IBD + other bowel conditions Flashcards
What is IBD
Strong immune response against normal bacterial flora
Unknown trigger - bacteria / virus / stress
What genes are involved in IBD
HLA / PANCA - UC
NOD2 - CD
What is ulcerative colitis
- Proctitis
- Distal colitis
- Extensive
- Pan colitis
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
Who is affected by UC
F>M
Peak at 20 + 50 - bimodal
Smoking helps but not worth it (though due to anti-inflammatory of nicotine
What are the symptoms of UC
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
What is the colon lumen like in UC
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
What is a severe attack of UC
Mod = 4-6, no systemic
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
What are the complications of IBD
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)
What does toxic dilatation lead to and what should you do
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
What are non-systemic complications of UC (MSK / occular / skin / hepatobiliary / other)
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
What are the differentials for UC
IBS Malignnacy Chronic diarrhoea Ileus caecal TB - Rx will worsen Cambylobacter colitis / Salmonella Diverticulitis Lymphoma NSAID colitis - reduced prostaglandin = increased acid
Why is it important to differentiate between TB and UC
Treatment for UC if TB will make it worse
What is Chron’s
Patchy granulomatous inflammation from mouth to anus
Relapsing remitting
Terminal ileum = most commonly involved
Trans-mural so fissure / fistula and stricture more common
What does Chron’s present like
Chronic with exacerbations
What are the symptoms of Chron’s
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
What is the colon lumen like in Chron’s
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
What are the complications of Chron’s
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
What mimics Chron’s
Nicorandil (angina) toxicity
NSAID can worsen as increase acid
How do you investigate IBD
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
What do you look for in the bloods
High ESR and CRP - indicates active inflammation Increased platelet Increased WCC Low Hb Low albumin
What does calproctein test show
<50 = normal 50-200 = no active inflammation but IBD >200 = active inflammation
How do you classify IBD
Montreal classification
What does Montreal classification take in
Age Location Behaviour Extent Severity
What are the extra-intestinal manifestations of Chron’s
Same as UC
Clubbing
Erythema nodosum
Kidney stone / gall stones
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
What is as effective as steroids in children
Elemental feeding so just giving the electrolyte body needs in shakes
What else can be done to treat IBD
FODMAP Diet - More in IBS no role IBD Antibiotics Surgery Chron's more difficult for surgery
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
What should you consider in Chron’s if persistent abdominal pain
Abdominal sepsis
CT / USS / MRI often required to assess
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
What biologics in IBD
Anti-TNF (Infliximab)
If levels are therapeutic but stop working = diff mode of inflammation started rather than Ab
Why are Steroids last ditch in children
Growth
Adrenal
Infection
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)
What are SE of immunosuppression
Nausea
LFT
Affects renal
Cyclosporin >steroids but need kidney function
What can’t you use in UC
Methotrexate
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
What do you have to monitor with 5ASA
FBC + U+E + trough level
Whhat do you add after 5ASA
Steroid
Reduce over 4-8 weeks
When do you do emergency surgery
Acutely ill
If bloods stable = time to try medical Mx
Toxic dilatation / perforation / haemorrhage = colectomy
WHat other imaging options
Abdo X-Ray = distention
CXR = free air if perforation or AS
Barium enema = loss of haustra = lead pipe colon
What is surveillance in IBD
Colonoscopy to reduce risk of bowel cancer
Esp if PSC
10 years from Dx
What type of anaemia
Normochromic normocystic
Iron or folate
What is an option for imaging small bowel in chron’s
MRI enteroscopy
Doesn’t show large well
When would you need transvaginal ISS
Fistula
What could you use in acute presentation
CT
What is diversion colitis
After stoma
Distal bowel = no bacteria
Causes colitis
When can’t you anastomose
Above a stricture
So if Chron’s = anal stricture have to take out colon as anastomoses would burst
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
What is radiation proctitis
After RT
What treatment for radiation proctitis
Transfusion if needed
Argon phototherapy
Hyperbaric oxygen
Sulcrafate enema
What is ischaemic colitis
Acute compromise to large bowel - IMA causing inflammation
Inflammation / ulceration / haemorrhage
Bloody diarrhea + abdo pain + vomit = classic triad
Intermittent
Where is common site
Splenic flexure
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
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
What are the symptoms
Sudden onset abdo pain out of proportion Rectal bleeding Diarrhoea Fever Hypovolaemia Can develop shock / SIRS
What are RF for bowel ischaemia / mesenteric
AF - AF + abdo pain think mesenteric Age SMoking HYpertension DM Cocaine Malignancy Endocarditis Surgery abdominal aneurysm
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
How do you treat mesenteric ischaemia
Urgent surgery as risk of perforation
Fluid resus + Ax + DVT usually required
High mortality due to septic peritonitis
What is a volvulus
Torsion of bowel resulting in imaired blood flow + obstruction
Where is volvuolis common
