Inflammatory Bowel Disease Flashcards
Crohn’s Disease - Mx
Crohn’s disease is a form of inflammatory bowel disease. It commonly affects the terminal ileum and colon but may be seen anywhere from the mouth to anus. NICE published guidelines on the management of Crohn’s disease in 2012.
General points
patients should be strongly advised to stop smoking
some studies suggest an increased risk of relapse secondary to NSAIDs and the combined oral contraceptive pill but the evidence is patchy
Crohn’s Disease - Inducing Remission
Inducing remission
Glucocorticoids (oral, topical or intravenous) are generally used to induce remission. Budesonide is an alternative in a subgroup of patients
Enteral feeding with an elemental diet may be used in addition to or instead of other measures to induce remission, particularly if there is concern regarding the side-effects of steroids (for example in young children)
5-ASA drugs (e.g. mesalazine) are used second-line to glucocorticoids but are not as effective
Once remission is obtained then a thiopurine such as azathioprine or mercaptopurine is first line treatment to maintain remission. Methotrexate is an alternative agent but tends to be less well tolerated than thiopurines.
Azathioprine or mercaptopurine* may be used as an add-on medication to induce remission but is not used as monotherapy. Methotrexate is an alternative to azathioprine
Infliximab is useful in refractory disease and fistulating Crohn’s. Patients typically continue on azathioprine or methotrexate
Metronidazole is often used for isolated peri-anal disease
*assess thiopurine methyltransferase (TPMT) activity before offering azathioprine or mercaptopurine
Crohn’s Disease - Maintaining Remission
Maintaining remission
as above, stopping smoking is a priority (remember: smoking makes Crohn’s worse, but may help ulcerative colitis)
azathioprine or mercaptopurine is used first-line to maintain remission
methotrexate is used second-line
5-ASA drugs (e.g. mesalazine) should be considered if a patient has had previous surgery
Crohn’s Disease - Surgery
Surgery
around 80% of patients with Crohn’s disease will eventually have surgery
Surgical interventions in Crohn’s disease
The commonest disease pattern in Crohn’s is stricturing terminal ileal disease and this often culminates in an ileocaecal resection. Other procedures performed include segmental small bowel resections and stricturoplasty. Colonic involvement in patients with Crohn’s is not common and, where found, distribution is often segmental. However, despite this distribution segmental resections of the colon in patients with Crohn’s disease are generally not advocated because the recurrence rate in the remaining colon is extremely high, as a result, the standard options of colonic surgery in Crohn’s patients are generally; sub total colectomy, panproctocolectomy and staged sub total colectomy and proctectomy. Restorative procedures such as ileoanal pouch have no role in therapy.
Crohn’s disease is notorious for the developmental of intestinal fistulae; these may form between the rectum and skin (perianal) or the small bowel and skin. Fistulation between loops of bowel may also occur and result in bacterial overgrowth and malabsorption. Management of enterocutaneous fistulae involves controlling sepsis, optimising nutrition, imaging the disease and planning definitive surgical management.
*assess thiopurine methyltransferase (TPMT) activity before offering azathioprine or mercaptopurine
Aminosalicylate Drugs
Aminosalicylate drugs
5-aminosalicyclic acid (5-ASA) is released in the colon and is not absorbed. It acts locally as an anti-inflammatory. The mechanism of action is not fully understood but 5-ASA may inhibit prostaglandin synthesis
Sulphasalazine
a combination of sulphapyridine (a sulphonamide) and 5-ASA
many side-effects are due to the sulphapyridine moiety: rashes, oligospermia, headache, Heinz body anaemia, megaloblastic anaemia
other side-effects are common to 5-ASA drugs (see mesalazine)
Mesalazine
a delayed release form of 5-ASA
sulphapyridine side-effects seen in patients taking sulphasalazine are avoided
mesalazine is still however associated with side-effects such as GI upset, headache, agranulocytosis, pancreatitis*, interstitial nephritis
Olsalazine
two molecules of 5-ASA linked by a diazo bond, which is broken by colonic bacteria
*pancreatitis is 7 times more common in patients taking mesalazine than sulfasalazine
Mesalazine and Acute Pancreatitis - Example Question
A 25-year-old with recently diagnosed ulcerative colitis is started on mesalazine after a recent tapering of high dose steroids. Two weeks later, he develops severe pain in his epigastrium and right upper quadrant. What is the most likely diagnosis?
