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Gastro > Inflammatory bowel disease > Flashcards

Inflammatory bowel disease Flashcards

1
Q

How do you define acute severe colitis?

A

Truelove and Witts criteria
Bloody stools over 6 per day

plus at least one of:

  • pulse over 90
  • febrile over 37.8
  • Hb under 105
  • ESR over 30
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2
Q

What is the management of acute severe colitis?

A 
Hydrocort 100mg QID
subcut heparin
IVT
electrolyte support
IV abx
aim Hb over 100

Daily assessment, stool chart, surg review, stool MC and S, AXR, bloods

If day 3 no response (over 8 bloody motions per day or CRP over 45 by Travis score)–>surg or salvage tx with cyclosponine or infliximab

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3
Q

Which extraintestinal manifestations of IBD correlate with intestinal disease severity?

A

Episcleritis, iritis
Small joint peripheral arthritis
Erythema nodosum

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4
Q

Which extraintestinal manifestations of IBD do not correlate with intestinal disease severity?

A

Axial arthritis
Some say pyoderma gangrenosum
Apthous ulcers
PSC

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5
Q

What are the lipid abnormalities in PBC?

A

very high HDL, mild LDL, mild VLDL

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6
Q

Fat soluble vitamin deficiency in PBC- how to measure?

A

Can be deficient even if not cirrhotic.
Need to measure 25, hydroxyvitamin D as 1,25 (calcitriol) levels will be normal usually

Diarrhoea is from fat malabsorption rather than pancreatic insufficiency

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7
Q

Ursodeoxycholic acid- what effect on PBC patients?

A

Survival benefit if treated not late in disease

Only 50% have a complete biochemical response

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8
Q

What is the relationship between PSC and IBD?

A

80% PSC patients have UC, but only 2-3 % patients with UC have PSC

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9
Q

What are the serological markers in UC and CD?

A

UC: atypical P ANCA
CD: anti-saccharomyces cerevisiae antibodies

Can use to help distinguish in some situations
Poor prognosis generally

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10
Q

Typical clinical presentation UC?

A

Frequent small volume diarrhoea
Bloody diarrhoea
Urgency

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11
Q

Typical clinical presentation of CD?

A 
Malnutrition
Diarrhoea with abdominal pain
Abdominal mass
Stomatitis
Perianal lesions

When there is diffuse small bowel involvement, can have a more systemic presentation with weight loss, nutritional def and fever with few gut sx.

*stronger genetic link than UC

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12
Q

How is the term disease remission in CD actually defined?

A

Best’s Chrons disease activity index less than 150 for at least 12 months
(estimates clinical severity of disease and not the degree of inflammation)

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13
Q

How do you define the severity of disease in UC?

A

Montreal classification based on the Truelove and Witts criteria (pulse, temp, Hb, ESR, bloody, stools/day)

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14
Q

Differentiating features between IBD and IBS?

A 
weight loss
CRP up
nocturnal diarrhoea 
bloody stools
fever
anaemia, iron def, low albumin
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15
Q

Can you give live vaccines on 5-ASA if there are no immunomodulators?

A

yes, safe with aminosalycilic acid

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16
Q

What is the first line investigation in suspected IBD?

A

colonoscopy and ileoscopy with multiple biopsies

trying to reduce CT/radiation exposure
If need cross sectional anatomy, MRI first choice (thought not on PBS)

17
Q

What other reasons (other than diagnosis) is colonoscopy useful in IBD?)

A
  • if not responding to usual therapy to look for CMV on microscopy, IHC, and PCR)
  • screening for dysplasia with longstanding extensive colonic disease; 8 years after onset pancolitis or 12-15 years after the onset of left sided colitis the cancer risk becomes significant. Colonoscopy with biopsies for dysplasia every 1-2 years
18
Q

How can the blood film catch you out in IBD?

A

Normal MCV but increased RDW indicating dimorphic picture and potentially iron and B12/folate def

Note can also get selenium, zinc, potassium deficient

19
Q

How is faecal calprotectin useful? And lactoferrin.

A

Present in inflammatory diarrhoea (both infectious and IBD causes) - not present in functional diarrhoea.

Usually only used when over 1 month symptoms and not if bloody diarrhoea

20
Q

Ferritin under 100 with raised CRP suggests…..

A

Iron deficiency

nonabsorbed ferrous iron has the potential to worsen IBD symptoms and aggravate intestinal inflammation
Consider IV

21
Q

When do you use abx in IBD?

A

Acute severe colitis empirically
Complicated Crohn’s disease: fistula, perianal disease, mass, bacterial overgrowth in the context of stricture
Cipro, metronidazole for induction of remission in CD but not maintenance.
Metronidazole helps post ileal resection in Crohn’s

22
Q

Which drugs IBD can you continue in pregnancy?

