Inflammatory Bowel Disease Flashcards
Acronym NEST for Crohn’s disease
No blood or mucus
Entire GI tract
Skip lesions
Terminal ileum most affected and Transmiral inflammation
Smoking is risk
Acronym CLOSE UP for ulcerative colitis
Continuous inflammation
Limited to colon and rectum
Only superficial mucosa affected
Smoking is protective
Excrete blood and mucus
Use aminosalicyclates
Primary sclerosing cholangitis
What does faecal calprotectin indicate
Released by the intestines when inflamed for useful screening which is 90% specific and sensitive
What is the diagnostic test for IBD
Endoscopy with OGD and colonscopy with biopsy
What are US, CT and MRI’s useful for in IBD
Look for complications such as fistulas, abscesses and strictures
What do routine bloods look for
Anaemia, infection, thyroid, kidney and liver function
What tests should be undertaken in IBD
Routine bloods, CRP, faecal calprotectin, endoscopy with biopsy, imaging
What is first line for inducing remission in Crohn’s
Steroids - oral pred or IV hydrocortisone
What immnuosuppressants can be used to induce remission in Crohn’s
Azathioprine, mercaptopurine, methotrexate, infliximab, adalimumab
First line drugs for maintaining remission in Crohn’s
Azathioprine and Mercaptopurine
What surgical options are there for Crohn’s
Surgical resection of distal ileum and treatment of strictures and fistulas
What is first line for inducing remission in moderate UC
Aminosalicyclate (mesalazine oral or rectal)
What is second line for inducing remission in moderate UC
Corticosteroids (prednisolone)
What is first line for inducing remission in severe UC
IV corticosteroids (hydrocortisone)
What is second line for inducing remission in severe UC
IV ciclosporin
Maintaining remission in UC
Aminosalicyclate (mesalazine oral or rectal)
Azathioprine
Mercaptopurine
Surgical options for UC
Removing colon and rectum so then the patient is left with an ileostomy or ileo-anal anastomosis
Investigations into Crohns
Stool culture, faecal calprotectin raised, endoscopy for diagnosis, MRI in suspected small bowel disease, upper GI series showing ‘string sign of kantour’
Medical management in Crohn’s
Monotherapy with glucocorticoids - pred or IV hydrocortisone. Azathioprine or mercaptopurine may be added (after assess TPM). Methotrexate may be added if not tolerated
What is the treatment in children
Enteral nutrition as steroids suppress growth
Medical management in severe or unresponsive Crohn’s
Biological agents - infliximab or adalimub
Which areas does UC cover
Limited to colon - backwash ileitis. More severe in distal colon, and sometimes may only involve rectum. Caecal patch lesions
Microscopic features of UC
Inflammation limited to the mucosa, acute and chronic. Cryptitis and crypt abscesses. Evenly distributed inflammation, mucosal granulomas, distortion of glands
Macroscopic features of UC
Superficial mucosal ulceration, pseudopolyp formation, normal serosal surface, confluent involvement, featureless mucosa in chronic disease
Distribution in Crohn’s disease
May involve entire GI tract, oral ulceration, perianal fistulas, abscesses, classically involves terminal ileum
Rose-thorn ulcers in Crohn’s
Deep penetrating linear ulcers/ fissuring typically seen within stenosed terminal ileum with thickened wall
Signs and symptoms in UC
Diarrhoea with blood/mucus, tenesmus or ugency, pain LIF, weight loss, fever, pale (anaemia), clubbed, distension, tender on palpation, PR exam reveals tenderness, blood/mucus
Extramanifestations of UC
Erythema nodusum, pyoderma gangrenosum, anterior uveitis, episcleritis, conjunctivitis, arthritis, primary sclerosing cholangitis, amyloidosis
Bloods tests into UC
FBC - anaemia and raised WCC. ESR/CRP raised. LFT -malabsorption/low albumin
To exclude infective colitis
Stool microscopy culture and C diff toxin
Macroscopic features of Crohn’s
Deep ulceration - cobblestone mucosa. Bowel wall thickening and strictures. Abnormal serosa - fat wrapping. Patchy involvement - skip lesions
Microscopic features of Crohn’s
Transmural inflammation - acute and chronic, lymphoid aggregates. Fissuring ulceration, patchy inflammation, transmural granulomas, neuronal hyperplasia
Complications of Crohn’s
Fistula formation - enteroenteric, enterovesical, entervaginal, enterocutaneous. Abscess and sinus formation, bowel obstruction - inflammatory stricture formation. Malignancy
Colonoscopy findings in UC
continuous inflammation with erythematoid mucos, loss of haustral markings and pseudopolyps
Biopsy findings in UC
Loss of goblet cells, crypt abscesses and inflammatory cells.
