Inflammatory bowel disease Flashcards
What is Crohn’s disease?
Crohn’s disease is a form of inflammatory bowel disease that commonly affects the terminal ileum and colon but may be seen anywhere from the mouth to anus.
What is the cause of Crohn’s disease?
The cause is unknown but there is a strong genetic susceptibility.
What layers of the gastrointestinal tract are affected by Crohn’s disease?
Inflammation occurs in all layers, down to the serosa.
What complications are patients with Crohn’s disease prone to?
Patients with Crohn’s are prone to strictures, fistulas, and adhesions.
What percentage of Crohn’s disease patients have small bowel involvement?
80% of patients have small bowel involvement, usually in the ileum.
What are the common presentations of Crohn’s disease?
Common presentations include weight loss, lethargy, diarrhoea, abdominal pain, and perianal disease.
What investigations are used for Crohn’s disease?
Investigations include raised inflammatory markers, increased faecal calprotectin, anaemia, and low vitamin B12 and vitamin D.
What are common extra-intestinal features of Crohn’s disease?
Common extra-intestinal features include arthritis, erythema nodosum, episcleritis, and osteoporosis.
What is Crohn’s disease?
Crohn’s disease is a form of inflammatory bowel disease that commonly affects the terminal ileum and colon but may be seen anywhere from the mouth to anus.
What blood test correlates well with Crohn’s disease activity?
C-reactive protein correlates well with disease activity.
What is the investigation of choice for Crohn’s disease?
Colonoscopy is the investigation of choice.
Features suggestive of Crohn’s include deep ulcers and skip lesions.
What histological features are seen in Crohn’s disease?
Inflammation in all layers from mucosa to serosa, goblet cells, and granulomas.
What is the purpose of a small bowel enema in Crohn’s disease?
It has high sensitivity and specificity for examination of the terminal ileum.
What sign indicates strictures in Crohn’s disease during a small bowel enema?
‘Kantor’s string sign’ indicates strictures.
What are the features of Crohn’s disease observed in small bowel enema?
Proximal bowel dilation, ‘rose thorn’ ulcers, and fistulae.
What is Crohn’s disease?
Crohn’s disease is a form of inflammatory bowel disease that commonly affects the terminal ileum and colon but may be seen anywhere from the mouth to anus.
What guidelines were published for the management of Crohn’s disease?
NICE published guidelines on the management of Crohn’s disease in 2012.
What lifestyle change should patients with Crohn’s disease be advised to make?
Patients should be strongly advised to stop smoking.
What medications are generally used to induce remission in Crohn’s disease?
Glucocorticoids (oral, topical or intravenous) are generally used to induce remission.
What is an alternative medication for inducing remission in a subgroup of Crohn’s disease patients?
Budesonide is an alternative in a subgroup of patients.
What is the role of enteral feeding in Crohn’s disease management?
Enteral feeding with an elemental diet may be used in addition to or instead of other measures to induce remission, particularly if there is concern regarding the side-effects of steroids.
What are 5-ASA drugs used for in Crohn’s disease?
5-ASA drugs (e.g. mesalazine) are used second-line to glucocorticoids but are not as effective.
What medications may be used as add-on therapy to induce remission in Crohn’s disease?
Azathioprine or mercaptopurine may be used as an add-on medication to induce remission but are not used as monotherapy.
What is the role of infliximab in Crohn’s disease?
Infliximab is useful in refractory disease and fistulating Crohn’s.
What is the first-line medication to maintain remission in Crohn’s disease?
Azathioprine or mercaptopurine is used first-line to maintain remission.
What should be assessed before starting azathioprine or mercaptopurine?
+TPMT activity should be assessed before starting.
What percentage of patients with Crohn’s disease will eventually have surgery?
Around 80% of patients with Crohn’s disease will eventually have surgery.
What is the investigation of choice for suspected perianal fistulae?
MRI is the investigation of choice for suspected perianal fistulae.
What is a draining seton used for?
A draining seton is used for complex fistulae.
What are the risks associated with Crohn’s disease?
Patients are at risk of small bowel cancer, colorectal cancer, and osteoporosis.
What is the standard incidence ratio for small bowel cancer in Crohn’s disease?
The standard incidence ratio for small bowel cancer is 40.
