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Gen Med: GI > Inflammatory Bowel Disease > Flashcards

Inflammatory Bowel Disease Flashcards

1
Q

What is IBD?

A
  1. Autoimmune disease of the gastrointestinal (GI) tract characterized by
    - Mucosal inflammation
    - Recurrent diarrhea & abdominal pain
  2. Chronic & relapsing
  3. Idiopathic
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2
Q

What is ulcerative colitis?

A
  • Affects colon & rectum
  • Diffuse mucosal inflammation
  • Involves the rectum ≈ 95% of cases
  • Extends proximally in continuous pattern
  • Rarely involves anus
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3
Q

What is Crohn’s Disease?

A
  • Can involve any part of GI tract (mouth to anus)
  • Transmural inflammation
  • Most commonly affects ileum & proximal colon, extends distally
  • Interrupted or “skip lesions”
  • Perianal involvement
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4
Q

IBD Associated Comorbidities

A 
Gallstones 
Malnutrition
UTI 
Kidney stones 
Amyloidosis
Arthritis 
 Uveitis
Episcleritis
Aphthous stomatitis
Erythema nodosum 
Pyoderma gangrenosum 
(red-blue pus containing sores)
Ankylosing spondylitis
Sacroiliitis
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5
Q

Differential Diagnosis : IBD

A
  1. Irritable bowel syndrome (IBS)
    A. GI syndrome characterized by chronic abdominal pain & altered bowel habits w/out organic cause
    B. NOT associated w/ inflammation
  2. Celiac disease (aka celiac sprue or gluten-sensitive enteropathy)
    A. Small-bowel disorder characterized by mucosal inflammation, villous atrophy & crypt hyperplasia
    B. Sx’s occur w/ingestion of dietary gluten
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6
Q

Crohn’s Disease: Etiology/Pathogenesis

A
  1. Idiopathic
  2. Disruption of immune homeostasis of intestine
    (→ overreacts to environmental, dietary, infectious agents)
  3. Hereditary predisposition
  4. Edema w/ linear ulcerations of mucosal surface
    (“Cobblestoning”)
  5. Noncaseating granulomas - pathognomonic
  6. High risk for
    a. Scarring
    b. Obstruction
    c. Penetrating ulcers
    d. Abscesses
    e. Fistulas
  7. Hypercoagulable state
    -Stroke, retinal thrombus, DVT, PE
  8. Extra-intestinal manifestations
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7
Q

Signs & Symptoms : Crohn’s Disease

A
  1. Chronic diarrhea
  2. (+) blood if Crohn’s colitis
  3. Crampy abdominal pain
  4. Fever
  5. Anorexia
  6. Wt loss
  7. Fatigue
  8. Anemia
  9. Sx’s wax & wane
    - “Flares” mild/brief → severe/prolonged
  10. N/V w/ partial or complete bowel obstruction
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8
Q

Differential Diagnosis : Crohn’s Disease

A
  • Appendicitis
  • Diverticulitis
  • IBS
  • UC
  • Bacterial/viral gastroenteritis
  • Food poisoning
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9
Q

Diagnostic Studies : Crohn’s Disease

A
  1. Stool guaiac
  2. CBC w/ diff
    a. Microcytic/hypochromic
  3. B12, Fe, TIBC, folate
    -↓ Iron
    -↓ B12
  4. Stool for WBC, O&P, C. diff, Cx
  5. ↑ ESR
  6. ↑ CRP
  7. CMP
    -↓ Albumin
  8. (+) ANCA (Anti-Saccharomyces CerevisiaeAb)
  9. (-) pANCA (Perinuclear Anti-Neutrophil Cytoplasmic Ab)
  10. KUB
    a. Air-fluid levels (obstruction), pneumoperitoneum (perforation)
  11. CT abdomen/pelvis (procedure of choice)
    a. Dx Crohn’s (“string sign” in terminal ileum) & manage abscesses
    b. Wall thickening, abscess
  12. Barium enema
    a. Fistula, inflammation, skip lesions
  13. UGI w/SBFT
    a. Inflammation, stricture
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10
Q

Where does crohns disease start?

