Inflammatory Bowel Disease Flashcards
1
Q
What is IBD?
A
A spectrum of disease
2
Q
What does IBD stand for?
A
Inflammatory bowel disease
3
Q
What are the 3 spectrum subtypes of IBD?
A
Crohn’s disease
Ulcerative colitis
Indeterminate colitis
4
Q
What is indeterminate colitis?
A
Exactly in the middle of the spectrum of UC and CD
5
Q
Definition of IBD
A
Idiopathic inflammation of the bowel
6
Q
What % does indeterminate colitis make up of IBD?
A
10 - 15%
7
Q
Causes of IBD
A
Unknown Genetic predisposition Unregulated intestinal immune response Loss of tolerance against certain enteric flora Environmental triggers
8
Q
Pathology of IBD
A
Non-ceasating granuloma
9
Q
What does UC stand for?
A
Ulcerative colitis
10
Q
Definition of UC
A
A chronic inflammatory ulcerative disease affecting mucosa of the rectum and colon
11
Q
What peak age groups get UC?
A
15 - 30 yrs major peak
50 - 70 yrs smaller peak
12
Q
What is serosa?
A
Visceral peritoneum
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
14
Q
What decreases the risk for UC / reduces attacks?
A
Smoking
Appendectomy before age 20 for acute appendicitis
15
Q
What is a crypt abscess?
A
Abscess at the bottom of the mucosa
16
Q
Where does UC affect?
A
Mucosa
Starts in rectum and extends proximally in CONTINUTIY
17
Q
What is UC confined to?
A
Rectum
Colon
18
Q
What is spared in UC?
A
Anal canal
19
Q
Subtypes of UC
A
Proctosigmoiditis
Left sided colitis
Pancolitis
Backwash ileitis
20
Q
How often does UC affect the ileum?
A
Very rarely
21
Q
Which gender gets UC more?
A
F > M
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
23
Q
The risk of development of cancer in UC is related to….
A
Extent of disease
Duration of disease (>10 years)
24
Q
Indications for surveillance colonoscopy
A
Total colitis > 10 years
Left sided colitis > 15 years
25
If the patient has anal disease, what does this indicate as the diagnosis?
Crohn's disease
26
Systemic complications of UC
```
Large joint disease
Uveitis
Spondylitis
Erythema nodosum
Pyoderma gangrenosum
Fatty Liver
Liver cirrhosis
Cholangiocarcinoma
```
27
Presentation of UC
```
Diarrhoea
Rectal bleeding
Tenesmus
Passage of mucus (could be blood stained)
Cramping abdominal pain
```
28
Definition of tenesmus
A continual or recurrent inclination to evacuate the bowels
29
What do the severity of symptoms of UC correlate with?
Extent of disease
30
What can surgery for UC offer?
Long lasting symptom control
31
What is there NO ROLE FOR in surgery for UC?
Segmental resection
MUST TAKE WHOLE RECTUM AND COLON OUT
as disease would just come back in the remaining portions
32
Why do UC patients often have Hypoalbuminia?
Loads of mucus is secreted which is rich in protein
33
In severe inflammation in UC, what can happen?
Muscle wall can fail leading to perforation
34
What diameter does the caecum perforate at?
10cm
35
What does a stricture in UC usually indicate?
Malignancy
36
What does inflammation for a long period of time lead to?
Dysplasia
| Which leads to neoplasia
37
If have dysplastic changes in UC, what has to be done and why?
Surgery
| As will advance to cancer
38
What does colon cancer with UC result in?
Poorer prognosis
39
Why would cancer in IBD spread very easily?
As already on immunomodulators as treatment
40
What is a cholangiocarcinoma?
Malignant tumour of the biliary tree
41
What does cramping abdominal pain indicate?
Colonic disease
42
The more the symptoms of UC, what does this imply?
The more of the colon is affected
43
Types of UC
Fulminating
| Chronic
44
Features of fulminating UC
```
Bowel movements > 10 / 24 hours
Fever
Tachycardia
Continous bleeding
Anaemia
Hypalbuminaemia
Abdominal distention (toxic dilatation of the colon)
```
45
Features of chronic UC
Initial attack of moderate severity followed by recurrent exacerbations
Patient looked wasted (from severe diarrhoea) and anaemic (from chronic blood loss)
46
Another name for toxic megacolon
Acute toxic dilatation of the colon
47
Definition of toxic megacolon
Transverse or right colon with a diameter > 6cm, with loss in haustration in patients with severe UC
48
What % of acute attacks have a toxic megacolon?
5%
49
What can trigger an attack of toxic megacolon?
Electrolyte abnormalities
| Narcotics
50
What % of toxic megacolon will resolve with medical therapy alone?
50%
51
What is required to those with toxic megacolon who do not improve?
Urgent colectomy
52
What is the most dangerous local complication of toxic megacolon?
Perforation
53
Morality of toxic megacolon
Approx. 15%
54
What signs may be absent in toxic megacolon? Why is this?
