Inflammatory Bowel Disease Flashcards
What are inflammatory bowel diseases?
Idiopathic chronic relapsing and remitting gastrointestinal +/- extragastrointestinal disorder
Typical IBD
1. Ulcerative colitis
2. Crohn’s disease
Atypical IBD
1. Collagenous colitis
2. Lymphocytic colitis
3. Diversion colitis
4. Behcet’s disease
5. Indeterminate colitis
What causes IBD?
- Genetics
- 10-fold increase in risk in 1st degree relatives
- CARD15 (NOD2) gene in chromosome 16 - Environmental
- Smoking vs non-smoking
- Enteric infection (salmonella, campylobacter)
- Drugs - NSAIDs, antibiotics, OCP
- Highly refined sugar, low fibre diet
Epidemiology of IBD
Similarities
1. Age of onset - bimodal peak (20-40s, 70-90s)
2. Infection risk - increased risk
Differences
1. Smoking (CD) vs non-smoking (UC)
2. OCP use (CD)
3. Appendectomy protection (UC)
Ulcerative colitis inflammation is limited to __
Crohn’s disease inflammation is __ and __ can be affected
How would you differentiate between UC and CD?
UC: colonic mucosa
CD: transmural, any parts of GI tract
What are the gastrointestinal complications of IBD?
- UC (M: ABCD)
- CD (M: ABC)
Ulcerative Colitis
1. Anaemia - recurrent bleeding
2. Bacterial infection - clostridium difficile
3. Cancerous transformation
4. Dilation (toxic megacolon)
Crohn’s disease
1. Anal abscess and fistula
2. Burst (perforated) bowel
3. Constriction (strictures)
What are the extra-gastrointestinal manifestations of IBD? (M: CCCASE)
- Cholangitis (sclerosing)
- Leading to liver cirrhosis, cholangiocarcinoma - Fatty liver disease
- Calcium oxalate stones - gallstone, nephrolithiasis
(urate stone in UC) - Clotting (hypercoagulability)
- Leading to stroke, pulmonary embolism - Arthritis - ankylosing spondylitis, sacroilitis, peripheral
- Aphthous ulcer
- Skin - erythema nodosum (CD), pyoderma gangrenosum (UC)
- Eyes - episcleritis, iritis, anterior uveitis
- Amyloidosis, granolomata
How would you investigate a patient with suspected IBD?
A. Assessing severity
1. FBC, CRP ,ESR: anaemia, raised inflammatory markers
2. Vitals: fever, tachycardia
3. Diarrhoea frequency, extent of involvement
B. Investigations
1. Stool microscopy, culture and sensitivity (MCS), ova cyst and parasite (OCP)
2. Stool CMV PCR for CMV colitis
3. AXR: exclude toxic megacolon and mucosal islands
4. OGD, sigmoidoscopy or colonoscopy and biopsies
5. Bowel contrast study (look for fistulae)
6. CT AP +/- enterography +/- liver
What are the clinical subtypes of ulcerative colitis?
Classical classification
1. Proctitis
- Rectal bleed, mucous discharge, tenesmus, urgency, constipation, pruritus ani
- Mild UC
- Less than 4 diarrhoea a day
- Little to no rectal bleeding, no systemic disturbance - Moderate active UC
- 4-6 diarrhoea a day
- Moderate rectal bleed
- Systemic disturbance
- Or mild disease fail to respond to treatment - Acute severe UC (total or subtotal disease)
- Profuse diarrhoea, severe rectal bleed, abdominal pain
- Systemic disturbance (anorexia, LOW, fever, tachycardia, anaemia, leukocytosis, ESR)
Montreal Classification of UC Phenotype
1. Extent of inflammation
- E1 (proctitis); E2 (left side up to splenic flexure); E3 (extensive)
2. Severity
- S0 (remission); S1 (<4 diarrhoea); S2 (>4 without systemic); S3 (6 diarrhoea and systemic)
Outline the management of ulcerative colitis
- Non pharm, pharm, surgery
Multidisciplinary team - Gastro, colorectal surgery, dietitian, psychologist
Non-pharmacological
1. Dietary and nutritional support
- Reduce high fat, high sugar diet; increase high fibre diet
- Elemental diet and polymeric diet
- Vitamin supplementation
2. Smoking ironically reduces incidence and severity of UC
3. Psychological support
Pharmacological
Mild/moderate: topical steroids, oral steroids, 5-ASA
Severe: IV steroids, IV ciclosporin
Maintenance: oral steroids, 5-ASA, azathioprine
Surgery
1. Subtotal colectomy with ileostomy
2. Colectomy with ileoanal pouch
3. Panproctocolectomy with ileostomy
What are the indications for surgery in ulcerative colitis?
- Chronic symptomatic relief
- Emergency surgery for refractory colitis
- Colonic dysplasia/carcinoma
What are the clinical subtypes of Crohn’s disease?
Classical classification
1. Active ileal and ileocaecal disease
- Pain with RIF inflammatory mass, diarrhoea, LOW
- Small bowel obstruction (stricture)
- Malabsorption
2. Active Crohn’s colitis
- Similar to active UC
- Extraintestinal manifestation
- Perianal CD
- Fissuring, fistulae or abscesses - Others
Montreal Classification of CD phenotype
1. Age: A1 (<16); A2 (17-40); A3 (>40)
2. Location: L1 (ileal); L2 (colon); L3 (ileocolon); L4 (isolated or UGI)
3. Behaviour: B1 (non-stricture, non-penetrating); B2 (stricturing); B3 (penetrating)
Outline the management of Crohn’s disease?
- Non-pharm, pharm, surgical
Multidisciplinary team - Gastro, colorectal surgery, dietitian, psychologist
Non-pharmacological
1. Dietary and nutritional support
- Reduce high fat, high sugar diet; increase high fibre diet
- Elemental diet and polymeric diet
- Vitamin supplementation
2. Smoking cessation - helps with CD
3. Psychological support
Pharmacological
Mild/moderate: oral steroid, 5-ASA
Severe: IV steroids, infliximab
Maintenance: oral steroids, azathioprine, methotrexate, TNF-inhibitors (infliximab)
Surgery (see indication)
1. Seton insertion for perianal fistulae
2. Right hemicolectomy
3. Panproctocolectomy with ileostomy
What are the indications for surgery in Crohn’s?
- Obstruction
- Complications from fistulae
- Failure to respond to medical therapy
Describe this skin lesion
What is it commonly associated with?
Erythema nodosum / panniculitis
- Inflammation of subcutaneous fat, with tender red nodules over anterior shins
Associations
1. Crohn’s disease
2. Sarcoidosis
3. Malignancy - NHL, carcinoid, pancreatic
4. Leprosy
5. Behcet’s disease
6. Others - bacterial, idiopathic, pregnancy
Describe this skin lesion
What is it commonly associated with?
Pyoderma gangrenosum
- Neutrophilic dermatoses
- Painful pustules, nodules that become ulcers
Associations
1. IBD - UC > CD
2. RA as well as seronegative arthritis
3. Leukaemia, myelofibrosis
4. Monoclonal gammopathy
5. Solid tumors
