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IBD + other bowel conditions Flashcards

1
Q

What is IBD

A

Strong immune response against normal bacterial flora

Unknown trigger - bacteria / virus / stress

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2
Q

What genes are involved in IBD

A

HLA / PANCA - UC

NOD2 - CD

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3
Q

What is ulcerative colitis

  • Proctitis
  • Distal colitis
  • Extensive
  • Pan colitis
A

Continuous inflammation and ulceration of rectum (proctitis) and colon (colitis)
Localised in rectum and spreads proximally
Never goes past ileocaecal valve
Anus not usually involved
Non-stricturing
Relapsing + remitting

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4
Q

Who is affected by UC

A

F>M
Peak at 20 + 50 - bimodal
Smoking helps but not worth it (though due to anti-inflammatory of nicotine

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5
Q

What are the symptoms of UC

A 
Bloody diarrhoea episodic or chronic 
Abdominal pain
Cramps 
Tenesmus suggest proctitis
Faecal urgency  = common
Weight loss 
Fatigue 
Anaemia 
N+V
Dehydration 
Malabsorption

Systemic symptoms in attack - fever, malaise, anorexia. tachycardia

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6
Q

What is the colon lumen like in UC

A 
Histology 
Dilated + thin 
Limited to mucosa 
Fibrosis 
Depleted goblet cells (Chron's has increased) 
Crypt abscess 
No granulomas

Endoscopy
Continuous 
Ulcers 
Pseudopolyps 
No skip lesions 
FIsula = rare 
Ulcerated + friable, continuous

Imaging

  • Lead pipe
  • Lack of haustra
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7
Q

What is a severe attack of UC

Mod = 4-6, no systemic

A 
Stool frequency >6 
Fever >37.8
Tachy >90
Anameia <105
Raised ESR / CRP >30
Hypoalbumin <30g
Leucocytosis / thrombocytosis 
Other signs / evidence of systemic disturbance 
Urgency 
Abdo pain / distension
Reduced bowel sounds 
Malaise / anorexia
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8
Q

What are the complications of IBD

A

Colon cancer
- More with U.C
Haemorrhage = anaemia
Electrolyte disturbances
Toxic dilatation with risk of perforation + peritonitis = failure
- Both can cause
VTE
- Prophylaxis required in all hospital stays even if bleeding due to high high risk
Strictures / obstruction = unlikely (more common malignancy)

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9
Q

What does toxic dilatation lead to and what should you do

A

Perforation and faecal peritonitis which is fatal
Due to inflammation leading to stasis and septic bowel

Must remove if >10cm or if medication not working due to risk of perforation - give 72 hours

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10
Q

What are non-systemic complications of UC (MSK / occular / skin / hepatobiliary / other)

A

MSK - think if back pain / check Vit D / ALP

  • Arthritis = common
  • Osteoporosis
  • AS / sacroilitis

Occular

  • Uveitis - common UC
  • Episcleritis - common CD
  • Conjunctivitis
  • Sjogren’s

Skin

  • Erythema nodosum
  • Pyoderma gangrenosumouth

Hepatobiliary

  • Fatty liver
  • Cirrhosis
  • Cholangiocarcinoma
  • Gall stone = Chrons
  • PSC = UC

Other

  • Mouth ulcers
  • VTE
  • Amyloidosis
  • Myocarditis
  • Vasculitis
  • Clubbing
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11
Q

What are the differentials for UC

A 
IBS 
Malignnacy 
Chronic diarrhoea
Ileus caecal TB - Rx will worsen 
Cambylobacter colitis / Salmonella 
Diverticulitis
Lymphoma 
NSAID colitis - reduced prostaglandin = increased acid
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12
Q

Why is it important to differentiate between TB and UC

A

Treatment for UC if TB will make it worse

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13
Q

What is Chron’s

A

Patchy granulomatous inflammation from mouth to anus
Relapsing remitting
Terminal ileum = most commonly involved
Trans-mural so fissure / fistula and stricture more common

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14
Q

What does Chron’s present like

A

Chronic with exacerbations

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15
Q

What are the symptoms of Chron’s

A 
Abdominal pain - often colicky 
Diarrhoea +- blood
Weight loss / fatigue / anorexia  - sometime present just with this 
Fever
Oral disease - orofacial granulomatosis 
Anaemia 
N+V
Anorexia  
Malabsorption / vitamin deficiency 
Mouth ulcers / skin tags / anal stricutres
Fistula common with anal disease 
Vitamin deficiency
Can present mimicking appendicitis
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16
Q

