Inflammatory bowel disease Flashcards
What is ulcerative colitis
diffuse inflammation of colonic mucosa ( one layer)
only affects rectum and colon
affects variable lengths of colon
continuous inflammation
no known cause
What are risk factors for ulcerative colitis
family history HLA-B27
smoking is protective factor against UC
affects males more than females
bimodal peak - 20-40 and 60
What may someone with UC present with
bloody diarrhoea
rectal bleeding and mucus
abdominal pain and cramps
tenesmus
weight loss
What is the criteria for acute severe colitis
frequency of stool >6
overtly bloody stool
fever > 37.5
tachycardia >90
anaemia Hb <105
Raised ESR >30
What are some extra-intetsinal manifestations of UC
colonic carcinomas
massive rectal haemorrhage
large joint arthritis
primary sclerosing cholangitis
anterior uveitis
aphthous ulceration
What may be seen on examination in someone with UC
anaemic pallor
blood on DRE
abdominal tenderness
What investigations are required
colonoscopy and biopsy
– but if patient has severe colitis flexible sigmoidoscopy is preferred to avoid risk of perforation
abdominal X-ray
- dilated bowel and thumbprinting will be seen
Bloods-
LFTs and FBC
Stool sample
Double contrast barium enema
- loss of haustration
-pseudopolyps
-if chronic , colon is narrow and short
What are typical findings in a patient with UC on colonoscopy and biopsy
red raw mucosa- bleeds easily
no inflammation beyond submucosa
crypt abscesses
pseudopolyps
depletion of goblet cells and mucin
granulomas are infrequent
How is the severity of UC classified
mild - <4 stools a day , small amounts of blood
moderate 4-6 stools a day , no systemic upset , varying amounts of blood
severe >6 bloody stools per day and features of systemic upset
How do you manage mild/moderate UC
Mesalazine - topical/rectal then oral
steroids if remission not achieved
- oral beclamethasone
How do you manage severe ulcerative colitis
IV steroids - hydrocortisone
IV cyclosporine
( immunosuppressant ) if remission not achieved
Add low molecular weight heparin - because those with acute severe UC are at high risk of thromboembolic events - risk of clot> than risk of bleeding
How do you maintain remission following a mild - moderate ulcerative colitis flare
Aminosalicylate ( mesalazine )
How do you maintain remission following a severe UC relapse or >=2 exacerbations in the past year
Immunosuppressants -
oral azathioprine or mercaptopurine
What drug do you give if none of the earlier treatments are working for UC
Infliximab is rescue theory
What is Crohns disease
transmural inflammation of GI tract
can affect anywhere from mouth to anus
skip lesions- tissue is healthy in between
most commonly affects terminal ileum and perianally
Inflammation – ulceration – all layers affected – non caseating granuloma formation
What are risk factors for Crohns disease
family history, smoking, OCP, high refined sugars
Ashkenazi Jews
Bimodal peak
15-40 AND 60-80
What may be a patient with Crohn’s present with
crampy or constant abdominal pain-
RLQ and peri-umbilical
Diarrhoea -
mucus,blood,pus
can be nocturnal
Perianal lesions
-skin tags, fistulae,abscesses
-fatigue, weight loss, mouth ulcers, malnourishment
What are some extra-intestinal manifestations of crohns
arthropathy ( joint pain )
skin lesions
–erythema nodosum
–pyoderma gangrenosum
uveitis , episcleritis
What may be seen on examination in someone with crohns
abdominal tenderness/lower right mass
aphthous ulcers
perianal lesions
What investigations are required for crohns
Bloods
- FBC, iron studies, vitamin/folate, inflammatory markers
CRP correlates well with disease activity
Colonoscopy
-deep ulcers, skip lesions
cobblestone apperance
Histology
inflammation in all layers mucosa to serosa
goblet cells
non-caseating granulomas
Small bowel enema
- Kantors string sign
-proximal bowel dilation
-rose thorn ulcers
-fistulae
What is the management for Crohns
Steroids
- PREDNISOLONE
-budesonide
Immunomodulators
-AZATHIOPRINE
-mercaptopurine
methotrexate
Biological therapy
ADALIMUMAB
infliximab
vedolizumab
Surgery - for severe presentations
What management is required once remission is achieved
maintain with immunomodulators and or biologics
What are the key differences in symptoms between crohns disease and ulcerative colitits
Crohns -
non-bloody diarrhoea
weight loss prominent
upper GI symptoms
abdominal mass palpable in RIF
UC-
bloody diarrhoea
abdominal pain in LLQ
tenesmus
What are the key differences in complications between crohns and UC
Crohns
-obstruction,fistula,colorectal cancer
UC
risk of colorectal cancer is higher
Key differences in pathology between UC and Crohns
crohns
-lesions can be seen anywhere from mouth to anus
skip lesions may be present
UC
-inflammation always starts at rectum and does not spread beyond ileocaecal valve
continuous disease
What is the differences in histology between UC and Crohns
Crohns
-inflammation in all layers from mucosa to serosa
increased goblet cells
granulomas
UC-
- no inflammation beyond submucosa
crypt abscesses
depletion of goblet cells and mucin from gland epithelium
What radiology is used for crohns and what is seen
SMALL BOWEL ENEMA
-high sensitivity and specificity for examination of terminal ileum
-strictures -kantors string sign
-proximal bowel dilation
-rose thorn ulcers
-fistulae
What radiology is used for UC and what is seen
loss of haustrations
superficial ulceration = pseudopolyps
drainpipe colon in long standing disease
