Inflammatory Bowel Disease Flashcards by Zofia Koryga

What is inflammatory bowel disease?

Chronic, relapsing, remitting inflammation of the GI tract

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What are examples of inflammatory bowel disease?

Crohn’s disease

Ulcerative colitis

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What do Crohn’s disease and ulcerative colitis differ in?

Location and inflammation

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When does inflammatory bowel disease commonly present?

In the teens and twenties

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What can IBD be due to?

Genome

Microbiome

Environment

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Is IBD medelian inherited?

No, but has genetic susceptibility

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What kind of genetic variation makes people genetically susceptible to IBD?

SNPs (single nucleotide polymorphisms)

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What percentage of someones offspring who has IBD will also develop IBD?

10%

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What do genes that cause inflammatory bowel disease regulate?

Epithelial barrier

Immune response

Bacterial handling

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What is the pathogenesis of IBD?

Pathogenic gut causes altered microbiota

Damaged epithelial barrier increases bacterial adhesion and translocation

Chronic inflammation occurs

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What is the ratio of microbial cells in the gut lumen to eukaryotic cells in the human body?

10:1

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How many different species of bacteria are present in the gut?

At least 500 different species

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What is the metabolic activity of all gut bacteria equivalent to?

That of the liver

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What part of the gut contains the most bacteria?

Colon

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What is different in the microbiota of people with IBD compared to those without?

In IBD there is a dysbosia in microbial communities

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What kind of bacteria is massively more present in people with IBD than those who do not have it?

Proteobacteria

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What is ulcerative colitis?

Chronic condition caused by inapropriate immune response against colonic flora in genetically susceptible people

It affects the colon and rectum

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How does ulcerative colitis affect males compared to females?

Both affected the same

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What are symptoms of ulcerative colitis?

Episodic / chronic diarrhoea

+/- blood and mucous

crampy abdominal discomfort

bowel movement frequency is related to severity

systemic symptoms - fever, malaise, anorexia, decreased weight

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What is the pathology of ulcerative colitis?

Haemorrhagic colon mucosa +/- pseudopolyps formed by inflammation = limited to the mucosa

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What is in the histology of ulcerative colitis?

mucosal

goblet cells are depleted

crypt abcesses are more likely

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What investigations are done for ulcerative colitis?

Bloods for markers of inflammation

Stool culture to rule out infection = c.diff

Faecal calprotectin = released into intestines when inflammation is present

Colonoscopy/sigmoidoscopy and colon mucosal biopsies = assess disease severity

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What are examples of markers of inflammation checked for in ulcerative colitis?

Normocytic anaemia

Increased CPR/platelets

Low albumin

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What is considered normal faecal calprotectin?

<50ug/g of stool

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What is considered elevated faecal calprotectin?

\>200ug/g of stool

What is faecal calprotectin?

Substance that is released into the intestines when inflammation is present

Where in the GI tract is inflammation due to ulcerative colitis present?

Only in the colon, starting at the rectum and working proximally

What percentage of people with ulcerative colitis require a colectomy within 10 years of diagnosis?

20-30%

What are the different levels of severity of ulcerative colities?

Mild Moderate Severe Fulminant

What are characteristics of mild ulcerative colitis?

\<4 stools/day With or without blood Normal ESR No signs of toxicity

What are characteristics of moderate ulcerative colitis?

4-6 stools/day Occasional blood Minimal signs of toxicity CRP less than or equal to 30mg/L

What are characteristics of severe ulcerative colitis?

More than or equal to 6 blood stools/day AND any of: temperature \> 37.8 tachycardia \> 90bpm anaemia (Hb \< 105g/L) ESR \> 30mm/h, CRP \> 30mg/L

What are characteristics of fulminant colitis?

10 stools/day Continuous bleeding Toxicity Abdominal tenderness or distention Transfusion requirement Colonic dilation on x-ray

What is proctitis?

Condition where lining of tissue in inner rectum becomes inflammed

What is stool like with proctitis?

Frequency, urgency, incontinence Small volume mucus, blood Constipation

What does proctitis respond to?

Topical therapy

What percentage of mortality does acute severe colitis have?

2%, very serious condition

What percentage of people with acute severe colitis get an emergency colectomy at admission?

20-30%

What do patients with acute severe colitis often look like?

