Inflammatory Bowel Disease Flashcards
What is IBD?
A term used to describe two chronic GI inflammatory conditions
- Ulcerative colitis
- Chron’s disease
What are the risk factors for Crohn’s?
Poor diet
FH
Smoking
Altered immune states
What is the underlying pathophysiology of Crohn’s?
Inflammation can affect any part of GI tract
-most commonly terminal ileum/ascending colon
-skip lesions present
-narrowed bowel, thickened wall
-deep ulcers (Rose thorn, cobblestone appearance on CT)
Inflammation throughout all layers of bowel
-fistulae/stenosis common
What are the clinical features of Crohn’s?
Abdo pain
Diarrhoea (steatorrhoea in ileal disease, bloody in colonic)
Wt loss
Severe apthous ulceration of mouth (early sign)
Anal complications- fistula, fissure, haemorrhoids
Extra GI manifestations
Acute RIF pain/mass
What are the anal complications of Crohn’s?
Fissure Fistula Haemorrhoids Skin tags Abscesses
What effect does smoking have on UC?
Protective
What is the underlying pathophysiology of UC?
Inflammation starts in rectum, extends proximally along colon
-proctitis if affects rectum only
Inflammation of distal terminal ileum (backwash ileitis)
Inflammation only affects mucosa (excessively ulcerate)
-adjacent mucosa looks like inflam polyps
What are the clinical features of UC?
Crampy lower abdo discomfort
Gradual onset diarrhoea (often bloody)
Urgency/tenesmus (if disease confined to rectum)
Extra-GI sx
What is the histological difference b/w UC & Crohn’s?
Chron’s - transmural inflammation, lymphoid hyperplasia, granulomas
UC - mucosal inflammation, crypt abscesses, goblet cell depletion
What is indeterminate inflammatory colitis?
Diagnosis given when biopsy taken in acute phase, not always possible to distinguish UC/Chron’s
What is fulminant IBD?
Most of mucosa lost, leaving only a few islands of normal tissue
Toxic dilatation can occur
What investigations are appropriate in suspected IBD?
Bloods - FBC, U&Es, CRP/ESR, LFTs, Fe/B12
Stool studies - stool chart, MCS x3, calprotectin
AXR/CXR/CT
Endoscopy (+/- biopsy)
What medical therapy is available for a mild acute Crohn’s flare?
SYMPTOMATIC BUT SYSTEMICALLY WELL
- oral prednisolone
- tapered steroids
What medical therapy is available for a severe acute Crohn’s flare?
SYMPTOMATIC AND SYSTEMICALLY UNWELL
- admission (if raised temp, pulse, CPR/ESR, low albumin)
- IV hydrocortisone 100mg/6h
- make pt NBM w/ parenteral nutrition)
- high level monitoring
- thiopurines/methotrexate if not responding
- infliximab (if refractory)
- transfer to oral prednisolone
What medical therapy is available for Crohn’s maintenance?
1st Line = Thiopurines (azathiopurine/6-mercaptopurine) 2nd Line = Methotrexate/infliximab Oral metronidazole (if anal disease)
What screening should always be done before prescribing Thiopurines?
TPMT deficiency
-unable to metabolise thiopurine
What is classed as a mild flare of UC?
<4 diarrhoea stools a day- can have blood
Systemically well
What medical therapy is available for acute severe/fulminating UC?
MDT management (consider surgical intervention)
IV corticosteroids
SC heparin
Avoid anti-motility drugs (including opioids)
2nd line = IV ciclosporin (if sx worsen/no improvement w/i 72hrs steroids)
3rd line = biological agents (specialist)
What are the indications for surgical treatment of acute severe/fulminating UC?
>8motions/day Pyrexia Tachycardia Colonic dilatation Low albumin Low Hb CRP >45
What medical therapy is available for UC maintenance?
Post mild-moderate flare
- proctitis= topical mesalazine OR oral and topical OR oral alone (not as effective)
- sigmoiditis= low dose oral mesalazine
Severe
- 1 severe exacerbation or >2 exacerbations in 1 yr
- azathioprine or mercaptopurine
What monitoring do UC pts require?
Monitoring appropriate to specific drug
Bone health monitoring
What are the general complications of Crohns?
Episcleritis Colonic cancer Small bowel cancer Osteoporosis Malabsorption Fistula and abscess
What are the features of toxic dilatation?
Persistent fever
Tachycardia
Loose-blood stained stool
What investigations are appropriate in suspected toxic dilatation?
Falling albumin/K
AXR (dilated colon, >6cm, w/ mucosal islands)
What is the management of toxic dilatation?
Perforation imminent
Surgical management
What are the surgical options for Chron’s disease?
Never curative
Temporary ileostomies - ‘rest’ distal diseased bowel
Limited resection of worst areas
What is short bowel syndrome?
Malabsorption if <1m small bowel remains
What are the surgical options for UC?
Bowel resection curative Emergency -subtotal colectomy & end ileostomy -proctolectomy & end ileostomy Elective -completion proctocolectomy & ileoanal pouch reconstruction -colectomy & ileorectal anastomosis
What are the extra colonic manifestations of IBD present during the active phase?
Eyes - conjunctivitis/episcleritis/iritis
Joints - arthralgia of large joints
Skin - erythema nodosum, pyoderma gangrenosum
VTE
Fatty liver
What are the extra colonic manifestations of IBD unrelated to disease activity?
Autoimmune hepatitis
Gallstones
Renal calculi
What is a moderate flare of UC?
4-6 stools a day with minimal systemic disturbance
What is a severe flare of UC?
> 6 bloody stools a day
Systemic upset
-fever
-tachycardia
What is the management of a mild-moderate flare of UC?
Proctitis
- topical mesalazine
- if no improvement in 4 wks then add oral
- still no improvement then add oral prednisolone
Sigmoiditis and descending colitis
- topical mesalazine
- no improvement after 4wks then add oral OR switch to oral mesalazine and topical steroid
- still no improvement then add oral prednisolone
Extensive disease
- oral and topical mesalazine
- no improvement after 4wks then add either topical or oral steroid
What are complications of UC?
Toxic megacolon
Uveitis
Primary sclerosing cholangitis
Cholangiocarcinoma