A

In the terminal ilieum

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11
Q

Ulcerative colitis starts?

A

in the rectum (progresses proximal through the rectum), never effects the small bowel, mucosal surface (more superficial)

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12
Q

String Sign

A
  1. Seen on CT w/contrast or UGI w/SBFT

2. Narrowing & stricturing in terminal ileum

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13
Q

Medical Management : Crohn’s Disease

A
  1. Step I
    a. Acute/maintenance
    b. Aminosalicylates – Asacol/Lialda/Pentasa/Rowasa/Apriso (mesalamine), Azulfidine (sulfasalazine) PR
  2. Step I-A
    a. Antibiotics – Metronidazole (Flagyl) or Ciprofloxacin (Cipro) prn fistula/abscess
  3. Step II
    a. Corticosteroid – Solu-Medrol/Cortef IV, Prednisone PO, Cortenema (Hz) enema PR,
    b. Entocort EC (budesonide) PO or PR prn exacerbation
  4. Step III
    a. Immune modifiers – Imuran (azathioprine), methotrexate, cyclosporine
    b. Use if difficult to maintain remission w/ aminosalicylates alone
  5. Step III-A
    a. TNF inhibitors – Remicade (infliximab), Humira (adalimumab)
  6. Hospital Admission
    a. Failed OP Tx
    b. Dehydration
    c. Uncontrolled diarrhea/pain
  7. Speciality consultation prn
    a. Extra-intestinal manifestations
    b. Surgical indications
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14
Q

Symptomatic treatments: Crohn’s Disease

A
  • Antidiarrheal agents – Lomotil
  • Antispasmodic agents - Bentyl
  • Bile sequestrants – Questran
  • Antispasmodics – Bentyl, Levbid
  • Acid suppressants – H2 blockers, PPI’s
  • Parenteral nutrition if severe
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15
Q

Surgical Management : Crohn’s Disease

A
  1. Therapeutic
    a. Not curative - high recurrence
    b. Mostly for complications (strictures, fistulas, bleeding, abscess, dysplasia/CA)
    - CT percutaneous abscess drainage has shown great success w/↓ rate of recurrence, as compared to surgery
    c. Segmental resection w/ re-anastomosis
    d. Stricturoplasty
    e. Diverting ileostomy/colostomy (severe perianal disease allowing healing for 6-12 mo)
    f. Fistula resection
    g. Perirectal abscess drainage
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16
Q

Emergency Management : Crohn’s Disease

A
  1. Steroids
  2. Bowel rest
  3. NG suction
  4. IV hydration
    a. Electrolytes prn
  5. Surgical consult & admission
    a. Toxic
    b. Obstruction
    c. Hemorrhage
    d. Peritonitis
17
Q

Maintenance/Prevention : Crohn’s Disease

A
  1. Diet
    - Low residue
    - Lactose avoidance if intolerant
  2. Sitz baths/soap & water after stooling if perianal sx
  3. Dietary supplements
    - Probiotics, Ca/Vit D if steroid use
    - Vit A, D, E, K, Fe, folic acid if taking sulfasalazine
  4. Psych support
18
Q

Morbidity & Mortality : Crohn’s Disease

A
  1. Prognosis
    - 10% w/prolonged remission
    - 75% w/chronic intermittent Dz
    - 12% w/unremitting Dz
  2. Obstruction occurs in 20-30% of cases
  3. Intestinal perforation in 1-2% of cases
  4. Fistulas w/ abscess in 50% of cases
  5. GI cancer (Adenocarcinoma)
    - Leading cause of mortality in Crohn’s Dz
    - Occurs in small & large intestine in areas of chronic Dz
19
Q

What is ulcerative colitis?

