Inflammatory bowel disease

Question 1

At what age does Crohn’s disease typically present?

Answer 1

15-40 years

Question 2

Describe the treatment for induction of remission of Crohn’s.

Answer 2

1st line - corticosteroids (prednisolone, methylprednisolone, hydrocortisone)
Add azathioprine or mercaptopurine if >2 exacerbations per year or steroids not sufficient to induce remission
Use methotrexate instead if aza/mer not tolerated
Consider biologics (inflixumab, adalimumab - TNF-alpha inhibitors) in severe disease

Question 3

What are the potential constitutional symptoms of Crohn’s disease?

Answer 3

Weight loss and malnutrition
Fatigue / lethargy
Fever

Question 4

Describe the management of Crohn’s disease in the maintenance stage

Answer 4

Continue azathioprine / mercaptopurine
Use methotrexate only if these are not tolerated
Continue biologics if used to induce remission and there is evidence of effect
Do not use steroids
Surgery if treatment fails

Question 5

In general, what methods / drugs can be used in the management of Crohn’s disease

Answer 5

Corticosteroids
Immunosuppressants - azathioprine, mercaptopurine, methotrexate
Biologics - TNF-alpha inhibitors e.g. inflixumab, adalimumab
Surgery (not curative)
Antibiotics when required
Nutritional support
Management of extra-intestinal manifestations
Symptomatic treatment e.g. antidiarrhoeals

Question 6

What are the potential extra-intestinal manifestations of Crohn’s?

Answer 6

Arthritis
Erythema nodosum
Pyoderma gangrenosum
Skin tags
Perianal fistulas
Anal fissues
Aphthous stomatitis
Osteoporosis
Uveitis
Keratopahy
Episcleritis
Dry eyes
Amyloidosis
Hydronephrosis
Primary sclerosis cholangitis
Hepatitis
Gallstones
Iron deficiency anaemia
Folate / B12 deficiency anaemia

Question 7

What is the typical age of onset of UC?

Answer 7

20-40 years with a second peak incidence ~60 years

Question 8

What is the acute management of acute severe UC?

Answer 8

IV corticosteroids
Ciclosporin or inflixumab
Consider surgery
Supportive measures (fluids, transfusion, electrolyte replacement, VTE prophylaxis, analgesia etc.)

Question 9

What is the acute management of moderate-severe UC?

Answer 9

Oral corticosteroids
Biologic (infliximan, adalimumab)
Immunosuppressant (azathioprine, mercaptopurine methotrexate)
Consider colectomy

Question 10

What is the acute management of mild proctitis in UC?

Answer 10

Rectal or oral aminosalicylate

Consider rectal corticosteroids

Question 11

What is the acute management of mild left-sided colitis UC?

Answer 11

Oral and rectal aminosalicylate

Consider oral budesonide

Question 12

What is the acute management of mild extensive colitis in UC?

Answer 12

Oral and rectal aminosalicylate

Consider oral corticosteroid

Question 13

What is the ongoing management of acute severe UC?

Answer 13

Infliximab or thiopruine

Question 14

What is the ongoing management of moderate-severe UC?

Answer 14

Thiopurine
Biologic
Tofacitinib

Question 15

What is the ongoing management of mildUC?

Answer 15

Oral +/- topical aminosalicylate

Tofacitinib for proctitis