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GI/Liver > Inflammatory Bowel Disease > Flashcards

Inflammatory Bowel Disease Flashcards

1
Q

What is ulcerative colitis?

A

Diffuse mucosal inflammation limited to the colon

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2
Q

What is ulcerative colitis defined by?

A

Distal colitis limited to rectum (proctitis) or rectum and sigmoid (proctosigmoiditis)
Left sided colitis to splenic flexure
Extensive colitis to hepatic flexure
Pancolitis

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3
Q

What is Crohn’s disease?

A

Patchy, transmural inflammation affecting any part of the GI tract

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4
Q

What is Crohn’s disease defined by?

A

Location - colonic, terminal ileum, perianal

Pattern of disease - inflammation, stricturing and fistulating

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5
Q

Which gender is more likely to get which disease?

A

Slight female predominance - Crohn’s

Slight male predominance - ulcerative colitis

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6
Q

Briefly describe the epidemiology of both diseases.

A

Diseases of young people

  • 10-40 years, peak incidence
  • 15% present over the age of 60
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7
Q

What is the pathogenesis of both diseases?

A 
Unknown 
Host response to environmental triggers in genetically susceptible individuals 
Genetic factors implicated
Smoking
- increases risk of Crohn's
- reduces risk of ulcerative colitis
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8
Q

What would you ask for in the history when you suspect an IBD?

A

Stool frequency, consistency, urgency, blood
Abdominal pain, malaise, fever
Weight loss
Extraintestinal symptoms (joint, eyes and skin)
Travel
Family history
Smoking (passive)

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9
Q

What skin conditions can be associated with IBD?

A

Erythema nodosum (shins commonly)
Pyoderma gangrenosum
- mostly UC

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10
Q

What eye conditions can someone with IBD get?

A

Iritis
Uveitis
Dry eyes
Keratopathy

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11
Q

What mouth problems can someone with IBD get?

A

Mouth ulcers
Cracked/fissuring lips
- particularly Crohn’s

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12
Q

What do you expect to see on perineal examination in someone with Crohn’s disease?

A

Fistula’s
Stricturing
Skin tags
Peri-anal abscesses

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13
Q

If you suspect someone has IBD, what initial investigations should you do?

A 
FBC, ESR
U&Es, LFTs
CRPs
Stool cultures for C.Diff toxin
Faecal calprotectin 
- non-specific, but if low, it exclude inflammation
Abdominal X-Ray
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14
Q

If you suspect someone has IBD, what in depth investigations should you do?

A 
Rigid sigmoidoscopy 
Colonoscopy - used most
Avoid endoscopic examination in severe disease (bad symptoms)
Small bowel radiology/MRI
Labelled WCC scanning
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15
Q

Describe the colon appearance in ulcerative colitis.

A 
Granular mucosa
Not much ulceration
Lack of definition of the blood vessels
Contact bleeding 
Luminal pus
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16
Q

Describe the appearance of the intestines in Crohn’s disease.

A 
Ulceration
- fissuring ulceration
Patchy involvement of the colon or ileum
- not the rectum
Cobblestone appearance 
- areas of ulceration separated by narrow areas of healthy tissue
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17
Q

What are the treatments for ulcerative colitis?

A

Corticosteriods
Thiopurines
Biologics
5ASAs if needed

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18
Q

What are the treatments for Crohn’s disease?

A 
Corticosteriods
Thiopurines
Biologics
Methotexate
Immune modulating diet
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19
Q

What corticosteriods are used for IBD treatment?

A

Glucocorticoids

  • IV hydrocortisone
  • IV methyloprednisolone
  • oral prednisolone
  • budesonide
  • beclometasone
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20
Q

How are steriods given and why in IBD?

A

They are given high dose at first to rapidly induce remission, then they are put on a slowly reducing course, to allow mucosal healing

  • because steroids can’t maintain remission
  • prednisolone 40mg/day for 1 week
  • reduce by 5mg/week
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21
Q

What are the possible side effects of steroid use?

A 
Immunosuppression
Impaired glucose tolerance 
Osteoporosis
Weight gain
Cushingoid appearance
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22
Q

What is 5ASAs?

A 
Mesalazine
- 5-aminosalicylate (5ASA)
Different methods of release
- pH dependent release/renin coated
- time controlled release
- delivery by carrier molecules 
Can be effective as a topical therapy for distal disease
- suppositories and enemas
- good for symptomatic proctitis
23
Q

What are aminosalicylates?

A

Anti-inflammatory product used to treat ulcerative colitis

24
Q

What is the function of aminosalicylates?

A

Induction of remission in mild/moderate ulcerative colitis
Maintenance of remission
Efficacy relies on compliance
Maintenance therapy reduces cancer risk

25
Q

What are the benefits of high doses of aminosalicylates?

