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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
Q

How do you treat IBD to maintain remission

A

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

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26
Q

What is as effective as steroids in children

A

Elemental feeding so just giving the electrolyte body needs in shakes

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27
Q

What else can be done to treat IBD

A 
FODMAP Diet
- More in IBS no role IBD 
Antibiotics 
Surgery 
Chron's more difficult for surgery
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28
Q

When do you do surgery

A

If still severe after steroids, biologics and immunosuppression
Max therapy / prolonged steroid
Risk of perforation
Effecting growth / puberty in child

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29
Q

What should you consider in Chron’s if persistent abdominal pain

A

Abdominal sepsis

CT / USS / MRI often required to assess

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30
Q

How do you manage severe attack and what is 1st line treatment

A 
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
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31
Q

What biologics in IBD

A

Anti-TNF (Infliximab)

If levels are therapeutic but stop working = diff mode of inflammation started rather than Ab

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32
Q

Why are Steroids last ditch in children

A

Growth
Adrenal
Infection

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33
Q

What is used to decrease need for steroid

A

Immune modulation - used for remission
Azahioprine / methotrexate / cyclosporin
Allopurinol + azathioprine (blocks XO which metabolises azatho so increases dose)

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34
Q

What are SE of immunosuppression

A

Nausea
LFT
Affects renal
Cyclosporin >steroids but need kidney function

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35
Q

What can’t you use in UC

A

Methotrexate

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36
Q

What is 1st line in Ulcerative colitis to induce remission

A

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

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37
Q

What do you have to monitor with 5ASA

A

FBC + U+E + trough level

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38
Q

Whhat do you add after 5ASA

A

Steroid

Reduce over 4-8 weeks

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39
Q

When do you do emergency surgery

A

Acutely ill
If bloods stable = time to try medical Mx
Toxic dilatation / perforation / haemorrhage = colectomy

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40
Q

WHat other imaging options

A

Abdo X-Ray = distention
CXR = free air if perforation or AS
Barium enema = loss of haustra = lead pipe colon

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41
Q

What is surveillance in IBD

A

Colonoscopy to reduce risk of bowel cancer
Esp if PSC
10 years from Dx

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42
Q

What type of anaemia

A

Normochromic normocystic

Iron or folate

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43
Q

What is an option for imaging small bowel in chron’s

A

MRI enteroscopy

Doesn’t show large well

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44
Q

When would you need transvaginal ISS

A

Fistula

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45
Q

What could you use in acute presentation

A

CT

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46
Q

What is diversion colitis

A

After stoma
Distal bowel = no bacteria
Causes colitis

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47
Q

When can’t you anastomose

A

Above a stricture

So if Chron’s = anal stricture have to take out colon as anastomoses would burst

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48
Q

What is microscopic colitis and what can cause

A

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

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49
Q

What is radiation proctitis

A

After RT

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50
Q

What treatment for radiation proctitis

A

Transfusion if needed
Argon phototherapy
Hyperbaric oxygen
Sulcrafate enema

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51
Q

What is ischaemic colitis

A

Acute compromise to large bowel - IMA causing inflammation
Inflammation / ulceration / haemorrhage
Bloody diarrhea + abdo pain + vomit = classic triad
Intermittent

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52
Q

Where is common site

A

Splenic flexure

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53
Q

How do you Dx and treat

A

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

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54
Q

What is mesneteric ischaemia and what causes

A

Typically small bowel in contrast to ischaemic colitis
Due to embolism of SMA etc
Hypercoagulable states
Rare - trauma / vasculitis/ RT

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55
Q

What are the symptoms

A 
Sudden onset abdo pain out of proportion
Rectal bleeding
Diarrhoea
Fever
Hypovolaemia
Can develop shock / SIRS
56
Q

What are RF for bowel ischaemia / mesenteric

A 
AF - AF + abdo pain think mesenteric 
Age
SMoking
HYpertension
DM
Cocaine
Malignancy
Endocarditis
Surgery abdominal aneurysm
57
Q

How do you investigate

A

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
Q

How do you treat mesenteric ischaemia

A

Urgent surgery as risk of perforation
Fluid resus + Ax + DVT usually required
High mortality due to septic peritonitis