Sigmoid
Can occur gastric / caecal
What are symptoms of volvulus
Constipation Abdo pain Bloating DISTENSION N+V Failure to pass NG / severe pain / non-bilious if gastric
What is volvulus associate with
Elderly
Constipation
DMD / Parkinson
Schizophrenia
Caecal - preg / adhesions / fistula 2 Chron’s
How do you Dx and Rx
AXR
Central distended bowel in Ceacal as causes small bowel obstruction
Sigmoid causes large bowel obstruction
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
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
Where is common site
Sigmoid
Can occur in R side - more common in Asian and look like appendicitis
What is diverticular disease
Symptomatic diverticulum in absence of infection / other complication
What are the symptoms of diverticular disease
Altered bowel habit L sided colic / pain - intermittent Often relieved defaecation Nausea Flatulence Bloating
What are RF for diverticular disease
Lack of fibre Age Obesity Smoking NSAID
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
How do you treat diverticular disease
Anti-sposmadic
Surgery occasionlly
Increasing fibre does not help but some people suggest
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
What is diverticulitis
Inflammation of a diverticulum
Beware in immunocompromised who present late
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
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
What do you do for mild diverticulitis
Analgesia
Bowel rest - fluid
Analgesia
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
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
What do you do for haemorrhage
Embolization or colonic resection if massive
What do you do for perforation
Stoma formation
What do you do for abscess
Ax
USS / CT guided drainage
What do you do for fistula
Surgery
What are signs of perforation
Peritonitis
SHock
Ileus
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)
What do you do if severe attack or >2 relapses in one year
Add oral azathioprine
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
What do mild and moderate attacks have
Increased stool frequency
No systemic disturbance
Mild <4 stool
Mod 4-6
What are strictures more likely to be in ulcerative colitis
Malignancy
What is tenesmus
Painful feeling of inability to evacuate bowel
What is toxic megacolon
Increase in diameter >6cm
Loss of haustration
How do you deal with toxic megacolon
Medical therapy
Urgent colectomy if doesn’t resolve
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
When can you not do ileal pouch
Chrons
Complications of surgery
General Splenc injury Anastomotic injury Intra-abdominal abscess Poor function / failure of pouch
What is another type of colitis not related to IBD that can cause flares
Lymphocytic colitis
What is main am of IBD Rx
Induce remission
Maintain remission
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
How do you induce remission in extensive disease
Topical + oral 5ASA
Steroid if no improvement
What if severe attack
Hospital for IV hydration and steroid
How do you maintain remission
Topical 5ASA / oral
Immunosuppression
What do you do if severe attack or >2 exacerbations
Add azathioprine
How does chronic mesenteric ischaemia present (intestinal angina)
Severe colicky abdo pain Weight loss Upper abdo bruit PR bleed Malabsorption N+V
How do you Dx
Rare and difficult
CT angio
How do you Rx
Consider surgery
Angioplasty and stent
What is appendicitis
Inflammation of the appendix, a prominent lymphoid tissue which regresses with age
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
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
When may it present differently
Elderly - shock / confused
Child - vague abdominal pain, not eating favourite food
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
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
What are complications
Appendix abscess
Perforation
What are differentials
Gastroenteritis IBS Constipation UTI Ectopic PID Chron's Peptic ulcer Mesenteric adenitis
What should you beware of in the elderly
Underlying malignancy
How do you treat abscess
Supportive
Ax
Appenidcetomy once resolved
What investigation when admitted to hospital with IBD flare
AXR look for toxic megacolon which could cause
How does a colonic vesicle fistula present
Pneumohaematuria
Faeces in urine
How do you Dx
CT
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
Complications
High risk of VTE
Dishiscence
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
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
Takeaway UC
Superficial COntinuous Only colon Non-stricture Associated PSC Pseudopolyp
Takeaway Chron’s
Transmural Skip lesions Mouth to anus Stricture, fissure, fistulae and collection Cobble stone Peri-anal
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
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
What is colonoscopy show
Gold standard to show distribution and severity
Also allows biopsy
What should patients get during stay if IBD flare
VTE prophylaxis always
Daily blood
Daily abdominal exam to feel for dilatation
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
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
What is most common cause of peri-anal abscess
IBD
What is most common cause of small bowel abscess
Chron’s
If toxic megacolon what imaging
AXR as fast but will get CT
As FY1 what is role
Full Hx and exam
Blood test
Resus
Early discussion
Cancer surveillance in IBD
After 10 years from Dx = colonoscopy
Can you do pouch as emergency
No only elective
If emergency = no time for reconstruction
If someone presents diarrhoea what should you ask
Recent Ax as risk of C.diff colitis
