Inflammatory bowel disease Flashcards
How do you define acute severe colitis?
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
What is the management of acute severe colitis?
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
Which extraintestinal manifestations of IBD correlate with intestinal disease severity?
Episcleritis, iritis
Small joint peripheral arthritis
Erythema nodosum
Which extraintestinal manifestations of IBD do not correlate with intestinal disease severity?
Axial arthritis
Some say pyoderma gangrenosum
Apthous ulcers
PSC
What are the lipid abnormalities in PBC?
very high HDL, mild LDL, mild VLDL
Fat soluble vitamin deficiency in PBC- how to measure?
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
Ursodeoxycholic acid- what effect on PBC patients?
Survival benefit if treated not late in disease
Only 50% have a complete biochemical response
What is the relationship between PSC and IBD?
80% PSC patients have UC, but only 2-3 % patients with UC have PSC
What are the serological markers in UC and CD?
UC: atypical P ANCA
CD: anti-saccharomyces cerevisiae antibodies
Can use to help distinguish in some situations
Poor prognosis generally
Typical clinical presentation UC?
Frequent small volume diarrhoea
Bloody diarrhoea
Urgency
Typical clinical presentation of CD?
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
How is the term disease remission in CD actually defined?
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)
How do you define the severity of disease in UC?
Montreal classification based on the Truelove and Witts criteria (pulse, temp, Hb, ESR, bloody, stools/day)
Differentiating features between IBD and IBS?
weight loss CRP up nocturnal diarrhoea bloody stools fever anaemia, iron def, low albumin
Can you give live vaccines on 5-ASA if there are no immunomodulators?
yes, safe with aminosalycilic acid
What is the first line investigation in suspected IBD?
colonoscopy and ileoscopy with multiple biopsies
trying to reduce CT/radiation exposure
If need cross sectional anatomy, MRI first choice (thought not on PBS)
What other reasons (other than diagnosis) is colonoscopy useful in IBD?)
- 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
How can the blood film catch you out in IBD?
Normal MCV but increased RDW indicating dimorphic picture and potentially iron and B12/folate def
Note can also get selenium, zinc, potassium deficient
How is faecal calprotectin useful? And lactoferrin.
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
Ferritin under 100 with raised CRP suggests…..
Iron deficiency
nonabsorbed ferrous iron has the potential to worsen IBD symptoms and aggravate intestinal inflammation
Consider IV
When do you use abx in IBD?
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
Which drugs IBD can you continue in pregnancy?
5-ASAs
thiopurines
Women should also have yearly PAP smears in IBD on immunosupression.
Smoking and IBD
Increase risk of CD- if stop, 65% reduction in relapse rates
Protective for UC
What are the live vaccines?
MMR varicella Yellow fever- need to stop immunosuppression for at least 4 months live typhoid oral polio BCG
