Inflammatory Bowel Disease Flashcards by Aalap Asurlekar

What is Crohns disease

Chronic inflammation and ulcerating condition of GI tract that can affect anywhere from mouth to anus

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How does Crohns disease present

Abdominal pain, small bowel obstruction, diarrhoea, bleeding PR, anaemia, weight loss

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Typical presentation of Crohns

21-year-old male patient, abdominal pain with bloody diarrhoea for 3/12 and a tender abdomen

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Investigating Crohns

Endoscopy and mucosal biopsy

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Endoscopic pattern of Crohns

Patchy, segmental disease with skip area (lesions) anywhere in GI tract

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Histological appearance of Crohns

Increased chronic inflammatory cells in lamina propria and crypt branching with non-caeseating granulomas

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TB vs Crohns histologically

TB has caeseating granulomas whereas Crohns are non-caeseating

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Mucosa in Crohns can be described as

Cobblestone appearance due to deep fissures

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Layers affected in Crohns

Transmural, effecting all the layers

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What is ulcerative colitis (UC)

Chronic inflammatory disorder of rectum upto colon

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What layers are affected in UC

Mucosa and submucosa

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Who are more affected

30 year old male

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Presentation of UC

Diarrhoea
Mucous
Bloody PR

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Endoscopic pattern of UC

Diffuse continuous disease almost always involving the rectum

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Histological findings of UC

Basal lymphoplasmacytic infiltrate with irregular shape branching crypts and acute cryptitis or crypt abscess

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Does UC have granulomas

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Complications of UC

Toxic megacolon
Colorectal carcinoma
Anaemia due to blood loss
Electrolyte disturbance (hypokalaemia)
Anal fissures (not common)
Uveitis
Primary sclerosing cholangitis
Arthritis, ankylosing spondylitis
Pyoderma gangrenosum, Erythema nodosum

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Complication of Crohns

Malabsorption
Fistulas
Anal disease
Bowel obstruction
Perforation
Malignancy
Amyloidosis
Rarely toxic megacolon

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Is smoking associated with UC

No. it is with Crohns

Lifestyle advice for Crohns

Smoking aggravates Crohns

Diet not implicated in pathogenesis but can influence symptoms

Therapy options for UC

5-ASA or Mesalazine
Steroids
Immunosuppresants
Anti-TNF therapy

Therapy options of Crohns

Steroids
Immunosuppresants
Anti-TNF therapy

Topical corticosteroids

Budesonide. Initial high dose and reduce over 6-8 weeks

Azathioprine should not be prescribed with?

Allopurinol (XO inhibitor); decrease high blood uric acid levels

What contributes to Azathioprine toxicity

TMNT - Thiopurine methyltransferase

Anti-TNF therapy for IBD

IV infusion - Infliximab S/C injection - Adalimumab Reduces remission after single infusion. Duration of remission is 8-12 weeks after which re-treatment maintains remission.

Side-effects of TNF-a therapy

Infections, cancer risk

Surgery for Crohns

Minimise amount of bowel resected, not curative and might require repeat resections that can result in short gut syndrome

What is proctolectomy

Surgical removal of rectum and part/all of the colon

Surgery for UC

Generally curative by proctolectomy and pouch or permanent ileostomy.

Most established risk factor for IBD

Genetics

Inflammatory bowel disease and gut flora

Antibiotics are effective in treatment of peri-anal Crohns disease. Altered bacterial flora is seen in UC

Disease susceptibility gene located on chromosome 16q12

NOD2/CARD15 | Encodes a protein involved in bacterial recognition. Defect of this found in caucasian patients with Crohns disease

Crohns vs UC in antimicrobial activity of gut

Reduces in Crohns, relatively unchanged in UC

Extent of UC disease

Proctitis - Lining of rectum (36%) Left-sided colitis - Till splenic flexure (27%) Pancolitis - Entire colon (37%)

Main symptoms of UC

Diarrhoea + Bleeding

What constitutes severe UC

``` > 6 bloody stools / 24 hours and one of the following - Fever (>37.8) Anaemia (Hb < 10.5g/dl) Tachycardia (>90 beats/min) Elevated ESR (>30 mm/Hr) ```

What is ESR and what does it signify

ESR - Erythrocyte sedimentation rate. Elevated in inflammation but also in anaemia, infection, pregnancy and ageing.

Mucosal oedema due to inflammation in IBS shows as what on AXR

Thumbprinting sign - Haustra become thickened at regular intervals appearing like thumbprints

What can be found upon endoscopy

Used to define extent of inflammation Loss of blood vessel pattern to a messy collection Granular mucosa Contact bleeding may be present

Extra-intestinal manifestations of IBD

Skin - Erythema nodosum and pyoderma gangrenosum Joints - Spondylitis, sacrolitis, arthritis Eyes - Uveitis, episcleritis Liver - LFT's deranged, steatosis, sclerosing cholangitis

What is primary sclerosing cholangitis

Chronic inflammation of biliary tree

Symptoms of primary sclerosing cholangitis

Mainly asymptomatic, may have itch and rigors | May develop into cholangiocarcinoma

How can Crohns affect the anus

Development of peri-anal disease which includes recurrent abscess formation, pain, fistula with persistent leakage and damaged sphincters

Endoscopy findings on Crohns vs UC

Crohns has cobblestone appearance whereas UC has pseudopolyps

How can small bowel be assessed for Corhns

Barium follow through Small bowel MRI Technetium-labelled white cell scan; white cells are labelled which allows the operator to see inflamed part