Inflammatory Bowel Disease Flashcards
What are the two major forms of IBD?
- Crohn’s Disease
- Ulcerative colitis
What environmental factors are associated with the development of IBD?
- Smoking
- NSAID ingestion
- Hygeine
- Nutrition
What is thought to be the primary cause of IBDs?
Inappropriate immune response against the gut flora in a genetically susceptible individual
How much does smoking increase the risk of developing IBD?
3-4x the risk
What is ulcerative colitis?
Relapsing/Remitting inflammaotyr disorder of the colonic mucosa. It may affect the rectum, or extend to involve part of the colon, or the entire colon. It never spreads proximal to the ileocaecal valve (except for backwash ileitis)
What are the main sites the ulcerative colitis occurs?
- Proctitis - rectum
- Left-sided colitis
- Pancolitis - whole colon
What are the pathological features of UC?
- Hyperaemic/Haemorrhagic colonic mucosa +/-pseudopolyps
- Punctate ulceration - extends deep into lamina propria
What distinguishes UC from Crohn’s Pathologically?
- Crohn’s is transmural, whereas UC is primarily mucosal
- Granulomas are often present in Crohns
What are the pathological features of Crohn’s Disease?
- Granulomas
- Fissuring ulceration
- Focal/Patchy mucosal involvement
- Neuromuscular hypertrophy
Which IBD does skip lesions occur in?
Crohn’s - areas of unaffected bowel between areas of active disease
Which IBD does backwash ileitis occur in?
UC - usually in pancolitis
What is the difference in terms of the affected bowel between Crohn’s and UC?
- Crohn’s - Thickened wall + strictures/narrowed lumen
- UC - Ulcerated wall with dilated lumen
Which IBD produces granulomas?
Crohn’s
Which type of IBD tends to fistulate more commonly?
Crohn’s
Which type of IBD are more at risk of cancer?
UC
Why does the bowel wall thicken in Crohn’s?
Due to oedema and fibrosis
What are symptoms of UC?
Episodic attacks
- Diarrhoea (episode/chronic) +/- blood/mucus
- Crampy abdominal discomfort
- Increased frequency
- Urgency +/- tenesmus
- Systemic features in attacks - fever, malaise, anorexia, weight loss
What signs may be present in someone with UC?
May be none. If presenting during an attack:
- Fever
- Tachycardia
- Tender, distended abdomen
Extraintestinal signs (chronic)
What extraintestinal signs may be seen in IBD?
- Clubbing
- Erythema nodosum
- Pyoderma gangrenosum
- Conjunctivitis
- Uveitis/Episcleritis/Iritis
- Large joint arthritis
- Sacroiliitis
- Ankylosing spondylitis/inflammatory back pain
- PSC
- Nutritional defects
- Venous thrombosis
What is the following seen in?
Pyoderma gangrenosum
- Idiopathic: 25–50% of cases
- Inflammatory bowel disease: up to 50% of cases
- Rheumatological disease
- Paraproteinaemia
- Haematological malignancy
What is the following?
Erythema nosodum - A skin disorder of acute onset with eruption of red, tender nodules and plaques, predominantly over the lower extremities, especially the extensor surfaces. It is a form of panniculitis
What is the mechanism behind erythema nodosum?
In theory, immune complexes form after exposure to an antigen and are deposited in venules around areas of subcutaneous fat and connective tissue. The subsequent inflammation causes the lesions.
Why the lesions appear so frequently on the shins has not been explained - suggested that a combination of a relatively meagre arterial supply combined with gravitational effects on venous system gravitational favour deposition in that area
What are causes of the following?
- Inflammatory bowel disease
- Infections – streptococcal, tuberculosis, URTIs, yersiniosis
- Sarcoidosis
- Rheumatological disorders
- Drug reactions – usually sulfonamides and the oral contraceptive pill
- Malignancies
- Pregnancy
What is the following?
Clubbing
What are causes of the following?
- Cyanotic heart disease/Crohn’s
-
Lung disease - ABCDEF
- Abscess
- Bronchiectasis
- CF
- DON’T SAY COPD
- Empyema
- Fibrosis
- Ulcerative colitis
- Biliary cirrhosis
- Birth defect
- Infective endocarditis
- Neoplasm
- GI malabsorption syndrome (coeliac)
What is the following?
Episcleritis - benign, self-limiting inflammatory disease affecting part of the eye called the episclera.
What is the following?
Scleritis - a serious inflammatory disease that affects the white outer coating of the eye, known as the sclera
What are signs of anterior uveitis?
- Circumcorneal redness - ciliary flush
- Keratic precipitates on corneal epithelium
- Cells/flare in anterior chamber
- Miosis - due to sphincter spasm
- Hypopyon
- Posterior/Peripheral anterior Synechaie/Festooned pupil
- Iris atrophy
- Fibrinous membrane in the pupillary
What are symptoms of crohn’s disease?
- Diarrhoea
- Abdominal pain
- Weight loss
- Failure to thrive
- Fatigue
- Fever
- Malaise
- Anorexia
What are signs of crohn’s disease?