Well Self-caring Mobilising around ward Often young with physiogical reserve

What is the main differential of acute severe colitis?

Infection

What must be done within the first 24 hours of a patient being admitted with acute severe colitis?

IV glucocorticosteroids LMWH Abdomen x-ray IV hydration Stop non-steroidal analgesics, opiates, anti-diarrhoels, anti-cholinergics Stool chart Stool culture for C. Difficile

Why are patients with acute severe colitis given LMWH?

They are at 3x increased risk of thromboembolism

What is Crohn's disease?

Inflammatory disease characterised by transmural granulomatous inflammation affecting any part of the gut from mouth to anus - there is unaffected parts of bpwel between areas of active disease

What is the pathology of crohn's disease?

Mesentry thickening oedomatous or fibrosis narrowing of lumen ulceration = cobblestone effect

What is the histology of crohn's disease?

Granulomatous Transmural inflammation

Where can Crohn's disease occur?

Anywhere in the GI tract from mouth to anus Patchy disease (skip lesions) Clinical features depend on regions involved

What are possible complications of Crohn's disease?

Small bowel obstruction Toxic dilation Abcess formation Fistulae Colonic Cancer

What are clinical features of Crohn's disease?

Episodic abdominal pain = colicky Diarrhoea Systemic symptoms - fatigue, malaise, fever, anorexia, decreased weight loss, malabsorption, malnutrition Oral and perianal involvement - oral aphthous ulcers, perianal abcess

What investigations are done for Crohn's disease?

Blood for markers of inflammation Stool culture to rule out infection if dirrhoea Faecal calprotectin Colonoscopy with terminal ileum intubation and colon mucosal biopsies MRI small bowel study Capsule endoscopy Occasionally CT if acutely unwell and want to rule out complications such as abscess

What are differences in the histology of Crohn's disease and ulcerative colitis?

Granulomas in CD Transmural inflammation in CD Mucosal in UC Goblet cells depleted in UC Crypt abscesses more likely in UC than CD

What does PCD stand for?

Perianal Crohn's disease

What is perianal Crohn's disease?

Inflammation at or near the anus

What are symptoms of perianal Crohn's disease?

Perianal pain Pus secretion Unable to sit down

What investigations are done for perianal Crohn's disease?

MRI pelvis Examination under anaesthetic

What is the treatment for perianal Crohn's disease?

Surgery to drain abscess Antibiotics and biological therapy (anti-TNF)

What must be considered by IBD differential diagnosis?

Chronic diarrhoea Ileocaecal TB Colitis must also be distinguished from infective and amoebic and ischaemic colitis

What does chronic diarrhoea cause?

Malabsorption Malnutrition

What is a possible long term complication of colitis?

Colonic carcinoma

How do different kinds of colitis change the risk of colonic carcinoma?

Pancolitis 26x normal Left colitis 6x normal Proctitis minimal

What is done for IBD management?

Colorectal surgeon with IBD specialist interest Weekly IBD MDT Dedicated colonoscopy lists for surveillance Direct communication between GP and consultant IBD specialist nurse telephone hotline Nurse led infusion clinic every 3 weeks IBD pharmacist

What kind of approach does management of IBD use?

Step up approach

What medication is given to treat Crohn's disease by reducing inflammation?

Aminosalicylates

What are aminosalicylates?

Family of medications with various formulations that deliver active ingredient, mesalamine, to target sites

What is the abbreviation for aminosalicylates?

5-ASA

How do amionsalicylates work?

Blocking prostaglandins and leukotrienes

Is 5ASA effective with both ulcerative colities and Crohn's disease?

No, only with ulcerative colitis

When is rectal 5-ASA given?

For distal and left sided Crohn's disease

What do steroids induce in Crohn's disease and ulcerative colitis?

Remission

What are examples of steroids used to IBD?

Prednisolone Budenoside

What is an example of an immunomodulation therapy for IBD?

Azathioprine

What are side effects of azithioprine?

Leucopenia Hepatotoxicity Pancreatitis

What biological agents are used for IBD?

Anti-ANFa antibodies A4b7 integrin blockers

Explain each of the steps up in management of IBD?

1) 5-ASA 2) Steroids (prednisone or budesonide) 3) Immunomodulators 4) Biologic agents 5) Surgery