Inflammatory bowel disease

Question 1

What are the two types of inflammatory bowel disease?

Answer 1

1) ulcerative colitis
2) Crohn’s disease

Question 2

Give 5 general symptoms associated with IBD:

Answer 2

1) rectal bleeding
2) diarrhoea
3) abdominal pain
4) weight loss
5) fatigue

Question 3

Name 6 distinguishing features of Crohn’s disease?

Answer 3

1. Little/no blood or mucus in stool
2. Mouth-anus inflammation including mouth ulcers
3. Discontinuous inflammation
4. Transmural inflammation (Transmural inflammation is a condition where the inflammation affects all layers of the bowel wall. This can lead to complications such as fibrosis, obstruction, perforations, fistulae, lymphedema, and mesenteric fat)
5. Smoking is a risk factor
6. Typically right lower quadrant pain

Question 4

Mouth ulcers indicate which type of IBD?

Answer 4

Crohn’s disease

Question 5

Continuous inflammation indicates which type of IBD?

Answer 5

Ulcerative colitis

Question 6

Transmural inflammation indicates which type of IBD?

Answer 6

Crohn’s disease

Question 7

Severe rectal bleeding indicates which type of IBD?

Answer 7

Ulcerative colitis

Question 8

Inflammation in just the colon and rectum indicates which type of IBD?

Answer 8

UC

Question 9

True or false: Crohn’s disease is associated with strictures and fistulas

Answer 9

true

Question 10

Which region of the GI tract is most affected by Crohn’s?

Answer 10

terminal ileum

Question 11

Give 6 distinguishing features of ulcerative colitis:

Answer 11

1) continuous inflammation
2) inflammation limited to the colon and rectum
3) superficial mucosal inflammation
4) smoking may be protective against UC
5) rectal bleeding
6) Typically left lower quadrant pain

Question 12

Presentation alongside primary sclerosing cholangitis indicates which type of IBD?

Answer 12

ulcerative colitis

Question 13

What is crohn’s mean age of onset?

Answer 13

26
Can also present in children

Question 14

What is UC mean age of onset?

Answer 14

34

Question 15

What is the chance of surgery being required in Crohn’s disease?

Answer 15

50-80%

Question 16

What is the chance of surgery being required in UC disease?

Answer 16

20%

Question 17

What are common complications of Crohn’s disease?

Answer 17

Fistula, abscess, stricture. Most commonly the fistulae come from the anus to the peri-anal region and then produce pus

Question 18

What are the complications of UC?

Answer 18

Rare
Toxic megacolon

Question 19

What are protective factors for crohn’s disease?

Answer 19

1. High residue low sugar diet

Question 20

What are protective factors for UC?

Answer 20

Smoking, appendicectomy, high residue low sugar diet

Question 21

What is the pathology behind IBD?

Answer 21

In genetically susceptible individuals there is an adverse reaction to bacterial lipopolysaccharide. Normally the reaction against this is self limiting, but in IBD patients once the inflammation starts it may not stop. Thus ultimately it is a kind of autoimmune disease – and the inflammation ends up damaging the gut wall. The diseases follow a relapsing and remising course.

Question 22

What are the clinical features of Crohn’s disease?

Answer 22

Right iliac fossa mass/pain – this is present even when there is no abscess, abdominal discomfort, blood in the stools, vitamin B12 and iron deficiencies – Crohn’s commonly affects the small intestine and thus can cause malabsorption.
Clubbing seen in both Crohn’s disease and UC

Question 23

What are the clinical features of UC?

Answer 23

Diarrhoea due to excess mucus production. often also contains blood. Abdominal discomfort, bloating . symptoms usually less severe than Crohn’s
Clubbing

Question 24

Give 5 systemic conditions associated with IBD:

Answer 24

1) erythema nodosum
2) pyoderma gangrenosum
3) enteropathic arthritis
4) red eye conditions
5) primary sclerosis cholangitis

Question 25

What is erythema nodosum?

Answer 25

Tender red nodules usually found on the shins caused by inflammation of subcutaneous fat

Question 26

What is pyoderma gangrenosum?

