Inflammatory bowel disease

Question 1

What is inflammatory bowel disease?

Answer 1

Refers to 2 chronic diseases that cause inflammation of the intestine: Ulcerative Colitis + Crohn’s disease

Question 2

What is Crohn’s disease?

Answer 2

Chronic inflammatory bowel disease (IBD) that can affect any area of the gastrointestinal tract, from the mouth to the anus

Cause is unknown

Periods of exacerbations (inflammation) + remissions

Inflammation is across the whole wall of GI tract

Fissuring ulcers form (contents can leak out)

Damage caused by inflammation leads to submucosal fibrosis (body trying to repair)

Dense infiltration of lymphocytes + macrophages

Question 3

What is Ulcerative Colitis?

Answer 3

Inflammation affects mucosal (inner) layer of the colon + rectum

Cause ulcers

Loss of goblet cells (secretes mucus)

Infiltration of inflammatory cells into mucosa

Unknown cause

Question 4

What are the symptoms of Crohn’s?

Answer 4

Diarrhoea - impaired absorption

Pain

Narrowing of the gut lumen leading to strictures + bowel obstruction

Abscess formation

Fistulization to skin + internal organs

Question 5

What are strictures?

Answer 5

Inflammation leads to scar tissue formation

Narrowing of lumen + obstruction

Risk of rupture

Pain, cramping, bloating

Question 6

What are fistulae?

Answer 6

Inflammation leads to ulcers

Ulcers develop into tunnels

Between areas of GIT

or between organs

or to skin (anal fistulae)

Question 7

Whata are the consequences of Crohn’s disease?

Answer 7

Weight loss

Macronutrient deficiencies

Micronutrient deficiencies (minerals, calcium, iron)

Fatigue

Protein-energy malnutrition in 20-80% of patients

Question 8

What are the symptoms of ulcerative colitis?

Answer 8

Severe diarrhoea - changes in electrolytes

Blood loss

Loss of peristaltic function leading to rigid colonic tube

Toxic megacolon, perforation + sepsis

Question 9

Where can extra-intestinal inflammation occur?

Answer 9

Joints, eyes, skin, mouth + liver

Forms of IBD (inflammatory bowel disease)

Risk of colon cancer (especially in u.colitis)

Question 10

Treatment of Ulcerative Colitis

Answer 10

Drugs to reduce inflammatory response

5-aminosalicylate

Steroids (corticocosteroids)

Immunosuppressants

Question 11

Function of 5-aminosalicylate

Answer 11

Inhibits leukotriene + prostanoid synthesis

Scavenge free radicals (prevent them damaging cells) + decrease neutrophil chemotaxis (movement of neutrophil to site of infection) - effects on PPARy receptor

Sulfasalazine metabolised to mesalazine

Absorbed in small intestine but doesn’t reach colon

Question 12

Function of Corticosteroids

Answer 12

Anti-inflammatory, immunosuppressive actions

e. g. oral prednisolone
e. g. budesonide - poorly absorbed so fewer systemic side effects

Used to induce remission

Enemas used for more distal/rectal inflammation e.g. predfoam

Question 13

Function of Immunosuppressants

Answer 13

Aazathioprine + methotrexate inhibit purine synthesis + DNA synthesis

Reduce inflammatory cell proliferation

Azathioprine is converted to mercaptopurine (purine derivative) - inhibits purine synthesis

Cyclosporine inhibits InterLeukin-2 induced gene expression

• used in refractory disease

Question 14

Describe TPMT activity

Answer 14

One way merceptopurine is metabolised is by Thiopurine methyltransferase

Some patients have low TPMT

Some patients have no TPMT (risk of drug-induced bone marrow toxicity)

Some patients have high TPMT (risk of mercaptopurine resistance)

Question 15

What is TNF-alpha

Answer 15

Tumour necrosis factor alpha or TNFα is a cytokine. Cytokines are substances released by the body during inflammation.

Question 16

Function of anti-TNFalpha therapy

Answer 16

‘manufactured’ monoclonal antibody binds to TNFalpha + prevent from causing inflammation

Neutralises inflammatory cytokine TNF-alpha

• associated w/ TB risk (antibodies are peptides which will be broken down if given orally)

Infliximab = infusion

Adalimumab = injection

Question 17

What is the nutrition therapy in Crohn’s?

Answer 17

Basic (elemental feeds) nutrition - can induce remission

Reduce steroid use in severe Crohn’s

Use parenteral support

Small bowel removal - shortened bowel

• reduce absorption
• require nutritional support

Question 18

Probiotics

Answer 18

Ulcerative colitis is caused by the upset of colonic bacteria

Question 19

Treatment options to induce remission in Crohn’s

Answer 19

Monotherapy

Add-on treatment

Biological therapy/in severe active Crohn’s

Question 20

Drugs used in monotherapy in Crohn’s

Answer 20

Using a conventional glucocorticosteroid

• prednisolone
• methylprednisolone
• intravenous hydrocortisone

Alternative = budesonide/5-ASA

Question 21

Drugs used in add-on therapy in Crohn’s

Answer 21

First line = azathioprine or mercaptopurine to a conventional glucocorticosteroid or budesonide to induce remission of Crohn’s disease

Second line = Methotrexate

Question 22

Drugs used in biological therapy in Crohn’s

Answer 22

Infliximab/adalimumab

Question 23

Counselling points on oral steroids

Answer 23

Taken once a day in the morning after food

Avoid contact w/ people that have shingles, chickenpox or measles

Carry steroid treatment card if taking oral corticosteroids for > 3 weeks

Could have mood/behavioural changes

Cannot stop abruptly

Lifestyle recommendations to minimise side effects include:

• adequate dietary intake
• good nutrition
• maintain normal body weight
• smoking cessation
• moderate alcohol consumption
• physical exercise

Question 24

Counselling points on 5-ASA

Answer 24

Long-term effects of turnover of cells

Increased risk of bleeding, bruising, sore throat, fever, malaise (should be reported)

Enteric-coated tablets should be swallowed whole

Laxatives must be taken at least 2 hours before or after taking EC tablets

Sulfasalazine may colour tears yellow + urine orange + contact lenses to change colour

Question 25

Counselling points on Azathioprine + Mercaptopurine

Answer 25

Test TMPT levels before therapy

Seek medical advice if they develop:

• sore throat
• nausea
• vomiting
• jaundice
• pancreatitis (abdominal pain)