IBD- Jenkins Flashcards
***What is IBD? Is there a genetic component? What are the two types?
- a complex GENETIC disorder that is influenced by environmental risk factors
- genetic predisposition allows dysregulation of the GI immune system and host micro biome
- lack of complete penetrance
- Ulcerative colitis and Crohn’s disease
- **Rapid rise in certain geographical regions is NOT genetic!
IBD is a disease of _______ nations. What areas have the highest incidence of IBD?*
- IBD is a disease of industrialized nations
- increased incidence in developed countries (Europe and America) and increasing incidence in China and India as they become industrialized
- Increase risk in individuals when they move to a more developed country
What are some environmental risk factors for IBD? (6) What do other potential risk factors include (have not been proven)?
- Current smoker/Ex-smoker
- Oral contraceptives
- Appendectomy
- Diet
- Breastfeeding
- Antibiotics
- NSAID’s
-Other risks: H. pylori, family size, birth order, pets, other microorganisms
***What layers of the GI tract are affected in Ulcerative Colitis? What regions?
- diffuse MUCOSAL and SUBMUCOSAL ulceration and inflammation LIMITED TO THE COLON
- present in symmetrical, circumferential and CONTINUOUS pattern in the large intestine
***What % of UC involve the rectum?
100%!! (starts distally and moves proximally)
***Is smoking helpful in the treatment of UC?
Yes! the nicotine may help treat UC
***Bloody diarrhea for > 30 days in a young person (20-30) is _____ until proven otherwise
UC!
severity correlates with extent of disease
< 30 days is considered infectious
What is the typical clinical presentation of UC?
- bloody diarrhea on and off for > 30 days.
- negative stool for infectious causes (E. Coli, ova and parasites, C. diff)
***What are the most common associated conditions found with UC?
-Erythema nodosum (15%)
-Pyoderma gangrenosum (less common)
-rheumatologic (*peripheral arthritis, *ankylosing spondylitis, *sacroilitis, hypertrophic osteoarthropathy and pelvic/femoral osteomyelitis) –> often presents with back pain and bloody diarrhea
-uveitis
(Eyes, skin, joints, stones)
What are some other conditions associated with UC?
- ocular
- hepatobiliary
- Urologic
- Metabolic bone disorders
- Thromboembolic disorders
***People with HLA B27 and IBD are MOST LIKELY to get what associated condition?
Arthritis (sacroilitis / ankylosing spondylitis)
What does erythema nodosum look like?
- painful erythematous nodules in a symmetric distribution on the legs
- common on the anterior tibial surface
What does pyoderma gangrenosum present as? What is the treatment for this?
- Begins as a pustule, then spreads concentrically to rapidly undermine healthy skin.
- Lesions then ulcerate, with violaceous edges surrounded by a margin of erythema.
-treat with IV antibiotics then treat IBD
What are the endoscopic manifestations of UC?
- Ulceration (mucosal & submucosal)
- Loss of typical vascular pattern (edema)
- Erythema
- Granularity
- Friablity
- frank mucopurulent exudate is present in severe cases
What are the different classifications of UC?
Mild:
- BM < 4 per day
- Small amounts of hematochezia
- Mild anemia
- Endoscopy: Erythema, fine granularity, decreased vascular pattern
Moderate:
- BM 4-6 per day
- Moderate amount hematochezia
- Anemia
- Endoscopy: increased Erythema, granularity, absent vascular markings, friability
Severe:
- BM > 6 per day
- Marked hematochezia
- Fever >37.5 C
- Pulse > 90
- Endoscopy: spontaneous bleeding, ulcerations
***What are some of the complications of UC?
- Toxic megacolon
- carcinoma (more in UC than Crohns; biopsy frequently to monitor)
***What is the treatment for UC?
Remission and then maintenance therapy
Active: 5-ASA (Sulfasalazine) oral or enema (can add glucocorticoid enema and PO or IV glucocorticoid if severe acute UC or Crohns, NOT for MAINTENANCE)
maintenance:
- 5-ASA oral or enema
- 6-MP or azothioprine (used to wean pts off steroids) (long-term)
- also give Inflizimab (after 5ASA and steroids)
What is Mesalamine used to treat?
