Inflammatory Bowel Disease

Question 1

Management of UC

Answer 1

• Acute
  
  • Mild to moderate
    
    • First line is aminosalicylate/5ASAs (i.e. mesalazine)
    • Second line is corticosteroids
  • Severe
    
    • First line is IV corticosteroids
    • Second line is IV cyclosporine
• Remission
  
  • First line is aminosalicylate
  • Thiopurines (azathioprine and mercaptopurine, precent T-cell clonal expansion in response to antigenic stimuli, allow T-cell apoptosis, require regular monitoring for metabolites; 6TGN and 6MMP)
• Surgery
  
  • Panproctocolectomy will remove the disease and patient is left with a permanent ileostomy or an ileo-anal anastamosis (J-pouch)

Question 2

Management of Crohn’s disease

Answer 2

• Acute
  
  • First line is corticosteroids
  • Thiopurines (azathioprine and mercaptopurine, precent T-cell clonal expansion in response to antigenic stimuli, allow T-cell apoptosis, require regular monitoring for metabolites; 6TGN and 6MMP)
  • Biologics (i.e. infliximab, adalumimab)
• Remission
  
  • Thiopurines are first line
  • Methotrexate
  • Biologics
• Surgery
  
  • If disease only affects terminal ileum it is possible to resect this and prevent flares

Question 3

Features of Crohn’s disease (remember crows NESTS)

Answer 3

• No blood of mucus (less common)
• Entire GI tract
• ‘Skip lesions’ on endoscopy
• Terminal ileum most affected and Transmural inflammation
• Smoking is risk factor (don’t set the nest on fire)
• Crohn’s is also associated with weight loss, strictures and fistulas
• Granulomas are diagnostic

Question 4

Features of UC (remember U-C-CLOSEUP)

Answer 4

• Continuous inflammation/Crypt abscesses
• Limited to colon and rectum
• Only superficial mucosa affected
• Smoking is protective
• Excrete blood and mucus
• Use aminosalicylates
• PSC

Question 5

Features of Coeliac disease

Answer 5

• Autoimmune condition where exposure to gluten causes autoimmune reaction
• Auto-antibodies (anti-TTG and anti-EMA) to gluten target epithelial cells
• Commonly affects the jejunum
• Presentation:
  
  • Failure to thrive
  • Diarrhoea
  • Fatigue
  • Weight loss
  • Mouth ulcers
  • Anaemia secondary to iron, B12 and folate deficiency
  • Dermatitis herpitiformis
  • Neurological symptoms (peripheral neuropathy, cerebellar ataxia and epilepsy)
• Links with T1DM

Question 6

Diverticular disease

Answer 6

• Definitions
  
  • Diverticula - pouches in bowel wall
  • Diverticulosis - presence of diverticula without symptoms
  • Diverticulitis - inflammation in diverticula
• Presentation of diverticulitis
  
  • Left iliac fossa pain and tenderness
  • Diarrhoea
  • Fever
  • PR blood/mucus
  • Nausea and vomiting
  • Principally affects sigmoid colon
• Low roughage diet causes constipation and high sigmoid luminal pressure – herniation of mucosa through weaknesses in muscle coat of sigmoid
• May perforate, fistulae into bladder or bowel, bleed, or obstruct bowel
• Management
  
  • ​Antibiotics
  • Analgesia
  • Fluid resuscitation
  • May require surgical resection if septic of develops complications

Question 7

What are the causes of ischaemia of the gut?

Answer 7

• Mesenteric artery or vein thrombosis
• Mesenteric artery embolus
• Hypotension (watershed infarction)
• Strangulated hernia
• Volvulus

Question 8

How is gut ischaemia diagnosed?

Answer 8

• Endoscopy will show petechial haemorrhages, oedematous and fragile mucosa, segmental erythema, scattered erosion, longitudinal ulcerations, sharply defined segment of involvement

Question 9

Investigation if IBD

Answer 9

• Routine bloods for anaemia, infection, thyroid, kidney and liver function
• Faecal calprotectin (released by the intestines when inflamed)
• Endoscopy with biopsy is diagnostic
• Imaging to look for fistulas, abscesses and strictures

Question 10

Investigation of Coeliac disease

Answer 10

• Genetic associations
  
  • HLA-DQ2 and HLA-DQ8
• Auto-antibodies
  
  • Anti-tissue transglutaminase antibodies (anti-TTG)
  • Anti-endomysial antibodies (anti-EMAs)
  • Deaminated gliadin peptide antibodies (anti-DGPs)
• Endoscopy and biopsy:
  
  • Villous atrophy
  • Crypt hyperplasia
  • Increased number of intraepithelial lymphocytes
  • Increased numbers of plasma cells in lamina propria
• Management is gluten free diet

Question 11

Irritable bowel syndrome

Answer 11

• Functional bowel disorder - no identifiable organic disease
• Diagnosis of exclusion
• Suggestive symptoms include:
  
  • Abdominal pain/discomfort that is relieved on opening bowels or associated with a change in bowel habit
  • Any 2 of:
    
    • Abnormal stool passage
    • Bloating
    • Worse symptoms after eating
    • PR mucus
• Management:
  
  • Good fluid intake, small regular meals, limit caffiene and alcohol, probiotics, low FORMAP diet
  • Loperamide for diarrhoea
  • Laxatives (avoid lactulose)
  • Antispasmodics
  • TCAs
  • SSRIs
  • CBT