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Alimentary System > Inflammatory Bowel Disease > Flashcards

Inflammatory Bowel Disease Flashcards

1
Q

What investigations are done for ulcerative colitis?

A

Chronic, relapsing, remitting inflammation of the GI tract

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2
Q

What are examples of inflammatory bowel disease?

A

Crohn’s disease

Ulcerative colitis

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3
Q

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

A

Location and inflammation

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4
Q

When does inflammatory bowel disease commonly present?

A

In the teens and twenties

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5
Q

how many people have IBD in the UK?

A

620,000

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6
Q

What can IBD be due to?

A

Genome

Microbiome

Environment

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7
Q

Is IBD medelian inherited?

A

No, but has genetic susceptibility

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8
Q

IBDU

A

There are 2 forms- collagenous colitis (thickening of subepithelial collagen band) and lymphocytic (increased no of lymphocytes) colitis
Present with chronic, non-bloody, watery dhoea with no macroscopic abnormalities on scope
Commoner in women, mean age at px around 60 but 25% of cases in pts under 45
Causes frequent nocturnal dhoea and FI
Assoc with autoimmune disease eg rheumatoid, thyroid, coeliac. Can coexist with BAD in 33% of pts.
Use of NSAIDS, PPIs and SSRIs high in these patients and withdrawal can be assoc with improvement in sx
Dx in pt with c dhoea impt as specific and effective rx now available- Budesonide in controlled release preps can induce remission in both forms and also good evidence in maintaining remission in collag colitis . But up to 70% relapse and require further treatment, others remain sx free. 9-6-3.
Other drugs inc pred and immunosuppressants used in steroid refractory pts.

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9
Q

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

A

SNPs (single nucleotide polymorphisms)

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10
Q

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

A

10%

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11
Q

What do genes that cause inflammatory bowel disease regulate?

A

Epithelial barrier

Immune response

Bacterial handling

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12
Q

What is the pathogenesis of IBD?

A

Pathogenic gut causes altered microbiota

Damaged epithelial barrier increases bacterial adhesion and translocation

Chronic inflammation occurs

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13
Q

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

A

10:1

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14
Q

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

A

At least 500 different species

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15
Q

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

A

that of the liver

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16
Q

What part of the gut contains the most bacteria?

A

colon

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16
Q

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

A

In IBD there is a dysbosia in microbial communities

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17
Q

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

A

Proteobacteria

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18
Q

What is ulcerative colitis?

A

Chronic condition where the colon and rectum become inflammed

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19
Q

How does ulcerative colitis affect males compared to females?

A

Both affected the same

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20
Q

what is the peak incidence of UC?

A

Peak incidence 20 – 40 years

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21
Q

What are symptoms of ulcerative colitis?

A

Blood diarrhoea

Abdominal pain

Weight loss

Fatigue

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22
Q

What investigations are done for ulcerative colitis?

A

Bloods for markers of inflammation

Stool culture to rule out infection

Faecal calprotectin

Colonoscopy and colon mucosal biopsies

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23
Q

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

A

Normocytic anaemia

Increased CPR/platelets

Low albumin

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24
Q

What is considered normal faecal calprotectin?

A

<50ug/g of stool

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25
Q

What is considered elevated faecal calprotectin?

A

> 200ug/g of stool

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26
Q

What is faecal calprotectin?

A

Substance that is released into the intestines when inflammation is present

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27
Q

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

A

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

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28
Q

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

A

20-30%

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29
Q

What are the different levels of severity of ulcerative colities?

A

Mild

Moderate

Severe

Fulminant

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30
Q

What are characteristics of mild ulcerative colitis?

A

<4 stools/day sometimes with blood, normal ESR, no signs of toxicity

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31
Q

What are characteristics of moderate ulcerative colitis?

A

4-6 stools/day, occasional blood, minimal signs toxicity, CRP<30mg/L

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32
Q

What are characteristics of severe ulcerative colitis?

A

> 6 bloody stools/day and any:

temp>37.8
tachycardia>90bpm
anaemia<105g/L
ESR>30mm/h, CRP>30mg/L

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33
Q

What are characteristics of fulminant colitis?