What is the standard incidence ratio for colorectal cancer in Crohn’s disease?
The standard incidence ratio for colorectal cancer is 2.
What are the two main types of inflammatory bowel disease?
Crohn’s disease and ulcerative colitis.
What is a common symptom of Crohn’s disease?
Diarrhoea usually non-bloody.
What is a prominent symptom of ulcerative colitis?
Bloody diarrhoea more common.
What extra-intestinal manifestation is more common in Crohn’s disease?
Gallstones are more common secondary to reduced bile acid reabsorption.
What is a complication associated with Crohn’s disease?
Obstruction, fistula, colorectal cancer.
What is a complication associated with ulcerative colitis?
Risk of colorectal cancer is higher in UC than CD.
Where can lesions be seen in Crohn’s disease?
Lesions may be seen anywhere from the mouth to anus.
How does inflammation spread in ulcerative colitis?
Inflammation always starts at the rectum and never spreads beyond the ileocaecal valve.
What histological feature is common in Crohn’s disease?
Granulomas.
What histological feature is common in ulcerative colitis?
No inflammation beyond submucosa (unless fulminant disease).
What endoscopic appearance is associated with Crohn’s disease?
Deep ulcers, skip lesions - ‘cobble-stone’ appearance.
What endoscopic appearance is associated with ulcerative colitis?
Widespread ulceration with preservation of adjacent mucosa which has the appearance of polyps (‘pseudopolyps’).
What radiological sign is associated with Crohn’s disease?
‘Kantor’s string sign’ for strictures.
What radiological finding is associated with ulcerative colitis?
Loss of haustrations.
Which extra-intestinal manifestation is much more common in ulcerative colitis than in Crohn’s disease?
Primary sclerosing cholangitis.
What is ulcerative colitis (UC)?
Ulcerative colitis (UC) is a form of inflammatory bowel disease.
Where does inflammation in ulcerative colitis start?
Inflammation always starts at the rectum.
Does ulcerative colitis spread beyond the ileocaecal valve?
No, it never spreads beyond the ileocaecal valve.
What is the peak incidence age range for ulcerative colitis?
The peak incidence is in people aged 15-25 years and 55-65 years.
What are the initial symptoms of ulcerative colitis?
Symptoms include bloody diarrhoea, urgency, tenesmus, and abdominal pain, particularly in the left lower quadrant.
What is the preferred method for diagnosing ulcerative colitis?
Colonoscopy + biopsy is generally done for diagnosis.
What should be avoided in patients with severe colitis?
Colonoscopy should be avoided due to the risk of perforation; a flexible sigmoidoscopy is preferred.
What are typical endoscopic findings in ulcerative colitis?
Typical findings include red, raw mucosa that bleeds easily, no inflammation beyond submucosa (unless fulminant disease), and widespread ulceration with preservation of adjacent mucosa.
What is a characteristic feature of long-standing ulcerative colitis seen in a barium enema?
The colon appears narrow and short, described as ‘drainpipe colon’.
What are common extra-intestinal features of inflammatory bowel disease?
Common features include arthritis (pauciarticular, asymmetric), erythema nodosum, episcleritis, and osteoporosis.
Which extra-intestinal feature is most common in both Crohn’s disease and ulcerative colitis?
Arthritis is the most common extra-intestinal feature.
Which extra-intestinal feature is more common in Crohn’s disease?
Episcleritis is more common in Crohn’s disease.
What are extra-intestinal features unrelated to disease activity?
These include polyarticular, symmetric arthritis, uveitis, pyoderma gangrenosum, clubbing, and primary sclerosing cholangitis.
What is the risk of colorectal cancer in ulcerative colitis patients compared to the general population?
The risk of colorectal cancer is significantly higher than that of the general population, although studies report widely varying rates.
What is the main reason for the increased risk of colorectal cancer in ulcerative colitis patients?
The increased risk is mainly related to chronic inflammation.
How does the prognosis of ulcerative colitis patients compare to those without the condition?
Ulcerative colitis patients have a worse prognosis than patients without ulcerative colitis, partly due to delayed diagnosis.
What is a characteristic of lesions in ulcerative colitis?
Lesions may be multifocal.
What factors increase the risk of cancer in ulcerative colitis patients?
Factors include disease duration > 10 years, patients with pancolitis, onset before 15 years old, unremitting disease, and poor compliance to treatment.