Hepatitis > Acute pancreatitis Duodenal ulceration Flare in ulcerative colitis Primary sclerosing cholangitis
Gastric side-effects are not uncommon with oral aminosalicylates, including diarrhoea, nausea, vomiting and exacerbation of colitis. In occasional cases, it can cause acute pancreatitis. Pancreatitis is significantly more common as a side-effect with mesalazine than sulfasalazine.
UC and Colorectal Ca
Ulcerative colitis: colorectal cancer
Overview
risk of colorectal cancer is significantly higher than that of the general population although studies report widely varying rates
the increased risk is mainly related to chronic inflammation
worse prognosis than patients without ulcerative colitis (partly due to delayed diagnosis)
lesions may be multifocal
UC - Factors increasing risk of Cancer
Factors increasing risk of cancer disease duration > 10 years patients with pancolitis onset before 15 years old unremitting disease poor compliance to treatment
UC and Colorectal Ca - Colonoscopy Surveillance
Colonoscopy surveillance in inflammatory bowel disease patients should be decided following risk stratification.
In the UK, surveillance colonoscopy is recommended for all patients (excluding those with isolated proctitis alone) starting 10 years after diagnosis.
Lower risk
5 year follow up colonoscopy
Extensive colitis with no active endoscopic/histological inflammation
OR left sided colitis
OR Crohn’s colitis of <50% colon
Intermediate risk
3 year colonoscopy
Extensive colitis with mild active endoscopy/histological inflammation
OR Pancolitis
OR post-inflammatory polyps
OR family history of colorectal cancer in a first degree relative aged 50 or over
Higher risk
1 year follow up colonoscopy
Extensive colitis with moderate/severe active endoscopic/histological inflammation
OR stricture in past 5 years
OR dysplasia in past 5 years declining surgery
OR primary sclerosing cholangitis / transplant for primary sclerosing cholangitis
OR family history of colorectal cancer in first degree relatives aged <50 years
UC and Risk of Colorectal Ca - Example Question
A 25-year-old gentleman presents with bloody diarrhoea, fevers and lower abdominal pain. An initial colonoscopy shows extensive ulceration in his distal colon withs one mild active inflammation. His dad developed colorectal cancer at the age of 52. His gastroenterologist discusses the necessity of colonic surveillance. What is the risk that he will develop colorectal cancer?
Low risk (offer colonoscopy at 5 years) High risk (offer colonoscopy at 1 year) > Intermediate risk (offer colonoscopy at 3 years) Too early to ascertain No risk
In anyone with inflammatory bowel disease, be it Crohn’s or ulcerative colitis, a baseline colonoscopy with chromoscopy and target biopsy is necessary to determine the risk of developing colorectal cancer.
According to NICE guidance on the colonoscopic surveillance of colorectal cancer, this patient fulfils intermediate risk: extensive ulcerative or Crohn’s colitis with mild active inflammation (confirmed endoscopically or histologically) or post-inflammatory polyps or family history of colorectal cancer in a first-degree relative aged 50 or over.
Crohns Surgical Cx - Example Question
A 48-year-old female with a history of Crohn’s disease is admitted to hospital with abdominal pain and distension. This has been getting progressively worse over the past 24 hours.
Her Crohn’s disease is now well controlled with azathioprine. In the past she has had a number of abdominal operations to treat complications including an ileal resection.
An abdominal film is requested:
SEE AXR Caecal Volvulus
What is the most likely diagnosis?
Toxic megacolon Vesicocolonic fistula Faecal loading Intussusception > Caecal volvulus
The x-ray shows a large dilated loop of bowel centrally consistent with caecal volvulus. Adhesions secondary to Crohn’s and previous surgery are a risk factor for caecal volvulus.
Toxic megacolon is seen in ulcerative colitis.
Crohn’s Disease
Crohn’s disease
Crohn’s disease is a form of inflammatory bowel disease. It commonly affects the terminal ileum and colon but may be seen anywhere from the mouth to anus.
