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Gastrointestinal Pathology > Inflammatory Bowel Disease > Flashcards

Inflammatory Bowel Disease Flashcards

1
Q

What is IBD?

A

A spectrum of disease

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2
Q

What does IBD stand for?

A

Inflammatory bowel disease

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3
Q

What are the 3 spectrum subtypes of IBD?

A

Crohn’s disease
Ulcerative colitis
Indeterminate colitis

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4
Q

What is indeterminate colitis?

A

Exactly in the middle of the spectrum of UC and CD

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5
Q

Definition of IBD

A

Idiopathic inflammation of the bowel

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6
Q

What % does indeterminate colitis make up of IBD?

A

10 - 15%

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7
Q

Causes of IBD

A 
Unknown
Genetic predisposition 
Unregulated intestinal immune response
Loss of tolerance against certain enteric flora 
Environmental triggers
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8
Q

Pathology of IBD

A

Non-ceasating granuloma

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9
Q

What does UC stand for?

A

Ulcerative colitis

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10
Q

Definition of UC

A

A chronic inflammatory ulcerative disease affecting mucosa of the rectum and colon

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11
Q

What peak age groups get UC?

A

15 - 30 yrs major peak

50 - 70 yrs smaller peak

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12
Q

What is serosa?

A

Visceral peritoneum

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13
Q

Pathology of UC

A

Confined to mucosa
Inflammatory infiltrates and oedema
Crypt abscesses and ulceration
Mucosa gets destroyed and tries to heal -> this produces projections called pseudopolyps
Healing produces epithelial thickening between the ulcers

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14
Q

What decreases the risk for UC / reduces attacks?

A

Smoking

Appendectomy before age 20 for acute appendicitis

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15
Q

What is a crypt abscess?

A

Abscess at the bottom of the mucosa

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16
Q

Where does UC affect?

A

Mucosa

Starts in rectum and extends proximally in CONTINUTIY

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17
Q

What is UC confined to?

A

Rectum

Colon

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18
Q

What is spared in UC?

A

Anal canal

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19
Q

Subtypes of UC

A

Proctosigmoiditis
Left sided colitis
Pancolitis
Backwash ileitis

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20
Q

How often does UC affect the ileum?

A

Very rarely

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21
Q

Which gender gets UC more?

A

F > M

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22
Q

Local complications of UC

A 
Blood loss and anaemia
Protein loss
Acute toxic dilatation of colon and perforation 
Stricture (exclude malignancy)
Massive haemorrhage 
Carcinoma
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23
Q

The risk of development of cancer in UC is related to….

A

Extent of disease

Duration of disease (>10 years)

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24
Q

Indications for surveillance colonoscopy

A

Total colitis > 10 years

Left sided colitis > 15 years

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25
Q

If the patient has anal disease, what does this indicate as the diagnosis?

A

Crohn’s disease

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26
Q

Systemic complications of UC

A 
Large joint disease
Uveitis
Spondylitis 
Erythema nodosum 
Pyoderma gangrenosum 
Fatty Liver
Liver cirrhosis
Cholangiocarcinoma
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27
Q

Presentation of UC

A 
Diarrhoea
Rectal bleeding
Tenesmus 
Passage of mucus (could be blood stained)
Cramping abdominal pain
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28
Q

Definition of tenesmus

A

A continual or recurrent inclination to evacuate the bowels

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29
Q

What do the severity of symptoms of UC correlate with?

A

Extent of disease

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30
Q

What can surgery for UC offer?

A

Long lasting symptom control

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31
Q

What is there NO ROLE FOR in surgery for UC?

A

Segmental resection
MUST TAKE WHOLE RECTUM AND COLON OUT
as disease would just come back in the remaining portions

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32
Q

Why do UC patients often have Hypoalbuminia?

A

Loads of mucus is secreted which is rich in protein

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33
Q

In severe inflammation in UC, what can happen?

A

Muscle wall can fail leading to perforation

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34
Q

What diameter does the caecum perforate at?

A

10cm

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35
Q

What does a stricture in UC usually indicate?

A

Malignancy

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36
Q

What does inflammation for a long period of time lead to?

A

Dysplasia

Which leads to neoplasia

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37
Q

If have dysplastic changes in UC, what has to be done and why?

A

Surgery

As will advance to cancer

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38
Q

What does colon cancer with UC result in?

A

Poorer prognosis

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39
Q

Why would cancer in IBD spread very easily?

A

As already on immunomodulators as treatment

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40
Q

What is a cholangiocarcinoma?

