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General Medicine Pt1 > Inflammatory bowel disease > Flashcards

Inflammatory bowel disease Flashcards

1
Q

Define Crohn’s disease

A

Chronic relapsing IBD characterised by transmural granulomatous inflammation affecting any part of the GI tract.

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2
Q

When does Crohn’s disease typically present?

A

Bimodal distribution

  • 15-30yr
  • 60-80yr
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3
Q

Where is the commonest location for Crohn’s disease?

What metabolic condition is associated with this?

A

Terminal ileum

Vit B12 deficiency ➔ Pernicious anaemia (macrocytic)

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4
Q

Name two risk factors for Crohn’s disease

A
  • Smoking: more aggressive disease and earlier post-op relapse
  • Genetic: 15-20% will have an affected family member with IBD
  • Ethnicity: Western; Australian
  • Previous infective gastroenteritis
  • NSAIDs
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5
Q

List three symptoms of Crohn’s disease

A
  • Diarrhoea (80%): may be bloody
  • Abdominal pain
  • Weight loss/failure to thrive
  • Anorexia
  • General malaise
  • NaV
  • Fever (low grade)

15% have no GI symptoms

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6
Q

List two GI signs of Crohn’s disease

A
  • Abdominal tenderness
  • Abdominal distension or mass: RIF - can mimic appendicitis
  • Perianal abscess; fistula; skin tags (characteristic)
  • Anal strictures
  • Mouth ulcers
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7
Q

List three extra-intestinal signs of Crohn’s disease

A

Up to 35% experience extra-intestinal manifestations

  • Conjunctivitis; episcleritis; iritis
  • Arthritis (<5 large joints), ankylosing spondylitis
  • Erythema nodosum; pyoderma gangrenosum; clubbing
  • Fatty liver; PSC
  • Osteopenia; osteoporosis; osteomalacia
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8
Q

Suggest three macroscopic features of Crohn’s disease

A
  • Any part of the GI tract; rectal sparring
  • May involve gross bleeding
  • Perianal disease; fistulas
  • Malnutrition
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9
Q

Suggest three pathological features of Crohn’s disease

A
  • Transmural inflammation
  • Granulomas
  • Fibrosis
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10
Q

List four endoscopic features of Crohn’s disease

A
  • Discontinuous mucosal involvement
  • Cobblestone; linear ulcers; aphthous ulcers (mouth)
  • Fistula
  • Stenosis
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11
Q

Name four initial investigations for Crohn’s disease?

A
  • FBC: anaemia
  • ESR; CRP
  • U+Es: dehydration and electrolyte disturbance
  • Stool culture: include C. difficile toxin
  • Faecal calprotectin: rules out IBS
  • LFTs: hypoalbuminaemia (severe disease)
  • Coeliac serology
  • Vit B12; folate; ferritin; vit D: malabsorption or losses
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12
Q

Suggest four radiological investigations used to confirm Crohn’s disease?

A
  • Colonoscopy + multiple intestinal biopsy specimens
  • Upper GI endoscopy
    • All children and young people
    • Upper GI symptoms in adults
  • Small bowel imaging: USS, MRI, or capsule endoscopy
  • Pelvic MRI if suspected perianal disease
  • CT to stage Crohn’s disease
  • AXR: identify any obstruction
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13
Q

What test is used to differentiate IBD and IBS?

A

Faecal calprotectin

+ve in IBD -ve in IBS

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14
Q

Outline non-pharmacological management for Crohn’s disease

A
  • Smoking cessation
  • Patient information; support groups
  • Dietary advice
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15
Q

How is remission of mild-moderate Crohn’s disease induced?

A

Monotherapy: first presentation or single exacerbation in 1yr

  1. Corticosteroids
    • Consider enteral nutrition in children
  2. Budesonide (mild-moderate)
  3. Aminosalicylate: Mesalazine or sulfasalazine (mild-moderate)

Add-on treatment: 2+ exacerbations in 1yr; or cannot taper steroids

  • Thiopurines: Azathioprine; mercaptopurine
  • Methotrexate
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16
Q

Why should corticosteroids not be used for maintenance therapy in Crohn’s disease?

A

Longterm use of corticosteroids results in

  • Osteoporosis; fractures
  • Increased infection risk
  • Cushing’s syndrome
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17
Q

Why must corticosteroid treatment be tapered off?

A

Longterm use of corticosteroids may cause adrenal suppression

Abruptly stopping corticosteroids may cause addisonian crisis

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18
Q

What must be assessed prior to starting thiopurine add-on therapy such as Azathioprine or Mercaptopurine?

