Inflammatory Bowel Disease Flashcards
The mouth is part of the _________ tract
aerodigestive
What is the peritoneal space?
potential space surrounding abdominal organs, contained by the peritoneal sac
What is the blood supply for the foregut ?
Coeliac axis
What is the blood supply for the midgut?
superior mesenteric artery
What is the blood supply for the hindgut?
inferior mesenteric artery
What are the sections of the stomach?
cardia
fundus
Body
pylorus
What are the layers of the stomach?
mucosa
submucosa
muscularis externa (3 layers of smooth mucsle)
serosa
What is the blood supply of the stomach?
Coeliac axis
What is the vein that drains the stomach?
venous drainage into the portal vein
Portal vein receives blood from the GI tract; carries it into the liver
What are the cell types found in the stomach?
Mucous cells
G cells
Parietal cells
Chief cells
Enteroendocrine cells
What is the function of the mucous cells of the stomach?
secretes gel lining of the stomach
What is the function of G cells of the stomach?
secretion of gastrin (gastrin hormone then causes HCl secretion)
gastrin hormone then stimulates parietal cells for the release of gastric acid (HCl)
What is the function of parietal cells of the stomach ?
secretion of gastric acid (HCl) and intrinsic factor (IF used for B12 absorption)
What is the function of chief cells?
secretion of pepsinogen
Pepsinogen is converted into the enzyme pepsin by __________.
gastric acid
HCl
Change in pH ?
The enteroendocrine cells of the stomach are involved in endocrine secretion. Give examples of hormones released by these cells.
CCK- cholecytokinin
Secretin
What section of the stomach is referred to as the pre-exit area?
the pylorus
What are the functions of the stomach?
Neuroendocrine
Sterilisation
Storage
Absorption
Mechanical breakdown (pH)
Digestion (pepsinogen)
What are the sections of the small intestine?
duodenum
jejunum
ileum
What are the histological parts of the small intestine?
Mucosa (epithelium, lamina propria, muscularis mucosa)
Submucosa
Muscularis externa
Serosa
Where does the small intestine receive blood from?
coeliac axis
Superior mesenteric artery (SMA)
Venous drainage of the small intestine is to the ____________.
hepatic portal vein
takes blood to the liver
Name an important characteristic of the mucosa of the small intestine. Why is it important?
Mucosa is highly folded into villi and microvilli
This increase the surface area for absorption to take place
What are the functions of the small intestine?
- Motility - moves things along via peristalsis
- Chemical digestion of proteins lipids and carbohydrates
- Mixing- pancreatic juice (exocrine) and bile (gallbladder/liver) are mixed in the small intestine
- Immunological- peyers patches (MALT)
- Absorption- iron, vitamin B12, fatty acids, amino acids, fructose, glucose, bile salts
Where are iron and folate absorbed?
the jejunum
Where is B12 absorbed?
terminal ileum
How long is the duodenum?
25cm
How long is the jejunum?
200cm
How long is the ileum?
300cm
What are the sections of the large intestine?
Caecum
Ascending colon
Transverse colon
Descending colon
Sigmoid colon
Rectum
Anus
The appendix is attached to what part of the large intestine?
the caecum
What are the structures of the large intestine?
taeniae coli
haustra
colonic crypts
What is the blood supply for the large intestine?
superior mesenteric arteries
Inferior mesenteric arteries
Venous drainage from the large intestine is carried by …
portal vein
internal iliacs
What is a veriform appendix?
muscular structure attached to the caecum of the large intestine
dorsomedially attached to the caecum
What are the functions of the large intestine?
- Motility- faecal movement
- Microbiome- >700 types of bacteria
- Absorption- water and remaining nutrients; performs the final touches of absorption an makes sure you do not lose too much water
- storage
What is a barium enema ?
a radiological examination of the journey of barium in the gut
Give examples of imaging we are able to carry out to view the gut
Abdominal radiograph
Barium enema
Ultrasound
Barium meal
CT
Endoscopy
According to Eatwell guidance, what does a balanced diet look like?
5 portions of fruit and veg a day
carbohydrate should make up 1/3 of food (choose high fibre and wholegrain)
dairy should make up 1/6
proteins should make up 1/6- aim for 2 portions of oily fish per week
small amounts of unsaturated fats
small and infrequent amounts of high sugar, salt and high fat foods
6-8 cups of water a day
What is the recommended number of calories to be consumed by women?
2000 kcal
including all foods and all drinks
What is the recommended number of calories to be consumed by men?
2500 kcal
including all food and drinks
What is inflammatory bowel disease?
these are a group of autoimmune diseases which cause inflammation of the GI tract
What are the two main types of IBD?
