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GI > Inflammatory Bowel Disease > Flashcards

Inflammatory Bowel Disease Flashcards

1
Q

Which two conditions form IBD?

A

Crohn’s Disease

Ulcerative Colitis

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2
Q

What do Crohn’s and UC have in common?

A

Idiopathic
Chronic
Inflammatory

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3
Q

Where is the incidence of Crohn’s most common?

A

Western countries

North of Scotland

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4
Q

Factors Contributing to the Pathogenesis of IBD

A

Genetic predisposition
Mucosal immune system
Environmental triggers

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5
Q

Genetics in IBD

A

Positive family history is best established risk factor
Early onset may have stronger links
Specifically, NOD2 gene on IBD-1 of chromosome 16

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6
Q

Theories of IBD Pathogenesis

A

Pathogenic bacteria
Abnormal microbial composition
Defective host containment of commensal bacteria
Defective host immunoregulation

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7
Q

Environmental Factors in IBD

A

NSAIDs risk for IBD
Smoking =
Aggravates Crohn’s
Protective in UC

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8
Q

UC - Clinical Features

A

Peak in 20-30s
Relapsing course
Affects rectum, proximally and continuously

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9
Q

UC - Disease Extent

A

Proctitis
Left-sided colitis
Pancolitis

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10
Q

UC - Natural History

A

Variable
15% develop sever attack
of these, 30-40% will fail to respond and require surgery

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11
Q

UC - Symptoms

A 
Diarrhoea + bleeding
Night rising 
Increased bowel frequency 
Urgency 
Tenesmus
Incontinence 
Lower ado pain (LIF)
Constipation with proctitis
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12
Q

IBD - Important Features of History

A 
Recent travel 
Antibiotics
NSAIDs 
Family history 
Smoking 
Skin, eyes, joints
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13
Q

UC - Determining Severity

A 
>6 bloody stools/24 hrs
\+ 1 or more of:
Fever 
Tachycardia 
Anaemia
Elevated ESR/CRP
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14
Q

UC - Further Assessment

A

Albumin (inflammation detection)
Plain AXR
Endoscopy
Histology

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15
Q

UC - Plain AXR

A

Stool absent in inflamed colon
Thumb printing = mucosal oedema
Toxic megacolon = Transverse >5.5cm, caecum >9cm

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16
Q

UC - Endoscopy

A 
Loss of vessel pattern
Granular muscosa
Contact bleeding
Ulcers
Poss pseudopods (mostly benign)
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17
Q

UC - Histology

A

Inflammation to mucosal layer ONLY

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18
Q

UC - Long Term Complication

A

Increased risk of colorectal cancer:
Severity
Duration
Extent

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19
Q

UC - Extra Intestinal Manifestations

A 
Skin - erythema nodosum
Joints - axial and peripheral pain
Eyes - pain, redness
Deranged LFTs 
Oxalate renal stones
20
Q

UC - Primary Sclerosing Colangitis

A

Inflammatory condition affecting biliary tree
Fibrotic strictures
Histology with onion skin appearance
Mostly asymptomatic, or itch and rigors
HIGHLY increased risk of cholangiocarcinoma/colorectal cancer

21
Q

Crohn’s - Onset

A

Earlier onset than UC

Mean age 27, but 15% before 15

22
Q

Crohn’s - Distribution

A

Any region of GI tract
Skip lesions
Transmural inflammation

23
Q

Crohn’s - Peri Anal Disease

A 
Recurrent abscess formation 
Pain 
Can lead to fistula with persistent leakage 
Damaged sphincters
Incontinence
24
Q

Crohn’s - Natural History

A

25% continuous disease
50% intermittent flares
75% need surgery within 8-10 years

25
Q

Crohn’s - Symptoms (Determined by Site)

A

Small Intestine = peri-umbilical abdo cramps, diarrhoea, weight loss
Colon = lower abdo cramps, bloody diarrhoea, weight loss
Mouth = painful ulcers, swollen lips, angular chielitis
Anus = peri anal pain, abscess