Pathology
cause is unknown but there is a strong genetic susceptibility
inflammation occurs in all layers, down to the serosa. This is why patients with Crohn’s are prone to strictures, fistulas and adhesions
Crohn’s Disease - Features
Crohn’s disease typically presents in late adolescence or early adulthood. Features include:
presentation may be non-specific symptoms such as weight loss and lethargy
diarrhoea: the most prominent symptom in adults. Crohn’s colitis may cause bloody diarrhoea
abdominal pain: the most prominent symptom in children
perianal disease: e.g. Skin tags or ulcers
extra-intestinal features are more common in patients with colitis or perianal disease
Extra-intestinal Features of IBD
Questions regarding the ‘extra-intestinal’ features of inflammatory bowel disease are common:
Common to both Crohn’s disease (CD) and Ulcerative colitis (UC)!
Related to disease activity:
Arthritis: pauciarticular (oligoarticular), asymmetric
Erythema nodosum
Episcleritis
Osteoporosis
- Arthritis is the most common extra-intestinal feature in both CD and UC
- Episcleritis is more common in CD
Unrelated to disease activity: Arthritis: polyarticular, symmetric Uveitis Pyoderma gangrenosum Clubbing Primary sclerosing cholangitis - Primary sclerosing cholangitis is much more common in UC - Uveitis is more common in UC
Note that whilst some features are present in both, some are much more common in one of the conditions, for example colorectal cancer in ulcerative colitis
IBD Autoantibodies
Anti-Saccharomyces cerevisiae antibodies are more likely to be positive in Crohn’s disease. Ulcerative colitis patients are more likely to be pANCA positive.
IBD Example Question
A 26-year-old man comes to the outpatient clinic. He describes a 2-month history of weight loss, cramping lower abdominal pain with increasing stool frequency. His stools often have blood and mucus in them and occasionally he passes pure blood with no faeces. He is normally fit and well and takes no regular medications. On examination, he has a low-grade fever at 37.5 and pale. His abdomen is soft but tender across the lower half. His bloods checked by the GP earlier in the week are as follows:
Hb 110 g/l
Platelets 400 * 109/l
WBC 12.0 * 109/l
Neuts 9.0 * 109/l
Na+ 139 mmol/l K+ 4.5 mmol/l Urea 4.0 mmol/l Creatinine 89 µmol/l CRP 60 mg/L (<10)
Bilirubin 8 µmol/l
ALP 78 u/l
ALT 34 u/l
Albumin 36 g/l
Stool cultures sent by the GP are negative.
He is admitted the same day for a flexible sigmoidoscopy which shows mild colitis extending to the mid-descending colon. Biopsies are taken which are show mild colitis but of indeterminate cause.
He is transferred to the ward and started on IV hydrocortisone 100mg QDS and he clinically improves and is started on regular mesalazine. He is found to be positive for anti-Saccharomyces cerevisiae antibodies but negative for pANCA. What is the likely cause of his colitis?
Ulcerative colitis Microscopic colitis C.difficile infection Behcet's disease > Crohn's disease
This patient has Crohn’s disease. Anti-Saccharomyces cerevisiae antibodies are more likely to be positive in Crohn’s disease. Ulcerative colitis patients are more likely to be pANCA positive. The patient has microscopic colitis on flexible sigmoidoscopy excluding microscopic colitis. Behcet’s usually present in Middle Eastern men with oral and genital ulcers, conjunctivitis and colitis.
Mesalazine Monitoring
A 25-year-old man who is normally fit and well presents with a 2-week history of crampy abdominal pain and bloody diarrhoea. A colonoscopy shows erythema and oedema in the distal colon and evidence of proctitis. He is started on mesalazine. What blood test(s) must be done prior to its commencement?
> Renal function and full blood count Thiopurine methyltransferase activity Amylase Hepatitis screen Liver function test and full blood count
Renal function should be monitored before starting an oral aminosalicylate, at 3 months and then annually thereafter. This should be done more often in the presence of renal impairment. Blood disorders can also occur with mesalazine, and patients should be asked to look out for bruising, bleeding, purpura, fever and sore throat.
TPMT levels should only be needed on commencement of mercaptopurine or azathioprine.
Amylase, hepatitis screen and liver function tests are not required in aminosalicylate therapy monitoring.
Reference: British National Formulary
UC - Mx
Ulcerative colitis: management
Treatment can be divided into inducing and maintaining remission. NICE released guidelines on the management of ulcerative colitis in 2013.
