Inflammatory Bowel Disease Flashcards
Define Crohn’s disease
Chronic granulomatous transmural inflammation of any part of the GI tract, mainly the distal ileum and proximal colon
What are the structural features of Crohn’s disease
Inflammation occurs anywhere from mouth to anus, Common in the terminal ileum (40%, R lower abdo pain) and peri-anal region
TRANSLUMINAL/full thickness inflammation
Skip lesions (inflamed and normal bowel interspersed)
Formation of strictures and fistulae, risk of obstruction
Goblet cell and granuloma involvement
What are the suggested causes for and risk factors of Crohn’s disease
Genetic: CARD15, IL-23
RF:
White ethnicity
15-40 or 60-80
FHx IBD
Environmental: smoking, OCP, high refined sugar
What are the symptoms of Crohn’s disease
Abdominal pain (cramping, constant, RLQ/peri-umbilical, relieved by defecation)
Prolonged diarrhoea (NON-bloody (or intermittent)
Obstruction → bloating, distension, vomiting, constipation
Fever
Malaise, fatigue, lethargy
Weight loss, growth failure, delayed puberty
Extra-intestinal: Ulcers, arthritis, erythema nodosum, pyoderma gangrenosum
- Anterior uveitis: painful red eye with loss of vision
- Scleritis : painful red eye with no loss of vision
- Episcleritis: uncomfortable red eye with no loss of vision
Crohn’s colitis → diffuse abdo pain, mucous blood and pus in stool
What are the signs of Crohn’s disease on examination
General: pallor (anaemia)
ENT:
- Aphthous mouth ulceration
- Scleritis : painful red eye with no loss of vision
- Episcleritis: uncomfortable red eye with no loss of vision
Skin: erythema nodosum, pyoderma gangrenosum
Abdo: abdominal tenderness
PR: peri-anal lesions e.g. skin tags, fistulae, scarring, abscess
What investigations should be done for Crohn’s disease
bedside: Faecal calprotectin (raised, but better for adults), stool culture
Blood:
- FBC: raised platelets, WCC, IDA
- ESR/CRP: raised
- Albumin: raised
- Iron studies: IDA
- Vit 12/folate: ?anaemia
- Plasma viscosity: raised
Other
- Upper intestinal endoscopy and biopsy
- AXR: narrowing, fissuring, bowel wall thickening, calcification
- CT abdomen: String sign of Kantor - fibrosis + strictures, ‘rose-thorn- fissures’
- Abdo US: ? osbtruction
What is found on endoscopy and biopsy for Crohn’s disease
Mucosal oedema and ulceration with Cobblestone mucosa, fistulae, abscesses
Patchy inflammation
Ulceration appears yellow, horizontal or longitudinal
Biopsy
Transmural chronic inflammation with macrophage infiltration, lymphocytes and plasma cells
Superficial AND deep ulcerations
Histology: non-caseating epithelioid cell granulomata
What is the management for Crohn’s disease
Induce and maintain remission
Monitor ferritin, B12, calcium and Vitamin D
Assess impact of symptoms on daily functioning (anxiety, depression)
Resources: Crohn’s and Colitis UK
Encourage stopping smoking
Assess risk of osteoporosis
Symptomatic treatment
Pre-immunological therapy vaccination
Describe induction of remission therapy for Crohn’s disease
First line: Steroids (oral/IV) prednisolone
Second line: Immunomodulators (oral/IV) azathioprine, mercaptopurine, methotrexate
Third line: Biological (IV) adalimumab, inflixmab, vedolizumab
If corticosteroids CI → aminosalicylates (mesalazine, sulfasalazine)
Nutritional therapy:
- Whole protein modular feeds (polymeric) for 6-8 weeks, excessively liquid
- May required NG tube if struggling to drink
Describe maintenance therapy for remission of Crohn’s disease
Immunomodulators e.g. azathioprine, Mercaptopurine, methotrexate
Amino salicylates e.g. mesalazine
Biological therapy (Anti-TNF antibodies) e.g. infliximab, adalimumab, vedolizumab
When is surgery for Crohn’s disease indicated and what is the aim
Failure of medical treatment
Failure to thrive
Complications: obstruction, fistulae, abscess
Aim: resection of the affected bowel + stoma formation
What are the complications of Crohn’s disease
Intestinal:
Obstruction
Haemorrhage
Toxic megacolon
Fistulae (bowel, bladder, vagina)
Abscess, sepsis
Perforation
Malignancy
Anaemia → IDA, B12 deficiency
Short-bowel syndrome
Extra-intestinal
Cholelithiasis
Primary sclerosis cholangitis
Hepatic steatosis, liver abscess, granulomatous hepatitis
Arthropathy
uveitis, episcleritis
Amyloidossis
Hypocalcaemia → osteoporosis
What is the prognosis for Crohn’s disease
Relapsing-remitting, life-long disease
Long term prognosis for Crohn’s beginning in childhood is GOOD
Most people live normal lives, despite occasionally relapsing