What is the colon lumen like in Chron’s

A

Endoscopy

  • Narrow + thick
  • Skip lesion
  • Cobble stone
  • Psuedopolyp
  • FIbrosis
  • Fistula
  • Ulcer
  • Stricture
  • Adhesions
  • Proximal dilatation

Histology

  • Granuloma- non-ceasating
  • Crypt abscess - more common in UC but can occur
  • Whole mucosa inflammation so more prone to fistula etc

Imaging

  • Cobble stone
  • Frequent stricture and fistula
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17
Q

What are the complications of Chron’s

A 
Malabsorption
Strictures
Obstruction 
Fissures leading to fistula
Abscess
Perforation
Colon cancer

Non-systemic same as UC

  • CLubbing = more Chron
  • Erythema = more Chron’s
  • Gall stones = more churn
  • Episcleritis
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18
Q

What mimics Chron’s

A

Nicorandil (angina) toxicity

NSAID can worsen as increase acid

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19
Q

How do you investigate IBD

A

Bloods - FBC, ESR, CRP, U+E, LFT, blood culture, coeliac, thyroid, ferritin
Often raised WCC, CRP, platelet and low albumin
- Acute phase reactants
- Albumin = very poor marker of nutrition
Low B12 / folate due to malabsorption
Stool MC+S = -ve but always check with diarrhoea
qFIT if suspect malignancy
Calproctein test
- Detects neutrophils suggests inflammation
- If raised need further test
Colonoscopy / endoscopy = gold standard as rx life long and can be toxic
MRI endoscopy if still unsure as shows small bowel
- Good for Chron’s
pANCA etc
Imaging for complications such as fistula / abscess

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20
Q

What do you look for in the bloods

A 
High ESR and CRP - indicates active inflammation 
Increased platelet
Increased WCC
Low Hb
Low albumin
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21
Q

What does calproctein test show

A 
<50 = normal 
50-200 = no active inflammation but IBD
>200 = active inflammation
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22
Q

How do you classify IBD

A

Montreal classification

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23
Q

What does Montreal classification take in

A 
Age
Location
Behaviour
Extent 
Severity
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24
Q

