Inflammatory Bowel Disease

Question 1

What are the two major forms of chronic idiopathic inflammatory bowel disease?

Answer 1

1. Ulcerative colitis

2. Crohn’s disease

Question 2

What is a chronic idiopathic inflammatory bowel disease?

Answer 2

Relapsing and remitting inflammatory condition of the GIT with characteristic extra-intestinal manifestations.

Question 3

What are granulomas and in what conditions are they commonly seen?

Answer 3

1. Aggregation of activated epithelial macrophages.

2. Mycobacterium infections, sarcoidosis, Crohn’s.

Question 4

How do UC and Crohn’s compare in this feature?

Spread through GI wall.

Answer 4

UC - mucosa

Crohn’s - transmural (entire wall)

Question 5

How do UC and Crohn’s compare in this feature?

Site affected.

Answer 5

UC - colon

Crohn’s - any part of GIT (terminal ileum and proximal colon commonly)

Question 6

How do UC and Crohn’s compare in this feature?

Type of disease process.

Answer 6

UC - ulceration and inflammation

Crohn’s - granulomatous inflammation

Question 7

How do UC and Crohn’s compare in this feature?

Pattern of spread.

Answer 7

UC - diffuse and continuous

Crohn’s - patchy and discontinuous (skip lesions)

Question 8

How do UC and Crohn’s compare in this feature?

Type of ulcers.

Answer 8

UC - superficial ulcers

Crohn’s - deep fissuring ulcers

Question 9

How do UC and Crohn’s compare in this feature?

Presence of granulomas.

Answer 9

UC - not present

Crohn’s - present

Question 10

What is the pattern of extension of ulcerative colitis?

Answer 10

Can affect juts the rectum and spread proximally (continuous fashion) to left-sided colon or all of colon.

Question 11

How do UC and Crohn’s compare in this feature?

Affect of smoking.

Answer 11

UC - stopping smoking may precipitate flares

Crohn’s - smoking exacerbates

Question 12

What is the aetiology of ulcerative colitis and Crohn’s disease?

Answer 12

Inappropriate immune response against colonic flora in genetically susceptible individuals.

Question 13

What are the risk factors of ulcerative colitis compared to Crohn’s disease?

Answer 13

UC - FHx, HLA-B27 positive

Crohn’s - FHx, Caucasian, 15-40 years old

Question 14

What is this a presentation of?
Episodic/chronic diarrhoea (+/- blood or mucus), LLQ abdominal pain, bowel frequency relates to severity, urgency/tenesmus, fatigue, fever, malaise, anorexia.

Answer 14

Ulcerative colitis

Question 15

What is this a presentation of?

Diarrhoea, RLQ abdominal pain, weight loss/failure to thrive, fatigue, fever, malaise, anorexia.

Answer 15

Crohn’s disease

Question 16

What are the signs present on examination in ulcerative colitis compared to Crohn’s disease?

Answer 16

UC - may be none, fever, tachycardia, tender and distended abdomen.
Crohn’s - abdominal tenderness, perianal abscess/fistulae/skin tags/anal strictures.

Question 17

What are the general extra-intestinal signs in inflammatory bowel disease?

Answer 17

Clubbing, oral ulcers, erythema nodosum, conjunctivitis, uveitis, large joint arthropathies.

Question 18

What extra-intestinal conditions are seen in ulcerative colitis and not in Crohn’s?

Answer 18

Sclerosing cholangitis and cholangiocarcinoma

Question 19

How is suspected inflammatory bowel syndrome investigated?

Answer 19

1. Bloods - anaemia, leucocytosis, thrombocytosis, raised CRP and ESR, iron studies, B12, folate (malabsorption)
2. Stool - elevated faecal calprotectin, discriminate between IBD and IBS, exclude infection
3. Colonoscopy for diagnosis
4. CT contrast/MRI for Crohn’s

Question 20

What would you see on an AXR of ulcerative colitis?

Answer 20

Thumbprinting and leadpiping

Question 21

What would you seen on a colonoscopy of someone with Crohn’s?

Answer 21

Cobblestone appearance - surviving mucosa between fissuring ulcers

Question 22

What is faecal calprotectin and what does it help to distinguish between?

Answer 22

1. Released during neutrophil degranulation

2. IBD (raised) and IBS (normal) - but has a high negative prediction value (if normal then IBD is unlikely)

Question 23

What is the treatment for mild-moderate ulcerative colitis?

Answer 23

1. Mild - 5-ASA (mesalazine) PR for distal disease, PO for extensive disease. Topical steroids may also be given.
2. Moderate - induce remission with PO steroids, then maintain on 5-ASA.

Question 24

What is the treatment for severe ulcerative colitis?

Answer 24

1. IV fluids, IV steroids, PR steroids
2. Cyclosporin/infliximab to avoid colectomy if still severe on day 3-5.
3. Azathioprine if patients flare on steroid tapering.
4. Subtotal colectomy and terminal ileostomy needed in 20%.

Question 25

What is the treatment for mild-moderate Crohn’s disease?

Answer 25

Prednisolone PO and taper

Question 26

What is the treatment for severe Crohn’s disease?

Answer 26

1. IV fluids, IV steroids
2. Azathioprine if patients flare on steroid tapering.
3. Infliximab (anti-TNFa), anti-integrin, anti-IL12/23
4. Surgery (not curative) in 50-80% - drug failure or GI obstruction.

Question 27

What are the complications of ulcerative colitis?

Answer 27

1. Increased risk of colorectal cancer - mucosal central disease (more likely than Crohn’s)
2. Inflammatory polyps (not dysplastic)
3. Toxic megacolon, perforated colon, VTE, dehydration.

Question 28

What are the complications of Crohn’s disease?

Answer 28

1. Increased risk of colorectal cancer (less likely than UC)
2. Bowel obstruction - caecal volvulus, stricture formation
3. Ulcers, fistulas, adhesions, anal fissures.

Question 29

What is the important part of follow-up for inflammatory bowel disease?

Answer 29

Colonoscopy screening for cancer 8-10 years after diagnosis and sooner if higher risk factors.