59
Q

What is a volvulus

A

Torsion of bowel resulting in imaired blood flow + obstruction

60
Q

Where is volvuolis common

A

Sigmoid

Can occur gastric / caecal

61
Q

What are symptoms of volvulus

A 
Constipation
Abdo pain
Bloating
DISTENSION 
N+V
Failure to pass NG / severe pain / non-bilious if gastric
62
Q

What is volvulus associate with

A

Elderly
Constipation
DMD / Parkinson
Schizophrenia

Caecal - preg / adhesions / fistula 2 Chron’s

63
Q

How do you Dx and Rx

A

AXR
Central distended bowel in Ceacal as causes small bowel obstruction
Sigmoid causes large bowel obstruction

64
Q

How do you Rx

A

No role for conservative as will become ishcameic and perforate
Sigmoidoscopy and tube insertion
Hemicolectomy if caecal
Laparotomy if perforation / obstruction

65
Q

What is a diverticulum

A

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
Q

Where is common site

A

Sigmoid

Can occur in R side - more common in Asian and look like appendicitis

67
Q

What is diverticular disease

A

Symptomatic diverticulum in absence of infection / other complication

68
Q

What are the symptoms of diverticular disease

A 
Altered bowel habit
L sided colic / pain - intermittent 
Often relieved defaecation
Nausea
Flatulence
Bloating
69
Q

What are RF for diverticular disease

A 
Lack of fibre
Age
Obesity
Smoking
NSAID
70
Q

How do you Dx diverticular disease

A

Colonoscopy - often incidental
NEVER do in active inflammation but do after episode of diverticulitis
CT colonogram or barium enema

71
Q

How do you treat diverticular disease

A

Anti-sposmadic
Surgery occasionlly
Increasing fibre does not help but some people suggest

72
Q

What are complications of diverticular disease

What requires elective surgery

A 
Diverticulitis
Haemorrhage
Stenosis / stricture 
Fistula
- Colovesical
- Colo-vaginal = pneumaturia 
Perforation
Peritonitis
Volvulus 
Abscess

Elective = stenosis, fistula, recurrent bleeding / flare up’s

73
Q

What is diverticulitis

A

Inflammation of a diverticulum

Beware in immunocompromised who present late

74
Q

What are signs of diverticulitis

A 
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
Q

How do you Dx diverticulitis and to Dx complications

A

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
Q

What do you do for mild diverticulitis

A

Analgesia
Bowel rest - fluid
Analgesia

77
Q

What do you do if not controlled within 72 hours and what do you do after

A

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
Q

What are complications of diverticulitis

A

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
Q

What do you do for haemorrhage

A

Embolization or colonic resection if massive

80
Q

What do you do for perforation

A

Stoma formation

81
Q

What do you do for abscess

A

Ax

USS / CT guided drainage

82
Q

What do you do for fistula

A

Surgery

83
Q

What are signs of perforation

A

Peritonitis
SHock
Ileus

84
Q

What suggests abscess

A

Swinging fever
Leucocytosis
Localising signs e.g. mass
Suspect if pus nowhere but signs suggestive e.g. pus under diaphragm (sub-phrenic abscess)

85
Q

What do you do if severe attack or >2 relapses in one year

A

Add oral azathioprine

86
Q

What is 1st line in Chrons in induce remission

How do you maintain remission

A 
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
Q

What do mild and moderate attacks have

A

Increased stool frequency
No systemic disturbance
Mild <4 stool
Mod 4-6

88
Q

What are strictures more likely to be in ulcerative colitis

A

Malignancy

89
Q

What is tenesmus

A

Painful feeling of inability to evacuate bowel

90
Q

What is toxic megacolon

A

Increase in diameter >6cm

Loss of haustration

91
Q

How do you deal with toxic megacolon

A

Medical therapy

Urgent colectomy if doesn’t resolve

92
Q

What surgery for UC

A

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
Q

When can you not do ileal pouch

A

Chrons

94
Q

Complications of surgery

A 
General 
Splenc injury
Anastomotic injury
Intra-abdominal abscess
Poor function / failure of pouch
95
Q

