Inflammatory Bowel Disease Flashcards
What does IBD stand for?
Inflammatory Bowel Disease
IBD includes conditions such as ulcerative colitis and Crohn’s disease.
What is the aetiology of IBD?
Unknown, occurs in genetically susceptible individuals with an inappropriate immune response to gut flora. There is an inflammatory response and there is failure of protective mechanisms from the Paneth cells which produce alpha-defensin, mucus production by goblet cells and the intercellular junctions in the intestinal epithelia. IgM, IgA and IgG will be ielevated
Tobacco is a strong risk factor for Crohn’s disease but protective in ulcerative colitis.
What age group is typically affected by IBD?
15 to 30 years old
What are common symptoms of IBD?
Diarrhoea Occurring at night , abdominal pain, tenesmus, tachycardia, anxiety, fever, dehydration
What is a key diagnostic marker for intestinal inflammation in IBD?
Faecal calprotectin which is a marker for increased neutrophils in intestine, pointing to intestinal inflammation
Which imaging techniques are used for diagnosing IBD?
Ultrasound, MRI for fistula, CT scan for perforation, wool obstruction or strictures
What is a colic stricture?
Narrowing of the colon
Describe the inflammation pattern of ulcerative colitis.
Superficial inflammation beginning in the rectum and travels up the sigmoid colon. Onset has a bmiodal pattern between 15-300 and 50-70. There is increased risk with appendectomy prior to age 20. Tobacco is a protective factor.
What is the lead pipe appearance associated with?
Ulcerative colitis due to loss of haustra markings
What is pancolitis?
Inflammation of the entire colon in ulcerative colitis
List some extraintestinal manifestations of ulcerative colitis.
Non-deforming asymmetrical arthritis”
“ Aphthous stomatitis”
* Erythema nodosum”
“* Primary sclerosing cholangitis”, “* Ankylosing spondyloarthropathy”,
Toxic megacolon”]
What is primary sclerosing cholangitis?
bile ducts of liver become scarred which increases the risk of colorectal cancer
What is ankylosing spondylarthropathy?
inflammation of the joints and ligaments of the spine spine, which worsens with rest and is partially bad at night. There may be dyspnoea, fatigue, loss of appetite and weight loss
What is toxic megacolon?
Dilation of colon greater than 6cm due to inflammation that causes thinning of colonic walls and deep ulcers. There is acute trans ray inflammation of colon with necrosis and granulation tissue filled with inflammatory cells. They typically represent with diarrhoea, malaise and abdominal pain and distention. There is a risk of bowel perforation and peritonitis, resulting in fever, abdominal pain, hypotension and confusion
What is used to assess disease severity in UC?
Simple clinical colitis activity index.
What are the criteria for suspecting ulcerative colitis?
[”* Bloody diarrhoea persisting more than 6 weeks”, “* Faecal urgency and/or incontinence”, “* Nocturnal defecation”, “* Tenesmus”, “* Abdominal pain in LEFT LOWER quadrant”, “* Weight loss or delayed puberty in children”]
What are the positive examination findings for Crohn’s disease?
[”* Pallor”, “* Clubbing”, “* Abdominal tenderness”,
Aphthous sotomatitis
Diarrhoea more than 4-6 weeks
Hepatobiliary manifestation with
Jaundice
Nocturnal defaecation
Pain in right LOWER quadrant
Pre-defaecation pain
Gradual onset and periods of remission adn relapse
Worsened by smoking cessation
Worsened by NSAIDs
“* Perianal skin tag/fistula”, “* Signs of malnutrition”]
How does partial bowel obstruction present?
abdominal colicky pain, distention and diarrhoea
How does complete bowel obstruction present?
severe abdominal pain, vomiting, complete constipation and no flatus (wind)
What are the findings for endoscopy in ulcerative colitis?
Endoscopy will show fragile or ganloar mucosa, with loss of vascular pattern and erosions and pseudo polyps
2 Biopsy from at least five different sites of the bowel, including the ileum and rectum
What are the histologies features of ulcerative colitis?
mucus depletion, villous surface irregularity, crypt atrophy and basal plasmocytosis.
What is fulminant colitis?
more than 10stools a day, with continuous bleeding, abdominal pain, distention and fever and weight loss.
What is the typical presentation of Crohn’s disease?
Frequent diarrhoea, faecal urgency, abdominal pain or discomfort
What is the significance of the accordion sign in CT imaging?