Signs of peritonitis
| Due to reduced immune response
55
Who do we not give enemas or laxatives to? Why?
Patients with acute abdominal pain
| As may cause perforation
56
Endoscopic findings of UC
Loss of normal vascular pattern
Mucous, pus or blood in the lumen
Mucosal reddening and contact bleeding
Ulceration, granulation tissue and pseudopolyps
57
Investigations for UC
Endoscopy
AXR
Erect CXR
CT Abdomen
58
What can be seen in AXR for UC?
Gross colonic distention
59
What would be an indication for AXR in UC?
Acute fulminating colitis
60
Why would you do an erect chest x ray in UC? What would you see?
To exclude a silent perforation
| Free air under the diaphragm
61
Why would you do a CT of the abdomen in UC?
To suspect diagnosis when acute abdomen
| to exclude perforation
62
3 signs of acute toxic dilatation on AXR
1. Oedematous wall
2. Dilated
3. No haustrations
63
In an acute admission of a patient with IBD, what investigations must NOT BE DONE and why? And what investigation should be done?
NO ENDOSCOPY
NO BARIUM ENEMA
could perforate
DO A CT SCAN
64
Indications for surgery in an acute attack of UC
Failure to respond to medical Tx
Acute toxic dilatation (unless dramatic response within 48 hours)
Perforation or massive haemorrhage
65
Which of the colon or rectum is more likely to perforate? Why?
Colon - it is thinner
66
Surgery in acute attack of UC
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
In emergency surgery for acute attack of UC, what is taken out first?
Colon
68
What comes out of a terminal ileum stoma?
Faeces
69
What comes out of a rectosigmoidal stoma?
Mucous
70
What is a ileal pouch?
The distal ileum is made into a pouch
Rectum taken out but anal canal remains
The ileum is connected to the anal canal
71
Indications for chronic disease UC
Continuous disabling symptoms
| Carcinoma, dysplasia or risk of developing carcinoma
72
What is the surgery for chronic UC?
Total protocolectomy and permanent ileostomy
OR
Total protocolectomy and formation of ileal pouch
73
Definition of protocolectomy
Surgical removal of rectum and the whole of the colon
74
Indications for an ileal pouch
Ulcerative colitis
| FAP
75
Contraindications to ileal pouch
Crohn's disease
| Significant anal incontinence
76
What is an issue when preparing to remove the rectum?
Very close to the nerves responsible for sexual dysfunction
In women may also alter fertility
May need counselling for this
77
What are the two procedures done if want an ileal pouch?
Protocolectomy - if patient has no previous surgery
| Completion protectomy - if patient has previous colectomy
78
Complications of early ileal pouch
Splenic injury
Anastomotic complications
Intra abdominal abscesses
79
Late complications of ileal pouch
```
Poor function
- frequency
- incontinence
- pouchitis
Pouch failure
```
80
What % of patients get pouch failure?
5 - 10%
81
Features of a stoma pouch
```
5 - 6 x per day
1 - 2 x per night
Very liquid
Incontinence
Leakage when asleep
```
82
Definition of pouchitis
Inflammation of the pouch
83
How long can pouches last for?
Approx. 30 years
84
Blood results in IBD
```
High ESR and CRP
High platelets
High WCC
Low Hb
Low albumin
```
85
What does the stool contain in IBD?
Calprotectin
86
What is calprotectin?
White protein only present in the leumocytes In the bowel - if inflammation then these will be up in the stool
87
What is a normal value of calprotectin?
< 50
88
What is an elevated value of calprotectin?
> 200
89
Extraintestinal manifestations of IBD
```
Uveitis
Episcleritis
Conjunctivitis
Sacroilitis
Monoarticular arthritis
Ankylosing spondylitis
Liver and biliary tree changes
Vasculitis
Pyoderma gangrenosum
Erythema nodosum
```
90
Differential diagnosis of IBD
Chronic diarrhoea
- malabsorption
- malnutrition
Ileo-caecal TB
91
Definition of Crohn's disease
A non specific chronic transmural inflammatory disease that can affect any part of the GI tract
92
What age gets CD?
Most patients < 30
| Peak incidence 14 -24 years
93
Smoking and CD
Contributes to the development, exacerbation and recurrence of CD
Medication and surgery for CD wont work if you smoke
94
Definition of transmural
Affects all 3 layers
- mucosa
- muscular
- serosa
95
Why in CD can you get fibrotic strictures?
Due to the transmural nature
96
Where can CD affect?
ANY PART of the GIT from mouth to anus
97
Frequency of sites affected in CD
Small intestine 30%
Large intestine 20%
Small and large intestine 40%
Perianal 10%
98
Pathological subtypes of CD
Stricturing
Inflammatory
Fistulating
99
What can CD mimic and why?
Acute appendicitis
| As tends to affect the caecum
100
What is an anal fistula?
An opening between the anal canal and the skin
101
What is there a risk of In an anal fistula and therefore what should be done?