A

Malignant tumour of the biliary tree

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41
Q

What does cramping abdominal pain indicate?

A

Colonic disease

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42
Q

The more the symptoms of UC, what does this imply?

A

The more of the colon is affected

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43
Q

Types of UC

A

Fulminating

Chronic

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44
Q

Features of fulminating UC

A 
Bowel movements > 10 / 24 hours
Fever 
Tachycardia
Continous bleeding
Anaemia 
Hypalbuminaemia
Abdominal distention (toxic dilatation of the colon)
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45
Q

Features of chronic UC

A

Initial attack of moderate severity followed by recurrent exacerbations
Patient looked wasted (from severe diarrhoea) and anaemic (from chronic blood loss)

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46
Q

Another name for toxic megacolon

A

Acute toxic dilatation of the colon

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47
Q

Definition of toxic megacolon

A

Transverse or right colon with a diameter > 6cm, with loss in haustration in patients with severe UC

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48
Q

What % of acute attacks have a toxic megacolon?

A

5%

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49
Q

What can trigger an attack of toxic megacolon?

A

Electrolyte abnormalities

Narcotics

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50
Q

What % of toxic megacolon will resolve with medical therapy alone?

A

50%

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51
Q

What is required to those with toxic megacolon who do not improve?

A

Urgent colectomy

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52
Q

What is the most dangerous local complication of toxic megacolon?

A

Perforation

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53
Q

Morality of toxic megacolon

A

Approx. 15%

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54
Q

What signs may be absent in toxic megacolon? Why is this?

A

Signs of peritonitis

Due to reduced immune response

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55
Q

Who do we not give enemas or laxatives to? Why?

A

Patients with acute abdominal pain

As may cause perforation

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56
Q

Endoscopic findings of UC

A

Loss of normal vascular pattern
Mucous, pus or blood in the lumen
Mucosal reddening and contact bleeding
Ulceration, granulation tissue and pseudopolyps

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57
Q

Investigations for UC

A

Endoscopy
AXR
Erect CXR
CT Abdomen

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58
Q

What can be seen in AXR for UC?

A

Gross colonic distention

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59
Q

What would be an indication for AXR in UC?

A

Acute fulminating colitis

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60
Q

Why would you do an erect chest x ray in UC? What would you see?

A

To exclude a silent perforation

Free air under the diaphragm

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61
Q

Why would you do a CT of the abdomen in UC?

A

To suspect diagnosis when acute abdomen

to exclude perforation

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62
Q

3 signs of acute toxic dilatation on AXR

A
  1. Oedematous wall
  2. Dilated
  3. No haustrations
63
Q

In an acute admission of a patient with IBD, what investigations must NOT BE DONE and why? And what investigation should be done?

A

NO ENDOSCOPY
NO BARIUM ENEMA
could perforate
DO A CT SCAN

64
Q

Indications for surgery in an acute attack of UC

A

Failure to respond to medical Tx
Acute toxic dilatation (unless dramatic response within 48 hours)
Perforation or massive haemorrhage

65
Q

Which of the colon or rectum is more likely to perforate? Why?

A

Colon - it is thinner

66
Q

Surgery in acute attack of UC

A

EMERGENCY
- Total colectomy, ileostomy and closure of rectal stump
OR
- Total colectomy, ileostomy and rectosigmoid mucous fistula
FOLLOWING RECOVERY FROM EMERGENCY SURGERY
- excision of the rectum and permanent ileostomy
OR
- formation of ileal pouch

67
Q

In emergency surgery for acute attack of UC, what is taken out first?

A

Colon

68
Q

What comes out of a terminal ileum stoma?

A

Faeces

69
Q

What comes out of a rectosigmoidal stoma?

A

Mucous

70
Q

What is a ileal pouch?

A

The distal ileum is made into a pouch
Rectum taken out but anal canal remains
The ileum is connected to the anal canal

71
Q

Indications for chronic disease UC

A

Continuous disabling symptoms

Carcinoma, dysplasia or risk of developing carcinoma

72
Q

What is the surgery for chronic UC?

A

Total protocolectomy and permanent ileostomy
OR
Total protocolectomy and formation of ileal pouch

73
Q

Definition of protocolectomy

A

Surgical removal of rectum and the whole of the colon

74
Q

Indications for an ileal pouch

A

Ulcerative colitis

FAP

75
Q

Contraindications to ileal pouch

A

Crohn’s disease

Significant anal incontinence

76
Q

What is an issue when preparing to remove the rectum?

A

Very close to the nerves responsible for sexual dysfunction
In women may also alter fertility
May need counselling for this

77
Q

What are the two procedures done if want an ileal pouch?