The severity of UC is usually classified as being mild, moderate or severe:
mild: < 4 stools/day, only a small amount of blood
moderate: 4-6 stools/day, varying amounts of blood, no systemic upset
severe: >6 bloody stools per day + features of systemic upset (pyrexia, tachycardia, anaemia, raised inflammatory markers)
UC - Inducing Remission
Inducing remission
treatment depends on the extent and severity of disease
rectal (topical) aminosalicylates or steroids: for distal colitis rectal mesalazine has been shown to be superior to rectal steroids and oral aminosalicylates
oral aminosalicylates
oral prednisolone is usually used second-line for patients who fail to respond to aminosalicylates. NICE recommend waiting around 4 weeks before deciding if first-line treatment has failed
severe colitis should be treated in hospital. Intravenous steroids are usually given first-line
UC - Maintaining Remission
Maintaining remission
oral aminosalicylates e.g. mesalazine
azathioprine and mercaptopurine
methotrexate is not recommended for the management of UC (in contrast to Crohn’s disease)
there is some evidence that probiotics may prevent relapse in patients with mild to moderate disease
UC and Infliximab: Example Question
A 19-year-old man presented to the Emergency Department with frequent, bloody diarrhoea. He reported increasing stool frequency over the past two weeks and at presentation was opening his bowels 20 times per day including nocturnal episodes. He also reported feeling increasingly tired and lethargy with some cramping abdominal pains. The patient had no previous past medical history and took no regular medications Past medical history was unremarkable and the patient took no regular medications. He worked as a trainee plumber, drank alcohol moderately and did not smoke.
Examination demonstrated some diffuse lower abdominal tenderness but with no signs of peritonism. Blood tests at presentation demonstrated anaemia (Hb 105 g / dL) and raised inflammatory markers (ESR 85 mm / h). Initial impression was of an acute severe colitis and treatment with intravenous hydrocortisone and oral 5-aminosalicylates was initiated. A limited flexible sigmoidoscopy demonstrated severe proctitis with inflammation extending beyond the limits of the study at the mid-sigmoid colon. Plain film imaging of chest and abdomen was unremarkable.
A summary of the patients observations and investigations at day 4 from presentation is given below.
Stool chart: 12 large volume bloody type 7 stools over previous 24 hours
Blood pressure: 105 / 67 mmHg
Heart rate: 98 beats / min
Respiratory rate: 19 breaths / min
Temperature: 36.5ºC
Haemoglobin 99 g / dL White cell count 15 * 109/l Neutrophils 13.2 * 109/l Platelets 421 * 109/l Urea 6.8 mmol / L Creatinine 87 micromol / L Erythrocyte sedimentation rate 67 mm / h
What is the next step in management?
> Infliximab Azathioprine Colectomy Add topical 5-aminosalicylates Rituximab
The patient is suffering from an acute severe colitis as assessed using the Truelove-Witt criteria with > 5 bloody stools per day, tachycardia, raised ESR and anaemia. Appropriate initial treatment is IV glucocorticoids. Response to glucocorticoid therapy should be assessed after 3-5 days with consideration of rescue therapy with Infliximab (or Ciclosporin) if disease remains severely active.
Meta-analysis has shown a significant effect of infliximab over placebo in moderate-severe disease with a relative risk of remission not being achieved of 0.72 (0.57-0.91).
If Infliximab has not given adequate response at 5-7 days post-treatment then colectomy must be considered. Azathioprine has a role as maintenance therapy in ulcerative colitis once remission has been achieved. Topical 5-aminosalicylates have a key role in the management of mild disease but are unlikely to achieve remission in severe flares. Rituximab is not used as a treatment for ulcerative colitis.
UC and Risk of Colorectal Ca: Example Question
A 36-year-old man was diagnosed with ulcerative colitis 10 years previously. At his initial presentation a course of intravenous hydrocortisone was required to achieve remission. Subsequently, the patients disease has been fairly well controlled with azathioprine, although occasion courses of oral steroids had been required to treat minor flares. The patient had experienced no extra-gastrointestinal manifestations of his disease and had no other past-medical history. Family history included the patients father being diagnosed with sigmoid adenocarcinoma at the age of 67 years.
