Inflammatory Bowel Disease Flashcards
What are inflammatory bowel diseases?
Idiopathic chronic relapsing and remitting gastrointestinal +/- extra-gastrointestinal disorder
Typical IBD
1. Ulcerative colitis
2. Crohn’s disease
Atypical IBD
1. Microscopic colitis (precipitated by NSAIDs)
- Collagenous colitis
- Lymphocytic colitis
2. Diversion colitis
3. Behcet’s disease
4. 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)
Crohn’s disease is an inflammatory disorder of excessive __, causing ____ in ____ of the GI tract (from mouth to the anus).
Symptoms: (6)
Endoscopy findings (5)
T-cell response
Transmural mucosal inflammation
In any parts
Symptoms
1. Chronic unexplained diarrhoea
2. Abdominal pain
3. Fatigue
4. Fever
5. Weight loss
6. Growth failure
Endoscopic findings
1. Chronic transmural inflammation
2. Deep, linear serpiginous ulcers
3. Discontinuous involvement (skipped areas)
4. Strictures
5. Fistula
Ulcerative colitis is an inflammatory disease restricted to the __ and only involves __, with __ almost always involved.
Patient may have varying degrees of involvement, from __ (limited to rectum in 30%), __ (left sided in 45%) to __ (entire colon including caecum in 35%)
Symptoms (4)
Endoscopy findings (5)
Mucosa
Colon, rectum
Proctitis
Left sided colitis (extending to sigmoid flexure)
Pancolitis
Symptoms
1. Rectal bleeding, tenesmus and urgency, mucus in stool
2. Diarrhoea and abdominal cramps relieved with bowel movement
(Abdominal pain sometimes localised to left lower quadrant)
3. Alternatively: constipation and rectal spasm
4. Constitutional - fever, fatigue, malaise, weight loss
Endoscopic findings
1. Superficial continuous mucosal inflammation and oedema
2. Superficial ulcers and erosions +/- pseudopolyps above ulcerated areas
3. Granularity, friability, and bleeding
Backwash ileitis is __ of distal few cm of terminal ileum with pancolitis, appearance on endoscopy similar to UC (__)
If however there is __, should suspect Crohn’s disease with ileal involvement
Limited inflammation
Superficial continuous inflammation
Deep linear ulcers and strictures
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), sweet syndrome
- Eyes - episcleritis, iritis, anterior uveitis
- Amyloidosis, granulomas
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
Toxic megacolon
Severe attack of colitis with total or segmental dilation of colon (>6cm of transverse colon)
- XR showed loss of haustration and dilatation of colon, outlined by air
Mandatory criteria: dilatation of colon
Additional criterias (2 or more):
1. Tachycardia > 100/min
2. Fever > 38.6 degree
3. Leukocytosis > 10
4. Hypoalbuminaemia < 30 g//L
What is the natural history of Crohn’s disease?
1/3 population: ileal, ileocolic or colonic inflammation
Minority: upper GI involvement
6-14% have change in disease location over time
50% will develop complications within 20 years - fistula, stricture, abscess
Most patients have chronic intermittent symptoms
(Few patients have either continuous active symptomatic disease or prolonged symptomatic remission)
50% patients steroid dependent or steroid resistance in absence of immunomodulators or biologics
Reduction of 10-year surgical resection risk from 50% to 30% with use of biologics
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
A. Induction - always with steroids or infliximab
- Mild/moderate: oral steroid, 5-ASA
- Severe: IV methylprednisolone, infliximab
B. Maintenance: oral steroids, azathioprine, methotrexate, TNF-inhibitors (infliximab)
C. Anti-TNF: infliximab, adalimumab, certolizumab, golimumab
(certolizumab suitable for pregnancy - does not cross BBB)
D. Emerging biologics: vedolizumab, ustekinumab, risankizumab
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?
- Strictures and obstruction
- Complications from fistulae - abscess, perforation
- Failure to respond to medical therapy
- Dysplasia and cancer
- Intractable haemorrhage
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
Microscopic colitis is a ____ disease of the colon either __ or __, characterised by (3)
Usually presents in __, more common in __ (sex)
Mainly triggered by: (5 meds), (5 conditions), (1 RF)
Subtypes (2)
Chronic inflammatory, either diffuse or discontinuous
Characterised by :
1. Chronic non-bloody watery diarrhoea
2. Grossly normal appearing mucosa
3. Histology positive on biopsy
Triggers:
1. NSAIDs
2. SSRI - sertraline
3. Antipsychotics - clozapine
4. PPI and ranitidine
5. Statin
6. Thyroid disease
7. Coeliac disease
8. Diabetes mellitus
9. RA
10. Asthma
11. Smoking
Usually in middle age, common in females
Subtypes:
1. Collagenous colitis
2. Lymphocytic colitis
Clinical features of microscopic colitis
- Mostly middle-aged women taking NSAIDs or have existing medical condition, insidious or acute
- Chronic non-bloody diarrhoea
- Weight loss
- Abdominal pain
- Urgency
- Nocturnal diarrhoea
Management of microscopic colitis
Non-pharmacologic
1. Lifestyle modification - avoid caffeine, alcohol, dairy, smoking
2. STOP medications associated with MC
Pharmacologic
3. Anti-diarrhoeal: loperamide, cholestyramine
4. Oral budenoside 9mg OM for 6-8 weeks, slow taper
(60-80% recurred with cessation)
5. Possible use: bismuth, sulfasalazine, mesalazine
6. IST - MTX, 6-MP, azathioprine
7. Ongoing anti-TNF research: infliximab, adalimumab
Refractory or very severe cases
8. Diverting ileostomy or colostomy