What are the extra-intestinal manifestations of Chron’s

A

Same as UC
Clubbing
Erythema nodosum
Kidney stone / gall stones

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25
How do you treat IBD to maintain remission
5ASA - monitor FBC + U+Es Anti-inflammatory Steroids - not long term - only in flare Immunosuppression Biologics - if others don't work Used to work up but now starting on biologics / immunosuppression sooner Surgery
26
What is as effective as steroids in children
Elemental feeding so just giving the electrolyte body needs in shakes
27
What else can be done to treat IBD
``` FODMAP Diet - More in IBS no role IBD Antibiotics Surgery Chron's more difficult for surgery ```
28
When do you do surgery
If still severe after steroids, biologics and immunosuppression Max therapy / prolonged steroid Risk of perforation Effecting growth / puberty in child
29
What should you consider in Chron's if persistent abdominal pain
Abdominal sepsis | CT / USS / MRI often required to assess
30
How do you manage severe attack and what is 1st line treatment
``` Admit for IV hydration IV steroids = 1st line IV ciclosporin if steroid CI or not responding VTE prophylaxis ALWAYS - EVEN IF BLEED If fails to improve in 72 Hours / 3 days with steroid Consider IV ciclosporin Biologics if all else fails Early surgeon involvement ```
31
What biologics in IBD
Anti-TNF (Infliximab) | If levels are therapeutic but stop working = diff mode of inflammation started rather than Ab
32
Why are Steroids last ditch in children
Growth Adrenal Infection
33
What is used to decrease need for steroid
Immune modulation - used for remission Azahioprine / methotrexate / cyclosporin Allopurinol + azathioprine (blocks XO which metabolises azatho so increases dose)
34
What are SE of immunosuppression
Nausea LFT Affects renal Cyclosporin >steroids but need kidney function
35
What can't you use in UC
Methotrexate
36
What is 1st line in Ulcerative colitis to induce remission
5ASA (Melezaine / Pentasa / Sulphalazine = meleza + Ax) - good in joint disease PR if anal disease / mild - moderate Oral if no remission or further round gut Poorly absorbed so stays in the gut Maintaining = 5ASA or immunosuppression If severe = need in patient
37
What do you have to monitor with 5ASA
FBC + U+E + trough level
38
Whhat do you add after 5ASA
Steroid | Reduce over 4-8 weeks
39
When do you do emergency surgery
Acutely ill If bloods stable = time to try medical Mx Toxic dilatation / perforation / haemorrhage = colectomy
40
WHat other imaging options
Abdo X-Ray = distention CXR = free air if perforation or AS Barium enema = loss of haustra = lead pipe colon
41
What is surveillance in IBD
Colonoscopy to reduce risk of bowel cancer Esp if PSC 10 years from Dx
42
What type of anaemia
Normochromic normocystic | Iron or folate
43
What is an option for imaging small bowel in chron's
MRI enteroscopy | Doesn't show large well
44
When would you need transvaginal ISS
Fistula
45
What could you use in acute presentation
CT
46
What is diversion colitis
After stoma Distal bowel = no bacteria Causes colitis
47
When can't you anastomose
Above a stricture | So if Chron's = anal stricture have to take out colon as anastomoses would burst
48
What is microscopic colitis and what can cause
Bowel looks normal but abnormal under microscope Lympohcytic infiltration Causes chronic diarrhoea Rx = steroid (budenoide) Want to get endoscopy in elderly if suspect + biopsy as Rx will help QOL PPI / NSAID / smoking
49
What is radiation proctitis
After RT
50
What treatment for radiation proctitis
Transfusion if needed Argon phototherapy Hyperbaric oxygen Sulcrafate enema
51
What is ischaemic colitis
Acute compromise to large bowel - IMA causing inflammation Inflammation / ulceration / haemorrhage Bloody diarrhea + abdo pain + vomit = classic triad Intermittent
52
Where is common site
Splenic flexure
53
How do you Dx and treat
CT = 1st line AXR = thumb print Rx = Supportive with fluid rests and Ax May need angioplasty / thrombolysis with IR Srictures = common after Surgery if peritonitis / perforation / haemorrhage
54
What is mesneteric ischaemia and what causes
Typically small bowel in contrast to ischaemic colitis Due to embolism of SMA etc Hypercoagulable states Rare - trauma / vasculitis/ RT
55
What are the symptoms
``` Sudden onset abdo pain out of proportion Rectal bleeding Diarrhoea Fever Hypovolaemia Can develop shock / SIRS ```
56
What are RF for bowel ischaemia / mesenteric
``` AF - AF + abdo pain think mesenteric Age SMoking HYpertension DM Cocaine Malignancy Endocarditis Surgery abdominal aneurysm ```
57
How do you investigate
X-ray may show thumb printing (marker of ischaemia) CT = for all bowel ischaemia inc colitis Why it is used in acute presentation Bloods = elevated WCC + lactic acid Metabolic acidosis
58
How do you treat mesenteric ischaemia
Urgent surgery as risk of perforation Fluid resus + Ax + DVT usually required High mortality due to septic peritonitis
59
What is a volvulus
Torsion of bowel resulting in imaired blood flow + obstruction
60
Where is volvuolis common
Sigmoid | Can occur gastric / caecal
61
What are symptoms of volvulus
``` Constipation Abdo pain Bloating DISTENSION N+V Failure to pass NG / severe pain / non-bilious if gastric ```