The patient was referred for routine screening colonoscopy. This demonstrated extensive colitis extending to the hepatic flexure but no active endoscopic inflammation or post-inflammatory polyps. Mapping biopsies were taken with no evidence of histological inflammation.
Prior to the procedure the patient stated his concern regarding his future risk of colorectal cancer due to his ulcerative colitis and expressed his willingness to undergo surveillance colonoscopy at the recommended time interval.
In what time interval should the patient undergo his next surveillance colonoscopy?
1 year 2 years > 3 years 5 years 10 years
A meta-analysis of population-based studies found that patients with ulcerative colitis have approximately double the incidence of colorectal cancer than individuals without the disease. In the UK, surveillance colonoscopy is recommended for all patients (excluding those with isolated proctitis alone) starting 10 years after diagnosis.
The interval of subsequent surveillance colonoscopy depends on risk stratification of the patient. Factors to be considered include the extent of colitis, the presence of endoscopic or histological inflammation, the presence of pseudo-polyps, a history of primary sclerosing cholangitis and family history of colorectal cancer. Patient preference is also a factor to be included in decisions around surveillance.
In this case, the patient has a family history of colorectal cancer in a first-degree relative diagnosed at an age greater than 50 years placing him in the intermediate risk category. A further colonoscopy in three years is therefore appropriate. Those in lower risk and higher risk groups are recommended to have colonoscopies every 5 years and 1 year respectively.
Crohn’s PSC and the risk of Colorectal Ca
Patients with Crohns disease have an increased risk of small bowel and colorectal malignancy (standard incident ratios 40.6 and 1.9 respectively). Surveillance usually begins 10 years after the diagnosis of inflammatory bowel disease with risk stratification to determine frequency of surveillance. The concurrence of Crohns disease and primary sclerosing cholangitis confers greatly increased risk of malignancy with recommendations calling for annual surveillance after diagnosis.
Example Question:
A 45-year-old man with long-standing Crohns disease is reviewed in gastroenterology clinic. Initial diagnosis was 12 years previously when he presented as an emergency due to a perianal fistula and associated abscess. This had necessitated emergency surgery and treatment with intravenous corticosteroids. Once remission had been obtained through use of corticosteroids, azathioprine had been used as an immunomodulating agent to maintain remission. Subsequently, the patients disease had been fairly well controlled with disease flares on average less than every 2 years. When flares occurred they tended to cause the patient severe bouts of bloody diarrhoea. Large bowel endoscopies performed following disease exacerbation tended to show colonic inflammation with multiple biopsies consistent with the original histological diagnosis of Crohns disease.
Two months previously, the patients routine monitoring bloods had demonstrated derangement of liver function tests prompting further investigations (details given below). Following conclusion of these investigations, the patient had been initiated on cholestyramine and vitamin supplementation.
Alanine aminotransferase 45 U / L Alkaline phosphatase 356 U / L Bilirubin 105 micromol / L Albumin 30 g / L ANCA (PR3) Negative ANCA (MPO) Positive Anti-smooth muscle antibody Positive
Endoscopic retrograde cholangio-pancreatogram: multiple intrahepatic bile duct strictures and beading
Following discussion with the patient about his new diagnosis he raised his concerns about his future risk of bowel cancer and whether he would require regular endoscopic surveillance.
What is the appropriate frequency of surveillance colonoscopy for this patient?
Not indicated > Every 1 year Every 3 years Every 5 years Every 10 years
The patients investigation results point to a new diagnosis of primary sclerosing cholangitis, known to be associated with Crohns disease and ulcerative colitis.
Crohn’s Disease and Infliximab: Example Question
A 25-year-old woman is reviewed in gastroenterology clinic six weeks after a recent hospital admission with abdominal symptoms. During the initial admission, the patient had presented with a 6 week history of very frequent bloody diarrhoea, a 10 kg weight loss and intermittent severe abdominal pain. Endoscopy had demonstrated a pan-colitis with histological features consistent with Crohn’s disease. In addition, a CT scan of the abdomen had revealed a localised abscess associated with the proximal colon that had required percutaneous drainage and a course of IV antibiotics.
