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Finals: Medicine > Inflammatory bowel disease > Flashcards

Inflammatory bowel disease Flashcards

1
Q

Define inflammatory bowel disease

A

umbrella term for chronic, relapsing-remitting, non-infectious inflammatory diseases of the gastrointestinal system

involve inflammation of the walls of the GI tract and are associated with periods of remission and exacerbation

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2
Q

Name the two conditions that make up inflammatory bowel disease

A

Ulcerative colitis (UC)

Crohn’s disease (CD)

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3
Q

Describe which part of the GI tract is ulcerative colitis affect

A

Continuous inflammation of the mucosa starting in the rectum (in most cases) and limited to the colon.

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4
Q

Describe which part of the GI tract is Crohn’s disease affect

A

Transmural patchy inflammation is seen throughout the gastrointestinal tract.

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5
Q

Describe the inflammation associated with ulcerative colitis

A

Continous

Mucosal

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6
Q

Describe the inflammation associated with Crohn’s disease

A

Patchy transmural granulomatous

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7
Q

Describe the distribution of the inflammation in ulcerative colitis

A

Rectum and variable amount of colon

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8
Q

Describe the distribution of the inflammation in Crohn’s disease

A

seen throughout the gastrointestinal tract i.e. mouth to anus

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9
Q

Describe the characteristics of Crohn’s disease

A

inflammatory bowel disease characterised by patchy, transmural inflammation (full thickness) of intestinal mucosa.

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10
Q

What does transmural mean

A

Full thickness i.e. in crohns disease it means it affects the full thickeness of the colon wall

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11
Q

Crohn’s disease can affect any part of the gastrointestinal tract from mouth to anus. Where it is usually seen

A

The terminal ilium and perianal locations.

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12
Q

What is fistula

A

an abnormal opening that connects two or more organs or spaces inside or outside the body

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13
Q

The transmural inflammation often leads to fibrosis causing intestinal obstruction. The inflammation can also result in sinus tracts that burrow through and penetrate the serosa, thereafter giving rise to perforations and fistulae.

What is a sinus tract in Crohn’s disease

A

A sinus tract in CD is a narrow opening extending from a wound in the epithelium of the GI tract through the walls.

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14
Q

At what age is incidences of Crohn’s disease seen in

A

bimodal incidence

peaks between the ages of 15-30 and 60-80 years old.

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15
Q

Granulomas formation is the key feature of CD.

What is Granulomas

A

Granulomas are collections of macrophages and neutrophils

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16
Q

A number of pathophysiological changes occur in Crohn’s disease due to chronic inflammatory processes.

Describe the macroscopic (seen during endoscopy) features of Crohn’s disaese

A

Cobblestone appearance

Bowel wall thickening

Lumen narrowing

Deep ulcers

Fistulae

Fissures

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17
Q

“crows NESTS” is used to remember the key features of Crohn’s disease

What does it stand for

A

N – No blood or mucus (less common)

E – Entire GI tract

S – “Skip lesions” on endoscopy (where normal bowel mucosa is found between diseased areas)

T – Terminal ileum most affected and Transmural (full thickness) inflammation

S – Smoking is a risk factor (don’t set the nest on fire)

Crohn’s is also associated with weight loss, strictures and fistulas.

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18
Q

Name some of the microscopic (seen on histology) features of Crohn’s disease

A

· Inflammatory infiltration is noted on the lamina propria.

· Lymphoid hyperplasia

· Non-caseating granulomas.

· Skip lesions

· Transmural ulceration

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19
Q

Name some of the risk factors for Crohn’s disease

A

Smoking – causative in CD

Family history of inflammatory bowel disease (IBD)

More common in white than in black or Asian people

Ashkenazi Jews have a 2- to 4-fold increased risk

Previous infectious gastroenteritis

Drugs e.g. NSAIDs

Males and females are equally affected

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20
Q

Name some of the symptoms associated with Crohn’s disease

A

Fatigue

Diarrhoea (more watery than bloody)

Abdominal pain

Weight loss

Fever

GI bleeding.