62
What is volvulus associate with
Elderly Constipation DMD / Parkinson Schizophrenia Caecal - preg / adhesions / fistula 2 Chron's
63
How do you Dx and Rx
AXR Central distended bowel in Ceacal as causes small bowel obstruction Sigmoid causes large bowel obstruction
64
How do you Rx
No role for conservative as will become ishcameic and perforate Sigmoidoscopy and tube insertion Hemicolectomy if caecal Laparotomy if perforation / obstruction
65
What is a diverticulum
Outpouching of gut wall Usually at site of entry of arteries Intraluminal pressure forces mucosa + submucosa to herniate through mucularis externa at weak points Diverticulosis if have this
66
Where is common site
Sigmoid | Can occur in R side - more common in Asian and look like appendicitis
67
What is diverticular disease
Symptomatic diverticulum in absence of infection / other complication
68
What are the symptoms of diverticular disease
``` Altered bowel habit L sided colic / pain - intermittent Often relieved defaecation Nausea Flatulence Bloating ```
69
What are RF for diverticular disease
``` Lack of fibre Age Obesity Smoking NSAID ```
70
How do you Dx diverticular disease
Colonoscopy - often incidental NEVER do in active inflammation but do after episode of diverticulitis CT colonogram or barium enema
71
How do you treat diverticular disease
Anti-sposmadic Surgery occasionlly Increasing fibre does not help but some people suggest
72
What are complications of diverticular disease What requires elective surgery
``` Diverticulitis Haemorrhage Stenosis / stricture Fistula - Colovesical - Colo-vaginal = pneumaturia Perforation Peritonitis Volvulus Abscess ``` Elective = stenosis, fistula, recurrent bleeding / flare up's
73
What is diverticulitis
Inflammation of a diverticulum | Beware in immunocompromised who present late
74
What are signs of diverticulitis
``` Same as above Acute pain Urinary Sx e.g. frequency if bladder irritated PR bleed Fever N+V Anorexia Tender LIF Peritonitis - often localised, tachy, guarding, rebound Symptoms of fistula Increased CRP + WCC ```
75
How do you Dx diverticulitis and to Dx complications
Hx - SOCRATES, urinary Sx, red flags etc - PMH - surgery / endoscopy - DH - anti-coagulant Abdo exam + DRE Blood test - FBC, U+E, LFT, CRP, amylase, culture VBG as signs of infection for lactate Urine dip if Sx Preg test ``` Imaging CT abdomen / pelvis with contrast to Dx complications is best way = 1st line to diagnose acute diverticulitis Erect CXR for perforation AXR - obstruction / free air Urgent USS for abscess Avoid colonoscopy as risk of perforation ```
76
What do you do for mild diverticulitis
Analgesia Bowel rest - fluid Analgesia
77
What do you do if not controlled within 72 hours and what do you do after
ABCDE if haemodynamically unstable Admit NBM Analgesia IV fluid - balanced crystalloid (Hartmann / PlasmaLyte) IV Ax - local (co-amox / gent) Percutaneous drainage if localised abscess Surgery for peritonitis / perforation (10%) - May need resection or Hartmann's After 6 weeks do colonoscopy / CT colonogrph to ensure not missed
78
What are complications of diverticulitis
SEPSIS Abscess formation Fistula - enteric-cutaneous / enteric vaginal Peritonitis Perforation Obstruction - Ileus or mechanical from degree of stricture Haemorrhage - usually painless, but common cause of big rectal bleeds Post infective stricture
79
What do you do for haemorrhage
Embolization or colonic resection if massive
80
What do you do for perforation
Stoma formation
81
What do you do for abscess
Ax | USS / CT guided drainage
82
What do you do for fistula
Surgery
83
What are signs of perforation
Peritonitis SHock Ileus
84
What suggests abscess
Swinging fever Leucocytosis Localising signs e.g. mass Suspect if pus nowhere but signs suggestive e.g. pus under diaphragm (sub-phrenic abscess)
85
What do you do if severe attack or >2 relapses in one year
Add oral azathioprine
86
What is 1st line in Chrons in induce remission How do you maintain remission
``` Corticosteroid - oral pred or IV hydroxotisone Add immunosuppression if doesn't work - Azathioprine - Methotrexate Same to maintain remission (not steroid) 5ASA don't work as well in Chron's ```
87
What do mild and moderate attacks have
Increased stool frequency No systemic disturbance Mild <4 stool Mod 4-6
88
What are strictures more likely to be in ulcerative colitis
Malignancy
89
What is tenesmus
Painful feeling of inability to evacuate bowel
90
What is toxic megacolon
Increase in diameter >6cm | Loss of haustration
91
How do you deal with toxic megacolon
Medical therapy | Urgent colectomy if doesn't resolve
92
What surgery for UC
Colectomy + ileostomy or create ileal pouch if no proctitis - Go to toilet a lot and no formed stool / infection or close rectal stump if proctitis Surgery can be curative for Chron's but may still get extra-intestinal effects
93
When can you not do ileal pouch
Chrons
94
Complications of surgery
``` General Splenc injury Anastomotic injury Intra-abdominal abscess Poor function / failure of pouch ```
95
What is another type of colitis not related to IBD that can cause flares
Lymphocytic colitis
96
What is main am of IBD Rx
Induce remission | Maintain remission
97