Crohns disease
Ulcerative colitis
What is intermediate IBD?
this is colitis without specific features to allow for classification
What is the characteristic of crohns disease?
can affect any part of the GI tract
can also affect the mouth
Crohns disease classically appears as “skip lesions”; there is no continuity for lesions; they are not continuous and do not affect just one area of the GI tract
What is the characteristic of ulcerative colitis ?
only the colon and rectum are inflammed
begins at the anus and continues a variable distance up the colon
There is continuity, no break in the affected area of the colon
does not affect the small bowel
What is the aetiology of crohns disease?
Aetiology is unknown but there is a likely interaction between the following factors:
genetic susceptibility
intestinal microbiota
environmental factors
These all have an effect on the host immune system which then begins to attack the GI tract
What gene mutation potentially has an impact on risk of crohns disease
NOD2 gene mutations on chromosome 16
there is a greatly increased risk if homozygous (two identical alleles)
____% of crohns disease cases do not have the NOD2 mutation
75
What other genetic links have been for crohns disease?
> susceptibility loci (locations on genes?) that could possibly influence how the immune system interacts with the gut flora
What environmental factors can have an impact on the development of crohns disease?
Smoking- worsens crohns
oral contraceptive pill
Measles
Mycobacterium avium paratuberculosis
Acute gastroenteritis (infection which can lead to chronic disease)
What part of the world is IBD most common in?
developed part of the world
What type of IBD is more common?
ulcerative colitis more common than crohns
What is the typical age of onset for IBD?
20-40 years
More men are likely to suffer from IBD compared to women. True or false
True
What is an ulcer?
an ulcer is characterised by segmental or more extensive loss of the epidermis (top layer) including the basement membrane
(does not involve the dermis)
What is erosion?
there is partial loss of the epithelium, basement membrane remains intact
What is a fistula?
an abnormal connection/passage-way that connects two organs or vessels that do no usually connect
abnormal connection between 2 epithelialised surfaces
What part of the GI tract (histolgically) does ulcerative colitis affect?
Mucosa
does not affect deeper than the submucosa
What are the histological characteristics of ulcerative colitis?
distortion of crypt architecture
ulceration confined to submucosa
crypt abscesses
pseudopolyps
inflammatory cells in lamina propria (mucosa)
What are the histological characteristics of crohns disease
fistulation
stricturing
ulceration (full thickness- epithelium, mucosa, muscularis)- beyond submucosa unlike UC
granulomata
Skip lesions
cobblestone
Briefly describe the distribution of ulcerative colitis
limited to the colon
with or without backwash ileitis (inflammation of the ileum)
ileitis is however classically caused by crohns disease and is the inflammation of the ileum of the small intestine
Briefly describe the distribution of crohns disease
anywhere from the mouth to the anus
can have patches in between known as skip lesions
What are the most common sites of crohns disease ?
distal ileum
colon
perineum
What is the clinical presentation of IBD ?
abdominal pain
prolonged diarrhoea
bloody stools
fatigue
weight loss
extra GI manifestations
What are crohns specific clinical presentations?
perianal lesions
obstructions
fever
fistulations
What are ulcerative colitis specific presentations?
mucous in stools
toxic megacolon
What is the presentation of crohns perianal disease?
characterised by inflammation near the anus
presentation includes:
-skin tags
-discolouration
-fissuring ulcers
-fistulae
Fistulae forms in crohns disease and not in ulcerative colitis becasuse…
microscopically, inflammation occurs in all layers whereas in UC ulceration is confined to submucosa
What are the categories of crohns fistulaes?
Internal
External
Give an example of an external intestinal fistulae
entero-cutaneous - this is a fistulae which connects the intestine to the skin
Give examples of internal fistulae
entero-vaginal?
colo-vesical- connection between colon and bladder; allows faecal matter to enter the bladder
Give examples of extra GI manifesations of IBD on the skin
Erythema nodosum- inflammation of fat tissue in subepithelial tissues
Pyoderma gangrenosum- pyoderma dermatitis, can be seen in the mouth
Give examples of extra GI manifestations of IBD in the eyes
Iritis- localised inflammation around the iris of the eye
Anterior uveitis- full anterior chamber inflammation
Episcleritis- partial inflammation of the sclera
Give examples of extra GI manifestations of IBD in joints
seronegative arthritis (small joint polyarthropathy or large joint arthopathy); seronegative for being negative for rheumatoid arthritis
Sacroilitis- pain around sacroiliac joint
Ankylosing spondilitis- inflammation nearly causing fusion of the spinal column; the ligaments that connect each vetebrae start to fibrose
Give examples of extra GI manifestations of IBD in the biliary system
gall stones- leads to disruption in normal bile salt absorption
Primary sclerosing cholangitis
What is cholangitis?
this is inflammation of the bile duct system
there is chronic/progressive fibrosis and structuring of the biliary tree
Biliary tree includes - cystic duct, common hepatic duct, common bile duct
__% of patients with ileitis or ileal resection develop gallstones
30
crohns disease commonly affect ileum
UC can also be associated with ileitis?
