Inflammatory bowel disease Flashcards
what is ibd
inflammation of the GI tract and the umbrella term for crohns and Ulcerative collitis
Distinguishing factors of Crohns disease
N – No blood or mucus (less common)
E – Entire GI tract
S – “Skip lesions” on endoscopy
T – Terminal ileum most affected and Transmural (full thickness) inflammation
S – Smoking is a risk factor (don’t set the nest on fire)
distinguishing factors of Ulcerative collitis
C – Continuous inflammation
L – Limited to colon and rectum
O – Only superficial mucosa affected
S – Smoking is protective
E – Excrete blood and mucus
U – Use aminosalicylates
P – Primary Sclerosing Cholangitis
What is UC
IBD
Involves rectum and extends to affect colon - never spread beyond ileocaecal valve - confined to large bowel
microscopic features of ulcerative collitis
-mucosa only inflamed
- crypt abscesses
-depleted goblet cells
microscopic features of Crohn’s disease
- transmural inflammation
- granulomas
- increased chronic inflammatory cells and lymphoid hyperplasia
cause of Ulcerative colitis
inappropriate immune response against colonic flora in genetically susceptible individuals
HLAB27 association
risk factors for UC
Family history - HLA b27
NSAIDS
Onset
Flares/relapse
Chronic stress + depression - triggers flares
White
epidemiology of UC
- 50/50 m and f
-20-40 yr olds - incidence is 3x higher in smokers
- Highest incidence and prevalence in Northern Europe, UK and North America
- Affects caucasians and eastern European Jews most
Pathophysiology of UC
Form ulcers along the inner-surface or lumen of the large intestine, including both the colon and the rectum.
ulcers are spots in the mucosa and submucosa where the tissue has eroded away and left behind open sores or breaks in the membrane.
Cytotoxic T cells are often found in the epithelium lining the colon, and they may be responsible for destroying the cells lining the walls of the large intestine, leaving behind ulcers
P-ancas
Signs of UC
- Abdominal tenderness
- Fever - in acute UC
- Tachycardia - in acute severe UC
Symptoms of UC
- REMISSIONS and exacerbations
- abdo pain, lower left quadrant
- weight loss
- episodic or chronic diarrhoes with blood
- fever and malaise
systemic effects in UC attacks
fever
anorexia
malaise
weight loss
complications of UC with regards to the colon
Blood loss
Perforation
Toxic dilatation
Colorectal cancer
complications of UC and Crohns with regards to skin
Erythema nodosum
Tender red bumps
Symmetrically on shins
Complications of UC with regards to liver
Fatty change
chronic pericholangitis
sclerosing cholangitis
complications of uc with regards to joints
ankylosing spondylitis
arthritis
Primary investigations
Faecal calprotectin
FBC
LFTs
CRP/ESR
Colonoscopy + Biopsy GS
what may blood tests show for UC
Raised WCC4
Raised platelets
Raised CRP and ESR
Anaemia
pANCA may be positive
what other investigations would you ask for if you suspect Ulcerative Collitis
- stool samples, to exclde c diff
- faecal calprotein
- colonoscopy
- abdo xray
GS investigation for ulcerative collitis
colonoscopy
sigmoid oscopy
what would colonoscopy show for UC
- continous lead pipe inflammation
- Crypt abscessesdue to neutrophil migration through gland walls
- Goblet cell depletion, withinfrequentgranulomas
mild to moderate management of Ulcerative Collitis
1st line- aminosalicylate
2nd line - corticosteroids
how do aminosalicylate work
limiting the inflammation in the lining of the GI tract
management for severe disease of UC
1st line- corticosteroids
2nd line- IV ciclosporin
SEVERE cases with no response to treatmemt :
colectomy
- whole colon removed
-ileoanal anastomosis
Complications of UC
- Toxic megacolon:
- Perforation: associated with high mortality
- Colonic adenocarcinoma
- Strictures and obstruction:
What is Crohn’s disease
inflammatory bowel disease characterised by transmural inflammation of the gastrointestinal tract (anywhere from mouth to anus), with the terminal ileum and colon most commonly affected
Epidemiology of Crohns
- Highest incidence and prevalence in Northern Europe, UK and North America
- The disease has its peak onset in early life (20-40 years) with a second peak among the elderly (50-80)
- F>M
cause of chrons disease
IM system triggered by foreign pathogen (TB or psudomona) in GI tract
IM system targets pathogen but large and uncontrolled > destruction of cells in GI tract
Th cells > cytokines > macrophages
Macrophages: proteases, Platelet activating factor and free radicals
How does transmural inflammation occur?
The immune cells invade deep into the mucosa and organise themselves into granulomas. Eventually ulcers form, which can go through all the layers. This is known as transmural.
risk factors for crohns disease
Family history
Stronger genetic association than UC
Smoking – 2-4x risk
NSAIDs – exacerbate it
Chronic stress + depression
symptoms if crohns is in the small bowel
- abdo pain
- malabsorption
- weight loss
- terminal ileum— right iliac fossa pain
What will malabsorption cause?
- b12/folate deficiency
- gall stones/ kidney stones
- diarrhoea
- failure to thrive
clinical signs of crohns
Bowel ulceration
Abdo tenderness
Abdo mass
Perianal disease
What investigations would you do for crohns
pANCA -ve
fecal calprotectin elevated
FBC
CRP/ESR
UE
LFT
Colonoscopy - GS
DDs for Crohns
- Ulcerative colitis
- Alternative causes of diarrhoea should be excluded e.g. Salmonella spp, Giardia intestinalis and rotavirus
- Chronic diarrhoea
What would biopsy show for crohns
transmural inflammation with non caseating granulomas
what would blood tests show with crohns
Raised WCC
Raised platelets
Raised CRP & ESR
pANCA negativw
Anaemia
management for crohns disease to induce remission
1st line- Glucocorticoids ORAL PREDNISOLONE for flare ups or IV steroids
Immunosuppresants
Antibiotics
To maintain remission
1st line:Azathioprine or Mercaptopurine
2nd line:Methotrexate, Infliximab, Adalimumab
Post-surgery: consider azathioprine, with or without methotrexate
Non medical management of crohns
smoking cessation
iron/ folate/b12 supplements
Stop NSAIDs
if a patient is non responsive to steroids in crohns disease what are the options…
Anti - TNF antibodies
Histological features that will be seen in ulcerative collitis
Increase in plasma cells in lamina propria
Ulceration
Crypt distortion
What does tnf-a cause
- An increased immune response
- Angiogenesis - formation of new blood vessels
- Paneth cells necrosis
- Intestinal epithelium cell death
What would you give for remission in crohns
azathropine
