Inflammatory Bowel Disease Flashcards
specific goals for IBD treatment*
-3 treatment objectives:
-terminate the acute, symptomatic attack
-achieve complete remission of clinical and endoscopic disease activity -> why is this important? -> increased risk of colon cancer
-normal histology -> reoccurrence likely is less -> treat to target
-prevent recurrence of attacks
5 ASA (5 aminosalicylic acid)
-Active tx of UC and Crohns
-ileum or colon
-Topically active agents with anti-inflammatory effects:
-Oral Mesalamine-COLON** (dont need to know the types)
-Delzicol 400mg 12/day
-Lialda 1.2g 4/day
-Apriso .375g 4/day
-Oral Mesalamine-terminal ILEUM and COLON -> Pentasa 500mg 8/day
-Oral Azo Compounds-released within COLON -> Sulfasalazine AND Balsalazide 750mg 9/day
-Topical mesalamine: deliver much higher 5-ASA to distal colon -> Canasa suppositories (RECTUM) AND Rowasa Enemas (REACHES WHOLE LEFT SIDE-> take laying down on left side)
corticosteroids
-Used in short term tx of moderate to severe disease
-anti-inflammatory in combo with tx
-IV hydrocortisone or methylprednisolone -> continuous infusion or every 6 hours (sick in hospital)
-Oral prednisone or methylprednisolone, or budesonide
-Topical preparations: Hydrocortisone:
Suppositories (100 mg)
Foam (90 mg)
Enemas (100 mg)
budesonide
-Oral glucocorticoid with high topical anti-inflammatory activity but low systemic activity
-more topical and less systemic absorption - steroid -> less SE
-Controlled-release formulation that targets delivery to terminal ileum and colon
-Less suppression of hypothalamic-pituitary-adrenal axis
-Fewer steroid-related effects
mercaptopurine and azothioprine (just know they exist)
-Thioprine drugs
-Used to reduce or withdraw the corticosteroids and to maintain patients in remission
-Was used frequently with Biologics (helper)
-Allergic and nonallergic side effects (10%) -> Pancreatitis, bone marrow suppression, infections, hepatitis or cholestatic jaundice and higher risk of neoplasm
-Monitor CBC, LFTs
methotrexate (she barely talked ab this in class)
-Used if intolerant to mercaptopurine (LAST RESORT)
-At low doses has anti-inflammatory properties -> inhibition of expression TNF-α in monocytes and macrophages
Given intramuscularly, subcutaneously, or orally
-SE: nausea, vomiting, diarrhea, alopecia, stomatitis, infections, bone marrow suppression, hepatitis, hepatic fibrosis, and life-threatening pneumonitis
-CBC, LFTs monitored
-Folate given
biologics (dont need to know any names)
-organically made MONOCLONAL ANTIBODIES -> MAB (ending)
-no such things as a generic- not made in lab
-all of these interfere with inflammatory cascade (block immune)
-pretty much take it forever
-very effective
-give vaccines before therapy start!
