Inflammatory Bowel Disease Flashcards
Why does Crohn’s treatment need to be specific?
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
What kind of inflammation is Crohn’s disease?
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
What kind of inflammation is involved in Ulcerative Colitis?
Affects the mucosal layer only
Infiltration of inflammatory cells into mucosa
Loss of goblet cells
Presence of ulceration a
Crohn’s disease symptoms
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
What are strictures / how are they formed?
Inflammation leads to scar tissue formation
Narrowing of lumen and obstruction
Pain cramping bloating
Risk of rupture
What are fistulae / how are they formed?
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
Consequences of Crohn’s
Weight loss
Macronutrients and micronutrients deficiencies (energy deficiency)
Fatigue
Protein-energy malnutrition in 20-80% of patients
Symptoms of ulcerative colitis
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
What is extra-intestinal inflammation and who does it affect? What can it increase the risk of?
Inflammation in joints, eyes, skin, mouth and liver can occur
Both forms of IBD are affected
Increased risk of colon cancer, particularly ulcerative colitis
Aims of treatment of IBD
Intended to reduce inflammatory response
How do 5-aminosalicylate’s treat IBD? Which disease are they most effective against?
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
What is sulfasalazine? How does it work?
5 amino salicylate
Metabolised by colonic bacteria into Mesalazine (sulphapyridine is the other metabolic product)
What is prednisolone?
Corticosteroid
Anti-inflammatory, immunosuppressive actions for the induction of remission
Systemic
What is budesonide?
Consider other forms…
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
What is azathioprine and methotrexate used for? How do they work?
Immunosuppressants
Inhibit purine synthesis and hence DNA
Reduces inflammatory cell proliferation
What azathioprine converted to and what does this do
Mercaptopurine which inhibits purine synthesis
How does cyclosporin act as an immunosuppressant?
When is it used?
Inhibits IL-2 induced gene transmission
Used in refractory disease or for steroid sparing
What is TPMT and what purpose does it serve?
Consequences of varying amounts?
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”
What is TNF alpha ?
Tumour necrosis factor - cytokine involved in inflammatory response
What are infliximab and adalimumab? How do they work?
Monoclonal antibody for severe and active Crohn’s disease
Neutralises inflammatory cytokine TNF alpha
How is infliximab administered?
Infusion
How is adalimumab administered?
Injection
How can nutrition be maintained in Crohn’s? How can we avoid malnourishment ?
Elemental feeds can induce remission and me be used to reduce steroid use
Parenteral feeding may be required to avoid malnourishment
What are the nutritional implications of small bowel removal?
Reduced absorption –> will require nutritional support
What are probiotics and what are there implications ?
Suggestion that UC can be exacerbated by imbalance of colonic bacteria / pathogenic bacteria
Probiotics to increase beneficial bacteria
What is monotherapy treatment for Crohn’s disease?
Conventional steroid
(Alternatively ; budesonide or 5 ASA
What are add on therapies for Crohn’s disease?
First line - azathioprine or mercaptopurine
Second line - methotrexate
What are severe active Crohn’s disease treatments ?
Monoclonal antibodies e.g. Infliximab or adalimumab
Crohn’s Disease - where does it effect?
What is the cause?
What is the pattern of symptoms?
Can effect anywhere on the GIT (mouth to anus)
Cause is unknown
Exacerbations and remission (no inflammation)
