Inflammatory bowel disease Flashcards
What are the two types of inflammatory bowel disease?
1) ulcerative colitis
2) Crohn’s disease
Give 5 general symptoms associated with IBD:
1) rectal bleeding
2) diarrhoea
3) abdominal pain
4) weight loss
5) fatigue
Name 6 distinguishing features of Crohn’s disease?
- Little/no blood or mucus in stool
- Mouth-anus inflammation including mouth ulcers
- Discontinuous inflammation
- 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)
- Smoking is a risk factor
- Typically right lower quadrant pain
Mouth ulcers indicate which type of IBD?
Crohn’s disease
Continuous inflammation indicates which type of IBD?
Ulcerative colitis
Transmural inflammation indicates which type of IBD?
Crohn’s disease
Severe rectal bleeding indicates which type of IBD?
Ulcerative colitis
Inflammation in just the colon and rectum indicates which type of IBD?
UC
True or false: Crohn’s disease is associated with strictures and fistulas
true
Which region of the GI tract is most affected by Crohn’s?
terminal ileum
Give 6 distinguishing features of ulcerative colitis:
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
Presentation alongside primary sclerosing cholangitis indicates which type of IBD?
ulcerative colitis
What is crohn’s mean age of onset?
26
Can also present in children
What is UC mean age of onset?
34
What is the chance of surgery being required in Crohn’s disease?
50-80%
What is the chance of surgery being required in UC disease?
20%
What are common complications of Crohn’s disease?
Fistula, abscess, stricture. Most commonly the fistulae come from the anus to the peri-anal region and then produce pus
What are the complications of UC?
Rare
Toxic megacolon
What are protective factors for crohn’s disease?
- High residue low sugar diet
What are protective factors for UC?
Smoking, appendicectomy, high residue low sugar diet
What is the pathology behind IBD?
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.
What are the clinical features of Crohn’s disease?
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
What are the clinical features of UC?
Diarrhoea due to excess mucus production. often also contains blood. Abdominal discomfort, bloating . symptoms usually less severe than Crohn’s
Clubbing
Give 5 systemic conditions associated with IBD:
1) erythema nodosum
2) pyoderma gangrenosum
3) enteropathic arthritis
4) red eye conditions
5) primary sclerosis cholangitis
What is erythema nodosum?
Tender red nodules usually found on the shins caused by inflammation of subcutaneous fat
What is pyoderma gangrenosum?
Rapidly enlarging painful skin ulcers
Give 3 examples of red eye conditions:
1) episcleritis
2) scleritis
3) anterior uveitis
Give 6 blood tests used to investigate IBD:
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)
What is the first line test for investigating IBD (pre-endoscopy)?
faecal calprotectin
What does a raised faecal calprotectin indicate?
intestinal inflammation (calprotectin protein indicates neutrophil migration)
What is the gold-standard investigation for IBD diagnosis?
colonoscopy with multiple intestinal biopsies
What imaging methods can be used to check for IBD complications such as fistulas, abscesses and strictures?
1) CT
2) MRI
3) ultrasound
What is a very useful test to investigate Crohn’s disease?
Barium Swallow
When would stool microscopy and culture be used to investigate suspected IBD?
to rule out infection
What is the first line medication for a mild/moderate acute episode of UC?
aminosalicylate e.g. mesalazine (oral or rectal)
What is the second line medication for a mild/moderate acute episode of UC?
corticosteroids e.g. prednisolone (oral or rectal)
steroid to initiate remission, then 5-ASA for maintenance
What is the first line medication for a severe acute episode of UC?
IV steroids e.g. hydrocortisone
trial steroid for 5-7 days. If no remission, then operate immediately.
Name medications other than steroids that can be used in a severe acute episode of UC:
1) IV ciclosporin
2) infliximab
Name three drugs used to maintain health in UC:
1) aminosalicylate e.g. mesalazine
2) azathioprine
3) mercaptopurine
What surgery is used to ‘cure’ ulcerative colitis?
panproctocolectomy (Removing part or all of your colon and rectum)
Why can a panprotocolectomy be used to cure ulcerative colitis but not Crohn’s disease?
ulcerative colitis only affects the large bowel and rectum while Crohn disease ranges from the mouth to anus
How can patients remove faecal waste following a panprotocolectomy? (2)
1) ileostomy
2) J pouch
What is an ileostomy?
where the end portion of the ileum is brought onto the skin with a spout that drains into a stoma bag
What is a J pouch?
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
Give the first-line treatment of an acute episode of Crohn’s disease:
steroids e.g. oral prednisolone or IV hydrocortisone
(alongside enteral nutrition)
Name 5 therapeutics other than steroids that may be used to treat an acute episode of Crohn’s disease:
1) azathioprine
2) mercaptopurine
3) infliximab
4) methotrexate
5) adalimumab
What is the first line treatment for maintaining remission in Crohn’s disease?
azathioprine or mercaptopurine
Give 3 surgical treatments that may be used in Crohn’s management:
1) resecting the distal ileum
2) treating strictures
3) treating fistulas
What other advice is given to patients with Crohn’s disease?
- Cessation of smoking
- May need B12 and iron supplements
- Low residue and fat diets may reduce symptoms
If UC or Crohn’s disease cannot be differentiated what are patients said to have?
Intermediate colitis
What is toxic megacolon?
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
What needs to be tested first before prescribing azathioprine?
Thiopurine Methyltransferase (TPMT) enzyme activity - if it is low it cannot be prescribed
What is found in histology for crohn’s disease?
- Transmural inflammation
- Goblet cells
- Granuloma
What is found in histology for ulcerative colitis?
- Inflammation confided to the mucosa
- Crypt abscesses
