Inflammatory Bowel Disease Flashcards
What is IBD comprised of?
Ulcerative colitis and Crohn’s Disease
What is the difference between UC and CD?
UC: mucosal inflammatory condition, confined to rectum and colon
CD: transmural inflammation of GI tract, can affect any part of the GI tract
What is UC?
chronic dz charactierized by diffuse mucosal inflammation limited to the colon. Pathogenesis poorly understood, abnormality of primary immune control. Inflammation limited to mucosa in a CONTINUOUS pattern. Affects ONLY distal colon and rectum, may extend proximally in a symmetrical, circumferential, uninterrupted pattern.
What are the sx of UC?
Pt usually presents w/D which may be assoc. w/blood. BMs small and frequent, often with colickly abdo pain, rectal urgency, tenesmus and incontinence. Severe: fever, anorexia, weight loss. course: chronic, recurrent, unpredictable. Inc. CA risk is UC >7-10 years
How is UC diagnosed?
stool examinations and sigmoidoscopy or colonoscopy and biopsy to confirm presence of colitis and r/o infectious and non-infectious etiologies - reveals mucosal changes consisting of loss of typical vascular pattern, granularity, friability and ulceration. (pANCA - perinuclear antineurophil cystoplasmic antibodies but also in pts w/CD)
How is severity of UC characterized?
mild: 4 or less/day, +/- blood, no signs of systemic toxicity, normal ESR, mild crampy symptoms; mod: >4/day loose bloody stools, mild anemia, and non severe abdo pain, minimal signs of systemic toxicity (low grade fever), adequate nutrition usually maintained; severe: frequent loose blood stools (>/= 6 per day) w/severe cramps and evidence of systemic toxicity.
What are some acute complications of UC?
severe bleeding, fulminant colitis and toxic megacolon, perforation. Extraintestinal manifestations.
What are the general principles of treatment for UC?
disease location, severity, complications (fistulas, toxic megacolon), patient response (prior symptomatic response, tolerance), therapy sequential (treat acute dz, maintain remission)
What if the dz is limited to distal (below the descending colon)?
distal means topical therapy
What if the disease extends proximally?
proximal means systemic therapy
Next to severity of inflammation needs to be determined mild, moderate, severe or fulminant?
mild, moderate or severe
fulminant: >10 stools/day, continuous bleeding (requiring transfusion), toxicity, ab tenderness and distention and colonic dilation.
What is the non-pharm management of UC?
psychological support. Nutritonal measure: no diet improves or exacerbates UC. Reduce dietary fiber during exacerbation. Folic acid (1mg/day) when leafy veggies restricted or sulfasalazine being used. Oral iron if anemia or considerable rectal bleeding. Metamucin 1-2 times/day for mild diarrhea during remissions.
How do you treat mild to moderate distal UC?
Oral aminosalicylates, topical mesalamine or topical steroids. Topical mesalamine superior to topical steroids or oral aminosalicylates. Combo or oral aminosalicylates and topical superior to EITHER alone. Refractory to oral aminosalicylates or topical steroids may still respond to topical mesalamine. Unusualy pt refractory to all may require PO prednisone or Infliximab.
How do you maintain remission in distal UC?
Mesalamine suppositories - proctitis; Mesalamine enemas - distal colitis. Oral aminosalicylates or comob or PO and topical agent (again better efficacy to combine). If fail w/both topical and PO then Thiopurines or Infliximab may prove effective.
How do you treat mild to moderate extensive UC?
Oral Aminosalicylate: Sulfasalazine, Mesalamine
Refractory: oral steroids in combo w/topical. if resistant to PO steroids, thiopurines or infliximab.
Resmission maintenance: PO aminosalicylates, thirpurines may be useful as steroid sparing agents if remission not maintained by PO aminosalicylates, infliximab if patient required it for induction of remission.
Treatment for Mild-moderate UC
Sulfasalazine 4-6 g/day -OR-
Mesalamine 4.8g/day -OR-
Aminosalicylate at dose equivalent to mesalamine 4.8g/day -OR-
if distal dz: Mesalamine enema/suppository, corticosteroid enema
Remission: reduce dose by half -OR-
with enema/suppository: reduce frequency to q1-2 days
How do you treat severe UC?
PO prednisone, oral aminosalicylates and topical meds. If refractory: infliximab if urgent hospitalization not required. Hospitalization required: IV steroids. Failure to respond w/in 5 days infication for colectomy or tx w/cyclosporine
Remission: enhanced by addition of 6-MP, Infliximab may also be effective in avoiding colectomy
Treament of severe UC continuted
Sulfasalazine 4-6g/day -OR-
Mesalamine 3-6 g/day PLUS Prednisone 40-60 mg/day
Resmission: taper pred, then reduce sulfasalazine or mesalamine after 1-2 mos. to approx. half
Refractory: add Azathioprine or Mercaptopurine (6-MP) -OR-
consider Inflixiamb if no response
How do you treat fulminant UC?
treated as severe. Kept NPO. Broad spectrum abx. Generally colectomy required
Treatment for severe or fulminant UC?
Hydrocortisone 100mg IV q6-8 hrs
Remission: change to pred, add sulfasalazine or mesalamine. If no response in 5-7 days: Cyclosporine IV 4mg/kg/day, TNF alpha blocker, moniclonal antibodies, if no response patient candidate for colectomy
Can surgery cure UC?
yes! High-grade dysplasia, suspected CA. Pts w/severe dz, requiring high-dose steroids that can’t be tapered after 6-12 mos. Exsanguinating, hemorrhage, perforation
What is the maintenance for UC?
Aminosalicylates and/or AZA or 6-MP. Alternatie Infliximab 5mg/kg q8 weeks
What is Crohn’s disease?
Autoimmune pathophysiology. Can affect ANY segment of the GI tract. Inflammation occurs throughout the full thickness of the bowel wall (not just mucosa like UC), SKIP pattern; strictures, fistulas and ulcers
What are the symptoms of CD?
D and abdo pain = cardinal sx. fever, perianal discomfrot, bleeding, arthralgias = common complaints. Extra-intestinal manifestations.
What are some etiologies of CD?
Infectious: viral, bacterial, mycobacteria, chlamydia
Genetics: 1st degree have higher risk, metabolic defect, connective tissue disorder
enviro: diet, smoking
immune defects: altered host susceptibility, immune mediated, mucosal damage
pshycological: stress?, emotional/physical trauma, occupational
What are some infectious factors that cause CD?
increase in pathogenic bacterai: Bacteroides, E. coli
Dec. beneficial bacteria: Bifidobacterium, Lactobacillus species
What are some immunological factors that cause CD?
CD pts usually have impaired immune response. Trauma of skin or intestine: dec. blood flow to site in pts wtih CD vs. non-CD pts, dec. neutrophils and IL-8 accumulation at injury site
What are some environmental factors that cause CD?
Luminal bacteria: aberrant immune response to enteric flora; diet: dietary antigens contribute to inflammation; smoking: protective for UC (negative correlation), more aggressive dz in CD (inc. in flares)