In addition to the above, the patient had been treated with IV hydrocortisone followed by a reducing course of prednisolone (initially 40 mg daily, tapered over 8 weeks). Steroid treatment had initially given a good response with the patients symptoms markedly improving during her hospital stay. Azathioprine treatment had been initiated prior to discharge in an attempt to maintain remission during wean of oral steroids.
In clinic, the patient reported being concordant with azathioprine therapy. However, she found that when she had reduced her prednisolone dose below 15 mg daily, she had recurrent abdominal pains and frequent bloody diarrhoea (although less severe than at presentation). She had also noted some pain to the left side of her anus when defecating.
Examination of the patients abdomen revealed some lower abdominal tenderness but without features of peritonitis. External examination showed an area of ulceration one centimetre lateral to the anus.
Haemoglobin 95 g / dL Mean cell volume 98 fL White cell count 16.9 x 10>3 / microlitre Neutrophils 12.6 x 10>3 / microlitre Platelets 451 x 10>3 / microlitre Urea 8.0 mmol / L Creatinine 97 micromol / L Sodium 143 mmol / L Potassium 3.9 mmol / L CRP 125 mg / L
What is the appropriate next line treatment to induce remission in this patient?
Colectomy Methotrexate Metronidazole > Infliximab Budesonide
This patient has multiple risk factors for a severe phenotype of Crohn’s disease. In particular, her young age (< 40 years), female sex, the need for steroids to control her first exacerbation, the presence of an intra-abdominal abscess and likely perianal disease are all associated with an aggressive disease course. Another feature of concern not present in this patient is lesions of the upper GI tract.
While having given some improvement, the appropriate initial steroid treatment has failed to induce full remission. In cases with features of a severe phenotype, a rapid step-up to biological therapy is indicated. Infliximab is effective at inducing remission in moderate-to-severe Crohn’s disease compared to placebo (remission rate at four weeks 81 % vs 17 %) and is also an effective treatment of peri-anal disease.
Budesonide is indicated to induce remission in mild-moderate disease confined to the small bowel or proximal colon and is associated with fewer side effects compared to other corticosteroids. Like azathioprine, methotrexate is effective in maintaining but not inducing remission from Crohn’s disease.
Surgery in Crohn’s disease is reserved to treat the consequences of failure of medical therapy only (for example, fistulas, abscesses or strictures). Ileocaecal resection can be first line treatment for discrete terminal ill disease, although anastomotic recurrence remains common. Metronidazole has a role in treating peri-anal Crohn’s disease although would not be sufficient to induce remission in this patient.
Crohn’s - Maintaining Remission: Example Question
A 42-year-old woman attends the gastroenterology clinic for outpatient review approximately one month following a recent admission to hospital. She had presented with a 6 week history of frequent bloody diarrhoea and cramping abdominal pain. In addition, she reported a long-standing tendency to suffer from multiple mouth ulcers. She had lost approximately, 8 kilograms of weight between the onset of diarrhoea and presentation to hospital.
The results of investigations performed during the hospital admission are given below. Following investigation, a short course of intravenous steroids had been given followed by oral prednisolone (initial dose 40 mg daily, slowly tapered over 8 weeks).
The patient reported near complete resolution of her previous symptoms and welcome relief from her oral ulceration. She had regained some of the weight she had previously lost and reported her appetite to be good. A discussion was had with the patient about future therapy and she indicated that she would prefer to consider the initiation of further medication to attempt to maintain her symptom remission.
Stool microscopy: no organisms seen
Stool culture: no organisms grown
Colonoscopy: patchy inflammation with ‘cobblestone’ appearance affecting ascending and transverse colon and terminal ileum
Colonic histology: multiple samples demonstrating signs of chronic transmural inflammation, crypt abscesses and submucosal fibrosis
CT abdomen: no evidence of intra-abdominal collection, structuring or abnormal fistulation
What is the most appropriate medication to maintain disease remission in this patient?
Methotrexate Infliximab Budesonide > Azathioprine Metronidazole
The patients presentation and investigation results are consistent with a new diagnosis of Crohns disease. She appears to have had a good response to initial treatment with corticosteroids, however introduction of an immunomodulating agent to maintain remission and limit steroid exposure is appropriate, especially given the patients risk factors for a severe Crohns disease phenotype (female sex; need for steroids to treat first flare).
