Inflammatory Bowel Disease Flashcards
What are the possible contributory factors to inflammatory bowel disease?
Genetics Bacteria Diet Vaccination history Social factors Ethnicity
What age group is the highest incidence for ulcerative colitis and in what gender is it more common?
20-40 years
More common in females
What part of the GI tract does ulcerative colitis affect?
Small intestine only
What is the pathology of ulcerative colitis?
Continuous inflammation of the small bowel with varying distribution and severity
What are the typical clinical features of ulcerative colitis?
Stool frequency > 6 times a day with blood Fever Tachycardia ESR raised Anaemia with Hb < 10 g/dl Albumin < 30 g/l Leucocytosis and thrombocytosis
What age groups have the highest incidence of Crohn’s disease
20-40 years and over 60s
What disease is more likely in children presenting with irritable bowel disease symptoms, Crohn’s or ulcerative colitis?
Crohn’s
What is the pathology of Crohn’s disease?
Patchy disease that affects anywhere in the GI tract from mouth to anus, discontinuous skip lesions causing patchy inflammation in multiple places
What are the clinical features of Crohn’s disease?
Diarrhoea Abdominal pain Weight loss Malaise Lethargy Anorexia Low grade fever Malabsorption
What differential diagnoses must be ruled out before confirming Crohn’s disease?
Chronic diarrhoea due to malabsorption or malnutrition
Ileo-caecal TB
Why is it important to differentiate between Crohn’s disease and ileo-caecal TB?
Ileo-caecal TB can look exactly like Crohn’s but the steroid treatment that might improve Crohn’s disease will cause rapid deterioration in the health of patients with ileo-caecal TB
What are the differential diagnoses of ulcerative colitis?
Infective, amoebic and ischaemic colitis
What is inflammatory bowel disease?
Chronic relapsing inflammatory conditions of the bowel
How might inflammatory bowel disease appear pathologically?
Microscopic colitis
Collagenous colitis
Lymphocytic colitis
What can be tested for in the blood that would be indicative of inflammation?
High ESR and CRP High platelet count High WCC Low Hb Low albumin
How does Crohn’s disease appear pathologically?
Granulomas on histology is the biopsy is taken at the exact site Non-specific inflammation Fistulae Peri-anal disease Entire bowel wall affected
What part of the bowel layer does ulcerative colitis affect?
The mucosal layer only
What investigations can be helpful when suspecting inflammatory bowel disease?
Radiology investigations
Colonoscopy and biopsy
Dye spray colonscopy
What drugs can be used to treat inflammatory bowel disease?
5ASAs Steroids Immunosuppressants Thiopurines Methotrexate Biologics - antibody medication Metronidazole Elemental Feeding
What is the first line treatment for mild-moderate ulcerative colitis and what are its benefits?
Sulfasalazine (pro-drugs, 5ASA)
60% of flare-ups will go into remission with this therapy
First line therapy for maintenance of remission
Reduced number and severity of relapses
Reduced colorectal cancer risk with daily lifelong therapy
If giving steroids for ulcerative colitis, what course would you give?
Short term treatment only, 4-8 week course
Name the immunosuppressive drugs used in the treatment of inflammatory bowel disease
Azathioprine
Mercaptopurin
Methotrexate
Infliximab
Under what circumstances would 5ASA maintain remission in Crohn’s?
Only if remission was induced by 5ASA
Name the steroids commonly used in treatment of inflammatory bowel disease
Prednisolone
Budenoside - slightly less effective than prednisolone but better side effect profile
For what areas affected by inflammatory bowel disease could you give budenoside?
For ileal and ascending colon disease only
What are the side effects of Azathioprine?
Leucopenia Hepatotoxicity Pancreatitis Long term lymphoma risk Non-specific flu-like symptoms e.g. malaise, muscle and joint aches, fatigue
What percentage of people will be intolerant to Azathioprine?
Up to 18%
In how many people with Azathioprine induce and maintain remission?
1/7
Methotrexate is only used in which inflammatory bowel disease?
Crohn’s
What percentage of people will be intolerant to methotrexate and what side effects can it cause?
10-18% intolerant
Can cause liver and lung problems
Under what circumstances would Cyclosporin be used?
As a salvage therapy for an acute attack of ulcerative colitis if the patient isn’t already on immunosuppressant therapy
What biologic antibody medication might be used in 8 weekly IV infusions for the treatment of inflammatory bowel disease?
Anti-TNF alpha antibodies
Alpha-4b7 Integrin blockers
Under what circumstances might metronidazole be used?
For Crohn’s peri-anal disease or sepsis or for small bowel bacterial overgrowth
In what age group is elemental feeding more effective?
Due to the disgusting taste it works better in children as they are more compliant
What would indicate a failure of medical therapy in the treatment of inflammatory bowel disease?
Recurrent courses of steroids needed
Relapse prior to or shortly after stopping therapy
Failure to control symptoms
Severe complications from steroids
Generally poor response to medical therapy
Surgery in inflammatory bowel disease may be either
emergency or elective
If acutely ill with severe ulcerative colitis, what surgical treatment is indicated?
Total colectomy with rectal preservation and ileostomy
What surgical procedure is indicated for patients chronically ill with ulcerative colitis?
Pouch procedure without ileostomy or proctocolectomy
What are the indications for surgery in Crohn’s disease?
Failure of medical management
For relief of obstructive symptoms
For management of fistulae e.g. bowel to bladder
For management of intra-abdominal abscess
For management of anal conditions
Failure to thrive
What are the common extra-intestinal complications of inflammatory bowel disease of the eyes?
Uveitis, episcleritis, conjunctivitis
What are the common extra-intestinal complications of inflammatory bowel disease of the joints?
Sacrolitis, monoarticular arthritis, ankylosing spondylitis
What are the common extra-intestinal complications of inflammatory bowel disease of the kidneys?
Renal calculi - only in Crohn’s
What are the common extra-intestinal complications of inflammatory bowel disease of the liver and biliary tree?
Fatty change, pericholangitis, sclerosing cholangitis, gallstones
What are the common extra-intestinal complications of inflammatory bowel disease of the skin?
Pyoderma gangrenosum, erythema nodosum, vasculitis
What is the main long term complication of ulcerative colitis?
Colonic carcinoma - dependent on the extent and duration of the disease
