Inflammatory Bowel Disease Flashcards
What two conditions come under the umbrella term of inflammatory bowel disease?
Crohn’s Disease and Ulcerative colitis
What is a good way to think about inflammatory bowel disease?
Think of IBD as a spectrum.
Overlap between Crohn’s and Ulcerative colitis and can be hard to distinguish
What is the Montreal Classification?
Classifies people on age, location, behaviour, extent and severity so that you can best treat their disease.
What is the aetiology of IBD?
Basically it is unknown
Environmental trigger as IDB used to be unheard of in the east but incidence has shot up now as people adopt a western lifestyle.
-Role of bacteria, Diet, vaccination history, social factors
Possibly genetically susceptible people.
Candidate gene identified NOD2.
What is the epidemiology of Ulcerative colitis?
VERY common
Can affect any age but peak incidence is 20-40 (when your most active in society)
More common in females
Local incidence 11.3 per 100,000
How do people with ulcerative colitis present?
Bloody diarrhoea
Abdominal pain
Weight loss
What is the difference between Crohn’s disease and UC in terms of location where they effect?
UC = Large intestine is the only affected site.
Disease starts at rectum and moves proximally.
Inflammation is continuous along the affected areas length
Crohn’s = Inflammation may occur in any part of the GI tract.
Inflammation may occur in patches
What is the difference in pain location in UC and Crohn’s?
UC common in lower left abdomen
Crohn’s common in lower right
How does the appearance of Uc and Crohn’s differ?
UC = Colon wall is thinner and shows continuous inflammation.
Mucosal layer may have ulcers but these do not extend beyond the inner lining.
Crohn’s = Wall may be thickened and may have a rocky appearance.
Ulcers along the digestive tract are deep and may extend through all layers of the bowel wall.
How does bleeding differ in Crohn’s and UC?
Crohn’s bleeding from the bowel through the rectum is not common.
UC = Bleeding through the rectum during bowel movements
What percentage of UC patients go on to have surgery?
3% at first attack
8% at 5 years
What are the clinical markers of a severe UC attack?
Stool frequency > 6 a day with blood
PLUS 1 of: Fever >37.5 Tachycardia >90 ESR raised Anaemia Hb
What is leucocytosis?
Increase in the number of WBC’s in the blood
What is thombocytosis?
The production of too many platelets
What is the epidemiology of Crohn’s disease?
M = F
Two peaks:
-Early adulthood (20-40)
-Over 60s (F>M)
Incidence 8.5 per 100,000
Why do the clinical features of patients suffering from Crohn’s disease differ?
Clinical features depend on the regions involved
Very difficult to predict how it will present
Why can fistula’s occur in crown’s disease?
Ulceration occurs all the way through the wall so Crohn’s can lead to fistula.
What are the clinical features of Crohn’s Disease?
Diarrhoea Abdominal Pain Weight loss Malaise, lethargy, anorexia Nausea and Vomiting Low grade fever Malabsorption -Anaemia, vitamin deficiency
What are the complications of crown’s disease?
Inflammation
Stricture
Fistula
What can you use to detect inflammation in IBD?
High ESR and CRP High Platelet count High White Cell Count Low Hb Low Albumin
What are the histological differences between UC and CD?
Granulomas in Crohn’s Disease (hard to find)
Goblet cells depleted in UC
Crypt accesses: UC > CD
Fistulae and peri-anal disease are present in which form of IBD?
Crohn’s Disease
Give some examples of extra-intestinal manifestations of IBD
Eyes: conjunctivitis
Joints
Renal calculi (CD only)
Liver and biliary tree (fatty change, sclerosing cholangitis, gallstones)
Skin (Erythema nodosum, vasculitis)
What is the differential diagnosis of IBD?
Chronic diarrhoeas
- Malabsorption
- Malnutrition
Ileo-caecal TB
Colitis must be distinguished from
-Infective, amoebic and ischaemic colitis
What is Sclerosing Cholangitis?
Disease of the bile ducts
Multiple strictures
Slowly progressive, can lead to cirrhosis
Colon cancer bigger risk if IBD and Sclerosing cholangitis
What is the complication of long term colitis?
Colonic Carcinoma
Extent and Duration significantly increases risk
How do you monitor patients who are at risk of progressing from chronic colitis to cancer?
Surveillance colonoscopy
- Extensive colitis
- –8-20 yrs (3 yearly)
- –30-40 yrs (2 yearly)
- –40+ years (annually)
What is the medical management of outpatient IBD?
5ASA Steroids Immunosuppression -Azathioprine -Mercaptopurine -Methotrexate -Infliximab
What is the hospital management of IBD patients?
