Inflammatory bowel disease

Question 1

Ulcerative colitis pathophysiology

Answer 1

diffuse mucosal inflammation limited to the colon

Question 2

What is it called if ulcerative colitis is limited to the rectum?

Answer 2

proctitis

Question 3

Crohn’s pathophysiology

Answer 3

patchy transmural inflammation (affects all layers, skip lesions present)

Question 4

Where in the GI tract can Crohn’s affect?

Answer 4

anywhere from mouth to anus

Question 5

Where is the most common area Crohn’s affects?

Answer 5

ileocaecal area

Question 6

Where in the GI tract does Crohn’s most affect in children?

Answer 6

upper GI tract

Question 7

What does abdominal pain and cherry red stool in infants suggest?

Answer 7

intussusception

Question 8

How is the appendix linked to IBD?

Answer 8

appendicectomy due to appendicitis:
- increases risk of Crohn’s
- protective of UC

Question 9

Ulcerative colitis presentation

Answer 9

symptoms correlate to extent
frequent bloody diarrhoea
mucus PR
tenesmus (urge to go to the bathroom without being able to go)
abdominal pain
fever

Question 10

Crohn’s presenting symptoms

Answer 10

depends where in GI tract it affects
fatigue
weight loss
fever
diarrhoea +/- bleeding
pain
vomiting
bloating
fistula
abscess

Question 11

What history features should be asked for IBD

Answer 11

previous episodes
family history
smoking
appendicectomy
travel
contacts
antibiotics/NSAIDs
extra-intestinal manifestations

Question 12

IBD signs

Answer 12

pyrexial
tachycardia
dehydrated
pale
tender abdomen
PR

Question 13

Investigations for IBD

Answer 13

bloods:
- anaemia
- thrombocytosis
- raised ESR/CRP
- hypoalbuminaemia (albumin goes down as inflammation goes up)

microbiology:
- stool culture
- clostridiodes difficile assay

Question 14

How can C diff present on endoscopy?

Answer 14

pseudomembranous colitis

Question 15

What is toxic megacolon?

Answer 15

motility through gut impaired
swelling and inflammation of colon
colon dilates
can perforate

Question 16

What do fluid levels on xray of the abdomen suggest?

Answer 16

bowel obstruction (small or large)

Question 17

What is pneumoturia?

Answer 17

gas in urine

Question 18

What does pneumoturia suggest?

Answer 18

fistula between gut and bladder

Question 19

IBD differential diagnosis

Answer 19

infective:
gastroenteritis/dysentery
clostridiodes difficile
amoebasis
tuberculosis (TB of ileum can mimic Crohn’s)
CMV
yersiniosis
histoplasmosis

non-infective:
appendicitis
diverticulitis
diverticular colitis
carcinoma
ischaemic colitis
lymphoma
endometriosis
carcinoid

Question 20

What is a phlegmon?

Answer 20

inflammatory mass

Question 21

Acute severe ulcerative colitis management

Answer 21

steroids (do not delay until stool cultures, cover with IV abx if necessary)

community = prednisolone 40mg OD

inpatient = hydrocortisone 100mg tds-qds/methylprednisolone 60-80mg OD

stool chart

daily abdominal xray if initial dilatation or subsequent deterioration

IV fluids (pt can eat and drink but may be dehydrated)

blood prn

daily bloods

LMWH (even if bleeding, thrombosis higher risk)

discontinue constipating drugs

unprepared flexible sigmoidoscopy

Question 22

Acute severe Crohn’s disease management

Answer 22

if inflammatory –> steroids
elemental/polymeric diet (all liquids)
Crohn’s colitis —> treat as UC
metronidazole or ciprofloxacin for fistulae

Question 23

Name some drugs used in IBD

Answer 23

aminosalicylates
corticosteroids (oral/topical - enema/suppository)
thiopurines eg. azathioprine (unlicensed)
methotrexate
ciclosporin
biologics eg. infliximab

Question 24

What levels should be measured before giving azathioprine?

Answer 24

TPMT
no TPMT = azathioprine will poison
some TPMT = lower dose azathioprine

Question 25

What are some extraintestinal manifestations of IBD?

Answer 25

episcleritis
mouth ulcers
uveitis
erythema nodosum
pyoderma gangrenosum
arthritis