Inflammatory bowel disease Flashcards
Define inflammatory bowel disease
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
Name the two conditions that make up inflammatory bowel disease
Ulcerative colitis (UC)
Crohn’s disease (CD)
Describe which part of the GI tract is ulcerative colitis affect
Continuous inflammation of the mucosa starting in the rectum (in most cases) and limited to the colon.
Describe which part of the GI tract is Crohn’s disease affect
Transmural patchy inflammation is seen throughout the gastrointestinal tract.
Describe the inflammation associated with ulcerative colitis
Continous
Mucosal
Describe the inflammation associated with Crohn’s disease
Patchy transmural granulomatous
Describe the distribution of the inflammation in ulcerative colitis
Rectum and variable amount of colon
Describe the distribution of the inflammation in Crohn’s disease
seen throughout the gastrointestinal tract i.e. mouth to anus
Describe the characteristics of Crohn’s disease
inflammatory bowel disease characterised by patchy, transmural inflammation (full thickness) of intestinal mucosa.
What does transmural mean
Full thickness i.e. in crohns disease it means it affects the full thickeness of the colon wall
Crohn’s disease can affect any part of the gastrointestinal tract from mouth to anus. Where it is usually seen
The terminal ilium and perianal locations.
What is fistula
an abnormal opening that connects two or more organs or spaces inside or outside the body
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 sinus tract in CD is a narrow opening extending from a wound in the epithelium of the GI tract through the walls.
At what age is incidences of Crohn’s disease seen in
bimodal incidence
peaks between the ages of 15-30 and 60-80 years old.
Granulomas formation is the key feature of CD.
What is Granulomas
Granulomas are collections of macrophages and neutrophils
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
Cobblestone appearance
Bowel wall thickening
Lumen narrowing
Deep ulcers
Fistulae
Fissures
“crows NESTS” is used to remember the key features of Crohn’s disease
What does it stand for
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.
Name some of the microscopic (seen on histology) features of Crohn’s disease
· Inflammatory infiltration is noted on the lamina propria.
· Lymphoid hyperplasia
· Non-caseating granulomas.
· Skip lesions
· Transmural ulceration
Name some of the risk factors for Crohn’s disease
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
Name some of the symptoms associated with Crohn’s disease
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.
Which type of inflammatory bowel disease is most associated with watery diarrhoea (instead of bloody)
Crohn’s disease
Which type of inflammatory bowel disease is most associated with bloody diarrhoea
Ulcerative colitis
Name some of the extra-intestinal manifestations of Crohn’s disease
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)
What is the key investigation used to distinguish between IBD and irritate bowel syndrome (IBS).
Faecal calprotectin
High in IBD; Normal in IBS
Faecal calprotectin is sensitive for inflammatory bowel disaese but not specific.
What does this mean
good at picking up inflammation but is not specific for IBD
Name some of the investigations of Crohn’s disease
Faecal calprotectin
Ileocolonoscopy
MR enterography
Intestinal biopsy
Routine bloods - for anaemia, infection, thyroid, kidney and liver function
CRP - detecting inflammation
MR enterography have high diagnostic accuracy for disease in which part of the GI tract
Small bowel disease
mesalazine is used in which type of inflammatory bowel disaese
Ulcerative colitis only
DO NOT USE IN CROHNs
The general principle in the management of Crohn’s disease is to induce and then maintain remission.
What pharmacological options induce remission
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.
The general principle in the management of Crohn’s disease is to induce and then maintain remission.
What pharmacological options are for maintenance therapy
predominantly thiopurines, methotrexate and biologics.
Give an example of a Thiopurines
azathioprine
mercaptopurine
What is the mechanism of action of Thiopurines in the maintence of Crohn’s disease
Work through purine synthesis inhibition in lymphocytes leading to immunosuppressive properties.
WHat must be checked before using Thiopurines and why?
Must check TPMT enzyme activity before use.
Homozygous mutations in TPMT can lead to dangerous bone marrow suppression.
Name a side effect of Thiopurines
pancreatitis
hepatotoxicity
Methotrexate can be used in the maintence of crohns disease
How does it work
Inhibits dihydrofolate reductase.
Has both immunomodulatory and anti-inflammatory properties.
WHat must be checked before using methotrexate
Liver and renal function
Name some of the side effects of methotrexate
bone marrow suppression, hepatotoxicity and pulmonary toxicity.
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
infliximab/adalimumab
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
vedolizumab
Name some of the side effects of biologics use
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.
What score is used as the standard evaluation of post-surgical recurrences at ileocolic anastomosis level (Crohn’s disease)
Rutgeerts score
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
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).
What is the cumulative rate of symptomatic recurrence of crohn’s disease after curative resection
50%
What is the most common inflammatory bowel disease
Ulcerative colitis
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
50%
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).
20%
What are Patients with pancolitis in ulcerative colitis at risk of
At risk of developing backwash ileitis
What is backwash ileitis.
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.
At what age is incidences of Ulcerative colitis seen in
15-25 and 55-65 years of age.
Is ulcerative colitis most common in:
males
or
females
Females
Which type of inflammatory bowel disease is skip lesions seen in
Crohn’s disease
Describe the histology of Ulcerative colitis
Tends to be superficial only affecting the mucosa so perforations and fistulae are not associated with UC.