Indicates colonic wall thickening Accordion sign is where the contrast appears trapped between the mucosal folds due to colonic wall thickening.
What does target sign indicate?
hyperaemia of mucosa
Which imaging type is not reccomended for ulcerative colitis?
colonoscopy
What are the diagnostic criteria for toxic megacolon?
[”* Radiographic evidence of dilation greater than 6cm”, “* At least three of the following: fever, heart rate >120, neutrophilic leukocytosis, anemia”, “* At least one of the following: dehydration, altered sensorium, electrolyte disturbances, hypotension”]
What is the presentation of toxic megacolon?
toxic megacolon present with severe abdominal pain, fever, chills, lethargy and abdominal distention and tachycardia.
What are the complications of toxic megacolon?
bowel rupture, peritonitis and abscess and abdominal compartment syndrome.
What is the initial treatment of toxic megacolon?
Initial: hydration, antibiotics and replacement of electrolytes. FBC, imaging, and correcting electrolyte disturbances like hypokalemia. If peritonitis is present, metronidazole or vancomycin should be use
How is c.diff infection treated?
Clostridium difficle infection: treat with vancomycin or fidaxomicin.
-> fidaxomicin inhibits RNA polymerase for transcription
-> vancomycin is a glycopepetide which is given for gram positive bacteria infection, preventing peptide subunits being incorporated into peptidoglycan cell wall.
What is a Hartmann pouch?
blind limb loop of sigmoid colon and rectum. This is formed when resection of part of the colon and joining the upstream end of the colon to the skin surface and the downstream end to a bind loop of a sigmoid colon and rectum which is theHartmann pouch.
What is the first-line treatment for mild to moderate ulcerative colitis?
Topical RECTAL aminosalicylate agents like mesalazine It inhibits inflammation by blocking cyclooxygenase and inhibiting prostaglandin production
What is second line for ulcerative colitis?
mesasalazine wit corticosteroid budenoside steroid which has significant first pass metabolism that reduces side effects
What is 3rd line for ulcerative colitis?
immune modifying drugs like Azathriopine and methotrexate
What is 4th line for ulcerative colitis?
hearin
Nicotine patch
Butyrate enema
What is the alast resort for ulcerative colitis?
Etrasimod can be used as last resort for acute severe disease, which is a selective sphingosine 1-phosphate receptor modulator which prevents movement of lymphocytes out of lymph nodes
What is the rescue therapy for ulcerative colitis?
immunosuppressant like Ciclosporin or infllximab
What is the treatment for acute severe UC?
IV corticosteroids
What are the surgical options for managing ulcerative colitis?
[”* Colectomy”, “* Panproctocolectomy which is removal of the entire rectum, anal canal and the whole colon and sewing up the back passage. The small bowel is bought out to the skin to form a stoma, known as an ileostomy wih inch is permanent..”* Ileostomy”]
What is the role of corticosteroids in the management of ulcerative colitis?
Used for moderate to severe disease and acute severe disease
Fill in the blank: Etrasimod is a selective _______ receptor modulator.
sphingosine 1-phosphate
List some extraintestinal manifestations of Crohn’s disease.
[”* Uveitis”, “* Nephrolithiasis”, “* Aphthous stomatitis”, “* Primary sclerosing cholangitis”, “* Erythema nodosum”, “* Ankylosing spondyloarthropathy”]
What complications are associated with toxic megacolon?
[”* Bowel rupture”, “* Peritonitis”, “* Abscess”, “* Abdominal compartment syndrome”]
What should be avoided during the treatment of ulcerative colitis due to the risk of toxic megacolon?
Anti-stool drugs like loperamide
What is the recommended surveillance for patients with ulcerative colitis?
Surveillance colonoscopy every 1-2 years for high-risk patients
What is the definition of colectomy?
Removal of a portion of the colon
What lifestyle changes may be recommended for patients with IBD?
Monitoring for skin malignancies, vaccinations against flu and herpes, depression screening
What is the bimodal distribution age range for Crohn’s disease?
15-30 years and 40-60 years
years
What is a key risk factor for the development of Crohn’s disease?
Tobacco use
What is the clinical presentation of Crohn’s disease?
Right LOWER quadrant pain Due to ileocaecal involvement and relieved by defaecation
Colicky pain
,weight loss, low-grade fever, non-bloody diarrhoea
What is the appearance of the mucosa in Crohn’s disease?
Cobblestone appearance due to ulcers. transmural ifnlammation with lymphocytic infiltrate skip lesions from mouth to anus, and a key risk factor is tobacco and there is risk of fistula formation, strictures and ifnlammation
What can fistula lead to?