A

10 stools/day continuous bleeding, toxicity, abdominal tenderness/distension, transfusion required, colonic dilatation on X-ray

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34
Q

What is proctitis?

A

Proctitis is inflammation of the lining of the rectum. Proctitis may be acute or chronic.

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35
Q

What is stool like with proctitis?

A

Frequency, urgency, incontinence, tenesmus

Small volume mucus and blood

Proximal faecal stasis (constipation)

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36
Q

What does proctitis respond to?

A

Responds to topical therapy

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37
Q

What percentage of mortality does acute severe colitis have?

A

2% risk of mortality, <1% specialised IBD centres

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38
Q

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

A

20-30% risk of emergency colectomy at admission

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39
Q

What do patients with acute severe colitis often look like?

A

These patients often look well, self caring and mobilising around ward – young with physiological reserve

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40
Q

What is the main differential of acute severe colitis?

A

10-15% present with acute severe disease – duration (>10 days), infection is main differential

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41
Q

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

A

Bloods for markers of inflammation- normocytic/microcytic anaemia
CRP/WCC/platelets
albumin
Stool culture to rule out infection
4 stool cultures for c.difficile

avoid / stop non steroidal analgesics/opiates, antidiarrhoeals, anticholinergics

IV glucocorticoids
IV hydration, correct electrolytes

LMWH
AXR

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42
Q

why are patients with acute severe colitis given LMWH?

A

3X increased risk of thromboembolism

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43
Q

what investigations are done for colitis

A

Bloods for markers of inflammation- normocytic/microcytic anaemia
CRP/WCC/platelets
albumin
Stool culture to rule out infection
Faecal Calprotectin
(0-50ug/g stool=normal, 50-200=equivocal, >200 elevated)
Colonoscopy and colon mucosal biopsies

44
Q

What is Crohn’s disease?

A

Crohn’s disease is a lifelong condition where parts of the digestive system become inflamed.

45
Q

Where can Crohn’s disease occur?

A

Patchy disease
mouth to anus
skip lesions
clinical features
depend on regions involved

46
Q

What are clinical features of Crohn’s disease?

A

Diarrhoea
Abdominal pain
Weight loss
Malaise, lethargy, anorexia, N&V, low-grade fever
Malabsorption
Anaemia, vitamin deficiency

47
Q

What investigations are done for Crohn’s disease?

A

Bloods for markers of inflammation
Stool culture to rule out infection if diarrhoea
Faecal Calprotectin (0-50ug/g stool=normal, 50-200=equivocal, >200 elevated) – may not be high if just small bowel disease
Colonoscopy with terminal ileum intubation and colon/TI mucosal biopsies
MRI small bowel study
Capsule endoscopy
Occasionally CT scan if acutely unwell and want to rule out complication eg abscess

48
Q

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

A

Different histology
CD granulomas
Goblet cells depleted in UC
Crypt abscesses: UC > CD
Transmural inflammation in CD
Limited to mucosa in UC

49
Q

What does PCD stand for?

A

perianal Crohn’s disease

50
Q

What are symptoms of perianal Crohn’s disease?

A

Perianal pain
Pus secretion
Unable to sit down

51
Q

What investigations are done for perianal Crohn’s disease?

A

MRI pelvis
Examination under anaesthetic (EUA)

52
Q

What is the treatment for perianal Crohn’s disease?

A

Surgery to drain abscess and place seton stitch
Medical – antibiotics and biologic therapy (anti-TNF)

53
Q

what are Extra-intestinal manifestations of IBD?

A

Mouth ulcers
Skin rashes/lesions
Musculoskeletal
Eyes
Primary sclerosing cholangitis

54
Q

What must be considered by IBD differential diagnosis?

A

Other causes of chronic diarrhoea
Malabsorption eg pancreatic insufficiency, bile acid malabsorption, coeliac disease
Irritable bowel syndrome (IBS)
Overflow diarrhoea
Ileo-caecal TB
Colitis must be distinguished from
infective, amoebic and ischaemic colitis

55
Q

What does chronic diarrhoea cause?

A

Malabsorption eg pancreatic insufficiency, bile acid malabsorption, coeliac disease
Irritable bowel syndrome (IBS)
Overflow diarrhoea

56
Q

What is a possible long term complication of colitis?

