Inflammatory Bowel Disease Flashcards
What is the general definition of IBD?
Dysregulation of the immune response to foreign proteins and host bacteria is the cause
Which type of IBD has been shown to have a stronger genetic input?
Crohn’s
What is a common gene affected in IBD and what is this involved in?
NOD2- encodes a protein involved in bacterial recognition
What are 5 common presenting complaints of IBD?
Change in bowel habit, PR bleeding, weight loss, anaemia, abdominal pain
What is most likely to be the diagnosis in a child < 12 with IBD symptoms?
Crohn’s
Symptoms of bloody diarrhoea, pain in the left lower quadrant and tenesmus are more likely to be what?
UC
Symptoms of non-bloody diarrhoea, upper GI symptoms, pain or mass in the right lower quadrant are more likely to be?
CD
Per-anal disease is more commonly associated with?
CD
Weight loss is more common in?
CD
What co-morbidities are more common in UC?
Primary sclerosing cholangitis and uveitis
What co-morbidity is more common in CD?
Gallstones
Which IBD has a higher risk of colorectal cancer?
UC
What are complications of CD?
Colorectal cancer, obstruction and fistula
Where in the GI tract does UC affect?
From rectum anywhere up to ileocaecal valve- continuously
Where in the GI tract does Crohn’s affect?
Anywhere from mouth to anus- usually patchy
Where does inflammation invade in UC?
Never beyond the submucosa
Where does inflammation invade in CD?
All layers from mucosa to serosa
Which IBD are pseudopolyps associated with?
UC
Which IBD is cobble-stoning of mucosa associated with?
CD
Which IBD does smoking protect against and which does it affect?
Protects- UC
Aggravate- CD
What age range is the peak incidence of UC?
20-30
What mediates UC?
Th1 and Th2
In UC, there is persistent activation of what?
T cells and macrophages
Natural killer cells in UC are mediated by what?
IL5 and IL13
Can there ever be a single attack of UC?
Yes, but rarely
Where does UC tend to attack first?
The rectum, then works proximally
What does proctitis mean?
UC affecting only the rectum
What is left-sided colitis?
UC affecting rectum and sigmoid/descending colon
What is UC affecting the whole colon known as?
Pancolitis
What are 5 common symptoms of UC?
Bloody diarrhoea, urgency and tenesmus, increased bowel frequency, incontinence and night rising and lower abdominal pain
What are 5 extra-intestinal manifestations of UC?
Skin rashes, joint pain, eye problems, deranged LFTs, renal stones
What are the criteria involved in Truelove and Witt for UC?
Number of bowel movements, bloody stool, temp > 37.8, HR > 90bpm, anaemia
A temp > 37.8, HR > 90bpm and anaemia suggests what type of UC?
Severe
What distinguishes between mild and moderate UC?
Mild: < 4 bowel movements, spots of blood
Moderate: 4-6 bowel movements, mild-severe blood
What tests would be done to assess UC?
Bloods, AXR, endoscopy or sigmoidoscopy, biopsy, histology
What would you test blood for in UC?
CRP and albumin
What should you look for on an AXR of UC?
Bowel dilatation, absent stool distribution, mucosal oedema (thumbprint), toxic megacolon
What is Wriggler’s sign?
Can see the outside of the bowel wall- suggests perforation
What would you look for on histology of UC?
Absence of goblet cells and crypt distortion
Will there be granulomas on UC histology?
No
When should UC be monitored for colorectal cancer?
Every 10 years if patients have extensive colitis (beyond splenic flexure)
What is an electrolyte complication of UC?
Hypokalaemia
What parts of the GI tract tend to be involved in Crohn’s in older and younger patients?
Younger- upper GI
Older- lower GI
What is the mediator of CD?
Th1
CD is driven by the production of what?
Interleukins, TNF alpha by dendritic cells and macrophages
What are symptoms of Crohn’s in the mouth?
Painful ulcers, cobble-stoning of buccal mucosa, angular stomatitis, swollen lips
What are symptoms of Crohn’s in the SI?
Abdominal cramps, diarrhoea, weight loss
What are symptoms of Crohn’s in the LI?
Abdominal cramps, bloody diarrhoea, weight loss
What are symptoms of Crohn’s in the anus?
Peri-anal pain, abscesses
What tests are used to assess CD?
Bloods, colonoscopy, endoscopy, mucosal biopsy, histology
What is looked for in blood tests of CD?
CRP, albumin, platelets, vitamin B12, ferritin
What will be seen on histology of CD?
Large, non-caseating granulomas
What can peri-anal disease lead to?
Fistula formation
What is used to treat peri-anal colitis?
Metronidazole
What type of effect do all IBD drugs have?
Anti-inflammatory
What are the drugs used for UC?
5ASA, steroids, immunosuppression, anti TNF
What are the drugs used for CD?
Steroids, immunosuppression, anti TNF
What is important to remember about the order of usage of IBD drugs?
Often start with strongest first to reduce symptoms and then decrease
As well as being an anti-inflammatory, what is another important effect of mesalazine?
Decreases risk of colorectal cancer
What are side effects of 5ASA?
Diarrhoea and nephritis
What is a suppository?
Solid dose in rectum
What is and enema?
Fluid dose in rectum
How can mesalazine be given?
Orally, suppository, enema
When should enemas and suppositories be used?
Enema- night
Suppository- morning
What are the first and second line corticosteroids used?
1- prednisolone
2- budesonide (not systemic)
What drugs should be co-administered with corticosteroids?
Omeprazole
Because of unwanted steroid dependence, what drugs are used long term instead?
Immunosuppressants
What should you avoid co-prescribing with immunosuppressants?
Allopurinol
What are side effects of immunosuppressants?
Pancreatitis, leukopenia, hepatitis, small risk of skin cancer
Biological agents work by blocking what?
TNF alpha secreted by dendritic cells and macrophages
What are side effects of biological agents?
Cancers, reactivation of TB, irreversible MS
What are some emergency operations for IBD?
Subtotal colectomy for UC, resection of Crohn’s
What are some elective operations for UC?
Proctocolectomy with end ileostomy, ileorectal anastomoses
What are some elective operations for CD?
Resection, stricturoplasty, fistula surgery, surgery for anal disease
Removal of the terminal ileum in Crohn’s is common. This leads to a deficiency of what?
Vitamin B12
What are some indications for elective surgery of IBD?
Medically unresponsive disease, intolerable, dysplasia or malignancy, growth retardation in children
What is a proctocolectomy?
Removal of some or all of the colon without the rectum
What is a panproctocolectomy?
Removal of some or all of the colon with the rectum
What side is an ileostomy usually on?
Right
What are the two types of ileostomy and which is preferred?
End or loop- loop is preferred
Why is it important that ileostomies are spouted?
What comes out is toxic and can cause skin reactions
Where usually is the spout from a colostomy?
Left
Who are pouches following a proctocolectomy more common in and what do they create?
Younger people- create a reservoir
What shapes can pouches be?
W, S, J
What are the functional outcomes of a pouch?
Bad- usually around 6 bowel movements in 24 hours
Who are pouches not given to?
Crohn’s patients (in UK) and young females without a family
What is pouchitis?
A common complication of pouch procedures which results in patients being at the toiler around 20-30 times a day with mucus and pain
How do you treat pouchitis?
Antibiotics and probiotics
Surgery for UC is usually what?
Curative
When is surgery for CD done?
Only when necessary- usually they will have it again after 10 years
What is a seton?
Technique used for fistulas