26
Q

Crohn’s - Assessment

A

Clinical Exam = weight loss, RIF mass, peri anal signs
Bloods = CRP, albumin, platelets, B12, ferritin
Colonoscopy
Histology

27
Q

Crohn’s - Histology

A 
Cobble-staining 
Thickened wall
Fissures
Transmural
Patchy 
GRANULOMAS
28
Q

Crohn’s - Small Bowel Assessment

A

Barium follow through
Small bowel MRI
Technetium labelled white cell scan

29
Q

Therapy - Lifestyle Advice

A 
Stop smoking (aggravates Crohn's)
Dietary factors - may influence symptoms
30
Q

UC - Drug Therapy Options

A

5ASA (mesalazine)
Steroids
Immunosuppressants
Anti-TNF therapy

31
Q

Crohn’s - Drug Therapy Options

A

Steroids
Immunosuppressants
Anti-TNF therapy

32
Q

5ASA - Mechanism of Action

A

Topical effect (lessens systemic effects)
Anti-inflammatory properties
Reduces risk of colon cancer

33
Q

5ASA - Side Effects

A

Diarrhoea

Idiosyncratic nephritis

34
Q

5ASA - Routes of Administration

A

Oral =
Prodrugs
pH dependent release
Delayed release

Topical =
Suppositories
Enemas

35
Q

5ASA - Suppositories vs Enemas

A

Suppositories -
Generally sufficient for proctitis
Coat lees than 20cm, but better mucosal adherence
Enemas -
Foam or liquid (patients generally prefer foam)
Less than 10% remain in rectum

36
Q

Corticosteroids - Mechanism of Action

A

Systemic inflammatory properties
E.g. prednisolone, budesonide
Aim to reduce remission
Given as a short course with high initial dose, reducing over 6-8 weeks

37
Q

Corticosteroids - Side Effects

A 
High dependency 
MSK = osteoporosis, avascular necrosis 
GI = nausea, vomiting, bleeding 
Cutaneous = Acne, skin thinning 
Metabolic = Weight gain, diabetes, hypertension 
Neuropsychiatric = manic, depression, disturbed sleep pattern
Cataracts 
Stunted growth (esp. when given to younger patients)
38
Q

Immunosuppression - Use

A

When most potent suppression of inflammation is needed
UC = steroid sparing agents
Crohn’s = maintenance therapy
E.g. azathioprine/mercaptopurine

39
Q

Immunosuppression - Mechanism of Action

A

Purine analogue which interferes with DNA synthesis

Can be given as a prodrug

40
Q

Immunosuppression - Azathioprine

A 
Slow onset of action (16 weeks)
TPMT activity contributes to toxicity 
Avoid with XO inhibitors 
Regular blood monitoring needed 
Side Effects = pancreatitis, leucopaenia, hepatitis, small risk of lymphoma and skin cancer
41
Q

Anti-TNFa Therapy - Mechanism of Action

A

TNFa = pro-inflammatory cytokine
Antibodies = infliximab, adalimumab
Promote apoptosis of activated T lymphocytes
Rapid onset of action

42
Q

Anti-TNFa Therapy - Safety Issues

A

Infusion reactions
Infection
Cancer (lymphoma, solid tumours)

43
Q

Anti-TNFa Therapy - Use

A

Part of long term strategy, including immune suppression, surgery, supportive therapy
Refractory/fistulising disease

44
Q

Crohn’s - Surgery

A

Minimise amount of bowel resected
NOT CURATIVE
Repeated resection may lead to short gut syndrome and need for parenteral nutrition

45
Q

UC - Surgery

A

CURATIVE

Permanent ileostomy or restorative proctocoloectomy and pouch

46
Q

Therapy Pyramid

A 
Smoking cessation 
5ASA (UC only)
Steroids if needed 
Immunosuppression 
Anti-TNFa therapy 
Surgery - may be best treatment in some

GI (24 decks)

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