Many patients have non-specific symptoms and remain undiagnosed for many years.

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21
Q

Which type of inflammatory bowel disease is most associated with watery diarrhoea (instead of bloody)

A

Crohn’s disease

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22
Q

Which type of inflammatory bowel disease is most associated with bloody diarrhoea

A

Ulcerative colitis

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23
Q

Name some of the extra-intestinal manifestations of Crohn’s disease

A

Clinical features that occur outside the gastrointestinal tract within CD.

Skin: Erythema nodosum, a panniculitis, is characterised by reddened, raised, tender nodules.

Skin: Pyoderma gangrenosum presents with ulcerating nodules characterised by black (gangrenosum) edges and central pus (pyoderma).

Eye: Episcleritis (inflammation of your episclera)

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24
Q

What is the key investigation used to distinguish between IBD and irritate bowel syndrome (IBS).

A

Faecal calprotectin

High in IBD; Normal in IBS

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25
Q

Faecal calprotectin is sensitive for inflammatory bowel disaese but not specific.

What does this mean

A

good at picking up inflammation but is not specific for IBD

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26
Q

Name some of the investigations of Crohn’s disease

A

Faecal calprotectin

Ileocolonoscopy

MR enterography

Intestinal biopsy

Routine bloods - for anaemia, infection, thyroid, kidney and liver function

CRP - detecting inflammation

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27
Q

MR enterography have high diagnostic accuracy for disease in which part of the GI tract

A

Small bowel disease

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28
Q

mesalazine is used in which type of inflammatory bowel disaese

A

Ulcerative colitis only

DO NOT USE IN CROHNs

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29
Q

The general principle in the management of Crohn’s disease is to induce and then maintain remission.

What pharmacological options induce remission

A

In patients presenting with CD for the first time, or those who develop a flare of CD, the principle aim is to induce remission.

Methotrexate and thiopurines are potential induction therapies however it is unclear the benefit of thiopurines as an induction therapy.

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30
Q

The general principle in the management of Crohn’s disease is to induce and then maintain remission.

What pharmacological options are for maintenance therapy

A

predominantly thiopurines, methotrexate and biologics.

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31
Q

Give an example of a Thiopurines

A

azathioprine

mercaptopurine

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32
Q

What is the mechanism of action of Thiopurines in the maintence of Crohn’s disease

A

Work through purine synthesis inhibition in lymphocytes leading to immunosuppressive properties.

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33
Q

WHat must be checked before using Thiopurines and why?

A

Must check TPMT enzyme activity before use.

Homozygous mutations in TPMT can lead to dangerous bone marrow suppression.

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34
Q

Name a side effect of Thiopurines

A

pancreatitis

hepatotoxicity

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35
Q

Methotrexate can be used in the maintence of crohns disease

How does it work

A

Inhibits dihydrofolate reductase.

Has both immunomodulatory and anti-inflammatory properties.

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36
Q

WHat must be checked before using methotrexate

A

Liver and renal function

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37
Q

Name some of the side effects of methotrexate

A

bone marrow suppression, hepatotoxicity and pulmonary toxicity.

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38
Q

Biologics are monoclonal antibodies. Can be used in the maintence of crohn’s disease.

Give an example of a tumour necrosis factor (TNF) alpha inhibitors

A

infliximab/adalimumab

39
Q

Biologics are monoclonal antibodies. Can be used in the maintence of crohn’s disease.

Give an example of an alpha-4/beta-7 integrin inhibitor

A

vedolizumab

40
Q

Name some of the side effects of biologics use

A

Shortness of breath, lead to immunosuppression so patients are prone to serious infections.

They can also lead to reactivation of dormant infections such as TB and hepatitis B.

41
Q

What score is used as the standard evaluation of post-surgical recurrences at ileocolic anastomosis level (Crohn’s disease)

A

Rutgeerts score

42
Q

Surgery still forms a key part of management in CD. Often patients require a combination of pharmacological and surgical management.