Once remission is obtained then a thiopurine such as azathioprine or mercaptopurine is first line treatment to maintain remission. Methotrexate is an alternative agent but tends to be less well tolerated than thiopurines.
Biological therapies such as infliximab are considered to maintain remission only after failure of treatment with the immunomodulating agents above. Budesonide is an oral corticosteroid and is therefore not an appropriate choice for maintenance of remission. Metronidazole has efficacy in perianal Crohns disease only.
IBD and CMV Colitis - Example Question
A 38-year-old man is referred in by his GP with increasing frequency of diarrhoea over the last 4 days. He is a known ulcerative colitis patient who is well managed on azathioprine 200mg OD and mesalazine 2.4mg BD. He last had a flare 2 years ago and has been well in the interim. He is passing up to 10 watery motions a day and is suffering from faecal urgency and nocturnal episodes. He describes cramping left iliac fossa pain. There is no blood or mucus in the stools. On examination, he is febrile at 38.2 degrees celsius. His blood pressure is 120/75 mmHg and his heart rate is 100/min. On examination, he is underweight with a BMI of 18.5 and dehydrated. His abdomen is soft but he is tender in the left iliac fossa. He refuses a PR examination. Respiratory and cardiovascular examinations are normal.
His blood tests show:
Hb 110 g/l Platelets 189 * 109/l WBC 3.8 * 109/l Neutrophils 0.89 * 109/l INR 1.1 (0.9-1.2)
Na+ 136 mmol/l K+ 4.9 mmol/l Urea 8.0 mmol/l Creatinine 100 µmol/l Mag nesium 0.79 mmol/L (0.7-1.0) Calcium 2.4 mmol/L (2.1-2.58) CRP 78 mg/l
Bilirubin 5 µmol/l
ALP 78 u/l
ALT 28 u/l
Albumin 33 g/l
He is started on IV hydrocortisone 100mg QDS and IV fluids. Stool specimens are sent and are reported as negative for C. difficile toxin. He has a flexible sigmoidoscopy the next day which shows widespread left sided colitis. The biopsy results show the presence of inclusion bodies in the colonic mucosa. What is the appropriate treatment to start for this gentleman?
Infliximab > Ganciclovir Metronidazole Fluconazole Tazocin
This patient has CMV colitis. It can be a consequence of immunosuppressive agents such as azathioprine. It can present with fever and diarrhoea +/- blood. It can also present as an exacerbation of IBD patients in those on immunosuppressants. Inclusion bodies are characteristic at biopsy. It will respond well to an antiviral agent and ganciclovir is the treatment necessary here. Tazocin, metronidazole and fluconazole will not treat appropriately and infliximab would only be indicated if a colitis flare was not due to an infective cause.
Crohn’s - Investigation
Crohn’s disease: investigation
Crohn’s disease is a form of inflammatory bowel disease. It commonly affects the terminal ileum and colon but may be seen anywhere from the mouth to anus
Bloods
C-reactive protein correlates well with disease activity
Endoscopy
colonoscopy is the investigation of choice
features suggest of Crohn’s include deep ulcers, skip lesions
Histology
inflammation in all layers from mucosa to serosa
goblet cells
granulomas
Small bowel enema high sensitivity and specificity for examination of the terminal ileum strictures: 'Kantor's string sign' proximal bowel dilation 'rose thorn' ulcers fistulae
UC and Cancer Screening: Example Question
A 29 year old man with ulcerative colitis presents to clinic. His colitis has been relatively well controlled since his diagnosis at 18 years old, with two flare-ups requiring steroids in the last 3 years. He has never needed hospital admission. He is currently in full time employment as an engineer.
He has been taking Pentasa (mesalazine) for two years, which is very well tolerated. On examination, his height is 180cm, and weight 58kg (body mass index 18 kg/m²). His abdomen is soft and non-tender. His last colonoscopy 8 months ago showed no active inflammation and no suspicious areas.
He is anxious as his father died from colorectal cancer in his 60’s. There is no other family history of gastrointestinal disease. How regularly should he have a surveillance colonoscopy?
Yearly > 3 years 2 years 4 years 5 years
Since this patient has a first degree relative with a history of bowel cancer over 50 years old, he would fall into the ‘intermediate category’, and thus require a 3 yearly colonoscopy.
Guidelines: BSG Guidelines for the management of inflammatory bowel disease
