Immune-mediated Disorders of the GI Tract

Question 1

3 things that contribute to the etiology of IBD

Answer 1

Genetic predisposition
Mucosal immune system
Environmental triggers

Question 2

Criteria for IBS

Answer 2

Recurrent abdominal pain/discomfort for 6 months
And symptoms for at least 3 days/month for the last 3 months
Accompanied by 2 or more of: pain is relieved by having a bm, onset of pain is related to a change in stool frequency, onset of pain is related to a change in the appearance of stool

Question 3

Red flags pointing away from IBS
On history (4)

Answer 3

Unintended weight loss**
Onset after 50 years
Family history of colorectal cancer, IBD, celiac
Joint pains or skin rashes

Question 4

Red flags pointing away from IBS
On physical (3)

Answer 4

Malnourished, anemic
Mass, obstruction
FOBT +ve

Question 5

Red flags pointing away from IBS

On investigations

Answer 5

Abnormal CBC
Elevated CRP/ESR
Altered biochemistry
Abnormal thyroid testing

Question 6

Distinguishing features of ulcerative colitis

Answer 6

Crampy lower abdominal pain relieved by bowel movement
Bloody stool
No mass
Mucosal inflammation
Continuous from rectum
No granulomas

Question 7

Distinguishing features of Crohn’s disease

Answer 7

Constant RLQ pain not relieved by bm
Not bloody
Mass RLQ (often)
Transmural
Skip lesions (anywhere in GIT)
Granulomas (minority)

Question 8

Some extraintestinal manifestations in IBD

Answer 8

Pyoderma
Erythema nodosum
Arthritis
Uveitis
Aphthous stomatitis

Question 9

6 goals of treatment in IBD

Answer 9

Induction of steroid-free clinical remission
Achieve mucosal healing
Amelioration of complications
Maintenance of clinical remission
Avoid hospitalizations/surgery
Prevention of colon cancer

Question 10

2 meds used for mild active crohns

Answer 10

Budenoside

Aminosalicylates

Question 11

3 meds used for moderate active crohns

Answer 11

Infliximab
Systemic corticosteroids
Oral steroids
Azathioprine or methotrexate can also be used here

Question 12

3 treatments for severe active crohns

Answer 12

Other biologicals
Infliximab
Surgery
Azathioprine or methotrexate can also be used here

Question 13

5-aminosalicylic acid

Answer 13

Often the first pharmacologic therapy used in crohns

2 compounds: sulfasalazine, mesalamine

Question 14

3 formulations for oral aminosalicylate delivery

Answer 14

pH dependent
Time release
Bacterial cleavage

Question 15

Corticosteroid treatment of crohn’s

Answer 15

Less than 50% of patients require corticosteroids
The need for them reflects a more complicated disease course
Effective in obtaining remission
Significant side-effects

Question 16

Budesonide

Answer 16

Topically acting steroid

Question 17

3 main side effects from corticosteroids

Answer 17

Adrenal insufficiency (short term)
Osteoporosis (long term)
Aseptic bone necrosis of the hip (long term)

Question 18

3 anti-TNF agents

Answer 18

Infliximab
Adalimumab
Certolizumab

Question 19

6 patient characteristics that place someone at intermittent to high risk for progression (crohns)

Answer 19

Young age at onset (< 18 years)
Non-inflammatory disease behaviour
Extensive disease
Early steroid need
Extra-intestinal manifestations
Active smoker

Question 20

General steps in crohn’s treatment with someone at intermittent to high risk for progression

Answer 20

Budenoside/corticosteroids + AZA or MTX, smoking cessation
If it improves, taper and stop steroids and continue immunosuppressants
If it doesn’t respond, add an anti TNF a
If that responds, maintain
If not, switch anti TNF a, then surgery

Question 21

Principles of surgery for crohns

Answer 21

Directed at relieving symptoms or complications
Effective treatment option for patients who have failed medical therapy or who have a compilation
Only done after careful consideration and consultation

Question 22

5 indications for surgery

Answer 22

Failure of medical therapy
Cancer risk
Perforation
Hemorrhage
Stricture

Question 23

7 risk factors for colorectal cancer in UC

Answer 23

Duration of colitis
Extent of colitis
Primary sclerosing cholangitis **
Family history of colorectal cancer
Development of dysplasia
Endoscopic appearance
Severity of inflammation at surveillance colonoscopy

Question 24

Latent vs silent celiac disease

Answer 24

Latent: increased T cells, no villous atrophy/crypt changes
Silent: seropositive, abnormal histology, ASYMPTOMATC

Question 25

2 best serologic tests for celiac

Answer 25

tTG IgA

EMA IgA

Question 26

Refractory celiac

Answer 26

Symptoms persist despite GF diet
Ensure patient compliance
May need to use an immunosuppressive therapy
Examine lymphocytes for clonal rearrangement