5 years

4th year passmedicine by topic (96 decks)

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