Complications such as perforations and fistulae are seen in which type of inflammatory bowel disease
Crohn’s disedase
No ulcerative colitis as the inflammation tends to be superficical only affects the mucosa
Smoking is protective in ____, whereas it is a risk factor in ____
Crohn’s or Ulcerative colitis
Smoking is protective in ulcerative colitis, whereas it is a risk factor in crohns
Mneominic “U – C – CLOSEUP” is used to remember the classic characteristics of ulcerative colitis.
What does it stand for
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
Describe the macroscopic changes seen in ulcerative colitis
Macroscopic changes can be seen in endoscopy
Red inflammed mucosa
Continous inflammation
Mucosa is easily friable to touch
Inflammatoy polyps
Describe the microscopic changes seen in ulcerative colitis
Microscopic changes can be seen in histology
Goblet cell depletion
Crypt absecesses
Inflammatory infiltrate in lamina propria
In which inflammatory bowel disease is there goblet cell depletion
Ulcerative colitis
There is increased inflammatory infiltration into the lamina propria in ulcerative colitis.
What type of cells make up the majority of the inflammatory infiltrates
Neutrophils
What is the hallmark feature of ulcerative colitis
Blood diarrhoea/ rectal bleeding
Name some of the clinical features of ulcerative colitis
Diarrhoea
Abdominal pain
Passing blood
Weight loss
What is the first line medication used to induce remission in mild to moderate ulcerative colitis
aminosalicylate e.g. mesalazine oral or rectal – topical i.e. rectal is better)
What is the second line medication used to induce remission in mild to moderate ulcerative colitis
corticosteroids e.g. prednisolone
What is the First line medication used to induce remission in severe ulcerative colitis
IV corticosteroids e.g. hydrocortisone
What is the second line medication used to induce remission in severe ulcerative colitis
IV ciclosporin
Does aminosalicylate e.g. mesalazine induce or maintain remission of ulcerative colitis
Both - used to induce and maintain remission
Which inflammatory bowel disaese has a strong link with colorectal cancer
Ulcerative colitis
Name some of the medications used to maintain remission of ulcerative colitis
Aminosalicylate e.g. mesalazine oral or rectal
Azathioprine
Mercaptopurine
Name some of the local complications associated with ulcerative colitis
Haemorrhage
Toxic dilation (aka toxic megacolon)
Name some of the systemic complications associated with ulcerative colitis
Skin; erythema nodosum, pyoderma gangrenosum
Liver; sclerosing cholangitis, cholangioCa
Eyes; iritis, uveitis, episcleritis
Ankylosing spondylitis
Bloody diarrhoea is more common in which inflammatory bowel disease
Ulcerative colitis
Watery, non-bloody diarrhoea is more common in which inflammatory bowel disease
Crohn’s disease
Weight loss is more prominent in which inflammatory bowel disease
Crohn’s disease
Which inflammatory bowel disease is there upper GI symptoms
Crohn’s disease
Which inflammatory bowel disease is associated with tenesmus i.e. not feeling quite finished after a bowel motion
Ulcerative colitis
Abdominal pain in the left lower quadrant is more associated with which inflammatory bowel disease
Ulcerative colitis
Abdominal mass palpable in the right iliac fossa is more associated with which inflammatory bowel disease
Crohn’s disaese
Gallstones are more common in which inflammatory bowel disease
Crohn’s disaese
Due to reduced bile acid reabsorption
Primary sclerosing cholangitis are more common in which inflammatory bowel disease
Ulcerative colitis
Name some of the complications associated with Crohn’s disease
Obstruction
Fistula
Colorectal cancer
In which inflammatory bowel disease is the lesions seen anywhere in the GI tract (from mouth to anus)
Crohn’s disease
In which inflammatory bowel disease is the inflammation starting at rectum and never spread beyond the ileocaecal valve
Ulcerative colitis
In which inflammatory bowel disease does the inflammation affect all layers of the bowel wall (from mucosa to serosa)
Crohn’s disease
In which inflammatory bowel disease does the inflammation affect only the mucosa and does not extend beyond submucosa
Ulcerative colitis
In which inflammatory bowel disease is there an increase of goblet cells seen in histology
Crohn’s disease
In which inflammatory bowel disease is there granuloma formation seen in histology
Crohn’s disease
In which inflammatory bowel disease is there crypt abscess formation seen in histology
Ulcerative colitis
In which inflammatory bowel disease is there a depletion of goblet cells seen in histology
Ulcerative colitis
What are the endoscopic features of crohn’s disease
Deep ulcers
Skip lesions
Cobble-stone appearance
What are the endoscopic features of ulcerative colitis
Widespread ulceration with preservation of adjacent mucosa
May have polyps (‘pseudopolyps’)
What kind of enema is used, in association with radiology, in Crohn’s disaese
Small bowel enema as it is high sensitivity and specificity for examination of the terminal ileum
What kind of enema is used, in association with radiology, in ulcerative colitis
Barium enema
What are the radiological features of crohn’s disease
strictures: ‘Kantor’s string sign’
proximal bowel dilation
‘rose thorn’ ulcers
fistulae
‘rose thorn’ ulcers are seen in radiology. What inflammatory bowel disease are they suggestive of
Crohn’s disease
