Inflammatory Bowel Disease Flashcards
What is included in IBD?
- Crohn’s
- Ulcerative colitis
- Microscopic colitis
- Collagenous colitis
- Lymphocytic colitis
Inflammatory bowel disease
Chronic relapsing inflammatory conditions of the bowel
What classification system is used in IBD?
Montreal classification
What is the aetiology of IBD?
- Unknown
- Environmental trigger?
- Genetically susceptible people?
What environmental factors are believed to trigger IBD?
- Role of bacteria
- Diet
- Vaccination history
- Social factors
- Ethnicity
When does peak incidence occur for UC?
20-40 years
What does UC present with?
- Bloody diarrhoea
- Abdominal pain
- Weight loss
What are the characteristics of UC?
- Continuous inflammation only affecting the colon
- Variable distribution
- Variable severity
What are the markers of a sever attack of UC?
Stool frequency >6 stools/day with blood AND -Fever >37.5 -Tachycardia >90 -ESR (CRP) raised -Anaemia: Hb <10g/dl -Albumin <30g/l -Leucocytosis -Thrombocytosis
What is the prevalence of Crohn’s ?
M=F
When are the 2 peaks of incidence of CD?
- 20-40 years
- 60+
What are the characteristics of CD?
-Patchy disease
-Can affects mouth to anus
-Skip lesions
-Clinical features depend on regions involved
-
What are the clinical features of CD?
- Diarrhoea
- Abdominal pain
- Weight loss
- Malaise
- Lethargy
- Anorexia
- Nausea and vomiting
- Low grade fever
- Malabsoprtion
What are the possible complications of CD?
- Inflammation
- Strictures
- Fistulas
What are the blood results of someone with IBD like?
- High ESR and CRP
- High platelet count
- High WCC
- Low Hb
- Low albumin
What are the categories of calprotectin results?
- <50 normal
- 50-200 equivocal
- > 200 elevated
How does the histology of CD and UC differ?
- CD has granulomas
- Goblet cells are depleted in UC
- Crypt abscess UC>CD
What features are present in CD but not in UC?
- Fistulae
- Peri-anal disease
What extra-intestinal manifestations of IBD can occur in the eyes?
- Uveitis
- Episcleritis
- Conjunctivitis
What extra-intestinal manifestations of IBD can occur in the joints?
- Sacroilitis
- Monoarticular arthritis
- Ankylosing spondylitis
What extra-intestinal manifestations of IBD can occur in the liver and biliary tree?
- Fatty change
- Pericholangitis
- Sclerosing cholangitis
- Gallstones
What extra-intestinal manifestations of IBD can occur in the skin?
- Pyoderma gangrenosum
- Erythema nodosum
- Vasculitis
Which IBD can present with renal calculi?
CD
What are the differential diagnoses for IBD?
- Chronic diarrhoeas (malabsorption/ malnutrition)
- Ileo-caecal TB
What must colitis be distinguisged from?
Infective, amoebic and ischaemic colitis
What is sclerosing cholangitis?
- Slow progressive disease of the bile ducts
- Involves multiple strictures
- Can lead to cirrhosis
What is a long term complication of colitis?
Colonic carcinoma
What is surveillance colonoscopy?
Annual, biannual etc colonoscopies with quadrantic biopsies every 10cm in patients with extensive colitis in order to detect any colonic cancers early
How can people with IBD be managed as outpatients?
- 5ASA
- Steroids
- Immunosuppression
How can people with IBD be managed in hospital?
- Steroids
- Anticoagulation
- Rest
- Antibiotics
- Surgery
What are the tiers in the IBD management pyramid from the bottom up?
- 5ASA or sulfasalazine
- Prednisolone or budesonide
- Immunomodulators (AZA, 6MP, MTX)
- Biological agents
- Surgery
What is 5ASA?
- 5 amino salicylic acid otherwise known as mesalazine
- Is an aminosalicylate
When are antibiotics indicated for IBD?
- CD peri-anal
- Small bowel bacterial over growth
In what ways may medial therapies fail?
- Relapse prior to or shortly after stopping therapy
- Failure to control symptoms
- Unacceptable complications of steroids
What unacceptable complications from steroids are there?
- Diabetes
- Severe osteoporosis
- Psychosis
What may show poor response to medical therapy?
- Fistulas
- Fibrotic strictures
- Peri-anal disease
- Severe fulminating disease
What 2 categories of surgery are ther for IBD?
- Emergency
- Elective
For someone who is acutely ill with severe colitis , what is the best surgical option?
Subtotal colectomy with rectal preservation and an ileostomy
What surgical options are there for chronic UC?
- Pouch procedure (no ileostomy)
- Proctocolectomy (ileostomy)
What are the surgical options for site with CD?
- Small intestine
- Ileocaecal area
- Colon and rectum
- Anus (fissures, abscesses, fistulas, skin tags)
What are the surgical indications fro CD?
- Failure of medical management
- Relief of obstructive symptoms
- Management of fistulas
- Management of intra-abdominal masses
- Management of anal conditions
- Failure to thrive
Why is CD surgery not considered curative?
50% need further surgery by 10 year mark
What different forms of mesalazine are there?
- Acrylic resin
- Ethylcellulose microgranules
What aminsalicylate pro drugs are there?
- Balsalazide
- Olzalazine
- Sulfasalazine
When is 5ASA given in mild- moderate UC?
-For distal and more extensive disease as they are superior to rectal steroids
When 5ASA is used in mild-moderate UC to induce remission what has >3g per day shown?
- No significant improvement in remission rate
- Greater and quicker clinical improvement
- No increase in adverse events
When 5ASA is used in mild-moderate UC for maintenance of remission what has it shown?
- Reduced number and severity of relapses
- Reduced CRC risk
When can 5ASA induce remission in CD?
Mildly active ileocolonic disease
When can 5ASA be used to maintain remission in CD?
- Only if medical remission had been induced by 5ASA
- Post small bowel resection
What steroids are used in IBD?
- Prednisolone
- Budenoside
How is prednisolone used in IBD?
- Optimal dose is 40mg per day
- Tapering reduction over 4 weeks
When are the only times that budenoside can be used in IBD?
-Ileal and ascending colon disease
What immunosuppressant’s are used in IBD?
- Azathioprine
- Methotrexate
- Ciclosporin
- Mycophenolate
- Tacrolimus
What can azathioprine be used for?
Induction and maintenance of remission
What are the significant side effects of azathioprine?
- Leucopenia
- Hepatotoxicity (requires regular blood monitoring)
- Pancreatitis
- Long term lymphoma risk
- Intolerance
Describe the use of methotrexate in CD.
- Induction and maintenance of remission
- Steroid dependen
- 10-18% intolerance
- Requires specialist follow up
What is ciclosporin used for?
- Salvage therapy for refractory UC
- 3-6 months as bridge to azathioprine
Why is mycophenolate rarely used?
No evidence
How effective is elemental feeding?
- Exclusive elemental feeding can be as effective as steroids
- More efficacious in children
- Compliance is difficult though
What biological agents are used in IBD?
- Anti-TNFa antibodies
- a4b7 integrin blockers
- IL12/IL23 blockers
What anti-TNFa antibodies are used in IBD?
- Infliximab (remicade): 8 weekly IV infusion
- Adulimumab (Humira): 2 weekly SC injections
What a4b7 integrin blockers are used in IBD?
-Vedolizumab: 8 weekly IV infusion
What IL12/IL23 blockers are used in IBD?
-Ustekinumab : IV loading followed by SC 8-12 weekly