3-7% of patients with ulcerative colitis develop primary sclerosing cholangitis. True or false
True
What are the consequences of primary sclerosing cholangitis?
jaundiced
cannot absorb fatty food
What are the extra GI manifestation of IBD in the mouth ?
oral ulcers- histologically similar to those found in the rest of the GI tract
Orofacial granulomatosis- persistent swelling of the lips, face and other areas of the mouth
What are the characteristics of orofacial granulomatosis?
persistent or recurrent enlargement of lips
full width gingivitis and gingival enlargment
swelling of peri-oral and peri-orbital soft tissues
fissuring of tongue
cobblestones in mouth possible (similar to cobblestone present in GI tract in crohns)
Orofacial granulomatosis is associated with _________ or can exist __________.
crohns
can exist alone
Crohns disease can lead to different types of anaemia. Why is this ?
This is because crohns disease can affect different parts of the GI tract
Crohns affecting jejunum affects folate and iron absorption
Crohns affecting ileum affects B12 absorption
What initial investigations are carried out for diagnosis of IBD?
FBC
CRP
Iron studies (B12 and folate)
stool sample for MC&S (microscopy, culture and sensitivity) and c difficile toxins
Abdominal xray
What imaging can be carried out for diagnosis of IBD?
contrast studies
CT with IV and PO contrast (MR where contrast contraindicated)
Technitium-99 WBC labelling and PER scans are non invasive options
Faecal calprotein and lactoferrin have a __________ diagnostic role for IBD
limited
What definitive diagnostic test can be used for IBD?
Endoscopy as biopsies can be taken
There is a risk of developing adenocarcinomas with what type of IBD?
ulcerative colitis
What are the complications of IBD
Stenosis and obstruction- narrowing from active inflammation, chronic fibrotic scarring
Nutritional inadequacy- poor intake, high output, poor absorption, iron and B12 deficiency/anaemia
Short bowel syndrome- this usually occurs after multiple resections, requires parenteral nutrition
Osteoporosis- especially treatment with steroids (steroids encourage bone resorption)
Colorectal cancer- primarily applies to UC
Fistulation
What are the management options of IBD?
Medical
Surgical -resections
Nutritional
Psychological
Smoking cessation- makes crohns worse; risk of development
Treatment choices of IBDa are influenced by:
age
site and activity of disease
behaviour of disease
previous drug tolerance and response to treatment
previous relapses on treatment
presence of extra intestinal manifestations
When is surgical treatment appropriate for IBD?
neoplastic or pre-neoplastic lesions
obstructive stenoses
suppurative complications
fistulating disease
medically intractable disease- cannot be controlled by medicine
Medical management of IBD is usually done with steroids to control inflammation. Give example of drugs that can be used
5-ASA (salicylates e.g. mesalasine)
immunosuppresants
Antibodies:
Anti-TNFa- e.g infliximab (antibody)
Anti-integrin
What is the surgical management of crohns disease?
resection of affected GI tract
mostly ileocaecal rection
scar tissue is left behind
What is the surgical management of UC?
colectomy
When should you consider early/emergent colectomy for UC?
in fulminant colitis which has been non responsive to steroids
When is nutritional support required for IBD?
if food intake is poor
if absorption is poor
What kinds of nutritional support should be aimed for for those with anatomically intact and functioning GI tract?
enteral feeding
feeding through GI tract
What kind of diet should be implemented for those place on nutritional support ? Why?
elemental diet
reduce remission
When should parenteral nutrition (feeding intravenously) be implemented?
those with fistulating disease (not anatomically intact)
those with short bowel syndrome (again not anatomically intact)
What is high output stoma?
this is when output is enough to cause dehydration (loss of water and sodium)
IBD can be profoundly disabling. Highlight some ways IBD can be disabling
limitations to lifestyle and ability to work
body issues with stomas, fistulation
What support is available for people suffering with IBD?
GI psychologist
IBD specialist nurse support
Crohns disease is a chronic relapsing condition that affects the whole GIT. True or false
True
Ulcerative colitis is a recurring condition that is confined to the large bowel. True or false
true
What is coeliac disease?
autoimmune disorder that affects the proximal jejunum. Patients may present with anaemia (iron and folate) malabsorption