Define ulcerative colitis
Chronic relapsing and remitting inflammatory and ulcerating bowel disease that characteristically affects the rectum and colon mucosa
What is the pathophysiology of ulcerative colitis
Most cases arise in the rectum (proctitis)
Incompetent ileocaecal valve or backwash ileitis → may extend ~30cm proximally → terminal ileitis
90% of children have pancolitis
Bowel wall is thin/normal but may appear thick due to oedema, muscle hypertrophy and fat accumulation
Only involves the mucosa → crypt abscesses and depletion of goblet cell mucin
Inflammation of the crypts of Liebekuhn + abscesses
Ulcerated areas are covered by granulation tissue
What are the risk factors for ulcerative colitis
Family history of IBD
HLA-B27 (Also associated with Ankylosing spondylitis)
Infection
NSAIDs
Non-smoker, former smoker
What are the symptoms of ulcerative colitis
Rectal bleeding/mucous passage (intermittent, gross or occult)
Diarrhoea (Bloody, <4 a day)
Abdominal pain and tenderness (cramps, associated with tenesmus)
Arthritis and spondylitis
Failure to thrive, weight loss and growth retardation (<Crohn’s)
Fever
Constipation
What are the signs of ulcerative colitis on examination
General: clubbing, pallor, dehydration
Obs: tachycardia
ENT: uveitis, episcleritis
Skin: erythema nodosum, pyoderma gangrenosum
Abdo: tenderness
PR: blood, mucous, tenderness
What investigations should be done for ulcerative colitis
bedside: Faecal calprotectin (raised, but better for adults), stool culture (-ve culture, raised WCC)
Blood:
- FBC: raised platelets, WCC, IDA
- ESR/CRP: raised
- U&Es: hypokalaemic metabolic acidosis
- LFTs: ?PSC
- Albumin: raised
- Iron studies: IDA
- Vit 12/folate: ?anaemia
Other
- Ileocolonoscopy and upper endoscopy + biopsy
- AXR: ? toxic megacolon
- Double-contrast barium enema: lead pipe appearance
What would be seen on ileocolonoscopy and biopsy for ulcerative colitis
Rectal involvement
Continuous uniform involvement
Loss of vascular marking
Diffuse erythema
Fistulas
Biopsy: Mucosal ulcers, crypt abscesses/loss/distortion, continuous distal disease, mucin depletion, basal plasmacytosis, diffuse mucosal atrophy of ONLY the mucosa and submucosa, absence of granulomata
What are the severity classifications of ulcerative colitis
Mild: <4 stools daily ± blood, NO systemic disturbance, normal ESR/CRP
Moderate: 4-6 stools a day, minimal systemic disturbance
Severe: >6 stools a day, containing blood + systemic disturbance (fever, tachy, abdo tenderness, distension, anaemia, hypoalbuminaemia)
How do you assess severity of ulcerative colitis
Paediatric Ulcerative Colitis Activity Index (PUCAI)
Markers of activity:
↓Hb
↓albumin
↑ESR/CRP
Diarrhoea frequency (<4 a day = mild,
>6 days = severe)
Bleeding
Fever
Flares: Truelove and Witts’ severity index
What is the management for ulcerative colitis
Induction and maintenance therapy
Induction:
1. Mesalazine (5-ASA) rectal 1000mg once daily at night for 3-6 weeks AND mesalazine oral
- remission not achieved by 4 weeks → oral aminosalicylate
2. Beclometasone diproprionate PO
Maintain:
1. azathioprine OR mercaptopurine
2. Infliximab IV at 0, 2, 6 weeks (TNF-alpha inhibitor)
3. Vedolizumab or tofacitinib (integrin receptor antagonists) IV
4. Ciclosporin
5. Colectomy
What is the management for non-fulminant acute ulcerative colitis
Non-fulminant
1. Rectal aminosalicylate (mesalazine)
2. Oral prednisolone
3. fulminant management
What is the management for fulminant acute ulcerative colitis
- admit
- IV corticosteroids e.g. hydrocortisone
- IV fluids, no bowel rest
- ciclosporin or infliximab
- Colectomy if not responsing to corticosteoirds
What are the complications of ulcerative colitis
Toxic megacolon
Colonic adenocarcinoma (3-5%)
Primary sclerosing cholangitis
Perforation
Infection
Massive LGI bleed
Benign stricture
Inflammatory pseudopolyps
Dysplasia-associated lesion or mass (DALM)
Extra-GI: Uveitis, renal calculi, arthropathy, sacroiliitis, ankylosing spondylitis, erythema nodosum, pyoderma gangrenosum, osteoporosis, amyloidosis
What is the prognosis for ulcerative colitis
Ulcerative colitis is a lifelong condition, characterized by periods of relapse and remission with recurrent cycles of inflammation
Overall mortality does not appear to be increased, but may be in older patients and those who develop complications
Surgery appears to increase mortality
Most common cause of death is toxic megacolon