- Abdominal tenderness/mass
- Perianal abscess/fistulae/skin tags
- Anal strictures
- Apthous ulcers
- Systemic features of IBD
What is the following?
Apthous ulcer - A painful open lesion anywhere within the oral cavity.
What are causes of the following?
- Trauma
- Stress
- Toothpaste
- Iron deficiency/Folate deficiency/Vitamin B12 deficiency
- Food hypersensitivity
- Humoural/immunological
- Inflammatory bowel disease
- Behçet’s disease
- SLE
- HIV/AIDS
- Nicorandil
How would you approach investigating someone who you suspected had UC?
- Bedside - NEWS score
- Bloods - FBC, ESR, CRP, U+E’s, LFTs, Blood culture
-
Imaging
- AXR
- Flexible sigmoidoscopy - acute attack
- Colonoscopy once controlled
- Other - stool culture, faecal calprotectin, biopsy
What might you find on stool studies in someone with UC?
- Negative culture
- WBC present
- Elevated faecal calprotectin
What might you see on FBC in someone with UC?
- Variable degree of anaemia
- Leukocytosis
- Thrombocytosis
What might you see on LFTs in someone with UC?
Looking for features of PSC:
- Elevated ALP
- Elevated Bilirubin
- Elevated AST/ALT
- Hypoalbuminaemia
What might you see on U+E’s in someone with UC?
- Hypokalaemia metabolic acidosis
- Hypernatraemia
What might you see on AXR in someone with UC?
- Dilated colonic loops - >6cm
- Mucosal thickening
- Lead pipe sign
- Pneumoperitoneum/Rigler’s Sign - If perforated
- Toxic megacolon
What can be seen in the following AXR?
Toxic megacolon - colon is very dilated in this patient with acute abdominal pain, sepsis, and a known history of ulcerative colitis.
There is evidence of bowel wall oedema with ‘thumbprinting’, and pseudopolyps or ‘mucosal islands
What feature of UC can be seen in the following AXR?
Lead pipe sign - featureless segment of transverse colon with loss of the normal haustral markings. This ‘lead pipe’ appearance is associated with longstanding ulcerative colitis.
What is the feature highlighted in the following AXR?
Mucosal thickening + ‘thumbprinting’ - The distance between loops of bowel is increased (arrows) due to thickening of the bowel wall. The haustral folds are very thick (arrowheads), leading to a sign known as ‘thumbprinting.’
What investigations would you consider doing in someone you suspected had Crohn’s Disease?
- Bedside - NEWS score
- Bloods - FBC, U+E’s, LFTs, CRP, ESR, INR, Iron studies, B12, Folate
- Imaging - AXR, Colonoscopy, Capsule endoscopy, CT/MRI, US, Barium meal
- Other - stool culture
When would you consider limited flexible sigmoidoscopy to investigate UC?
During attack
When and why would you perform a full colonoscopy in UC?
Once symptoms under control - To determine extent of disease
How would you assess the severity of a UC attack?
Truelove and Witts modified criteria
What are the criteria for the truelove and Witts criteria for assessing UC severity?
- Motions/day
- Rectal bleeding
- Temp
- Resting pulse
- Hb
- ESR/CRP
What is classified as Mild UC as per Truelove and Witts criteria?
- Motions/day - =4
- Rectal bleeding - small
- Temp - Apyrexial
- Resting pulse < 70bpm
- Hb - > 110g/L
- ESR - <30
What is classified as moderate UC as per Truelove and Witts criteria?
- Motions/day - 5
- Rectal bleeding - Moderate
- Temp - 37.1-37.8oC
- Resting pulse -70-90bpm
- Hb - 105-110g/L
What is classified as severe UC as per Truelove and Witts criteria?
- Motions/day - >/= 6
- Rectal bleeding - Large
- Temp - >37.8oC
- Resting pulse - >90bpm
- Hb - <105g/L
- ESR > 30/CRP >45mg/L
What are acute complications of UC?
- Toxic megacolon + perforation
- Venous thromboembolism
- Hypokalaemia
What can be seen in the following AXR?
Toxic megacolon of the transverse colon
What are chronic complications of Ulcerative colitis?
Colonic cancer
How would you manage someone with Mild UC?
Induction/Maintenance of remission
-
Distal colitis
- 1st line – topical* 5-ASA (mesalamine)
- 2nd line – topical* corticosteroids/oral mesalamine
- 3rd line – oral corticosteroid ± oral tacrolimus
-
Extensive disease
- 1st line – oral mesalamine
- 2nd line - oral corticosteroids +/- oral tactrolimus
*Suppository
How would you manage someone with Moderate UC?
- Induce remission - Prednisolone 40mg/day for 1 wk, then taper
- Maintenance - 5-ASA
How would you manage severe UC?
Admit
- IV fluids
- IV Steroids - hydrocortisone 100mg/6h
- VTE prophylaxis
- Monitoring - bloods, Stool chart, AXR
- Consider transfusion
- Consider rescue therapy - infliximab, ciclosporin
What are indications for surgery in ulcerative colitis?
