INFLAMMATORY BOWEL DISEASE

Question 0

What is Crohn’s disease?

Answer 0

A chronic inflammatory GI disease characterised by transmural granulomatous inflammation affecting any part of the gut from mouth to anus.

Question 1

What is ulcerative colitis?

Answer 1

A relapsing and remitting inflammatory disorder of the colonic mucosa primarily affecting the colon and rectum.

Question 2

What are the two main parts of the GI tract affected by Crohn’s?

Answer 2

The terminal ileum and the proximal colon.

Question 3

What is the difference between ulcerative colitis and Crohn’s in terms of the spread of disease within the GIT?

Answer 3

Ulcerative colitis starts in the rectum and spreads proximally. Crohn’s can develop anywhere in the GIT and diseased areas are separated by areas of unaffected GIT (skip lesions).

Question 4

Which form of IBD is more associated with bloody diarrhoea? Crohn’s or ulcerative colitis?

Answer 4

Ulcerative colitis

Question 5

In ulcerative colitis, what might be mixed with the patient’s stool along with blood?

Answer 5

Mucus

Question 7

How might someone with suspected Crohn’s disease present? (Name at least 4 symptoms)

Answer 7

Abdominal pain
Diarrhoea
Urgency to go to the loo
Foul smelling diarrhoea 
Weight loss
Vomiting
Fever
Malaise
Anorexia
Mouth ulcers

Question 8

On examination, what are some of the signs associated with Crohn’s?

Answer 8

Clubbing
Tenderness
Mouth uclers
Right iliac fossa pain
Anaemia
Anal and perianal complications

Extragastro-intestinal features associated with CD:
Uveitis
Conjunctivitis
Athropathy
Arthralgia
Ankylosing spondylitis
Inflammatory back pain
Erythema nodosum
Pyoderma gangrenosum

Question 9

What do we call inflammatory bowel disease that cannot be definitively classified as either ulcerative colitis or Crohn’s disease?

Answer 9

Colitis of undetermined type and etiology (CUTE)

Question 10

In terms of epidemiology, what ethnic group is most prone to IBD?

Answer 10

Jewish people

Question 11

Which sex is more often affected by IBD?

Answer 11

Females

Question 12

How is age related to severity of inflammatory bowel disease?

Answer 12

It is thought that those who develop symptoms earlier in life will experience more aggressive and extensive disease

Question 13

What is the largest independent risk factor for development of IBD?

Answer 13

Having a family member with the disease

Question 14

How is hygiene related to Crohn’s disease?

Answer 14

Good domestic hygiene has been shown to be a risk factor for CD. A ‘clean’ environment may not expose the intestinal immune system to pathogenic or non-pathogenic mircoorganisms such as helminths which seems to alter the balance between effector and regulatory immune responses.

Question 15

How is smoking related to ulcerative colitis?

Answer 15

Smoking has been shown to be protective against ulcerative colitis. Non- and ex-smokers are more at risks of developing ulcerative colitis, whereas one trial has actually shown that nicotine can be an effective treatment.

Question 16

How is smoking related to Crohn’s disease?

Answer 16

Smoking is a risk factor for CD, and sufferers are more likely to be smokers. Smoking increases the risk of disease recurrence after surgery.

Question 17

How are NSAIDs related to inflammatory bowel disease?

Answer 17

NSAID ingestion is associated with both the onset of IBD and flares of disease.

Question 18

What psychological factors may be associated with inflammatory bowel disease?

Answer 18

Chronic stress and depression seem to increase relapses in patients with quiescent disease.

Question 19

How is a previous appendectomy related to the development of Crohn’s and ulcerative colitis?

Answer 19

Appendectomy may be protective for the development of UC. In contrast, appendectomy may increase the risk of development of CD.

Question 20

What do we call ulcerative colitis that affects only the rectum?

Answer 20

Proctitis

Question 21

What are the histological differences between inflammation and ulceration in Crohn’s disease and ulcerative colitis?

Answer 21

Inflammation is transmural in CD, whereas only the mucosa is affected in UC.