Abscess
| Can stretch it open and seton to drain it
102
Pathology of CD
```
Skip lesions
Strictures
Mesenteric fat wrapping or creeping
Whole thickness of bowel affected
Non-caseating granulomatous reaction
Crypt abscesses, abscess and fistula formation
```
103
Presentation of acute CD
```
Acute abdomen simulating acute appendicitis
Intestinal obstruction (usually subacute)
Peritonitis due to bowel perforation
Fulminate colitis (less common than in UC)
```
104
Presentation of Crohn's disease
Recurrent abdominal pain
Recurrent subacute intestinal obstruction
Abdominal mass
Malnutrition
Chronic debility
Abdominal / perineal fistulas and abscesses
Mouth ulcers
105
Investigations for CD
Barium studies
Small bowel MRI (MRE)
CT
Endoscopy
106
What do barium studies show in CD?
Mucosal ulceration and "cobble stoning"
Areas of narrowing and skip lesions
Internal fistulae
String sign of kantor; marked narrowing of the terminal ileum
107
What is a CT used for in CD?
Acute presentation
| Also to diagnose complications
108
Types of endoscopy
Upper GI Endoscopy
Colonoscopy
Wireless capsules endoscopy
109
Indications for surgery in CD
COMPLICATIONS
- strictures
- fistula
- abscess
- intestinal obstruction
110
What is the only reason to operate in CD?
Onset of complications
111
What % of patients get operated on in small bowel CD?
80%
112
What % of patients get operated on in large bowel CD?
50%
113
Of those who get surgery, what % of patients will require further surgery in 10 years?
50%
114
Smoking related to surgery in CD
Increases risk for relapse
115
What does bypass surgery in CD result in? What is it for?
Small bowel attaches to the stomach
| Duodenal disease
116
What may the drainage of an abscess lead to?
Fistula
117
What is excisional surgery?
Resection of the affected segment of the bowel with end to end anastomoses
118
Surgical treatment for CD
Drainage of abscess
Excisional surgery
Strictureplasty
By pass surgery
119
What is strictureplasty for?
Multiple relatively short strictures
120
Treatment of IBD
```
Aminosalicylates (5ASAs)
Corticosteriods
Immunomodulators
- azathioprine
- methotrexate
- imfliximab
Biologics
```
121
What is a panprotocolectomy?
Removal of rectum and colon
122
Which of UC or CD does oral contraceptives increase the risk of?
CD
123
There is a higher risk in higher socioeconomic status groups in which of UC or CD?
CD
124
What is protective of CD?
Breastfeeding
125
Is abdominal pain common in UC? CD?
No - UC
| Yes - CD
126
Do you get masses and fistulas in UC or CD?
Occasionally in CD
| Never in UC
127
Which of UC and CD has an increased association to carcinoma?
UC
128
Involvement of small bowel in UC or CD
UC - spared, backwash only
| CD - frequent, virtually always benign
129
Features of a stricture in UC
Rare
| Virtually always malignant
130
Features of a stricture in CD
Frequent, virtually always benign
131
What ulcers are present in UC? and in CD?
UC - superficial ulcers
| CD - longitudinal ulcers
132
Which of UC and CD are abscesses present in?
Both
133
Mucus production is increased in which of UC or CD?
UC
134
Lymph nodes in UC
Reactive
135
Lymph nodes in CD
With granulomas
136
Side effects of thiopurines e.g. azathioprine
Leucopenia
Hepatotoxicity
Pancreatitis
Possible long term lymphoma risk
137
Which of UC and CD Is methotrexate used in?
CD
138
What biologics are used to treat IBD?
Monoclonal antibodies
Anti - TNFa antibodies
a4b7 integrin blockers
IL12/IL13 blockers
139
What is there a risk of when using immunomodulators/biologics?
Malignancy
140
When would antibiotics e.g. metronidazole be used in IBD?
Crohn's peri anal disease
| Small bowel bacterial overgrowth
141
What are associated conditions of IBD?
```
Sclerosing cholangitis (particularly UC)
Colonic carcinoma
```
142
Risk factors for colonic carcinoma in IBD
```
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
Which type of IBD do you get gallstones?
CD
144
In which type of IBD do you get rose thorn ulcers?
CD
145
Depletion of globlet cells is most commonly seen in which type of IBD?
UC
146
What is the first line treatment for a mild to moderate flare up of distal UC?
Topical (distal) aminosalicylates
147
Severity of UC
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
Treatment of extensive disease of UC
Topical (rectal) aminosalicylate PLUS high dose oral aminosalicylate
149
If remission is not achieved in treatment of extensive disease, what can be done?
Stop topical Tx
| Offer high dose oral aminosalicylate and oral corticosteroid
150
Treatment of severe colitis
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
Most common site affected in UC
Rectum
152
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?
Oral azathioprine
153
Treatment of an acute flare of CD when symptoms don't improve after 5 days of IV hydrocortisone
Biologic therapy