When would surgery be used as a treatment

A

treatment for localised CD (e.g. localised ileocaecal Crohn’s)

for patients wanting to avoid medical therapy or among patients that fail to respond to medical therapy

to manage complications (e.g. perforation, abscess formation).

43
Q

What is the cumulative rate of symptomatic recurrence of crohn’s disease after curative resection

A

50%

44
Q

What is the most common inflammatory bowel disease

A

Ulcerative colitis

45
Q

Inflammation of the rectal mucosa initially (proctitis) and may progress proximally to proximal parts of the colon.

What perctange of patients suffer from proctitis only

A

50%

46
Q

Inflammation of the rectal mucosa initially (proctitis) and may progress proximally to proximal parts of the colon.

What perctange of patients suffer from pancolitis (inflammation of the entire colon).

A

20%

47
Q

What are Patients with pancolitis in ulcerative colitis at risk of

A

At risk of developing backwash ileitis

48
Q

What is backwash ileitis.

A

backwash ileitis is the reflux of colonic contents into the distal few centimetres of the ileum through the ileocaecal valve.

Backwash ileitis can make distinction between UC and CD more difficult.

49
Q

At what age is incidences of Ulcerative colitis seen in

A

15-25 and 55-65 years of age.

50
Q

Is ulcerative colitis most common in:

males

or

females

A

Females

51
Q

Which type of inflammatory bowel disease is skip lesions seen in

A

Crohn’s disease

52
Q

Describe the histology of Ulcerative colitis

A

Tends to be superficial only affecting the mucosa so perforations and fistulae are not associated with UC.

53
Q

Complications such as perforations and fistulae are seen in which type of inflammatory bowel disease

A

Crohn’s disedase

No ulcerative colitis as the inflammation tends to be superficical only affects the mucosa

54
Q

Smoking is protective in ____, whereas it is a risk factor in ____

Crohn’s or Ulcerative colitis

A

Smoking is protective in ulcerative colitis, whereas it is a risk factor in crohns

55
Q

Mneominic “U – C – CLOSEUP” is used to remember the classic characteristics of ulcerative colitis.

What does it stand for

A

C – Continuous inflammation

L – Limited to colon and rectum (usually)

O – Only superficial mucosa affected

S – Smoking is protective

E – Excrete blood and mucus

U – Use aminosalicylates

P – Primary Sclerosing Cholangitis

56
Q

Describe the macroscopic changes seen in ulcerative colitis

A

Macroscopic changes can be seen in endoscopy

Red inflammed mucosa

Continous inflammation

Mucosa is easily friable to touch

Inflammatoy polyps

57
Q

Describe the microscopic changes seen in ulcerative colitis

A

Microscopic changes can be seen in histology

Goblet cell depletion

Crypt absecesses

Inflammatory infiltrate in lamina propria

58
Q

In which inflammatory bowel disease is there goblet cell depletion

A

Ulcerative colitis

59
Q

There is increased inflammatory infiltration into the lamina propria in ulcerative colitis.

What type of cells make up the majority of the inflammatory infiltrates

A

Neutrophils

60
Q

What is the hallmark feature of ulcerative colitis

A

Blood diarrhoea/ rectal bleeding

61
Q

Name some of the clinical features of ulcerative colitis

A

Diarrhoea

Abdominal pain

Passing blood

Weight loss

62
Q

What is the first line medication used to induce remission in mild to moderate ulcerative colitis

A

aminosalicylate e.g. mesalazine oral or rectal – topical i.e. rectal is better)

63
Q

What is the second line medication used to induce remission in mild to moderate ulcerative colitis

A

corticosteroids e.g. prednisolone

64
Q

What is the First line medication used to induce remission in severe ulcerative colitis

A

IV corticosteroids e.g. hydrocortisone

65
Q

What is the second line medication used to induce remission in severe ulcerative colitis