Fulminant acute attack
- Failure of medical treatment
- Toxic dilatation
- Haemorrhage
- Imminent perforation
Chronic disease
- Incomplete response to medical treatment/steroid dependant
- Dysplasia on surveillance colonoscopy
What would you consider if rescue therapy failed in someone with severe UC?
Colectomy - based on disease extent
When would you consider rescue/salvage therapy in someone with UC?
- CRP >45 mg/L
- >8 bowel motions after 3 days IV hydrocortisone
What are complications of Crohn’s Disease?
- Small bowel obstruction
- Toxic megacolon
- Abscess formation
- Fistulae
- Perforation
- Colon cancer
- PSC
- Malnutrition
- Anal disease - Fissure in ano, Haemorrhoids, SKin tags, Abscess, Anorectal fistula
What are the different types of fistulae that can occur in Crohn’s disease?
- Entero-enteric
- Colovesical
- Colovaginal
- Perianal
- Entercutaneous
What are the common sites for Crohn’s disease to occur?
- Duodenum/Ileum/Jejunum
- Ileocaecal disease
- Perianal disease/proctitis
- Colon
What might you see on CT/MRI in someone with Crohn’s Disease?
- Skip lesions
- Stricturing
- Bowel wall thickening
- Surrounding inflammation
- Abscess
- Fistulae
What might you see on biopsy of someone with Crohn’s disease?
Transmural involvement with non-caseating granulomas
What might you see on Colonosopy in someone with Crohn’s Disease?
- Hyperaemia
- Oedema
- Cobblestoning
- Skip lesions
What might you see on oesophagogastroduodenoscopy in someone with crohn’s Disease?
- Aphthous ulcers
- Mucosal inflammation
Why might you do iron studies in someone with Crohn’s?
Check for iron deficiecy 2o to GI bleeding
Why might you check B12 and folate levels in someone with Crohn’s?
Deficiency may be secondary to malabsorption - particularly in ileocaecal CD and post-ileocaecal resection
What might you see on AXR with barium meal in someone with crohn’s disease?
- Asymmetrical alteration in the mucosal pattern with deep ulceration
- Areas of narrowing or stricturing
- Cobblestoning
What are the three major endoscopic findings in crohn’s disease?
- Aphthous ulcers
- Cobblestoning - normal tissues in between the ulcers give the typical cobblestone appearance.
- Discontinuous lesions - areas of inflammation are interspersed between normal bowel ‘skip areas’.
How would you manage Mild/moderate Crohn’s Disease?
- Dietary modification
- Stop smoking
- Prednisolone - 1 wk, then taper
- Manage extraintestinal manifestations
- Consider maintenance therapy
Which type of IBD are 5-ASA’s not used in?
Crohn’s disease
How would you manage severe Crohn’s?
Admit
- IV fluids
-
IV Steroids - hydrocortisone 100mg/6h
- Switch to oral if response
- Consider biologics if no response
- VTE prophylaxis
- Stool screen - Culture etc.
- Physical examination daily + Bloods
- Monitor for abdominal sepsis
What are the main methods for induction of remission in Crohn’s disease?
- Oral/IV steroids
- Enteral nutrition
- ANti-TNF
What are the main Medications use to maintain remission in Crohn’s Disease?
- Azathioprine
- 6MP
- Methotrexate
- Mycophenolate mofetil
- Anti-TNF antibodies
What are examples of 5-ASA drugs?
- Mesalazine
- Sulfasalazine
What is the mechanism of action of 5-ASA drugs?
The precise mechanism of action of 5-ASA is unknown, but it has both anti-inflammatory and immunosuppressive effects, and appears to act topically on the gut rather than systemically
What are important adverse effects of 5-ASA drugs?
- Gastrointestinal upset (e.g. nausea, dyspepsia)
- Headache
- Leucopenia
- Thrombocytopenia
- Renal impairment
- Serious hypersensitivity reaction
When is Azathioprine used in Crohn’s Disease?
- Refractory to steroids/relapse on steroid taper
- Requiring > 2 steroid courses per year
What are side effects of Azathioprine?
- Abdo pain
- Nausea
- Pancreatitis
- Leucopenia
- Abnormal LFTs
What are indications for surgical intervention in Crohn’s Disease?
- Drug failure
- GI obstruction fromm stricture
- Perforation
- Fistulae
- Abscess
What are poor prognostic factors in Crohn’s Disease?
- Age < 40 yrs
- Steroids at first presentation
- Perianal disease
- Isolated terminal ileitis
- Smoking
How would you manage perianal disease in Crohn’s Disease?
- Oral antibiotics
- Immunosuppressant therapy - anti-TNF
- Local surgery +/- seton insertion
What mnemonic can you use to remember the extra-colonic features of IBD?
A PIE SACK
- Aphthous ulcers
- Pyoderma gangrenosum
- Iritis (uveitis)
- Erythema nodosum
- Sclerosing cholangitis
- Ankylosing spondylitis/arthritis
- Clubbing
- Kidney (nephrotic syndrome – unusual)