A

Colonic carcinoma
Risk Factors
Extent
Pancolitis 26 x normal
Left colitis 8 x normal
Proctitis minimal
Duration
< 10 yrs minimal risk
20 yrs 23 x normal
30 yrs 32 x normal

57
Q

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

A

Extent
Pancolitis 26 x normal
Left colitis 8 x normal
Proctitis minimal
Duration
< 10 yrs minimal risk
20 yrs 23 x normal
30 yrs 32 x normal

58
Q

What is done for IBD management?

A

Sub-specialty OP clinics
4/week
Proven diagnosis
Urgent IBD clinic

4 specialist IBD nurses

IBD pharmacist - Therapeutic drug monitoring

Nurse led infusion clinic
3/week

Nurse led infusion clinic
3/week

Shared care GP protocols drugs

Direct communication between GP-consultant for advice

Dedicated colonoscopy lists for surveillance with chromoendoscopy

Weekly IBD MDT –
GI consultants/trainees/IBD specialist nurses, colorectal surgeons, radiologist, dietitian, pharmacist

59
Q

What kind of approach does management of IBD use?

A

Step up vs top down approach

60
Q

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

A

Aminosalicylates (5-ASAs)

61
Q

What are aminosalicylates?

A

Mesalazine
Acrylic resin
Asacol®, Ipocol®, Mesren®, Salofalk®
Ethylcellulose microgranules
Pentasa®

Pro-drugs
Balsalazide
Olzalazine
Sulfasalazine

Work by blocking prostaglandins and leukotrienes

Topical to colonic mucosa

Release mechanisms lead to colonic delivery eg pH responsive

62
Q

What is the abbreviation for aminosalicylates?

A

(5-ASAs)

63
Q

How do amionsalicylates work?

A

Work by blocking prostaglandins and leukotrienes

64
Q

When is rectal 5-ASA given?

A

Induction of remission
1st line therapy
>3g orally per day
No significant improvement in remission rate
Greater and quicker clinical improvement
No increase in adverse events
Rectal 5ASA
For distal disease
Superior to rectal steroids

65
Q

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

A

Not effective in Crohn’s disease

Prednisolone
Optimal dose is 40mg per day
Tapering reduction over 4-8 weeks
Calcium/vit D supplementation

Budesonide
Slightly less effective than Prednisolone
Better side effect profile

66
Q

How do patients ussually present with IBD and medical treatment?

A

flare, remission, flare

poor prognosis - more flares

67
Q

what is the aim of medical treatment?

A

induction of remission
maintenance of remission

68
Q

what are the two different approaches that may be taken for medical treatment?

A

step up vs top down approach

69
Q

describe the stages of a step up approach

A

5ASA or Sulfasalazine
Prednisone/budesonide
immunomodulators
biologic agents
surgery

70
Q

describe the stages of a top down approach

A

surgery
biologic agents
immunomodulators
prednisone/budesonide
5ASA or sulfalazine

71
Q

Are aminosalicylates used in UC and chrons disease?

A

only UC

72
Q

examples of aminosalicylates

A

Mesalazine
Acrylic resin
Asacol®, Ipocol®, Mesren®, Salofalk®
Ethylcellulose microgranules
Pentasa®

73
Q

what are aminosalicylates first line therapy for?

A

induction of remission in mild/moderate UC

74
Q

how are aminosalicylates taken for patients with mild/moderate UC?

A

> 3g orally per day
No significant improvement in remission rate
Greater and quicker clinical improvement
No increase in adverse events

75
Q

when would you rectally use 5ASA
as topical therapy?

A

Rectal 5ASA
For distal disease
Superior to rectal steroids

76
Q

what else is 5ASA first line for

A

Maintenance of remission
1st line therapy
Reduced number and severity of relapses
Reduced colorectal cancer risk
Lifelong therapy with >2g per day

77
Q

side effects from 5ASA

A

nausea and diarrhoea sometimes

78
Q

what is the second step up from 5ASA as medical treatment for UC and Crohns?

A

steroids

79
Q

what are some examples of steroids used for UC and crohns disease?

