IBD - Odes Flashcards
Genetic factors of IBD
Chrohn’s: More familial (50%), polygenic
NOD2/CARD15 on chromosome 16 - associated with higher risk of surgery.
UC:
15% familial
Not gender associated.
Diagnosis of IBD
Serology used to supplement diagnosis
pANCA:
60-70% positive in UC, 15-20% in CD
ASCA:
<5% in UC, 40-60% in CD
Crohns:
Radiology: barium meal and enema, CT
EUS
MRI (best for perianal fistula)
MRCP for PSC (primary sclerosing cholangitis)
Colonoscopy, ileoscopy, enteroscopy (through mouth to ileum), biopsies
Video-capsule endoscopy
Serology (ASCA and other antibodies)
Genotypes (NOD2/CARD15)
CRP useful to followup. Tracks inflammation, normal values <1. Short halflife (recent). If stricture: want to know if fibrotic or inflammatory. Increases with more inflammation. Calprotectin also useful in stool samples.
Description of Ulcerative Colitis
A chronic, relapsing inflammatory disease of the lower gastrointestinal (GI) tract. Permanent distortion of glands.
Begins in rectum and demonstrates proximal (oral) progression.
Common symptoms include recurrent episodes of diarrhea, rectal bleeding, Stool frequency (above patient’s usual number)
Physician’s global assessment of patient well-being
Colonoscopic or sigmoidoscopic appearance of the mucosa (mild-crypt abscesses, progressive: gland distortion).
Rare - constitutional symptoms
Complications:
1 Refractory disease (no response to Rx)
Severe bleeding, Perforation (toxic megacolon)
2 Dysplasia – Cancer (stricture can mask cancer)
3 Extra-intestinal manifestations
Superinfection from CMV or C dificile (antibiotics).
Risk of cancer:
Family history, pseudopolyps, histological inflammation increase. 5-ASA, aspirin, NSAIDs and surveillance decrease.
Crohn’s Disease description
A chronic, relapsing inflammatory disease of the gastrointestinal (GI) tract
Can effect any part of the GI tract, but most commonly associated with the terminal ileum with/out right colon
Common symptoms include recurrent abdominal pain, diarrhea, weight loss, anemia (iron or B12, may not be supplementable) and fever
Serious complications include abdominal mass, abscess (sinus is like a fistula from an abscess), internal and perianal (most common) fistulas (no fistulas in UC), and intestinal obstruction. Bowel-bowel fistulas are rarely detected. Can also involve the gall bladder, mouth, etc, all layers up to serosa. Granulomas are pathognomonic. 90% develop penetrating or stricturing complications over time.
No real pattern in episodes. Worse prognosis at younger age (may be different phenotype).
Activity (determines remission vs. critical illness):
Number of liquid or very soft stools during the previous week
Severity of abdominal pain / cramping
General well-being
Extra-intestinal manifestations
Presence of abdominal mass
Use of antidiarrheal drug therapy
Hematocrit (compared with normal)
Body weight (compared with normal)
Extraintestinal complications of IBD
Complication UC CD (%)
Acute arthropathy (large joints-most common) 10–15 15–20
Sacroiliitis 9–11 9–11
Ankylosing spondylitis (permanent changes in joint structure) 1–3 3–5
Ocular complications 5–15 5–15
Erythema nodosum (in lower limbs) 10–15 15
Pyoderma gangrenosum 1–2 1–2
Primary sclerosing cholangitis 2–7.6 1
Choledocholithiasis — 15–30 (Patients with small bowel disease)
Nephrolithiasis — 5–10
Amyloidosis — Rare
Gall stones, renal stones-more in Crohn’s, Osteoporosis and osteopenia more associated with steroids
Therapy of IBD
Clinical remission
Symptomatic remission
Improved quality of life
Decrease of activity scores
Mucosal healing (Deep healing) – by colonoscopy (important because if no mucosal remission fast relapse)
Avoidance
of surgery
of malignancy
risk factors - smoking
Return the patient to full employment
Normal pregnancies and childbirth (perianal fistulas mean C-section)
Therapy:
Antibiotics (only if infected abscess otherwise C. dificile-metronidazole and Cipro)
5-ASA (even mild disease, no side effects, prevents colorectal cancer)
Corticosteroids (only short course-Prednisone for severe, Budesonide specific for ileal release for mild.)
Immunomodulation (6-mercaptopurine and azathioprine: imuran, maintenance of remission because takes 3 months for activation). Cyclosporines (UC more than Crohns). Methotrexate (last resort).
Biologicals (anti-TNFalpha, usually combined with immunomodulation for remission longer. Remicaid-q8w and Humira-q2w. Has effects within 2 weeks and lasts for 8.)
Surgery (only when needed).
Step up: start with steroids, then immunomodulation, then biologics than surgery. Step down: start with biologics, then as remission goes use others.