Answer 26

Rapidly enlarging painful skin ulcers

Question 27

Give 3 examples of red eye conditions:

Answer 27

1) episcleritis 2) scleritis 3) anterior uveitis

Question 28

Give 6 blood tests used to investigate IBD:

Answer 28

1) FBC 2) CRP 3) U&Es 4) LFTs (in severe IBD, albumin is low) 5) TFTs (hyperthyroidism is a cause of diarrhoea) 6) anti-TTG (to rule out Coeliac disease)

Question 29

What is the first line test for investigating IBD (pre-endoscopy)?

Answer 29

faecal calprotectin

Question 30

What does a raised faecal calprotectin indicate?

Answer 30

intestinal inflammation (calprotectin protein indicates neutrophil migration)

Question 31

What is the gold-standard investigation for IBD diagnosis?

Answer 31

colonoscopy with multiple intestinal biopsies

Question 32

What imaging methods can be used to check for IBD complications such as fistulas, abscesses and strictures?

Answer 32

1) CT 2) MRI 3) ultrasound

Question 33

What is a very useful test to investigate Crohn's disease?

Answer 33

Barium Swallow

Question 34

When would stool microscopy and culture be used to investigate suspected IBD?

Answer 34

to rule out infection

Question 35

What is the first line medication for a mild/moderate acute episode of UC?

Answer 35

aminosalicylate e.g. mesalazine (oral or rectal)

Question 36

What is the second line medication for a mild/moderate acute episode of UC?

Answer 36

corticosteroids e.g. prednisolone (oral or rectal) steroid to initiate remission, then 5-ASA for maintenance

Question 37

What is the first line medication for a severe acute episode of UC?

Answer 37

IV steroids e.g. hydrocortisone trial steroid for 5-7 days. If no remission, then operate immediately.

Question 38

Name medications other than steroids that can be used in a severe acute episode of UC:

Answer 38

1) IV ciclosporin 2) infliximab

Question 39

Name three drugs used to maintain health in UC:

Answer 39

1) aminosalicylate e.g. mesalazine 2) azathioprine 3) mercaptopurine

Question 40

What surgery is used to 'cure' ulcerative colitis?

Answer 40

panproctocolectomy (Removing part or all of your colon and rectum)

Question 41

Why can a panprotocolectomy be used to cure ulcerative colitis but not Crohn's disease?

Answer 41

ulcerative colitis only affects the large bowel and rectum while Crohn disease ranges from the mouth to anus

Question 42

How can patients remove faecal waste following a panprotocolectomy? (2)

Answer 42

1) ileostomy 2) J pouch

Question 43

What is an ileostomy?

Answer 43

where the end portion of the ileum is brought onto the skin with a spout that drains into a stoma bag

Question 44

What is a J pouch?

Answer 44

where the ileum is folded back on itself to create a larger pouch that is attached to the anus and functions like the rectum, collecting stools before the person opens their bowels

Question 45

Give the first-line treatment of an acute episode of Crohn's disease:

Answer 45

steroids e.g. oral prednisolone or IV hydrocortisone (alongside enteral nutrition)

Question 46

Name 5 therapeutics other than steroids that may be used to treat an acute episode of Crohn's disease:

Answer 46

1) azathioprine 2) mercaptopurine 3) infliximab 4) methotrexate 5) adalimumab

Question 47

What is the first line treatment for maintaining remission in Crohn's disease?

Answer 47

azathioprine or mercaptopurine

Question 48

Give 3 surgical treatments that may be used in Crohn's management:

Answer 48

1) resecting the distal ileum 2) treating strictures 3) treating fistulas

Question 49

What other advice is given to patients with Crohn's disease?

Answer 49

1. Cessation of smoking 2. May need B12 and iron supplements 3. Low residue and fat diets may reduce symptoms

Question 50

If UC or Crohn's disease cannot be differentiated what are patients said to have?

Answer 50

Intermediate colitis

Question 51

What is toxic megacolon?

Answer 51

this is where the colon becomes massively distended. It can induce tachycardia and shock, and may also present with fever. It is a medical emergency, and if it does not respolve, will require surgery to prevent perforation

Question 52

What needs to be tested first before prescribing azathioprine?

Answer 52

Thiopurine Methyltransferase (TPMT) enzyme activity - if it is low it cannot be prescribed

Question 53

What is found in histology for crohn's disease?

Answer 53

1. Transmural inflammation 2. Goblet cells 3. Granuloma

Question 54

What is found in histology for ulcerative colitis?

Answer 54

1. Inflammation confided to the mucosa 2. Crypt abscesses