A

Higher remission rates

Better mucosal healing

26
Q

What are the side effects of

A 
Renal impairment (interstitial nephritis, nephrotic syndrome)
- rare and idiosynchratic
Sulphasalazine (related to mesalazine)
- commonly badly tolerated
Intolerance
27
Q

What are thiopurines and when are they used?

A

Immunosuppressant
Steroid sparing agent
- used when patients require 2 or more steroid course a year
- have experienced relapse on less than 15mg prednisolone

28
Q

What are thiopurines used for?

A

Maintenance therapy for ulcerative colitis and Crohn’s disease
Post-op prophylaxis in complicated Crohn’s

29
Q

Describe the pathophysiology of thiopurines.

A

Purine anti-metabolites
Immune modulting drugs
Prevent T-cell clonal expansion in response to an antigenic stimuli and allows T-cell apoptosis

30
Q

Name some thiopruines.

A

Azathioprine

Mercaptopurine

31
Q

What is TMPT?

A

It’s an enzyme that metabolises mercaptopurine to one of it’s metabolities
Genetically determined
- reduced levels, reduces effect of immunosuppession

32
Q

What are the metabolites of mercaptopurine measured in therapeutic drug monitoring?

A

MeMP - methylmercaptopurine
- levels predict risk of a drug induced hepatitis
6TS - thioguanine nucleotide
- active metabolite, used for adjusting levels and checking compliance

33
Q

What are the common side effects of Thiopurines?

A 
Leucopenia
Nausea, vomiting (1 in 5)
Arthralgia
Pancreatitis 
Hepatitis (reversible) 
Squamous skin cancers 
- be careful in the sun, use sun cream
Haematological malignancy (slight)
34
Q

What is methotrexate?

A

Anti-metabolite
Folate scavenger - need folate supplements
Used in Crohn’s when they can’t tolerate Thiopurines

35
Q

What are the side effects of methorextare?

A 
GI upset
Hepatotoxicity
Immunosuppression
Sepsis
Pulmonary fibrosis
Teratogenic
36
Q

When would Infliximab be used?

A

Severe or fistulating Crohn’s disease
Rescue acute severe ulcerative colitis
Moderate severe ulcerative colitis that doesn’t respond to other treatment

37
Q

What is Infliximab?

A

A mouse anti-TNF monoclonal antiboidy

  • prevents macrophage activation
  • switches off inflammatory process in the mucosa
38
Q

How is Infliximab administered?

A

Loading regime at 0/2/6 weeks
2 month IV infusions thereafter
- maintenance therapy

39
Q

What are the complications associated with Infliximab?

A

The body may recognise it as foreign (mouse Ab) and produce antibodies

  • loss of efficacy
  • allergic reactions
40
Q

What is Adalumimab?

A

Humanised anti-TNF alpha monoclonal antibody

41
Q

What is the benefit of Adalumimab?

A

People are less likely to have a reaction compared to Infliximab
- humanised

42
Q

What is Golimumab?

A

Humanised anti-TNF alpha

43
Q

What is Golimumab used for?

A

Moderate to severe ulcerative colitis

- less so for Crohn’s

44
Q

With all anti-TNF drugs, what are the complications?

A 
Infection risk
- reactivation of TB
- reactivation of Hep B
Neurological
- incidence of MS
- progressive multifocal leucoencephalopathy
Malignancy
- possible increased lymphoma risk
45
Q

What is Vedoluzimab?

A

A new biologic
Anti-adhesion
- binds integrin (a lymphocyte adhesion molecule)

46
Q

What is acute severe colitis?

A

Patients who fail to respond to optimal treatment with 5ASA/prednisolone or with severe disease warrant hospital admission

47
Q

How is acute severe colitis?

A

IV steroid therapy
Liaison with colorectal surgeon
- stool frequency >8 day
- or CRP >45 on day 3 predicts colectomy in 85%

48
Q

What obs/blood results suggest acute severe colitis?

A 
>6 bowel movements per day
Frequent PR blood
Raised temperature
pulse >90 
< 10 Hb - anaemia 
ESR >30
49
Q

What investigations should you do if someone has suspected acute severe colitis?

A 
Daily FBCs, ESR, U&amp;Es and CRP
Stool cultures - C.Diff
- high incidence of infection
Daily abdominal X-Ray
Sigmoidoscopy 
- if it is a new presentation
50
Q

How is acute severe colitis treated?

A

Prophylactic LMWH heparin
- high risk of DVTs
IV hydrocortisone 100mg or methylprednisolone 30mg
Treat for 72 hours and if they improve, they can be given oral steroids
- if they don’t they need rescue therapy

51
Q

What is rescue therapy in acute severe colitis?

A

Ciclosporin IV
Infliximab single dose
Surgery
- if medical therapy doesn’t work

52
Q

What is the surgery done in ulcerative colitis?

A

Curative

Ileo-anal pouch (don’t need a stoma) or ileostomy

53
Q

When is surgery done in Crohn’s disease?

A

Indicated for stricturing, perforation, fistulising disease

Sparing

GI/Liver (12 decks)

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