A

TMPT activity

Consider methotrexate if TMPT deficient

19
Q

Define severe active Crohn’s disease

A

Very poor general health with one or more symptoms of:

  • Weight loss
  • Fever
  • Severe abdominal pain
  • Frequent (3-4+) diarrhoea daily.
20
Q

Outline the management of severe active Crohns disease

A

If conventional treatment fails or is contraindicated

Anti-TNF: Infliximab or adalimumab

21
Q

Outline how remission of Crohn’s disease is maintained

A

Monotherapy:

  1. Thiopurines: Azathioprine or mercaptopurine
  2. Methotrexate

Post- complete macroscopic resection: Azathioprine + metronidazole

22
Q

Outline the surgical management of Crohn’s disease

A

Limited to terminal ileum

  • Consider surgery early as alternative to medical treatment
  • Children with growth impairment and/or refractory disease

Balloon dilation for strictures

Resection of severely affected areas of the GI tract

23
Q

What long-term monitoring may be undertaken in Crohn’s disease?

A
  • Bone mineral density (DEXA) as per FRAX risk assessment in adults
  • Colonscopic surveillance for colorectal cancer
  • Impact of Crohn’s medication on pregnancy and fertility
24
Q

Define Ulcerative colitis

A

Relapsing and remitting inflammatory disorder of the colonic mucosa

25
Q

When does Ulcerative colitis present?

A

Bimodal distribution

  • 15-25yr
  • 55-65yr
26
Q

Name three risk factors for ulcerative colitis

A
  • FHx: esp. in first-degree relatives
  • No appendicectomy
  • NSAIDs
  • Non/ex-smoker
27
Q

List four clinical features of Ulcerative colitis

A
  • Bloody diarrhoea >6wk; rectal bleeding
  • Faecal urgency and/or incontinence
  • Nocturnal defecation
  • Tenesmus
  • LUQ abdominal pain
  • Pre-defecation pain
  • Non-specific: fatigue; malaise; anorexia; fever
  • Weight loss; faltering growth; delayed puberty in children
28
Q

List three signs of Ulcerative colitis

A

Rectal disease Abdominal distension ➔ risk of toxic megacolon

29
Q

List three extra-intestinal signs of Ulcerative colitis

A

30% of UC has extra-intestinal manifestations

  • Arthritis (<5 large joints)
  • Erythema nodosum
  • Aphthous mouth ulcers
  • Episcleritis
  • Osteopenia; osteoporosis; osteomalacia
  • VTE
30
Q

How is severity of Ulcerative colitis assessed?

A

Truelove and Witt’s score

31
Q

Name two macroscopic features of Ulcerative colitis

A
  • Involvement of rectum and colon: extending proximally
  • Gross bleeding
  • Purulent exudates
32
Q

List one pathological features of Ulcerative colitis

A

Crypt abscesses

33
Q

List two endoscopic features of Ulcerative colitis

A
  • Continuous mucosal involvement
  • Friable mucosa
34
Q

Request four investigations for suspected ulcerative colitis

A
  • FBC: anaemia
  • Raised ESR and CRP
  • U+E; LFTs
  • TFTs: exclude hypothyroidism
  • Ferritin; vitamin B12; folate; vitamin D
  • Coeliac serology
  • Stool culture inc. C. difficile toxin
  • Faecal calprotectin

May be normal during active ulcerative colitis

35
Q

What specialist investigation may confirm ulcerative colitis?

A

Colonoscopy* - gold standard Flexible sigmoidoscopy AXR essential for acute severe attacks to exclude colonic dilatation ➔ toxic megacolon

36
Q

When should suspected ulcerative colitis be admitted as an emergency?

A
  • Sytemically unwell with severe disease
    • Bloody diarrhoea
    • Fever
    • Tachycardia
    • Hypotension
37
Q

Outline how remission of ulcerative colitis is induced

A
  1. Topical aminosalicylate: Sulfasalazine
  2. Add oral aminosalicylate
  3. Corticosteroid (time-limited)
38
Q

Outline how ulcerative colitis remission is maintained

A
  1. Topical and/or oral aminosalicylate
  2. Thiopurines (azathioprine; mercaptopurine) PO if either:
    • 2+ exacerbations in 1yr needing IV corticosteroids
    • Not maintained by aminosalicylates
39
Q

Outline the management of acute severe ulcerative colitis

A
  • Involve gastroentereology + colorectal surgery
  • IV corticosteroids
    *
40
Q

Outline the surgical management for Ulcerative colitis

A

Curative surgical resection

41
Q

Why is toxic megacolon considered a severe complication of ulcerative colitis?

A
  • Dangerous stage of advanced disease
    • Impending perforation
    • High mortality (15-25%)
  • Requires urgent surgery if not resolved within 48hr
42
Q

How does toxic megacolon appear on AXR?

A
  • Dilated thin-walled colon
  • >6cm diameter
  • Gas filled with mucosal islands
43
Q

Name four complications of ulcerative colitis

A
  • Psychosocial impact
  • Toxic megacolon
  • Bowel obstruction
  • Bowel perforation
  • Intestinal strictures
  • Fistulas
  • Anaemia
  • Malnutrition; faltering growth; delayed puberty
  • Colorectal cancer

General Medicine Pt1 (25 decks)

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