IBD Therapy Flashcards
What are the aims of IBD therapy?
control inflammation + heal mucosa, restore normal bowel habit, improve quality of life
What are the therapeutic strategies?
Lifestyle advice, drugs, surgery
What therapy options are there for UC?
5ASA (mesalazine)
Steroids
Immunosuppresants
Anti-TNF therapy
What are the therapy options for CD?
Steroids,
Immunosuppresants
ANti-TNF therapy
What is the preferred action for 5ASA?
topical effect, anti-inflammatory properties, reduces risk of colon cancer, side effects are diarrhoea, idiosyncratic nephritis
5-Aminosalicylic acid (5-ASA)
Oral - prodrugs, pH dependant release, delayed release.
Topical - suppositories and enemas
What types of 5ASA are there?
Sulphasalazine, Balsalazide, Mazavant, mesalazine, pH release (asacol), delayed release (pentasa)
What 5ASA gets only released in the Colon?
Salazopyrin
What 5ASA gets released in the colon and the Ilium?
Balsalazide
What 5ASA gets released in the colon, the Ilium and the jejunum?
Asacol Salofalk
What 5ASA gets released in the colon, the Ilium, the jejunum and the duodenum?
Pentasa
Give two examples of Corticosteroids
Prednisolone (oral) and Budesonide (topical)
What is the purpose of Corticosteroids
To induce remission
Should corticosteroids be stopped immediately?
No, reduced over a period of 6-8 weeks
How many CD patients become steroid-dependant?
28% at one year
Name some musculoskeletal steroid side effects
Avascular necrosis
osteoporosis
Name some Metabolic side effects of Steroids?
Weight gain
Diabetes
Hypertension
Name some other steroid side effects
Acne
Thinning of skin
Cataracts
Growth failure
What immunosuppressant’s are used for IBD?
Azathioprine
Mercaptopurine
Methotrexate
What is the main metabolism of Azathioprine?
AZA –> 6-MP –> 6-TGN (active)
What are side products of Azathioprine metabolism?
imidazole, 6-MMP (via TPMT) and 6-TU (via Xanthine Oxidase)
Describe the effects of Azathioprine
Slow onset (16w) TPMT activity contributes to toxicity Avoid co-prescription of allopurinol (XO inhibitor) and regular blood monitoring required
What are Azathioprine side effects?
Pancreatitis
Leucopaenia
Hepatitis
Small risk of lymphoma, skin cancer
What is Anti-TNF?
Tumour Necrosis Factor a = proinflammatory cytokine.
Chimeric (infliximab; IV infusion
Humanised (adalimumab, S/C injection)
Promotes apoptosis of activated T-lymphocytes
Rapid onset of action
Remision rates of Infliximab
30-40%
Deescribe Anti-TNF
Rapid mucosal healing in responders
remission duration 8-12 weeks
Safety of Anti-TNFa
Infusion reactions - 13% HACA +ve
Infection - numerous
Cancer - Lymphoma and solid tumours
TB
When use Anti-TNFa?
Long term strategy, supportive etc.
refractory/fistulating disease
and exclude TB
Explain the 2 types of IBD surgery
Emergency - failure to respond to medical therapy, small bowel obstruction, abscess and fistulae
Elective - Failure to respind to medical therapy, Dysplasia of colon mucosa
Describe surgery for CD
Minimise amount of bowel resected, non curative, try not to induce short gut syndrome
Describe surgery for UC
Curative, option of permanent ileostomy or restorative protocoloectomy and pouch
What are the elective surgeries for CD?
Resection
Stricturoplasty
Fistulas
Anal disease
What are the elective surgeries for UC?
Proctocolectomy with end ileostomy
Proctocolectomy with ileorectal anastomosis
With a pouch
What are the emergency surgeries for IBD?
Sub total colectomy for UC
Resection for CD
Diagnostic laparoscopy
Rectal/anal disease
Why may you do elective surgery in UC?
Medically unresponsive disease Intolerability Dysplasia/malignancy growth retardation in children Attempted resolution of extra-intestinal disease
Difference between colostomy and ileostomy?
colostomy - left, flush, stool
ileostomy - right, spouted, effluent
Problems with a pouch?
Average 6 bowel movements a day leakage incontinence nocturnal incontinence failure and reversed to ileostomy
Complications of a pouch?
Immediate - haemorrhage and enterotomy - Anaphylaxis
Early - urinary dysfunction, wound infection, pelvic abscess, anastomotic leak - Artelectasis, Ileus and portal vein thrombosis
Late - Impotence, Infertility, Pouchitis - DVT/PE, small bowel obstruction
How do you assess acute attack severity?
ESR haemoglobin bloody stools temperature heart rate
How should you treat a rectal flare up?
With predfoam enemas etc. DO NOT ENTER
What is the cancer risk with IBD?
4% = CRC with UC
by 30 yrs, up to 18%
Signs of toxic megacolon
Sepsis Distension Pain Requires decompression may perforate and be fatal
What is Rigler’s sign?
Gas on outside of bowel wall
Considerations for CD surgery
DVT
steroids/immunosupp
nutritional status
Electrolytes
What are indications for CD surgery?
Stenosis causing obstruction Enterocutaneous fistulas Intra-abdominal fistulas Abscesses Bleeding Free perforation
Surgical treatment for Multisite disease
Stricturoplasty of lesions
Heineke-Mikulicz
Balloon dilatation
What are concerns for abscesses and fistulas?
SNAP - sepsis, nutrition, anatomy and plan.
Intra-abdominal and enterocutaneous
What are the types of CD colonic surgeries?
Emergency, segmental, total, panproctocolectomy, pouches
Types of perianal disease?
Primary lesions - fissure/ulcer
Secondary lesions - abscess, tages, fistula
Incidental lesions - pilesm hidradenititis
What is good treatment for Fistulas?
Seton.
Surgery is also good (lay open, stoma if bad enough)