Barium enema findings in UC
Lead piping inflammation, thumb printing, pseudopolyps
Acute exaccerbation scoring system in UC
Trustlove and Witt’s criteria for severity
Aims of treatment in moderate disease of UC
Induce remission, if not improved after 4 weeks then add oral aminosalicyclate
Drugs used in IBD
immunosuppressants and antibody therapy. Steroids and ASAs for inflammation
Use of aminosalicyclates
First line treatments for mild to moderate UC
Examples of ASA
Balsalazine, mesalazine, olsalazine, sulfasalazine
Side effects of ASAs
Nausea, mouth ulcers, reduced WCC and platelets, rash, orange urine and sweat, oligospermia
Uses of steroids
Main drugs used in acute attacks to induce and maintain remission. Adjunct to ASAs in refractory/moderate disease
Investigations into Crohn’s
Stool culture, faecal calprotectin, endoscopy, MRI
Manegement of Crohn’s
Monotherapy with glucocorticoids, enteral nutrition in children, azathioprine or mercaptopurine may be added
Options for severe or unresponsive Crohn’s
Biological agents such as adalimumab or infliximab
What drug can be used if patient is TPMT deficient
Methotrexate
Signs and symptoms of UC
Diarrhoea with blood/mucus, tenesmus, urgency, pain in LIF, weight loss, fever, pale, clubbed, distension, tender on palpation
Extra manifestations of UC
Erythema nodusum, pyoderma gangrenosum, anterior uveitis, episcleritis, conjunctivitis, arthritis, primary sclerosing cholangitis, amyloidosis
Blood test results in UC
Anaemia and raised WCC, CRP raised, low albumin
Microbiology investigations into UC
Exclude infective colitic with stool microscopy and culture. Faecal calprotectin
Emergency surgical indications in UC
Acute fulminant UC, toxic megacolon with no improvement after IV steroids and worsening symptoms
Surgical options for UC
Panproctacolectomy with permanent end ileostomy. Colectomy with temporary end ileostomy then ileal pouch and anastomosis
Elective surgical indications for UC
Failure to induce remission, can perform ileorectal anastomosis with no stoma if elective
Complications in UC
Toxic megacolon, massive lower GI haemorrhage, colorectal cancer, dysplasia, strictures, bowel onstruction, perforation, cholangiocarcinoma, primary sclerosing cholangitis, inflammatory polyps
Signs and symptoms in Crohn’s
Crampy abdominal pain, diarrhoea, weight loss, fever, cachetic, pale, digital clubbing, apthous mouth ulcers, abdo/RLQ tenderness, RIF mass, skin tags, fistulae and perianal abscess
Extra manifestations in Crohn’s
Erythema nodsum, pyoderma gangrenosum, anterior uveitis, episcleritis, arthritis, sacro-ileitis, gallstones, renal stones, amyloidosis
Blood test results of Crohn’s
Raised WCC, ESR, raised, thrombocytosis, anaemia, low albumin, iron, B12, folate
Management of proctitis and proctosigmoiditis
Topical aminosalicyclase or oral ASA. Consider adding oral pred, then consider oral tacrolimus
Management of acute severe UC step 1
IV corticosteroids - if untolerated use IV ciclosporin
Management of acute severe UC step 2
If worsens in 72 hours - add IV ciclosporin and if untolerated use infliximab. Consider surgery
Side effects of azathioprine
Nausea, vomiting, pneumonia, herpes, diabetes, pancreatitis
Side effects of calcineurin inhibitors
Expensive, toxic, opportunistic infection
Antibody therapy examples
Ustekinumab, infliximab, vedolizumab
Side effects of antibody therapies
Fever, chills, urticardia, serious infection
Examples of steroids used in UC
Prednisolone, hydrocortisone, budesonide
Route of administration for localised rectal disease
Liquid or foam enermas
Route of administration for severe/extensive disease
Oral or parenteral
Side effects of steroids
Osteoporosis, muscle wasting, diabetes, cushings, growth suppression, infection, adrenal atrophy long term. Unsuitable for maintenance
Use of immunosuppressants
Azathioprine - steroid dependent Crohn’s
Methotrexate - Crohn’s
Calcineurin inhibitors - steroid resistant UC
Eg of calcineurin inhibitors
Cyclosporin and Tacrolimus