A

Protocolectomy - if patient has no previous surgery

Completion protectomy - if patient has previous colectomy

78
Q

Complications of early ileal pouch

A

Splenic injury
Anastomotic complications
Intra abdominal abscesses

79
Q

Late complications of ileal pouch

A 
Poor function 
- frequency 
- incontinence 
- pouchitis 
Pouch failure
80
Q

What % of patients get pouch failure?

A

5 - 10%

81
Q

Features of a stoma pouch

A 
5 - 6 x per day 
1 - 2 x per night
Very liquid
Incontinence
Leakage when asleep
82
Q

Definition of pouchitis

A

Inflammation of the pouch

83
Q

How long can pouches last for?

A

Approx. 30 years

84
Q

Blood results in IBD

A 
High ESR and CRP
High platelets
High WCC
Low Hb
Low albumin
85
Q

What does the stool contain in IBD?

A

Calprotectin

86
Q

What is calprotectin?

A

White protein only present in the leumocytes In the bowel - if inflammation then these will be up in the stool

87
Q

What is a normal value of calprotectin?

A

< 50

88
Q

What is an elevated value of calprotectin?

A

> 200

89
Q

Extraintestinal manifestations of IBD

A 
Uveitis
Episcleritis
Conjunctivitis
Sacroilitis
Monoarticular arthritis
Ankylosing spondylitis
Liver and biliary tree changes 
Vasculitis
Pyoderma gangrenosum 
Erythema nodosum
90
Q

Differential diagnosis of IBD

A

Chronic diarrhoea
- malabsorption
- malnutrition
Ileo-caecal TB

91
Q

Definition of Crohn’s disease

A

A non specific chronic transmural inflammatory disease that can affect any part of the GI tract

92
Q

What age gets CD?

A

Most patients < 30

Peak incidence 14 -24 years

93
Q

Smoking and CD

A

Contributes to the development, exacerbation and recurrence of CD
Medication and surgery for CD wont work if you smoke

94
Q

Definition of transmural

A

Affects all 3 layers

  • mucosa
  • muscular
  • serosa
95
Q

Why in CD can you get fibrotic strictures?

A

Due to the transmural nature

96
Q

Where can CD affect?

A

ANY PART of the GIT from mouth to anus

97
Q

Frequency of sites affected in CD

A

Small intestine 30%
Large intestine 20%
Small and large intestine 40%
Perianal 10%

98
Q

Pathological subtypes of CD

A

Stricturing
Inflammatory
Fistulating

99
Q

What can CD mimic and why?

A

Acute appendicitis

As tends to affect the caecum

100
Q

What is an anal fistula?

A

An opening between the anal canal and the skin

101
Q

What is there a risk of In an anal fistula and therefore what should be done?

A

Abscess

Can stretch it open and seton to drain it

102
Q

Pathology of CD

A 
Skip lesions
Strictures
Mesenteric fat wrapping or creeping
Whole thickness of bowel affected
Non-caseating granulomatous reaction 
Crypt abscesses, abscess and fistula formation
103
Q

Presentation of acute CD

A 
Acute abdomen simulating acute appendicitis
Intestinal obstruction (usually subacute)
Peritonitis due to bowel perforation 
Fulminate colitis (less common than in UC)
104
Q

Presentation of Crohn’s disease

A

Recurrent abdominal pain
Recurrent subacute intestinal obstruction
Abdominal mass
Malnutrition
Chronic debility
Abdominal / perineal fistulas and abscesses
Mouth ulcers

105
Q

Investigations for CD

A

Barium studies
Small bowel MRI (MRE)
CT
Endoscopy

106
Q

What do barium studies show in CD?

A

Mucosal ulceration and “cobble stoning”
Areas of narrowing and skip lesions
Internal fistulae
String sign of kantor; marked narrowing of the terminal ileum

107
Q

What is a CT used for in CD?

A

Acute presentation

Also to diagnose complications

108
Q

Types of endoscopy

A

Upper GI Endoscopy
Colonoscopy
Wireless capsules endoscopy

109
Q

Indications for surgery in CD

A

COMPLICATIONS

  • strictures
  • fistula
  • abscess
  • intestinal obstruction
110
Q

What is the only reason to operate in CD?

A

Onset of complications

111
Q

What % of patients get operated on in small bowel CD?

A

80%

112
Q

What % of patients get operated on in large bowel CD?

A

50%

113
Q

Of those who get surgery, what % of patients will require further surgery in 10 years?

