Inflammatory bowel disease Flashcards
What are the two major forms of inflammatory bowel disease?
Crohn’s disease and Ulcerative colitis
What parts of the digestive system can be affected by Crohn’s disease? What area is most common?
Any area from mouth to anus. Terminal ileum and ascending colon are most common.
In which of the two are skip lesions found?
Crohn’s disease
In which of the two is perianal disease found?
Crohn’s disease
How can Crohn’s disease affect the perianal area?
Formation of perianal fistulae and fissures, haemorrhoids, skin tags, perianal abscess and ischiorectal abscess
What is the distribution of affected mucosa in Ulcerative colitis?
Starting at the rectum and extending continuously proximally to varying degrees up to the distal terminal ileum at most
Describe the macroscopic appearance of the mucosa in Crohn’s disease
Thickened and potentially narrowed bowel. A cobblestone appearance of the lining due to deep ulcers and fissures. Intra-abdominal fistulae and ulcers can be seen in penetrating disease.
Describe the macroscopic appearance of the mucosa in ulcerative colitis
The mucosa is reddened and inflamed and bleeds easily (friability). There may also be extensive ulceration
How are CD and UC differentiated in terms of depth of inflammation?
Full thickness in CD but only superficial in UC
In which of the two are granulomas often found? Describe these
CD often has non-caseating epitheloid cell aggregates with Langhans’ giant cells
In which of the two is goblet cell depletion seen?
UC
In which of the two are crypt abscesses more common?
UC
In patients with CUTE what are the antibodies that may be found upon serological testing and what does each suggest?
Anti-neutrophil cytoplasmic antibodies (ANCA)suggest UC and Saccharomyces cerevisiae antibodies (ASCA) suggest CD
What extraintestinal regions may exhibit manifestations of inflammatory bowel disease?
Eyes, joints, skin, liver and biliary tree, veins and kidneys
How might eyes be affected by inflammatory bowel disease?
Uveitis, episcleritis, conjunctivitis
How might joints be affected by inflammatory bowel disease?
Pauciarticular arthropathy, polyarticular arthropathy, arthralgia, ankylosing spondylitis, inflammatory back pain
How are pauciarticular and polyarticular arthropathies different?
Pauciarticular arthropathy is more short-lived and self limiting as well as being associated with relapses of IBD whereas polyarticular arthropathy is not
How might skin be affected by IBD?
Erythema nodosum, pyoderma gangrenosum
How might the liver and biliary tree be affected by IBD?
Sclerosing cholangitis, fatty liver, chronic hepatitis, cirrhosis, gallstones
How might kidneys be affected by IBD?
Nephrolithiasis
How might veins be affected by IBD?
Venous thrombosis
What are the common infective causes of diarrhoea?
Bacterial - Salmonella spp. Campylobacter jejuni, Shigella, E. coli, Staphylococcal enterocolitis, Bacillus cereus, Clostridium perfringens, C. botulinum, C, difficile, Gastrointestinal tuberculosis
Viral - rotavirus
Fungal - histoplasmosis
Parasitic - Amoebic dysentery, schistosomiasis, giardia intestinalis
What are the major symptoms of Crohn’s disease?
Diarrhoea, abdominal pain and weight loss
What are the constitutional symptoms of Crohn’s disease?
Malaise, lethargy, anorexia, nausea, vomiting and low-grade fever
In 15% of these there are no gastrointestinal symptoms present
What may be the main presenting symptoms of Crohn’s disease in children?
Reduced growth velocity and delayed puberty
What percentage of patients will require an intestinal resection within 5 years of diagnosis of Crohn’s disease?
~50%
Is presentation of CD acute or insidious?
Either
What are the possible characteristics of diarrhoea present in CD?
Blood mixed in or steatorrhea
Why might CD be confused with appendicitis on presentation?
Right iliac fossa pain in an emergency admission due to acute ileitis
How common are fistulae in CD?
Perianal and anal disease are the presenting feature in 25% of cases and 20-40% of patients will have enteric fistulae at some point
What may be found on examination in a patient with CD?
Weight loss and signs of malnutrition Aphthous ulceration of the mouth Sometimes abdominal tenderness and/or a RIF mass Perianal disease Extraintestinal signs of IBD
What may be found on blood tests for CD patients?
Anaemia - Anaemia of chronic disease not megaloblastic despite ileal involvement
Raised ESR
Raised CRP
Raised white cells
Raised platelets
Hypoalbuminaemia as part of an acute phase response to inflammation
Liver biochemistry may be abnormal
Serological testing may reveal negative ANCA and positive ASCA
What investigations need to be done in the case of a CD patient?
Bloods- standard as well as serological tests
Stool tests
Endoscopy
Imaging - Barium follow-through/CT scan with oral contrast/ small bowel ultrasound/ MRI enteroclysis
What stool tests need to be done? What would be found?
Stool cultures
C.difficile toxin assay if diarrhoea is present
Microscopy for parasites in patients with a relevant travel history
Faecal calprotectin raised in active disease
As is lactoferrin
What is the procedure for colonoscopy of patients with CD?
What may be found?
Essential in patients with suspected CD to have endoscopy of the terminal ileum.
2 biopsies in five areas including the rectum and the terminal ileum
Severe disease only required an unprepared sigmoidoscopy
Anything from aphthous ulceration to cobblestone appearance may be found
How are patients investigated if they have symptoms relevant to upper GI CD?
Upper GI endoscopy
How important is small bowel imaging in patients with suspected CD? What may be found?
It is mandatory Alteration in the mucosal pattern Areas of deep ulceration Areas of narrowing/structuring Skip lesions
Is ultrasound scanning useful in CD?
Yes for assessing disease activity in the ileum and colon
How is perianal disease evaluated in CD patients?
Perianal MRI or endoanal ultrasound
When might capsule endoscopy be indicated in CD?
When radiological examination is normal
How is disease activity monitored?
Hb, white cell count, inflammatory counters, serum albumin