- mild to moderate distal UC
- proctitis
- maintenance of remission
What are topical glucocorticoids used to treat?
acute treatment of distal UC
NOT maintenance
When is Cyclosporin A used to treat UC? What are some SE?
- severe UC that is refractory to IV glucocorticoids
- SE: HTN, HA, tremor, paresthesias, elecrolyte abnormalities, gingival hyperplasia
***Should antibiotics be used to treat UC?
NO!!!!
unless going to surgery
How often should a pt with IBD have a colonoscopy?
- annual or biennial in pts with >8-10 years of pan colitis of >12-15 years with left sided colitis
- risk of cancer increases 1%/year after 8-10 years of disease
***What is Crohn’s Disease? What makes it different from UC?
- Crohn’s is a segmental TRANSMURAL (goes through muscle layer) IBD that can affect ANY part of the GI tract FROM MOUTH TO ANUS with SKIP LESIONS
- UC is only in the mucosa and submucosa and only affects the colon
***How do cigarettes affect Crohn’s? What about UC?
- 2x increase risk for Crohn’s with smoking
- smoking can help in UC
***What are some complications of Crohn’s?
- Malabsorption with nutritional deficiencies (involve small intestine)
- Calcium oxalate nephrolithiasis
- *Abscess
- ***Fistula formation
- *sinus tracts
- Carcinoma
***Which IBD is carcinoma more common in?
UC
***What is fibrostenotic CD? How does this develop and where is it most commonly found?
- -Obstruction in CD due to thickening of the lumen walls d/t Crohn’s
- signs of obstruction: abd pain, n/v, distention
***Which IBD is toxic megacolon more associated with?
UC
***What are the 3 presentations of Crohn’s disease? Which is the most common?
- Chronic diarrhea *MOST COMMON –> for > 30 days, normally intermittent for years (~2-3yrs)
- Appendix-like pain (RLQ b/c it involves the TERMINAL ILEUM)–> appendix will be normal but small bowel will be thickened
- Bowel obstruction in large or small bowel
***How is Crohn’s diagnosed?
- Radiographic imaging (barium studies) and
- ENDOSCOPY WITH BIOPSY (most accurate)
- Histology of intestinal biopsy (Transmural granulomas)
What are the most common presenting sites of Crohn’s in both adults and peds?
ileocolitis and ileitis
***What will Crohn’s look like on endoscopy?
Cobblestone appearance
***What will the BE of a pt look like with Crohn’s in the terminal ileum?
“string sign”–> narrow lumen
What is the earliest detectable lesion found on endoscopy in Crohn’s? What does this look like?
-Aphthous ulceration
- Small , pinpoint lesions with exudate (white arrow) surrounded by an erythematous margin
- -> can be seen in mouth too
What serologic studies suggest Crohn’s? What about UC? What can high serum levels of markers indicate?
- ASCA is frequently + in Crohn’s
- ANCA is frequently + in UC
- high serum levels of markers can indicate aggressive disease and predict likelihood of surgery
***Which IBD is more likely to present with hematochezia?
UC*
***Which IBD is more likely to present with systemic symptoms and pain?
Crohn’s disease
What is the treatment for Crohn’s disease?
-Induction and then maintenance
Active:
- sulfasalazine oral/enema
- Budesonide (ileocecal disease)
- Flagyl or Cipro
- glucocorticoids (oral)
- TNF directed treatment (Infliximab or Adalimumab)
- Severe disease can include TPN diet and Certolizumab
Maintenance:
- –Inflammatory:
- Azathioprine or 6-MP
- Methotrexate
- Infliximab
- Certolizumab
- Budesonide: short term only
- –Perianal or fistulizing disease
- Azathioprine or 6-MP
- Infliximab
- Adalimumab
***Is surgery curable for Crohn’s? UC?
- not curable for Crohn’s (if removed, 50% will recur elsewhere in 5yrs– skip lesions; most pts will have at least 1 surgery–fistulas, complications)
- is CURABLE for UC
***Are there serology tests for UC and Crohn’s?
YES!
***When is it appropriate to use antibiotics in the treatment of Crohn’s?
Fistulas and abscesses
***If you have a 20yo pt w/ perianal fistulas, what should you think?
Crohn’s!
