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Diarrhea, IBD, other Inflammatory > Inflammatory Bowel Disease > Flashcards

Inflammatory Bowel Disease Flashcards

1
Q

IBD

A
  • Chronic intestinal inflammation from a dysregulated immune response to the enteric microbiome in a genetically predisposed host.
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2
Q

Pathogenesis of IBD

A
  • Luminal microbial antigens and adjuvants
  • Genetic susceptibility
  • Immune response (exaggerated)
  • Environmental triggers
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3
Q

IBD Epidemiology

A
  • ~3.5 million in the US
  • 7-10 per 100,000 IBD per year in US
    average age of diagnosis: 11-12 years
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4
Q

IBD Genetics

A
  • 50% concordance in identical twins
  • CARD 15/NOD2 polymophisms on IBD1 locus
  • SLC22A4 and SLC22A5 on IBD 5 loculs
  • HLA-B, HLA-DRB1, HLA-DQB1, and HLA-DP, especially UC
  • 6-9% of children born to a parent with UC and CD respectively, will develop IBD
  • 33% affected if both parents with IBD
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5
Q

IBD Environment

A

-higher predisposition in norther latitudes
-microbes and flora (use of antibiotics predisposes)
-Smoking worsens Crohn’s but is protective for UC
- Appendectomy: risk for Crohn’s and protective for UC

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6
Q

Ulcerative Colitis versus Crohn’s

A

UC: Mucosal, Continuous.
Crohn’s: Transmural, discontinuous, oral to perianal. rectal sparing, non-caseating granulomas
Indeterminate Colitis: patchy colic disruption, histopathologic features of UC, 30-70% are diagnosed as CD or UC during the course of follow up.

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7
Q

Extraintestinal manifestations: Musculoskeletal

A

Type 1: <5 joints, larger joints, brief, associated with luminal activity.
Type 2: multiple small joints, independent of luminal activity
Ankylosing spondylitis (<2%), progressive sacroillitis: HLA B27
Osteopenia.
Digitial clubbing: particularly with small intestine involvement

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8
Q

Extra intestinal manifestations: other

A

Skin: pyoderma gangrenosum, erythema nodosum, cancer, ?acne
Hepatic: Autoimmune hepatitis, PSC
Renal: stones, obstructive uropathy (ileal disease/ileal resection: oxalate malabsorption)
Hematologic: hypercoagulability, thromboembolic events

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9
Q

Diagnosis:

A
  • CBC, iron, TIBC, Ferritin
  • Albumin and liver chemistries
  • CRP/ESR
  • Fecal calprotectin/lactoferrin
    -serology: not recommended
  • Monitoring: above + therapeutic drug monitoring.
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10
Q

Exclusionary labs

A
  • Celiac
    -Stool infectious studies
  • TB/Amebic titers
  • young kids: question immune competence
  • vasculitis/multiple organs
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11
Q

Scope in Crohn’s disease

A

-EGD: upper GI system is usually spared, may see nonspecific esophagitis, gastritis, duodenitis
- Colonoscopy: skip lesions. loss of vascularity –> deep ulceration. Later: pseudopolyps

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12
Q

Scope in UC

A

Endoscopy:
Colonoscopy: pancolitis: 70-80%. Left sided: 20-30%, proctitis/proctosigmoiditis: 26%.
Can have non-classic findings: gastritis: 25-58%
backwash ileitis: 9%
Cecal path: small area of cecal inflammation after left sided disease: 9%

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13
Q

IBD Histology

A
  • Cryptitis, crypt abscesses, gland destruction/branching/remodeling.
  • acute and/or chronic inflammation
  • granulomas in CD: 10-25%
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14
Q

IBD Imaging

A
  • plain film: mural thickening, gas pattern (to exclude toxic megacolon)
  • CT scan: transmural changes and complications
  • MRE: same as above, but avoids radiation
  • US: abscess and bowel hyperemia
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15
Q

Toxic megacolon

A
  • NPO/antibiotics
  • surgical consultation and careful follow up
    -prevention with ambulation and avoid agents which slow motility (no opiates).
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16
Q

Steroid dosing

A
  • Start a real dose with aggressive taper: no real advantage above 40-60 mg daily.
    only induction, never maintenance. severe colitis: 3-5 day rule
    Side effects: facies, striae, weight gain, moody, bone disease, growth failure.
  • Consider topical steroid enemas
17
Q