How do you induce remission in proctitis / L sided colitis
Topical 5ASA Oral if no improvement after 4 weeks Add topical or oral steroid if no improvement
98
How do you induce remission in extensive disease
Topical + oral 5ASA | Steroid if no improvement
99
What if severe attack
Hospital for IV hydration and steroid
100
How do you maintain remission
Topical 5ASA / oral | Immunosuppression
101
What do you do if severe attack or >2 exacerbations
Add azathioprine
102
How does chronic mesenteric ischaemia present (intestinal angina)
``` Severe colicky abdo pain Weight loss Upper abdo bruit PR bleed Malabsorption N+V ```
103
How do you Dx
Rare and difficult | CT angio
104
How do you Rx
Consider surgery | Angioplasty and stent
105
What is appendicitis
Inflammation of the appendix, a prominent lymphoid tissue which regresses with age
106
What causes
Foecolith (poo) = obstruction Infection on top - Enterus vemicularis Can lead to perforation BEWARE OF COLON CANCER IF >40 as can obstruct appendix or perforate
107
What are the S+S of appendicits
Centre abdominal pain colic (visceral from obstruction of midgut) Severe lower right side pain (when periotneum irritated) Mcburney - 2/3 ASIS - umbilicus) Worse on pressing / coughing Roving - pressing LLQ increases pain in R (sign of peritonitis) N+V - continual vomit = not suggestive Diarrhoea Anorexia = very common Pyrexia mild Tachycardia Rebound tenderness / guarding DRE may show boggy sensation if pelvic abscess
108
When may it present differently
Elderly - shock / confused | Child - vague abdominal pain, not eating favourite food
109
How do you Dx
History + raised markers sometimes tough Bloods - FBC, CRP - neutrophil leucocytosis Pregnancy test Urine test - neutrophils + leucocyte (no nitrites) - exclude pregnancy, colic and UTI - May be irritated from inflamed appendix which is why leuocoytes Culture if spiking USS - >6cm diameter + rule out gynae CT - not routine but sensitive Diagnostic laparoscopy fi tests are -ve but high clinical suspicion
110
How do you Rx
If burst = surgery or history + inflammatory marker If uncertain wait 24 hours to see if symptoms improve ABCDE Adequate fluid Broad spec Ax pre-op Appendicetomy
111
What are complications
Appendix abscess | Perforation
112
What are differentials
``` Gastroenteritis IBS Constipation UTI Ectopic PID Chron's Peptic ulcer Mesenteric adenitis ```
113
What should you beware of in the elderly
Underlying malignancy
114
How do you treat abscess
Supportive Ax Appenidcetomy once resolved
115
What investigation when admitted to hospital with IBD flare
AXR look for toxic megacolon which could cause
116
How does a colonic vesicle fistula present
Pneumohaematuria | Faeces in urine
117
How do you Dx
CT
118
Surgical options U.C
Subtotal colectomy if emergency / not responding Rectum left in situ as high complications if removed Proctocolectomy can be curative and can create ileo-pouch if wish to avoid stoma but more complications
119
Complications
High risk of VTE | Dishiscence
120
Surgical options in Chron's
Protectomy if severe rectal Ileo-anal pouch not recommended due to high failure due to fistula's Ileal-caecal resection for terminal ideal chron's Always required if structuring / obstruction Usually end up with more complications e.g fistula / malabsorption and short gut Best to avoid
121
Anatomy of bowel
Caecum joins terminal ileum Ileo-caecal valve = point at where U.C stops as end of colon L colon = anus to splenic flexure R colon after
122
Takeaway UC
``` Superficial COntinuous Only colon Non-stricture Associated PSC Pseudopolyp ```
123
Takeaway Chron's
``` Transmural Skip lesions Mouth to anus Stricture, fissure, fistulae and collection Cobble stone Peri-anal ```
124
What does AXR show in IBD
``` Thumb print - marker of ischaemia Toxic dilatation Lead pipe colon / featureless String size on barium - stricture Obstruction if present ```
125
What does small bowel MRI show
Particular useful in CHronis Shows inflammation, stricture, skip, fistula in pelvic and abscesss Useful to Dx extent of disease and plan Rx
126
What is colonoscopy show
Gold standard to show distribution and severity | Also allows biopsy
127
What should patients get during stay if IBD flare
VTE prophylaxis always Daily blood Daily abdominal exam to feel for dilatation
128
Patient known UC, presents opening bowel 15x and passing blood. Looks ill
``` ABCDE Once stable take Hx Rule out infection IV steroid VTE AXR Early GI / surgical input ```
129
Pregnancy and IBD
``` Conception unlike if poor control Stay on meds during Most well controlled possibly due to steroid hormones Post-partum flare Risk of fistula with Chrons if vaginal ```
130
What is most common cause of peri-anal abscess
IBD
131
What is most common cause of small bowel abscess
Chron's
132
If toxic megacolon what imaging
AXR as fast but will get CT
133
As FY1 what is role
Full Hx and exam Blood test Resus Early discussion
134
Cancer surveillance in IBD
After 10 years from Dx = colonoscopy
135
Can you do pouch as emergency
No only elective | If emergency = no time for reconstruction
136
If someone presents diarrhoea what should you ask
Recent Ax as risk of C.diff colitis

GI (29 decks)

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