IBD Long Flashcards
Gastrointestinal Symptoms of IBD?
Weight loss, poor growth, abdominal pain, anorexia, N&V, dysphagia, diarrhoea, urgency, tenesmus, incontinence, rectal bleeding, fistulae, peri-rectal disease
Extraintestinal manifestation of IBD?
- Skin (erythema nodosum, pyoderma gangrenosum)
- Mouth (ulcers)
- Liver (primary sclerosing cholangitis)
- Joints (peripheral arthritis, ankylosing spondylitis)
- Vision (uveitis)
- Vasculitis
- Kidneys
- Pubertal delay
Steps in IBD examination?
1) IHUGVIDEP
2) General inspection: Weight, height, Tanner staging, Nutritional status (muscle wasting, fat, oedema, tongue, rashes, anaemia), Pallor, jaundice, Skin rashes (EN, PG)
3) Upper limbs: Clubbing, Pallor of palmar creases (iron/B12/folate/chronic disease), Arthritis, Palpable epiphyseal enlargement
4) Head and neck: Cushingoid facies, Conjunctival pallor or icterus (PSC/nephritis), Iritis, Cataracts (steroids), Aphthous stomatitis
5) Abdomen: Scars, stoma, striae (steroids), Hepatomegaly, ascites (protein losing enteropathy), Enlarged kidneys, Fistulae, perianal disease
6) Lower limbs: Joint swelling, Tibial bowing, Skin (EN, PG)
7) ask for: Stool and urine
Ix for IBD?
1) Stool: MCS, COP, C. diff, α 1 antitrypsin, Yersinia; Calprotectin has 95% sensitivity and 91% specificity for IBD diagnosis
2) Bloods: FBE (↓ Hb, ↑ WCC), ESR (more sensitive), CRP, ↓ albumin, LFT, U&E, Folate/B12/ADEK/coags, CMP, Fe, zinc, copper selenium, Vit D
3) Imaging: Plain AXR (bowel obstruction), Barium small bowel follow through (mucosal irregularities, fistulae), barium enema (nowadays use MRE); US, CT, MR, Pill cam/gastroscopy/colonoscopy
Short term and long term Mx goals in IBD?
- Short-term = mucosal healing
- Long-term = prevention of relapses, normalizing growth and pubertal development, maintaining bone mass, minimizing need for surgery
Crohn’s Disease Mx?
1) Initial therapy:
- EEN - for 8-10 weeks(most effective for remission - 75% within 10weeks)
- Antibiotics – metronidazole +/- ciprofloxacin
- Prednisolone (moderate severe disease)
- Budesonide (controlled ileal-release)
- Infliximab (anti-TNF α antibody for refractory disease, steroid dependency or fistulising disease)
- Adalimumab +/- other biologics
2) Maintenance (ie. once remission achieved)
- Azathioprine: Onset of action in 3-4 months so need nutritional therapy/steroids to start with. Long-term treatment –> BM suppression occurs in 2-5%, pancreatitis, hepatitis, Test the TPMT status –> if deficiency = toxic metabolite and ↑ BM suppression
- Methotrexate: Nausea, anorexia, stomatitis,
Malignancy potential in IBD?
o ↑ risk of colorectal Ca (secondary to colitis)
o ↑ risk of lymphoma and non melanoma skin Ca (secondary to immunosuppressants)
Mx of Ulcerative Colitis?
1) Remission with corticosteroids (moderate – severe disease) or 5-ASAs (mild – moderate disease) or infliximab
2) Maintain remission with immunomodulators (AZA/6MP) or infliximab
- Mild/moderate disease: Oral and rectal ASAs (SE = rash, BM suppression, nephrotoxicity), Steroid enemas, Infliximab
- Severe disease: Cyclosporine or tacrolimus (SE = parasthesiae, hypertrichosis, hypertension, renal insufficiency, tremor), Surgery (indications = haemorrhage, perforation), Ileostomy, proctocolectomy, ileo-anal reconstruction
SE of Cyclosporine/Tacrolimus?
parasthesiae, hypertrichosis, hypertension, renal insufficiency, tremor
How much gut is required post gut surgery to have normal function?
15-20cm - Can have less bowel if the ileo-caecal valve is intact
Questions to ask re: access issues in Short Gut Syndrome?
- What has been used
- If prev taken out - Why has it been taken out? Thrombosis, Infection
- What is left?
Note: TPN kids die because they run out of access
Complications/associations of Short Gut?
Do they have CLD?
Have they had sepsis?
Micro and macronutrient deficiency
* Fat globules – maldigestion
* Fat crystals – malabsorption
* Reducing substances
Growth and pubertal delay
Access Issues