A

Prednisolone
Optimal dose is 40mg per day
Tapering reduction over 4-8 weeks
Calcium/vit D supplementation

Budesonide
Slightly less effective than Prednisolone
Better side effect profile

80
Q

what must be taken alongside prenisolone?

A

Calcium/vit D supplementation

81
Q

what are the adverse side effects of steroids?

A

not for long term use/ maintence use

82
Q

what treatment would you use in patients with microscopic colitis?

A

budesonide

83
Q

what is a step up from steroids in the pyramid?

A

Thiopurines

84
Q

what are Thiopurines primarily used for?

A

maintenance in UC and Crohn’s

85
Q

what is an example of thiopurine

A

Azathioprine (6-Mercaptopurine)

86
Q

what are significant side effects of thiopurine?

A

Leucopenia
Hepatoxicity
Pancreatitis
Possible long term lymphoma risk and non melanoma skin cancers
Up to 28% intolerant
Can check TPMT to assess suitability/aid dose target

87
Q

what does a patient require while on thiopurine?

A

Weekly for 4 weeks and then every 8 weeks
Patients must see GP if sore throat/infection

88
Q

when should a person step up from steroids to thiopurine?

A

patients not settling with 5ASAs
patients that have required repeated courses of steroid medication
patients that have had more than two courses of steroids in a calendar year
patients whos disease and symptoms worsen on reducing dose of steroids
those who relapse six to eight weeks after stopping steroids

89
Q

is methotrexate used in both crohns disease and UC?

A

only crohns disease
Induction and maintenance of remission

For steroid dependant patients
10-18% intolerant

90
Q

what is an issue with methotrexate particularly in young patient group?

A

it is teratogenic - shouldnt be used in women that arent prepared to use two forms of contraception

91
Q

what do patients on methotrexate require?

A

specialist follow up

92
Q

what is a step up from methotrexate?

A

biologics

93
Q

what are the different groups of biologics?

A

Anti-TNFα antibodies
α4b7 Integrin Blockers
IL12/IL23 Blockers

94
Q

what are examples of Anti-TNFα antibodies?

A

Infliximab (Remicade, Remsima)
8 weekly IV infusion

95
Q

what are examples of α4b7 Integrin Blockers?

A

Vedolizumab
8 Weekly IV Infusions

96
Q

what are examples of IL12/IL23 Blockers?

A

Ustekinumab
IV loading followed by SC 8-12 weekly

97
Q

what are some newer treatments that are now available?

A

Tofacitinib

Small molecule
- Pan JAK inhibitor
(JAK 1 & 3)
- Oral

98
Q

what is Elemental Feeding?

A

Exclusive elemental feeding can be as effective as steroids
More efficacious in children
Compliance difficult

99
Q

in what two groups can you decide to operate?

A

emergency
elective

100
Q

when would you operate in an emergency

A

acute severe colitis not responding to high dose IV steroids +/- anti-TNF biologic ‘rescue’ therapy

complications such as perforation, obstruction, abscess

101
Q

when would you decide to operate in an elective procedure?

A

frequent relapses despite medical therapy
not able to tolerate medical therapy
steroid dependant
patient choice

102
Q

what is the surgery that is down for acute severe colitis?

A

Subtotal colectomy
Rectal preservation
Ileostomy

remove all large bowel apart from rectal stump, patients left with stoma

103
Q

following a subtotal colectomy what choices will the patient have?

A

“Pouch” procedure
Completion proctectomy

104
Q

what is pouch surgery?

A

Mobilise and lengthen small bowel
use of stapler

105
Q

is pouch surgery recommended in both UC and crohns disease?

A

no only for UC
Crohn’s can recur and cause lots of problems with pain, bleeding, fistulas, abscesses and breakdown of pouch.

106
Q

what are disadvantages of pouch surgery?

A

patient will have to go to toilet 5 times a day, once at night
can also become inflamed, obstruction

107
Q

what are surgical indications in crohns disease?

A

Failure of medical management
Relief of obstructive symptoms (small bowel)
Management of fistulae - e.g. bowel to bladder
Management of intra-abdominal abscess
Management of anal conditions
Failure to thrive

108
Q

is surgery in crohns disease ussually curative?

A

Not curative – 50% need further surgery by 10 years

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