What is another type of colitis not related to IBD that can cause flares

A

Lymphocytic colitis

96
Q

What is main am of IBD Rx

A

Induce remission

Maintain remission

97
Q

How do you induce remission in proctitis / L sided colitis

A

Topical 5ASA
Oral if no improvement after 4 weeks
Add topical or oral steroid if no improvement

98
Q

How do you induce remission in extensive disease

A

Topical + oral 5ASA

Steroid if no improvement

99
Q

What if severe attack

A

Hospital for IV hydration and steroid

100
Q

How do you maintain remission

A

Topical 5ASA / oral

Immunosuppression

101
Q

What do you do if severe attack or >2 exacerbations

A

Add azathioprine

102
Q

How does chronic mesenteric ischaemia present (intestinal angina)

A 
Severe colicky abdo pain
Weight loss
Upper abdo bruit 
PR bleed
Malabsorption
N+V
103
Q

How do you Dx

A

Rare and difficult

CT angio

104
Q

How do you Rx

A

Consider surgery

Angioplasty and stent

105
Q

What is appendicitis

A

Inflammation of the appendix, a prominent lymphoid tissue which regresses with age

106
Q

What causes

A

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
Q

What are the S+S of appendicits

A

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
Q

When may it present differently

A

Elderly - shock / confused

Child - vague abdominal pain, not eating favourite food

109
Q

How do you Dx

A

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
Q

How do you Rx

A

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
Q

What are complications

A

Appendix abscess

Perforation

112
Q

What are differentials

A 
Gastroenteritis
IBS
Constipation
UTI 
Ectopic
PID
Chron's
Peptic ulcer 
Mesenteric adenitis
113
Q

What should you beware of in the elderly

A

Underlying malignancy

114
Q

How do you treat abscess

A

Supportive
Ax
Appenidcetomy once resolved

115
Q

What investigation when admitted to hospital with IBD flare

A

AXR look for toxic megacolon which could cause

116
Q

How does a colonic vesicle fistula present

A

Pneumohaematuria

Faeces in urine

117
Q

How do you Dx

A

CT

118
Q

Surgical options U.C

A

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
Q

Complications

A

High risk of VTE

Dishiscence

120
Q

Surgical options in Chron’s

A

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
Q

Anatomy of bowel

A

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
Q

Takeaway UC

A 
Superficial 
COntinuous 
Only colon
Non-stricture
Associated PSC
Pseudopolyp
123
Q

Takeaway Chron’s

A 
Transmural
Skip lesions
Mouth to anus 
Stricture, fissure, fistulae and collection
Cobble stone
Peri-anal
124
Q

What does AXR show in IBD

A 
Thumb print - marker of ischaemia
Toxic dilatation 
Lead pipe colon / featureless
String size on barium - stricture
Obstruction if present
125
Q

What does small bowel MRI show

A

Particular useful in CHronis
Shows inflammation, stricture, skip, fistula in pelvic and abscesss
Useful to Dx extent of disease and plan Rx

126
Q

What is colonoscopy show

A

Gold standard to show distribution and severity

Also allows biopsy

127
Q

What should patients get during stay if IBD flare

A

VTE prophylaxis always
Daily blood
Daily abdominal exam to feel for dilatation

128
Q

Patient known UC, presents opening bowel 15x and passing blood. Looks ill

A 
ABCDE
Once stable take Hx
Rule out infection
IV steroid
VTE
AXR
Early GI / surgical input
129
Q

Pregnancy and IBD

A 
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
Q

What is most common cause of peri-anal abscess

A

IBD

131
Q

What is most common cause of small bowel abscess

A

Chron’s

132
Q

If toxic megacolon what imaging

A

AXR as fast but will get CT

133
Q

As FY1 what is role

A

Full Hx and exam
Blood test
Resus
Early discussion

134
Q

Cancer surveillance in IBD

A

After 10 years from Dx = colonoscopy

135
Q

Can you do pouch as emergency

A

No only elective

If emergency = no time for reconstruction

136
Q

If someone presents diarrhoea what should you ask

A

Recent Ax as risk of C.diff colitis

GI (29 decks)

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