How should colonoscopy surveillance be determined in inflammatory bowel disease patients?
Colonoscopy surveillance should be decided following risk stratification.
What is the follow-up for lower risk patients?
Lower risk patients should have a 5 year follow up colonoscopy if they have extensive colitis with no active endoscopic/histological inflammation, left sided colitis, or Crohn’s colitis of <50% colon.
What is the follow-up for intermediate risk patients?
Intermediate risk patients should have a 3 year colonoscopy if they have extensive colitis with mild active endoscopy/histological inflammation, post-inflammatory polyps, or a family history of colorectal cancer in a first degree relative aged 50 or over.
What is the follow-up for higher risk patients?
Higher risk patients should have a 1 year follow up colonoscopy if they have extensive colitis with moderate/severe active endoscopic/histological inflammation, a stricture in the past 5 years, dysplasia in the past 5 years declining surgery, primary sclerosing cholangitis, or a family history of colorectal cancer in first degree relatives aged <50 years.
What are common triggers for ulcerative colitis flares?
Most ulcerative colitis flares occur without an identifiable trigger. However, factors often linked include stress, medications, NSAIDs, antibiotics, and cessation of smoking.
How are flares of ulcerative colitis classified?
Flares are classified as mild, moderate, or severe.
What characterizes a mild flare of ulcerative colitis?
Fewer than four stools daily, with or without blood. No systemic disturbance. Normal erythrocyte sedimentation rate and C-reactive protein values.
What characterizes a moderate flare of ulcerative colitis?
Four to six stools a day, with minimal systemic disturbance.
What characterizes a severe flare of ulcerative colitis?
More than six stools a day, containing blood. Evidence of systemic disturbance, e.g., fever, tachycardia, abdominal tenderness, distension or reduced bowel sounds, anaemia, hypoalbuminaemia.
What should be done for patients with evidence of severe ulcerative colitis?
Patients with evidence of severe disease should be admitted to hospital.
What are the two main categories of treatment for ulcerative colitis?
Treatment can be divided into inducing and maintaining remission.
What are the classifications of the severity of ulcerative colitis?
The severity of UC is classified as mild, moderate, or severe.
What defines mild ulcerative colitis?
Mild: < 4 stools/day, only a small amount of blood.
What defines moderate ulcerative colitis?
Moderate: 4-6 stools/day, varying amounts of blood, no systemic upset.
What defines severe ulcerative colitis?
Severe: >6 bloody stools per day + features of systemic upset (pyrexia, tachycardia, anaemia, raised inflammatory markers).
What is the first-line treatment for mild-to-moderate proctitis?
Topical (rectal) aminosalicylate: rectal mesalazine is superior to rectal steroids and oral aminosalicylates.
What should be done if remission is not achieved within 4 weeks for mild-to-moderate proctitis?
Add an oral aminosalicylate.
What is the treatment approach for proctosigmoiditis and left-sided ulcerative colitis if remission is not achieved within 4 weeks?
Add a high-dose oral aminosalicylate OR switch to a high-dose oral aminosalicylate and a topical corticosteroid.
What is the treatment for extensive disease if remission is not achieved within 4 weeks?
Stop topical treatments and offer a high-dose oral aminosalicylate and an oral corticosteroid.
How should severe colitis be treated?
Severe colitis should be treated in hospital with IV steroids as first-line.
What should be considered if there is no improvement after 72 hours of treatment for severe colitis?
Consider adding IV ciclosporin to IV corticosteroids or consider surgery.
What is the maintenance treatment following a mild-to-moderate ulcerative colitis flare for proctitis and proctosigmoiditis?
Topical (rectal) aminosalicylate alone or an oral aminosalicylate plus a topical (rectal) aminosalicylate.
What is the recommended maintenance treatment for left-sided and extensive ulcerative colitis?
Low maintenance dose of an oral aminosalicylate.
What should be done following a severe relapse or >=2 exacerbations in the past year?
Oral azathioprine or oral mercaptopurine.
Is methotrexate recommended for the management of ulcerative colitis?
No, methotrexate is not recommended for the management of UC.
What evidence exists regarding probiotics in ulcerative colitis?
There is some evidence that probiotics may prevent relapse in patients with mild to moderate disease.