A

IV ciclosporin

66
Q

Does aminosalicylate e.g. mesalazine induce or maintain remission of ulcerative colitis

A

Both - used to induce and maintain remission

67
Q

Which inflammatory bowel disaese has a strong link with colorectal cancer

A

Ulcerative colitis

68
Q

Name some of the medications used to maintain remission of ulcerative colitis

A

Aminosalicylate e.g. mesalazine oral or rectal

Azathioprine

Mercaptopurine

69
Q

Name some of the local complications associated with ulcerative colitis

A

Haemorrhage

Toxic dilation (aka toxic megacolon)

70
Q

Name some of the systemic complications associated with ulcerative colitis

A

Skin; erythema nodosum, pyoderma gangrenosum

Liver; sclerosing cholangitis, cholangioCa

Eyes; iritis, uveitis, episcleritis

Ankylosing spondylitis

71
Q

Bloody diarrhoea is more common in which inflammatory bowel disease

A

Ulcerative colitis

72
Q

Watery, non-bloody diarrhoea is more common in which inflammatory bowel disease

A

Crohn’s disease

73
Q

Weight loss is more prominent in which inflammatory bowel disease

A

Crohn’s disease

74
Q

Which inflammatory bowel disease is there upper GI symptoms

A

Crohn’s disease

75
Q

Which inflammatory bowel disease is associated with tenesmus i.e. not feeling quite finished after a bowel motion

A

Ulcerative colitis

76
Q

Abdominal pain in the left lower quadrant is more associated with which inflammatory bowel disease

A

Ulcerative colitis

77
Q

Abdominal mass palpable in the right iliac fossa is more associated with which inflammatory bowel disease

A

Crohn’s disaese

78
Q

Gallstones are more common in which inflammatory bowel disease

A

Crohn’s disaese

Due to reduced bile acid reabsorption

79
Q

Primary sclerosing cholangitis are more common in which inflammatory bowel disease

A

Ulcerative colitis

80
Q

Name some of the complications associated with Crohn’s disease

A

Obstruction

Fistula

Colorectal cancer

81
Q

In which inflammatory bowel disease is the lesions seen anywhere in the GI tract (from mouth to anus)

A

Crohn’s disease

82
Q

In which inflammatory bowel disease is the inflammation starting at rectum and never spread beyond the ileocaecal valve

A

Ulcerative colitis

83
Q

In which inflammatory bowel disease does the inflammation affect all layers of the bowel wall (from mucosa to serosa)

A

Crohn’s disease

84
Q

In which inflammatory bowel disease does the inflammation affect only the mucosa and does not extend beyond submucosa

A

Ulcerative colitis

85
Q

In which inflammatory bowel disease is there an increase of goblet cells seen in histology

A

Crohn’s disease

86
Q

In which inflammatory bowel disease is there granuloma formation seen in histology

A

Crohn’s disease

87
Q

In which inflammatory bowel disease is there crypt abscess formation seen in histology

A

Ulcerative colitis

88
Q

In which inflammatory bowel disease is there a depletion of goblet cells seen in histology

A

Ulcerative colitis

89
Q

What are the endoscopic features of crohn’s disease

A

Deep ulcers

Skip lesions

Cobble-stone appearance

90
Q

What are the endoscopic features of ulcerative colitis

A

Widespread ulceration with preservation of adjacent mucosa

May have polyps (‘pseudopolyps’)

91
Q

What kind of enema is used, in association with radiology, in Crohn’s disaese

A

Small bowel enema as it is high sensitivity and specificity for examination of the terminal ileum

92
Q

What kind of enema is used, in association with radiology, in ulcerative colitis

A

Barium enema

93
Q

What are the radiological features of crohn’s disease

A

strictures: ‘Kantor’s string sign’

proximal bowel dilation

‘rose thorn’ ulcers

fistulae

94
Q

‘rose thorn’ ulcers are seen in radiology. What inflammatory bowel disease are they suggestive of

A

Crohn’s disease

Finals: Medicine (91 decks)

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