Inflammatory Bowel Disease Flashcards
What is IBD?
Inflammatory bowel disease (IBD) is a group of idiopathic chronic inflammatory intestinal conditions
- Idiopathic caused by dysregulated immune response to the intestinal normal flora
2 main categories of IBD?
- Crohns disease
- Ulcerative colitis
Causes of IBD?
- genetic predisposition
- dysregulated immune response
- an altered response to gut microorganisms
- Environmental risk factors e.g. smoking especially in UC
What is Crohns disease?
a chronic inflammatory bowel disease that affects the lining of the digestive tract
- segmental and rectal sparing
Symptoms of chronic disease?
Abdo pains(right sided lower quadrant)diarrhoea(nocturnal,incontinence), anorexia, peri-anal disease
Pathology of Crohns disease?
Transmural granulomas
Complications of Crohns disease?
Obstruction, strictures ,fistulas,fissures,abscesses & colorectal cancer
What is Ulcerative colitis?
a chronic inflammatory bowel disease that causes inflammation in the digestive tract usually only in the innermost lining of the colon and rectum
Symptoms of ulcerative colitis?
- Bloody diarrhoea
- tenesmus
- fever
- constipation (rectal involvement)
Pathology of ulcerative colitis?
mucosa inflammation, no granulomas
Complications of ulcerative colitis?
- Toxic megacolon(dilation of colon ≥6 cm on plain AXR & a medical emergency)
- colorectal cancer
Attacks seen in IBD?
- tender distended abdomen
- fever
- anorexia and weight loss
- may be triggered by infection
Non-intestinal manifestations?
- eyes - uveitis, episcleritis, conjuctivitis
- finger clubbing
- anemia, jaundice (primary sclerosing cholangitis)
- gall stones, kidney stones
- aphthous ulcers (Crohns disease)
- MSK - arthritis , ankylosing spondylitis
- erythema nodosum, pyoderma gangrenosum
- DVT
- amyloidosis
History taking for IBD?
Ask about symptoms
Duration of symptoms
Inquire about possible extraintestinal manifestations
Recent and past medical problems — intestinal infection
known TB contacts
Travel history
Medications — antibiotics, nonsteroidal anti-inflammatory drugs (NSAIDs)
Family history (IBD, celiac disease, colorectal cancer, TB).
Cigarette smoking
General signs on physical exam?
wellbeing,Pallor,Cachexia,Clubbing,Nutritionalstatus,Pulse rate, blood pressure, Body temperature
Abdominal signs on PE?
Mass,Distension,Tenderness,rebound,guarding,Altered bowel sounds (obstruction) Hepatomegaly,Surgical scars
Perianal signs on PE?
Tags, Fissures,Fistulas,Abscess,Digital rectal examination (assess for anal strictures, rectal mass)
Extra-intestinal manifestations on PE?
: inspection of mouth,eyes,skin,and joints:Aphthous ulcers, Arthropathy,Uveitis,episcleritis,Erythema nodosum,Pyoderma gangrenosum, Primary sclerosing cholangitis (manifestations of chronic liver disease)Metabolic bone disease
Lab-stool exam?
Routine feacal microscopy & culture
Clostridium difficile test
Occult blood & leucocytes
Lactoferrin-an iron binding protein in neutrophils & released into the stool during inflammation
Feacal Calprotectin-increased level indicates migration of neutrophils to the intestinal mucosa
Investigations?
FBC,ESR,CRP
Electrolytes ,Ferritin,Vit B12,Calcium,Magnesium
Liver enzyme and function tests(INR,bilirubin & albumin)
Viral screening:HIV HSV,HBV
Perinuclear antineutrophil cytoplasmic antibody (p-ANCA) and antiSaccharomyces cerevisiae antibodies (ASCA) for cases of unclassified IBD(NOT ROUTINELY DONE IF ENDOSCOPY IS READILY AVAILABLE)
Exclude intestinal TB-The interferon gamma release assay (IGRA)
Imaging?
Plain abdo X-ray:colitis,obstruction,toxic megacolon.
Sigmoidoscopy,colonoscopy,Endoscopy
MRI –fistula,abscess
CXR-rule out PTB
Assess bone mineral density-DEXA scan
Histopathology?
Assessment of crypt architecture distortion
Assessment of non caseating granulomas.
Identifying histological changes in areas of normal endoscopy to fully stage the extent of disease.
Cytomegalovirus (CMV) can be sought on tissue biopsy in patients receiving immunosuppressive agents or chronic corticosteroids
A search for dysplasia can be carried out if routine biopsies are being obtained for dysplasia surveillance, or if mass lesions are biopsied.
Identifying lymphocytic colitis or collagenous colitis in an otherwise endoscopically normal-appearing colon.
Goals of treatment?
- Improve and maintain patients’ general well-being (optimizing the quality of life, as seen from the patient’s perspective)
- Treat acute disease
Prevent complications, hospitalization, and surgery - Maintain good nutritional status
Truelove and Witts?
Mild UC?
Moderate UC?
Severe UC?
Severeity score for Crohns?
Mild Crohns treatment?
Moderate-severe Crohns treatment?
Perianal-fistulizing disease treatment?
Supportive therapy?
Diet and nutrition: if mild, low-fiber diet, & if severe, Total Parental Nutrition(TPN) and bowel rest .
Anti-diarrhoea: contraindicated in severe exacerbation and toxic mega colon .
Anti-inflammatory agents?
5 Aminosalicylic acid(5ASA) Suppositories: if localized disease. Mesalamine 1 g PR qhs
Steroids: glucocorticoid enema/suppositories daily-BID
Systemic 5ASA:for induction and maintenance (sulfasalazine induction 0.5 g PO BID, then titrate to 0.5–1.5gPOQID,maintenance 1g PO BID–QID; mesalamine 800–1600 mg PO TID maintenance 400–800 mg PO TID; olsalazine)
Glucocorticoids: for flares (methylprednisolone 30 mg IV BID, prednisone 50 mg PO daily, reduce by 5 mg/week)
Immunosuppressive agents?
Azathioprine 50 mg PO daily, increase by 25 mg daily every 2 weeks to a max of 2–3 mg/kg/day as tolerated, methotrexate 25 mg IM weekly
Antibiotics?
: metronidazole 500 mg PO TID, ciprofloxacin 500 mg PO BID
Biological agents?
infliximab
Surgery?
Surgery is rarely curative in CD
In UC indicated if failing to achieve medical treatment and presence of dysplasia