Steroids Anticoagulation Rest Other -Cyclosporin -Infliximab -Surgery
Give some examples of Aminosalicylates.
What must you be careful of when prescribing these?
Mesalazine
- Acrylic Resin
- Ethylcellulose Microgranules
Pro-drugs
- Balsalazide
- Olzalazine
- Sulfasalazine
Prescribe by the BRAND.
Brands are slightly different
What is the first line treatment in Mild-Moderate UC for achieving an induction in remission?
5ASA (5-aminosalicylic acid)
>3g per day
Rectally for distal and more extensive disease
How do Steroids compare to 5ASA in induction of remission in Mild Moderate UC?
Steroids have similar effects but work faster with more side effects
Rectal 5ASA better than steroids
What is the first line therapy for the maintenance of remission in Mild-Moderate UC?
5ASA
What is the maintenance of remission of UC with 5ASA associated with?
Reduced number and severity of relapses
Reduced CRC risk
-Lifeling therapy with >2g per day
How is 5ASA used in Crohn’s?
Widely used but limited evidence.
Induction of remission in mildly active ileocolonic disease
Maintenance of remission if induction is by 5ASA
Post small bowel resection
Help prevent progression to cancer
What steroids do you prescribe in IBD?
Prednisolone
- Optimal dose is 40mg daily
- Tapering reduction over 4 weeks
Budenoside
- Slightly less effective than Prednisolone
- Better side effect profile
- Ileal and ascending colon disease only.
What is the next step up in treatment of IBD after steroids?
Immunosuppression
Thiopurines = azathioprine (6-Mercaptopurine)
Methotrexate
Others:
Ciclosporin
Mycophenolate
Tacrolimus
Describe the use of Azathioprine to treat IBD
Induction (Number needed to treat NNT = 5)
Maintenance (NNT = 7)
Most patients feel rotten for the first few weeks then get better. Some don’t.
What is leucopenia?
Decrease of WBC’s found in the blood
What do you need to do with hepatotoxicity from azathioprine?
Blood Monitoring
- Weekly for 8 weeks then every 8 weeks
- Patients must see GP if sore throat/infection
What are the significant side effects of azathioprine?
Significant side effects (NNT = 14):
- Leucopenia
- Hepatoxicity
- Pancreatitis
- Possible long term lymphoma risk
- Up to 28% intolerence
Describe the use of methotrexate to treat IBD
Unlicensed use
Works better for Crohn’s but still sometimes used for UC
Induction and maintenance of remission
Require specialist follow up
What side effect do you have to keep in mind when prescribing methotrexate?
Cannot become pregnant on this
Long term treatment so have to look 10 years ahead
Describe the use of other immunosuppressants other than azathioprine and methotrexate
Ciclosporin
- Salvage therapy for refractory UC
- 3-6 months as bridge to azathioprine
Mycophenolate
- Rarely used (no evidence)
- If you see someone on this they are clutching at straws
Tacrolimus
-Increasing anecdotal evidence
What is the next step up in treatment of IBD after you have tried immunosuppressants?
Give some examples
Biologics
Anti TNF-a antibodies
Infliximab (Remicade)
-8 weekly IV infusions
Adulimumab (Humera)
-2 weekly SC injections (patient can administer)
What are the risks of biologics?
1 in 100 will get cancer from these drugs
Symptoms are so shit patients are willing to risk it
Why do anti TNF-a antibody drugs sometimes just stop working?
Body may start to produce anti anti TNF-a antibodies
What drug is used to treat peri anal disease in Crohn’s?
Metronidazole
Also used to treat small bowel overgrowth
What is elemental feeding?
Exclusive elemental feeding
Can be as effective as steroids
Works better in children because parents can force them and they have no other choice.
Adults really struggle to comply because it tastes shit
Give an overview of some of the failures of medical therapy in IBD
Recurrent courses of steroid Relapse prior to or shortly after stopping therapy Failure to control symptoms Unacceptable complications of steroids: -Diabetes -Severe osteoporosis -Psychosis
What are the surgical options in UC?
Emergency or Elective
PROCTOCOLECTOMY
Total colectomy with ileostomy and rectal preservation
This gives a rectal stump that may have symptoms
Wall in rectum is thick so shouldn’t perforate
May also do a pouch procedure which doesn’t give an ileostomy
What are the surgical options in Crohn’s?
Never going to cure
take away the smallest area possible
Chances of needing another operation 60%
What are the surgical indications for Crohn’s?
Failure of medical management
Relief of obstructive symptoms (small bowel)
Management of fistulae (e.g. bowel to bladder)
Management of intra-abdominal accesses
Management of anal conditions
Failure to thrive