A

50%

114
Q

Smoking related to surgery in CD

A

Increases risk for relapse

115
Q

What does bypass surgery in CD result in? What is it for?

A

Small bowel attaches to the stomach

Duodenal disease

116
Q

What may the drainage of an abscess lead to?

A

Fistula

117
Q

What is excisional surgery?

A

Resection of the affected segment of the bowel with end to end anastomoses

118
Q

Surgical treatment for CD

A

Drainage of abscess
Excisional surgery
Strictureplasty
By pass surgery

119
Q

What is strictureplasty for?

A

Multiple relatively short strictures

120
Q

Treatment of IBD

A 
Aminosalicylates (5ASAs)
Corticosteriods
Immunomodulators
- azathioprine
- methotrexate 
- imfliximab 
Biologics
121
Q

What is a panprotocolectomy?

A

Removal of rectum and colon

122
Q

Which of UC or CD does oral contraceptives increase the risk of?

A

CD

123
Q

There is a higher risk in higher socioeconomic status groups in which of UC or CD?

A

CD

124
Q

What is protective of CD?

A

Breastfeeding

125
Q

Is abdominal pain common in UC? CD?

A

No - UC

Yes - CD

126
Q

Do you get masses and fistulas in UC or CD?

A

Occasionally in CD

Never in UC

127
Q

Which of UC and CD has an increased association to carcinoma?

A

UC

128
Q

Involvement of small bowel in UC or CD

A

UC - spared, backwash only

CD - frequent, virtually always benign

129
Q

Features of a stricture in UC

A

Rare

Virtually always malignant

130
Q

Features of a stricture in CD

A

Frequent, virtually always benign

131
Q

What ulcers are present in UC? and in CD?

A

UC - superficial ulcers

CD - longitudinal ulcers

132
Q

Which of UC and CD are abscesses present in?

A

Both

133
Q

Mucus production is increased in which of UC or CD?

A

UC

134
Q

Lymph nodes in UC

A

Reactive

135
Q

Lymph nodes in CD

A

With granulomas

136
Q

Side effects of thiopurines e.g. azathioprine

A

Leucopenia
Hepatotoxicity
Pancreatitis
Possible long term lymphoma risk

137
Q

Which of UC and CD Is methotrexate used in?

A

CD

138
Q

What biologics are used to treat IBD?

A

Monoclonal antibodies
Anti - TNFa antibodies
a4b7 integrin blockers
IL12/IL13 blockers

139
Q

What is there a risk of when using immunomodulators/biologics?

A

Malignancy

140
Q

When would antibiotics e.g. metronidazole be used in IBD?

A

Crohn’s peri anal disease

Small bowel bacterial overgrowth

141
Q

What are associated conditions of IBD?

A 
Sclerosing cholangitis (particularly UC)
Colonic carcinoma
142
Q

Risk factors for colonic carcinoma in IBD

A 
Pancolitis 26 x normal 
Left colitis 8 x normal 
Proctitis minimal 
< 10 yrs minimal risk 
20 years 23x risk 
30 years 32 x risk 
If have chronic colonic inflammation
143
Q

Which type of IBD do you get gallstones?

A

CD

144
Q

In which type of IBD do you get rose thorn ulcers?

A

CD

145
Q

Depletion of globlet cells is most commonly seen in which type of IBD?

A

UC

146
Q

What is the first line treatment for a mild to moderate flare up of distal UC?

A

Topical (distal) aminosalicylates

147
Q

Severity of UC

A

Mild - < 4 stools / day, only a small amount of blood
Moderate - 4 - 6 stools / day, varying amounts of blood, no systemic upset
Severe - > 6 bloody stools / day, features of systemic upset

148
Q

Treatment of extensive disease of UC

A

Topical (rectal) aminosalicylate PLUS high dose oral aminosalicylate

149
Q

If remission is not achieved in treatment of extensive disease, what can be done?

A

Stop topical Tx

Offer high dose oral aminosalicylate and oral corticosteroid

150
Q

Treatment of severe colitis

A

Should be treated in hospital
IV steriods 1st line (IV ciclosporin may be used if steriods contraindicated)
If after 72 hours no improvement
- add IV ciclosporin to IV corticosteroids or consider surgery

151
Q

Most common site affected in UC

A

Rectum

152
Q

If a patient has UC, and has a severe relapse or >2 exacerbations in the past year, what should they be given to retain remission?

A

Oral azathioprine

153
Q

Treatment of an acute flare of CD when symptoms don’t improve after 5 days of IV hydrocortisone

A

Biologic therapy

Gastrointestinal Pathology (26 decks)

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