A

5-ASAs
thiopurines

Women should also have yearly PAP smears in IBD on immunosupression.

23
Q

Smoking and IBD

A

Increase risk of CD- if stop, 65% reduction in relapse rates

Protective for UC

24
Q

What are the live vaccines?

A 
MMR
varicella
Yellow fever- need to stop immunosuppression for at least 4 months
live typhoid 
oral polio
BCG
25
Q

Who should get calcium and vitamin D?

A

Anyone on steroids

Those with known reduced BMD

26
Q

Lifetime risk CRC in UC and Crohn’s colitis?

Tend to survey if over 1/3 colon involvement in CD

A

3-6%
Absolute risk is small and coming down with better treatment
Previously overestimated
Need to use chromoendoscopy with dye spray, not just standard scopes
Start at 8 years duration all UC extending above the rectum and CD with more than 1/3 colon involved.

Increased risk with

  • duration
  • extent
  • PSC (33% at 20 years- annual surveillance from time of diagnosis, consider prophylactic surgery or URSO)
  • family history of CRC (29% risk if first degree under age 50)
  • disease activity

If unable to fully resect dysplastic regions (flat or polypoid), endoscopic surveillance not enough and need colectomy

27
Q

How often is colonoscopy done after the initial 8 year mark?

A

Yearly if active disease, PSC, FH first degree under age 50, previous dysplasia, colonic stricture, multiple pseudopolyps

Three yearly if inactive UC, Crohn’s colitis, FH CRC first degree relative over age 50

Five yearly if two previously normal endoscopies.

28
Q

What predicts severe crohn’s?

A 
steroids at diagnosis (worst)
age under 40
perianal disease
need hospitalisation
need for IM, biologicals, surgery
29
Q

ACCENT and SONIC trials in CD treatment showed what?

A

Normalising CRP more likely to attain steroid free remission

Faecal calprotectin is also a good surrogate for demonstrating ongoing mucosal damage/healing

30
Q

5-ASA toxicities?

A 
Infrequent and similar across formulations:
interstitial nephritis
pancreatitis
blood dyscrasias
diarrhoea 3%

Unique to sulfasalazine: male azoospermia reversible (swap to mesalazine), SJS, sulphur intolerance

31
Q

What is better for infection risk? Infliximab, immunomodulators, or steroids?

A

Infliximab and immunomodulators are better, as per the TREAT registry

Early immuno

32
Q

When should you consider monitoring thiopurine metabolites?

A

When not responding, or get side effects, or both

33
Q

What cancers increased risk with thiopurine treatment?

A

Non melanoma skin

Lymphoma- NHL, hepatosplenic T cell lymphoma

34
Q

Methotrexate for use in…

A

Crohns! But not UC! For maintenance but not remission induction.

35
Q

List the 5 anti TNF agents and what they are made of?

A

Infliximab - chimeric and 75% human
CDP570 - humanised and 90% human
Adalimumab- 100% human
Certolizumab - humanised Fab polyethylene glycol
Ertanacept - human recombinant receptor/Fc fusion (100% fusion)

Infliximab and adalimumab are on PBS for IBD

  • Inflammatory Crohn’s (not stricturing)- refractory to steroids and 3 months of AZA/6MP/MTX. Must demonstrate response.
  • For fistulising Crohn’s disease “refractory to other medical therapies”
  • Acute severe colitis in UC and refractory UC
36
Q

TNF safety issues: 7

A
  1. Infection (TB, invasive fungal, viral- bacterial sepsis is rare)
  2. Lymphoma -esp if concomitant immunomodulator
  3. Demyelinating disorders
  4. Drug induced lupus syndrome but WITH ANA seroconversion
  5. CCF- avoid in NYHA 3, 4
  6. LFT 6%
  7. Derm- psoriaform (weird given also a treatment for psoriasis)

Also remember that infliximab can reduce effect over time (immunogenic)

37
Q

What is Vedolizumab in UC?

A

For maintenance therapy in UC

Anti aplha4/beta7 integrin
Reduces inflammation by inhibiting the adhesion of T lymphocytes to gastrointestinal tissues.
Does not cross BBB so no PML

38
Q

How do you assess what to do if not improving on standard therapy in acute severe colitis?

A

15-20% UC severe patients do not respond to IV steroids
Think on day 3, act on day 5
Travis score day 3 predicts colectomy rate: 85% chance if either
-motions 2-8 and CRP over 45
or
-motions over 8/day

?salvage therapy with cyclosporine or infliximab or j pouch formation. Recent data favour infliximab over cyclo for ASUC

39
Q

Cyclosporine used for CD or UC or both?

A

UC

Not CD

Gastro (12 decks)

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