Inflammatory Bowel Disease

Question 1

Why does Crohn’s treatment need to be specific?

Answer 1

Inflammation of certain areas e.g. Inflammation of small intestine will affect rate of absorption and therefore macro and micro nutrients may be deficient and this will need to be incorporated into patients treatment

Question 2

What kind of inflammation is Crohn’s disease?

Answer 2

Transmural inflammation - can go right across the wall of the GI Tract (UC inflammation is of the mucous layer only)
Dense infiltration of lymphocytes and macrophages
Fissuring ulceration - produce tunnels into wall
Submucosal fibrosis

Question 3

What kind of inflammation is involved in Ulcerative Colitis?

Answer 3

Affects the mucosal layer only
Infiltration of inflammatory cells into mucosa
Loss of goblet cells
Presence of ulceration a

Question 4

Crohn’s disease symptoms

Answer 4

Diarrhoea
Pain
Narrowing of the gut lumen (due to scar tissue build up) leading to strictures and bowel obstruction
Abscess formation (infection of ulcer)
Fistulization to skin and internal organs

Question 5

What are strictures / how are they formed?

Answer 5

Inflammation leads to scar tissue formation
Narrowing of lumen and obstruction
Pain cramping bloating
Risk of rupture

Question 6

What are fistulae / how are they formed?

Answer 6

Inflammation leads to ulcers
Ulcers develop into tunnels (fistulae)
Can go between areas of GIT, between organs (e.g. to bladder), or to skin e.g. anal fistula

Question 7

Consequences of Crohn’s

Answer 7

Weight loss
Macronutrients and micronutrients deficiencies (energy deficiency)
Fatigue
Protein-energy malnutrition in 20-80% of patients

Question 8

Symptoms of ulcerative colitis

Answer 8

Severe diarrhoea (changes in electrolytes)
Blood loss 
Loss of peristaltic function leading to rigid colonic tube --> this can lead to toxic megacolon, and perforation and sepsis

Question 9

What is extra-intestinal inflammation and who does it affect? What can it increase the risk of?

Answer 9

Inflammation in joints, eyes, skin, mouth and liver can occur
Both forms of IBD are affected
Increased risk of colon cancer, particularly ulcerative colitis

Question 10

Aims of treatment of IBD

Answer 10

Intended to reduce inflammatory response

Question 11

How do 5-aminosalicylate’s treat IBD? Which disease are they most effective against?

Answer 11

Inhibit leukotriene and prostanoid synthesis
Scavenge free radicals
Decrease neutrophil chemotaxis (effects on PPAR gamma receptor which causes change in gene transcription)

Questionable in Crohn’s but some effect in ulcerative colitis

Question 12

What is sulfasalazine? How does it work?

Answer 12

5 amino salicylate

Metabolised by colonic bacteria into Mesalazine (sulphapyridine is the other metabolic product)

Question 13

What is prednisolone?

Answer 13

Corticosteroid
Anti-inflammatory, immunosuppressive actions for the induction of remission
Systemic

Question 14

What is budesonide?

Consider other forms…

Answer 14

Corticosteroid
Used to induce remission (particularly in more severe disease)
Poorly absorbed so fewer systemic side effects
Foam enema is used for more distal or rectal inflammation e.g. predfoam

Question 15

What is azathioprine and methotrexate used for? How do they work?

Answer 15

Immunosuppressants
Inhibit purine synthesis and hence DNA
Reduces inflammatory cell proliferation

Question 16

What azathioprine converted to and what does this do

Answer 16

Mercaptopurine which inhibits purine synthesis

Question 17

How does cyclosporin act as an immunosuppressant?

When is it used?

Answer 17

Inhibits IL-2 induced gene transmission

Used in refractory disease or for steroid sparing

Question 18

What is TPMT and what purpose does it serve?

Consequences of varying amounts?

Answer 18

Mercaptopurine (azathioprine metabolite) metabolised by a number of pathways including thiopurine methyltransferase
Some patients have low / no activity –> risk of drug induced bone marrow toxicity

Some patients have high TPMT and so risk of mercaptopurine “resistance”

Question 19

What is TNF alpha ?

Answer 19

Tumour necrosis factor - cytokine involved in inflammatory response

Question 20

What are infliximab and adalimumab? How do they work?

Answer 20

Monoclonal antibody for severe and active Crohn’s disease

Neutralises inflammatory cytokine TNF alpha

Question 21

How is infliximab administered?

Answer 21

Infusion

Question 22

How is adalimumab administered?

Answer 22

Injection

Question 23

How can nutrition be maintained in Crohn’s? How can we avoid malnourishment ?

Answer 23

Elemental feeds can induce remission and me be used to reduce steroid use
Parenteral feeding may be required to avoid malnourishment

Question 24

What are the nutritional implications of small bowel removal?

Answer 24

Reduced absorption –> will require nutritional support

Question 25

What are probiotics and what are there implications ?

Answer 25

Suggestion that UC can be exacerbated by imbalance of colonic bacteria / pathogenic bacteria
Probiotics to increase beneficial bacteria

Question 26

What is monotherapy treatment for Crohn’s disease?

Answer 26

Conventional steroid

(Alternatively ; budesonide or 5 ASA

Question 27

What are add on therapies for Crohn’s disease?

Answer 27

First line - azathioprine or mercaptopurine

Second line - methotrexate

Question 28

What are severe active Crohn’s disease treatments ?

Answer 28

Monoclonal antibodies e.g. Infliximab or adalimumab

Question 29

Crohn’s Disease - where does it effect?
What is the cause?
What is the pattern of symptoms?

Answer 29

Can effect anywhere on the GIT (mouth to anus)
Cause is unknown
Exacerbations and remission (no inflammation)