Mesalamine

A
  • MOA: inhibit prostaglandin and leukotriene synthesis.
  • location of drug release dependent on formulation
  • minimally absorbed
  • Side effects: diarrhea (paradoxical reaction), headache, nausea, interstitial nephritis, pancreatitis, leukopenia and hepatitis.
  • Monitor: CBC, liver chemistries, BUN, Cr, and UA
    supplement folic acid with sulfasalazine
18
Q

Antibiotics: Ciprofloxacin and Flagyl

A
  • used in management of perianal disease
  • short term post-op prophylaxis
  • little pediatric evidence
    Side effects: peripheral neuropathy (Flagyl). Bone/achilles tendon rupture (Ciprofloxacin).
19
Q

Thiopurines: 6-MP and Imuran

A
  • Immune modifier
  • Use: maintenance of remission with and without biologic.
  • Side effects: Nausea, Vomiting, DIarrhea, allergic reaction, BM suppression, hepatotoxicity, pancreatitis (idiosyncratic), infections, lymphoma (HSTCL), nonmelanoma skin cancer, HLH in EBV naive patients
    Before starting: check vaccine acquired immunity
    o: TPMT before initiating therapy. Ongoing: CBC and liver chemistries.
20
Q

Methotrexate

A
  • Immune modifier
  • Use: maintenance of remission with and without biologic.
  • MOA: not fully known ?T cell apoptosis.
    Side effects: N/V, stomatitis, anorexia, diarrhea, BM suppression, hepatotoxicity, pneumonitis, hypersensitive skin reactions.
    Monitor: CBC and liver enzymes.
    Before starting: vaccine acquired immunity
  • Bad for pregnancy
21
Q

Tacrolimus and Cyclosporine

A
  • Calcineurin inhibitors
  • Use: induction of remission in moderate to severe disease and perianal disease
  • Side effects: HTN, Nausea, transaminitis, infection, nephrotoxicity, glucose intolerance, hypomagnesemia, seizures, infection, LPD.
    Cyclosporine: gingival hyperplasia, hirsutism, coarsening facil features.
    Monitor: Ca, MG, Phos, BUN/Cr, CBC, transaminases, lipids, cholesterol, fasting glucose, drug trough levels and PCP prophylaxis.
22
Q

Anti-TNFalpha

A

induction and maintenance of remission.
UC: only infliximab is pediatric approved
Monoclonal IgG antibody to TNFalpha
Infliximab: chimeric and adalimumab: fully human.
Side effects: infusion reaction/allergy, infections (fungal, TB), lymphoma (HSTCL in combo with thiopurines) non-melanoma skin cancer, cytopenias, transaminitis, psoriasis, demyelination syndrome, lupus- like reaction, worsening CHF
Monitor: PPD/Quang gold, CXR, vaccine acquired immunity

23
Q

Vedolizumab (antiadhesion)

A

Induction and maintenance of remission.
Monoclonal IgG1 antibody to alpha4 B7 integrin: inhibits lymphocyte migration across endothelium into inflamed bowel.
Side effects: headache, arthralgia, nausea, fever, fatigue, URI, ?PML
Monitor before starting therapy: PPD

24
Q

Nutritional Therapy

A
  • Induction (?maintenance? ) of remission in Crohn’s.
    MOA: avoidance of allergenic food elements and alteration of intestinal microflora.
    Ideally 80-100% caloric intake through formula. Elemental and polymeric formulas have equivalent efficacy
    largely related to NGT, may have diarrhea
25
Q

DDX of Perianal disease

A
  • Sexual abuse
  • Anal fissure (defecation disorders)
  • Infections
  • Hemorrhoids
  • Prolapse
  • Crohn’s disease
  • Perianal strep
26
Q

perianal abscess management

A

MRI and EUA to define the anatomic problem
surgery: get the pus out first.
Use setons as required to control sepsis.
treat proctitis/intestinal inflammation.
more definite surgical closer should be considered only after intestinal inflammation under control

27
Q

Surgery in Crohn’s disease

A
  • Transmural complications including abscess, perforation
  • Obstruction
  • Need for post-op surveillance
  • Need for prophylaxis against recurrence
28
Q

Surgery in UC

A
  • acute severe colitis
  • unresponsive disease
29
Q

Crohn’s Outcome

A

59% have complicating disease by 5 years
Risk of surgery: 20% at 3 years and 34% at 5 years from diagnosis

30
Q
A

Diarrhea, IBD, other Inflammatory (3 decks)

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