-TNF Inhibitor:
Infliximab (IV)
Adalimumab (sq)
Certolizumab (sq)
Golimumab (sq)
-Integrin Blocker:
Vedolizumab (IV)- targets gut (less immunosuppression)
Natalizumab (IV)
-Interleukin Antagonist:
Ustekinumab (sq)
Risankizumab (sq)
-JAK Inhibitor: inhibits triggers in bowel
Upadacitinib (pill) - quick
potential side effects of most biologics
-Sepis
-Pn
-Malignancy
-Lymphoma
-Myleosuppression
-Opportunistic infections
-Hepatic failure
-> Must monitor CBC and LFTS
ulcerative colitis and crohns disease
-Ulcerative colitis:
-Chronic recurrent disease
-Diffuse MUCOSAL inflammation involving only the colon
-Invariably involves rectum and may extend proximally in a CONTINUOUS fashion to involve part or all of colon
-colon and rectum
-Crohn’s:
-Chronic recurrent disease
-from mouth to anus
-PATCHY TRANSMURAL inflammation involving any segment of the gastrointestinal tract from the mouth to the anus
-all layers of GI - (not just mucosal)
epidemiology- 1.6 mil in US : ulcerative colitis and crohn’s
-US:
-15-30 and 50-80
-Slight > male
- > Jewish; white
-Runs in families
-Crohn’s:
-15-30 and 50-80
-Slight > female
- > Jewish; white
-Runs in families
-jewish > non-jewish white > african american > hispanic > asian
-runs in families
IBD types/causes
-genetic
-environmental triggers
-immunologic
genetics: IBD
- > 200 distinct susceptibility loci for IBD have been identified
-very common in First-degree relatives -> same disease patterns
-Clinical features of the disease demonstrate a heritable pattern -> Location
-Several genetic syndromes associated with IBD
immunologic: IBD
-Inflammatory mediators play an important role in the pathologic and clinical characteristics of these disorders
-autoimmune
-Immune response disrupts the intestinal mucosa and leads to a chronic inflammatory cascade
ulcerative colitis
-Idiopathic inflammatory condition involving mucosal surface of colon
-Diffuse friability* and erosions with bleeding
-angery
-1/4 proctosigmoiditis
-1/2 left-sided colitis
-1/4 extensive colitis ->Extends more proximally +/- backwash ileitis (secondary involvement) -> pancolitis
-extraintestinal manifestations- HEENT, derm, MS
ulcerative colitis S&S and PE
-based on severity of disease
-Frequency of BM*
-Rectal bleeding (UC>crohns) -> bc UC involves rectum and colon more
-Cramps
-Abdominal pain
-Fecal urgency
-Tenesmus
-Fever
-Wt change
-Extraintestinal manifestations
-physical exam- volume status, nutritional status, abdominal exam, rectal exam (perianal disease)
extraintestinal manifestations
-25% of patients with IBD:
-Oligoarticular or polyarticular nondeforming peripheral arthritis
-Spondylitis or sacroiliitis
-Episcleritis or uveitis
-Erythema nodosum- hot, red, tender (1-5cm) and found on anterior surface of lower legs, ankles, calves, thighs, and arms
-Pyoderma gangrenosum- common of dorsal surface of feet and legs (can also occur on arms, chest, stoma, and even face) -> begins as pustule and spreads concentrically -> then ulcerates with violaceous edges surrounded by margin of erythema, centrally they contain necrotic tissue with blood and exudates
-Sclerosing cholangitis- UC typically
-Thromboembolic events
serologic testing ulcerative colitis
-Antineutrophil cytoplasmic antibodies with perinuclear staining (p-ANCA):
-5–10% of pts with Crohn’s disease
-50–70% of patients with ulcerative colitis**
-Antibodies to the yeast Saccharomyces cerevisiae (ASCA):
-60–70% of patients with Crohn’s disease**
-10–15% of patients with ulcerative colitis
-sensitive not specific -> false pos/neg is common so cant be used to rule in or out
-not very helpful, not really done
labs for IBD
-do this with chronic -> rule out
-CBC- anemia?
-CMP
-ESR
-CRP
-Fecal Calprotectin, infection -> high with IBD *
-rule out c diff
-New onset: R/o other conditions: stool studies, thyroid tests, celiac panel
assessment of disease activity- ulcerative colitis (just an idea)
-stool freq - < 4 (mild), 4-6 (moderate), > 6 mostly bloody (severe)
-pulse/min - < 90 (mild), 90-100 (moderate), > 100 (severe)
-HCT% - normal (mild), 30-40 (moderate), < 30 (severe)
-Wt loss % - none (mild), 1-10% (moderate), >10% (severe)
-temp f - normal (mild), 99-100 (moderate), >100 (severe)
-ESR - <20 (mild), 20-30 (moderate), >30 (severe)
-albumin - normal (mild), 3-3.5 (moderate), <3 (severe)
diagnosis: colonoscopy- ulcerative colitis
-you need a colonoscopy for dx -> multiple blind bx
-In acute colitis -> dx is established by sigmoidoscopy or colonoscopy with bx
-Edema, friability (bleeds easily), mucous, and erosions
-Crypt abscess and destruction seen on pathology
-MC finding- extensive ulceration of mucosa
-irregular, diffuse erythematous, submucosal hemorrhage
-CONTINUOUS
-mucopurulent exudate
-pseudopolyps may form as reaction to inflammation
-cant see vessels
-narrow lumen