Inflammatory Bowel Disease

Question 1

Crohn’s Disease

Medical Management

Induce remission vs Maintainence

Answer 1

Induction of remission

1. Glucocorticoid e.g. prednisolone or IV Hydrocortisone
2. • Azathioprine (check not TMPT deficient beforehand)
3. OR + Methotrexate
4. OR + biologic e.g. infliximab

Maintenance of remission

1. Azathioprine
2. OR Methotrexate

Question 2

Crohn’s Disease

Surgical management

Answer 2

Surgery is not usually effective in chrohns disease (unlike in ulcerative colitis)

Only really used in peri-anal disease or complications e.g. bowel obstruction

Surgery examples include ileo-caecal resection or temporary loop Ileostomy

Question 3

Complications of Crohn’s Disease

Answer 3

Anal complications are common in Crohn’s Disease:

• Anal fissures
• Perianal Abscesses (investigated with an MRI pelvis)

Question 4

Feature of Crohn’s Disease

Answer 4

Crohn’s (crows NESTS)

N – No blood or mucus (less common)

E – Entire GI tract

S – “Skip lesions” on endoscopy + cobblestoning

T – Terminal ileum most affected and Transmural (full thickness) inflammation

S – Smoking is a risk factor (don’t set the nest on fire)

Crohn’s is also associated with weight loss, strictures and fistulas.

Question 5

Features of Ulcerative Colitis

Answer 5

Ulcerative Colitis (remember U – C – CLOSEUP)

C – Continuous inflammation

L – Limited to colon and rectum

O – Only superficial mucosa affected (+ crypt abscesses + goblet cell depletion + pseudopolyps)

S – Smoking is protective

E – Excrete blood and mucus

U – Use aminosalicylates

P – Primary Sclerosing Cholangitis

Question 6

Diagnosis of IBD

Answer 6

Routine bloods for anaemia, infection, thyroid, kidney and liver function

CRP indicates inflammation and active disease

Faecal calprotectin (released by the intestines when inflamed) is a useful screening test (> 90% sensitive and specific to IBD in adults)

Endoscopy (OGD and colonoscopy) with biopsy is diagnostic

Imaging with ultrasound, CT and MRI can be used to look for complications such as fistulas, abscesses and strictures.

Question 7

UC Management

Answer 7

INDUCING REMISSION
Mild to moderate disease
- First line: aminosalicylate (e.g. mesalazine oral or rectal)
-Second line: corticosteroids (e.g. prednisolone)

Severe disease

• First line: IV corticosteroids (e.g. hydrocortisone)
• Second line: IV ciclosporin

MAINTAINING REMISSION

• Aminosalicylate (e.g. mesalazine oral or rectal)
• Azathioprine
• Mercaptopurine

SURGERY

Ulcerative colitis typically only affects the colon and rectum. Therefore, removing the colon and rectum (PANPROCTOCOLECTOMY) will remove the disease.

The patient is then left with either a PERMANENT ILEOSTOMY or something called an ileo-anal anastomosis (J-pouch). This is where the ileum is folded back in itself and fashioned into a larger pouch that functions a bit like a rectum. This “J-pouch” which is then attached to the anus and collects stools prior to the person passing the motion.

Question 8

Complications for Ulcerative Colitis

Answer 8

Toxic Megacolon

Question 9

Complications of surgery

Answer 9

Short Bowel Syndrome:

• diarrhoea or steatorrhoea, weight loss and abdominal pain
• manage: Anti-diarrhoeal agents e.g. Loperamide, Vitamin supplements, Total parenteral nutrition, Transplant