Inflammatory bowel disease Flashcards
Define Crohn’s disease
Chronic relapsing IBD characterised by transmural granulomatous inflammation affecting any part of the GI tract.
When does Crohn’s disease typically present?
Bimodal distribution
- 15-30yr
- 60-80yr
Where is the commonest location for Crohn’s disease?
What metabolic condition is associated with this?
Terminal ileum
Vit B12 deficiency ➔ Pernicious anaemia (macrocytic)
Name two risk factors for Crohn’s disease
- 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
List three symptoms of Crohn’s disease
- Diarrhoea (80%): may be bloody
- Abdominal pain
- Weight loss/failure to thrive
- Anorexia
- General malaise
- NaV
- Fever (low grade)
15% have no GI symptoms
List two GI signs of Crohn’s disease
- Abdominal tenderness
- Abdominal distension or mass: RIF - can mimic appendicitis
- Perianal abscess; fistula; skin tags (characteristic)
- Anal strictures
- Mouth ulcers
List three extra-intestinal signs of Crohn’s disease
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
Suggest three macroscopic features of Crohn’s disease
- Any part of the GI tract; rectal sparring
- May involve gross bleeding
- Perianal disease; fistulas
- Malnutrition
Suggest three pathological features of Crohn’s disease
- Transmural inflammation
- Granulomas
- Fibrosis
List four endoscopic features of Crohn’s disease
- Discontinuous mucosal involvement
- Cobblestone; linear ulcers; aphthous ulcers (mouth)
- Fistula
- Stenosis
Name four initial investigations for Crohn’s disease?
- 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
Suggest four radiological investigations used to confirm Crohn’s disease?
- 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
What test is used to differentiate IBD and IBS?
Faecal calprotectin
+ve in IBD -ve in IBS
Outline non-pharmacological management for Crohn’s disease
- Smoking cessation
- Patient information; support groups
- Dietary advice
How is remission of mild-moderate Crohn’s disease induced?
Monotherapy: first presentation or single exacerbation in 1yr
- Corticosteroids
- Consider enteral nutrition in children
- Budesonide (mild-moderate)
- Aminosalicylate: Mesalazine or sulfasalazine (mild-moderate)
Add-on treatment: 2+ exacerbations in 1yr; or cannot taper steroids
- Thiopurines: Azathioprine; mercaptopurine
- Methotrexate
Why should corticosteroids not be used for maintenance therapy in Crohn’s disease?
Longterm use of corticosteroids results in
- Osteoporosis; fractures
- Increased infection risk
- Cushing’s syndrome
Why must corticosteroid treatment be tapered off?
Longterm use of corticosteroids may cause adrenal suppression
Abruptly stopping corticosteroids may cause addisonian crisis
What must be assessed prior to starting thiopurine add-on therapy such as Azathioprine or Mercaptopurine?
TMPT activity
Consider methotrexate if TMPT deficient
Define severe active Crohn’s disease
Very poor general health with one or more symptoms of:
- Weight loss
- Fever
- Severe abdominal pain
- Frequent (3-4+) diarrhoea daily.
Outline the management of severe active Crohns disease
If conventional treatment fails or is contraindicated
Anti-TNF: Infliximab or adalimumab
Outline how remission of Crohn’s disease is maintained
Monotherapy:
- Thiopurines: Azathioprine or mercaptopurine
- Methotrexate
Post- complete macroscopic resection: Azathioprine + metronidazole
Outline the surgical management of Crohn’s disease
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
What long-term monitoring may be undertaken in Crohn’s disease?
- 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
Define Ulcerative colitis
Relapsing and remitting inflammatory disorder of the colonic mucosa
When does Ulcerative colitis present?
Bimodal distribution
- 15-25yr
- 55-65yr
Name three risk factors for ulcerative colitis
- FHx: esp. in first-degree relatives
- No appendicectomy
- NSAIDs
- Non/ex-smoker
List four clinical features of Ulcerative colitis
- 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
List three signs of Ulcerative colitis
Rectal disease Abdominal distension ➔ risk of toxic megacolon
List three extra-intestinal signs of Ulcerative colitis
30% of UC has extra-intestinal manifestations
- Arthritis (<5 large joints)
- Erythema nodosum
- Aphthous mouth ulcers
- Episcleritis
- Osteopenia; osteoporosis; osteomalacia
- VTE
How is severity of Ulcerative colitis assessed?
Truelove and Witt’s score
Name two macroscopic features of Ulcerative colitis
- Involvement of rectum and colon: extending proximally
- Gross bleeding
- Purulent exudates
List one pathological features of Ulcerative colitis
Crypt abscesses
List two endoscopic features of Ulcerative colitis
- Continuous mucosal involvement
- Friable mucosa
Request four investigations for suspected ulcerative colitis
- 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
What specialist investigation may confirm ulcerative colitis?
Colonoscopy* - gold standard Flexible sigmoidoscopy AXR essential for acute severe attacks to exclude colonic dilatation ➔ toxic megacolon
When should suspected ulcerative colitis be admitted as an emergency?
- Sytemically unwell with severe disease
- Bloody diarrhoea
- Fever
- Tachycardia
- Hypotension
Outline how remission of ulcerative colitis is induced
- Topical aminosalicylate: Sulfasalazine
- Add oral aminosalicylate
- Corticosteroid (time-limited)
Outline how ulcerative colitis remission is maintained
- Topical and/or oral aminosalicylate
- Thiopurines (azathioprine; mercaptopurine) PO if either:
- 2+ exacerbations in 1yr needing IV corticosteroids
- Not maintained by aminosalicylates
Outline the management of acute severe ulcerative colitis
- Involve gastroentereology + colorectal surgery
- IV corticosteroids
*
Outline the surgical management for Ulcerative colitis
Curative surgical resection
Why is toxic megacolon considered a severe complication of ulcerative colitis?
- Dangerous stage of advanced disease
- Impending perforation
- High mortality (15-25%)
- Requires urgent surgery if not resolved within 48hr
How does toxic megacolon appear on AXR?
- Dilated thin-walled colon
- >6cm diameter
- Gas filled with mucosal islands
Name four complications of ulcerative colitis
- Psychosocial impact
- Toxic megacolon
- Bowel obstruction
- Bowel perforation
- Intestinal strictures
- Fistulas
- Anaemia
- Malnutrition; faltering growth; delayed puberty
- Colorectal cancer