Question 22

Are granulomas more associated with Crohn’s disease or ulcerative colitis?

Answer 22

Crohn’s disease

Question 23

Are goblet cells more affected by Crohn’s disease or ulcerative colitis?

Answer 23

Goblet cells are depleted in ulcerative colitis

Question 24

Are crypt abscesses more associated with Crohn’s disease or ulcerative colitis?

Answer 24

They are seen in both but are more present in ulcerative colitis

Question 25

What type of polyp is associated with inflammatory bowel disease?

Answer 25

Inflammatory polyps or pseudopolyps. They are in general benign with no cancer potential.

Question 26

Are the granulomas associated with Crohn’s disease caseating or non-caseating?

Answer 26

Non-caseating epitheloid cell aggregates

Question 27

Are anti-neutrophil cytoplasmic antibodies (ANCA) more associated with Crohn’s disease or ulcerative colitis?

Answer 27

Ulcerative colitis

Question 28

Are anti-Sacchoromyces cerevisiae antibodies (ASCA) more associated with Crohn’s disease or ulcerative colitis?

Answer 28

Crohn’s disease

Question 29

What should form the rest of your differential diagnosis when presented with someone displaying the signs and symptoms of inflammatory bowel disease?

Answer 29

Infective causes of diarrhoea (eg C. difficile)
Behcet's disease
Diverticular disease
Ischaemic colitis
Gastrointestinal lymphoma
Carcinoma of the bowel
Irritable bowel syndrome
Ileocolonic TB is common in developing countries which makes a diagnosis of CD difficult.

Question 30

What are the extragastrointestinal manifestations of inflammatory bowel disease which affect the eyes?

Answer 30

Uveitis
Conjunctivitis
Episcleritis

Question 31

What are the extragastrointestinal manifestations of inflammatory bowel disease which affect the joints?

Answer 31

Type I (pauciarticular) arthropathy
Type II (polyarticular) arthropathy
Arthralgia
Ankylosing spondylitis
Inflammatory back pain

Question 32

What are the extragastrointestinal manifestations of inflammatory bowel disease which affect the skin?

Answer 32

Erythema nodosum

Pyoderma gangrenosum

Question 33

What are the extragastrointestinal manifestations of inflammatory bowel disease which affect the biliary tree and liver?

Answer 33

Sclerosing cholangitis
Fatty liver
Chronic hepatitis
Cirrhosis
Gallstones

Question 34

What are the anal and perianal complications of Crohn’s disease?

Answer 34

Fissure in ano
Haemorrhoids
Skin tags
Ischiorectal abscess
Fistula in ano (bladder, vagina)
Anorectal fistulae

Question 35

What investigations should be undertaken into someone with suspected Crohn’s disease?

Answer 35

Bloods tests (FBC, ESR, CRP, LFTs, pANCA)
Blood cultures
Stool cultures
Colonscopy
Upper GI endoscopy
Capsule endoscopy
Abdominal CT
Perianal MRI or Endoanal US

Question 36

What might blood tests in someone with Crohn’s reveal?

Answer 36

Anaemia - maybe normochromic/normocytic but can also be caused by iron or folate deficiency due to malabsorption. Interestingly B12 deficiency is rarely seen.

Raised ERS
Raised CRP
Raised WCC
Raised platelets
Hypoalbuminaemia
Liver biochemistry may be abnormal
pANCA will be negative

Question 37

When should colonoscopy not be performed in Crohn’s patients?

Answer 37

When colonic involvement is not suspected

In those presenting with severe disease

Question 38

What may be seen during colonoscopy of someone with Crohn’s disease with colonic involvement?

Answer 38

Vary from patchy superficial apthous ulceration to more widespread larger and deeper ulcers producing a cobblestone appearance.

Question 39

What may be seen in small bowel imaging of someone with Crohn’s disease?

Answer 39

Asymmetrical alteration in the mucosal pattern with deep ulceration and areas of narrowing or stricturing.

Question 40

What is toxic megacolon?

Answer 40

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