Fecaluria: and Pneumaturia gas in urine due to vesico-colic fistula between bowel and bladder and Rectovaginal fistula.
What are common upper GI symptoms of Crohn’s disease?
Vomiting, nausea, and epigastric pain
What should be assessed during a rectal examination in Crohn’s disease?
Fistula formation, skin tags, abscess
What is fecaluria?
Gas in urine due to vesico-colic fistula between bowel and bladder
What mass in the right lower quadrant may indicate?
Abscess
What are symptoms of malabsorption in Crohn’s disease?
Steatorrhoea, anaemia from B12 insufficiency, clubbing
What are complications of Crohn’s disease?
Small bowel obstruction, abscess formation, fistula, perforation, colon cancer
What factors indicate a poor prognosis for Crohn’s disease?
Age below 40, steroids needed at first presentation, perianal disease, smoking, isolated terminal ileitis
What antibodies may be elevated in Crohn’s disease?
Perinuclear antineutrophilic cytoplasmic antibodies, anti-saccharomyces cerevisiae antibodies
What is the Crohn disease activity index (CDAI) used for?
To predict disease stage
What is the Harvey-Bradshaw index?
A tool used to assess Crohn’s disease severity
What laboratory tests are included in the diagnosis of Crohn’s disease?
FBC, stool sample, X-ray, CT scan, MRI, upper endoscopy, colonoscopy
What might a stool sample reveal in Crohn’s disease diagnosis?
Infective organisms
What does an upper endoscopy show in Crohn’s disease?
String sign of Cantour where there lumen in the terminal ileum is narrowed
What does colonoscopy reveal in Crohn’s disease?
Cobblestone mucosa, rose-thorn ulcers
What is the first line management for Crohn’s disease?
Oral mesalazine once a day
What is second line for Crohn’s?
Mesalazine with corticosteroid
What is 3rd line for Crohn’s?
immune modifying drugs like Azathriopine
Progression to methotrexate
What should be assessed before administering immune-modifying drugs?
Thiopurine methyltransferase activity which is an indicator of bone marrow activity. CXR and PPD test to assess for latent tuberculosis
What is the 4th line for Crohn’s?
thalidomide and interleukin-11
What is the role of thalidomide in Crohn’s disease treatment?
Fourth line treatment
Why is the PPD test performed prior to biological therapy?
To assess for latent tuberculosis
What vaccines are recommended for patients with Crohn’s disease?
Tetanus, hepatitis, COVID, flu
What is the typical indication for surgical management in Crohn’s disease?
Surgical management is rarely curative because disease can occur anywhere in the GI tract. Bowel obstruction from fibrostensosis, fistulisation, recurrent abscess
How is a fistula assessed?
digital rectal examination and proctoscopy should be performed to assess the mucosa. Anal fistulas can be treated with a seton, a thin rubber drain to been the fistula tract open and prevent abscess formation. The fistula can be removed, known as laying open where the probe is passed through the tract and overlying tissues are divided with a knife.
How is a perianal fistula managed?
Fistulostomy
What is the treatment for a perianal abscess?
Intravenous antibiotics with metronidazole and ceftriaxone
What common deficiencies are associated with Crohn’s disease?
Vitamin B12, vitamin D, iron
What is the initial management of Crohn’s flare up?
IV hydration, electrolyte replacement, IV steroids, prophylactic thromboembolism
What is the risk associated with anti-diarrhea drugs in Crohn’s disease?
Toxic megacolon
What is the goal of ‘treat to target’ in IBD?
To reduce risk of future relapse or complications, including mucosal healing
What should be assessed during a flare-up of Crohn’s disease?
BMI for malnutrition, serum C-reactive protein, fever, dehydration, tachycardia, hypotension
What type of vaccines are contraindicated in IBD due to immunosuppressive therapy?
Live vaccines
What examination should be performed to assess anal fistula in IBD?
Digital rectal examination and proctoscopy
What is a seton in the context of anal fistula treatment?
A thin rubber drain to keep the fistula tract open
What does the Goods all rule predict?
The trajectory of a fistula tract based on the location of the external opening.
Posterior to transverse anal linemen as it will follow a curved course to the posterior midline
Anterior to transverse anal line: fistula will have a straight radial course to the dentate line
What are complications of fistulotomy?
Damage to anal sphincter complex, recurrence, anal stenosis, delayed wound healing