A

Chronic inflammation & ulcerative disease of colonic mucosa & submucosa

Main sx of active disease is usuallydiarrheamixed w/ blood

Gradual onset

Systemic diseaseaffecting many parts of the body

20
Q

Epidemiology : UC

A
  1. Affect as many as 700,000 Americans
  2. M = W
  3. Most people Dx’d in mid-30’s
  4. Older men > older women
  5. Tends to run in families, but no clear pattern of inheritance
  6. ↑ Risk
    a. European caucasians
    b. Jewish heritage
21
Q

Cause of UC

A
  • Undetermined etiology
  • Autoimmune inflammatory colitis
  • Usually begins in rectum, may remain there or spread proximally
  • Severe disease causes large ulcers & purulent exudate
  • Pseudopolyps or hyperplastic tissue growth at sites of previous ulceration
  • Stricture formation
  • 10-20% develop adenoCA after 10 yr
22
Q

Signs & Symptoms : UC

A
  1. Exacerbations alt. w/remissions
  2. Bloody diarrhea
  3. Absent or minimal pain
  4. Fatigue
  5. Urgency to defecate
  6. Mild lower abdominal cramping
  7. Mucus &/or blood in stool
  8. May follow intestinal infection
  9. Loose/frequent (≥ 10) stools/day
  10. Tenesmus
  11. Systemic sx’s w/ severe disease
    a. Malaise, fever, anemia, anorexia, wt loss
23
Q

Diagnostic Studies : UC

A
  1. (+) pANCA (Perinuclear Anti-Neutrophil Cytoplasmic Ab) > 45% of cases
  2. (-) ANCA (Anti-Saccharomyces CerevisiaeAb)
  3. Stool guaiac
  4. CBC w/ diff
    a. Microcytic/hypochromic anemia
  5. Stool for WBC, O&P, C. diff, Cx
  6. ↑ ESR
  7. CMP
    a. ↓ Albumin , ↓ K, ↓ Mg, ↓ Ca
  8. Imaging generally not indicated
    a. Barium enema w/ rectal involvement, “stove-pipe” appearance due to loss of haustrae
    b. UGI w/SBFT if unable to perform complete BE due to stricture
    c. CT w/o abscesses or fistulas

Colonoscopy w/ Bx when not acute

24
Q

Medical Management : UC

A
  1. Tx acutesymptoms w/ goal to induce remission, then maintain
  2. Anemia often requires the use ofparenteral iron
  3. Low residue diet
  4. Correct nutritional deficiencies
    a. Folic acid
    b. TPN w/ bowel rest if severe
  5. Step I- Aminosalicylates
    a. Acute/maintenance
    b. Asacol/Lialda/Pentasa/Rowasa/Apriso (mesalamine) PO or PR, Azulfidine (sulfasalazine) PR, Dipentum (olsalazine) PO, Giazo/Colazal( balsalazide) PO
  6. Step II-Corticosteroid
    a. Solu-Medrol/Cortef IV, Prednisone PO, Cortenema (Hz) enema PR, Entocort EC (budesonide) PO or PR prn exacerbation
  7. Step III-Immunosuppressive drugs
    a. Mercaptopurine ( Purinethiol), Azathioprine (Imuran) ,Methotrexate (inhibitsfolic acid)
  8. Step IV-TNF inhibitors
    a. Infliximab (Remicade)

Those with less severe disease but do not respond to IV steroids w/in 7–10 days should be considered for colectomy or IV cyclosporine

25
Q

Hygiene Hypothesis

A
  1. Low incidence of autoimmune Dz in less developed countries
  2. ↑ autoimmune Dz in industrialized countries
  3. Suggests helminthic infections protect individuals from developing autoimmune Dz
  4. Helminthic therapy
    a. Inoculationof pt w/ specific parasitic intestinalhelminths
    b. Experimental Tx to reduce the severity of autoimmune response in IBD
26
Q

Dietary Recommendations: UC

A 
1. Lactose intolerancecommon in UC
a. Lactose breath hydrogen test
 b. Ca  supplement to avoid bone loss
2. If (+) cramping or diarrhea 
a. Avoid fresh fruit, caffeine, carbonated drinks, high fructose corn syrup &sorbitol
3. ”Specific Carbohydrate Diet”
a. Avoid disaccharides& polysaccharides 
b. Monosaccharides allowed

Gen Med: GI (9 decks)

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