Inflammatory bowel disease Flashcards by Anna Coull

Which 2 diseases fall under the umbrella term Inflammatory bowel disease?

ulcerative colitis

Chron’s disease

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At what age does IBD usually present?

teens and twenties

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Define what IBD is?

chronic relapsing inflammatory conditions of the bowel

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What is microscopic colitis?

similar to ulcerative collitis
has 2 main forms:- Collagenous colitis
Lymphocytic colitis

main difference to UC is that the tissue can only be seen under a microscope

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3 contributing factors that cause IBD

genome - own make up - hereditary conditions?
envirome - smoking, diet, drugs
microbiome ie in the gut

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Which genetic alteration is related to IBD?

single nucleotide polymorphisms in a particular gene

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What functions does the Gut’s microbiota serve?

Metabolic - production of viatmins, digestion of dietary carcinogens

Energy source

Immune system and barrier

protective - inflammatory cytokine oversite, colonisation resistance

Antimicrobial secretion

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What does dysbiosis of microbiota lead to

leaky epithelial barrier

which in turn causes disorded, perpetual innate and adaptive immune response

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Ulcerative colitis info

can affect any age - peak 20-40 y/o

M=F

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symptoms of ulcerative colitis (4)

Bloody diarrhoea
Abdominal pain
Weight loss
Fatigue

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Investigations for ulcerative colitis?

Bloods for markers of inflammation (normocytic anaemia, increased CRP/platelets, low albumin)

Stool culture to rule out infection

Faecal Calprotectin (0-50ug/g stool=normal, 50-200=equivocal, >200 elevated)

Colonoscopy and colon mucosal biopsies

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Where does ulcerative colitis begin?

begins in the rectum and works proximally - only affects the colon!

variable distribution and severity too

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what procedure do patients who are diagnosed with ulcerative colitis usually require within the following 10 years?

colectomy

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If a patient comes in with acute severe colitis what is the approach for the first 24 hours (6)

Specialist GI assessment and early surgical review. Psychological support too.,

Stool chart - 3 cultures for C.dificile

Avoid/stop non steroidal analgesics, opiates, anti-diarrhoeals, anti-cholinergics

IV glucocorticoids

Administer LMWH - anti-inflammatory - 3x increased risk of thromboembolism

abdominal chest xray - looking for toxic dilatation with mucosal oedema, lead pipe (loss of haustral markings - TC), proximal faecal loading

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What size does the colon have to be to be conisdered as ‘toxic megacolon’

> 5.5cm

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Why is Chron’s disease considered a patchy disease?

it affects the GI tract from mouth to anus but has skip lesions ie lesions aren’t continuous the whole way through

clinical features depends on regions involved - could be normal, inflammed, strictures, fistula

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Clinical features of Chron’s disease (10)

Diarrhoea
Abdominal pain
Weight loss. 
Malaise, lethargy
anorexia
Nausea + vomiting
low-grade fever
Malabsorption
Anaemia
vitamin deficiency

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Investigations for Chron’s disease (6)

Bloods for markers of inflammation

Stool culture to rule out infection if diarrhoea

Colonoscopy +/- colon/terminal ileum mucosal biopsies

MRI small bowel study

Capsule endoscopy - pill sized camera that can be swallowed

Occasionally CT scan if acutely unwell and want to rule out complication eg abscess

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What is perianal Chron’s disease? Common symptoms?

inflammation at or near the anus, including tags, fissures, fistulae, abscesses, or stenosis

perianal pain
pus secretion
unable to sit down

Investigations for perianal chron’s disease

MRI pelvis

examination under anaesthetic

Treatment for perianal chron’s disease?

Surgery to drain abscess

Medical – antibiotics and biologic therapy (anti-TNF)

Differential diagnosis of chronic diarrhoeas?

malnutrition

malabsorption

What is ileo-caecal tuberculosis

tuberculosis infection that spreads to the intestine

very serious, mimicks other abdominal pathologies very well - hard to detect

Colitis needs to be distinguished from which 3 types?

infective
amoebic
ischaemic

Long term complication of colitis

colonic carcinoma

How is IBD managed nowadays

3 specialist IBD nurses IBD pharmacist - therapeutic drug monitoring Weekly IBD MDT Nurse led infusion clinic 3/weeks dedicated colonoscopy lists for surveillance Colorectal surgeon with IBD specialist interest

Treatment aims through natural course of IBD relapse and remission?

Sometimes use top-down approach - start with most potent drug and work down

What are the 3 main Aminosalicylates (5-ASA) drugs and what do they do

Mesalamine Olsalazine Sulfasalazine work by damping down the inflammatory process, so allowing damaged tissue to heal - block leukotrienes + prostaglandins usually enteric - not dissolved by gastric acid - released to colon not small bowel

What is the 1st line therapy to get a patient into remission after mild- moderate flare up of UC?

5- ASA drug treatment Over time - it reduces chance of colorectal cancer

when is rectal 5ASA opted for?

for distal and left sided disease (descending colon and below etc)

Which disease are 5ASA drugs not effective treatment for?

Chron's disease

Discuss steroid use for both ulcerative collitis and Chron's?

it can induce remission for both prednisolone - optimal = 40mg a day - reduce over 4-6 weeks - give Ca and vit d supplements with it as steroids cause bone thinning Budenoside - Slightly less effective at being absorbed by systemic circ. - treats the ascending colon and ileum

Why do we need to reduce steroid dose?

Need to limit steroid exposure for patients with IBD Steroids are good for people who are unwell and have active disease but not long term

Discuss the use of Thiopurines for maintenance of UC and Chron's

Don’t work for everyone to control their disease Side effects can be very severe - Drug can dampen down inflammation in the gut. Cap off immune surveillance so dampen down body’s ability to make immune response – increased chance of cancer developing

What is Methotrexate

type of immunosuppressant good for Chron's takes a long time to work serious side effects like liver toxicity + pulmonary fibrosis It is teratogenic

If patient has active disease what is usually used first?

steroids

What type of biologic agents are there?

monoclonal antibodies like anti-TNF alpha IL12/IL23 blockers alpha 4b7 integrin blockers

what is another treatment option that can be as effective as steroids?

elemental feeding - liquid diet - good nutrition in simplest form - nasogastric tube usually as tastes horrible especially effective in children + is usually 1st line treatment as steroids are potent and can interrupt growth/development

When do we know if UC therapy has failed?

recurrent courses of steroid - ie >2 courses a year is deemed excessive relapse (flare up) prior to or shortly after steroid stopping therapy unacceptable side effects acute severe colitis not responding to 72 hrs high dose IV steroids +/- anti-TNF biologic

So if a patient doesn't respond to IV steroids for more than 3 days then what do you do?

give more potent immunosuppression and then they will need an emergency ileectomy or colectomy

Surgery for acute severe colitis

Total colectomy Rectal preservation Ileostomy

After a total colectomy what will a patient be left with?

end ileostomy - remove the large colon + ileum is brought out of the abdomen through a smaller cut and stitched on to the skin to form a stoma rectal stump - sewn or stapled closed and the anus is left intact

What is a completion proctectomy?

You take out the rectal stump and have a permanent end ileostomy – usually done if people have complications with end ileostomy or elderly with poor anal sphincter muscles

what is a pouch procedure?

Mobilise and lengthen the small bowel and construct a pouch - so the ileum is joined to anal canal and this forms a pouch where the stool collects before defecation

Surgical indications for Chron's disease (6)

Failure of medical management Relief of obstructive symptoms (small bowel) – ie stricture Management of fistulae - e.g. bowel to bladder Management of intra-abdominal abscess – managed with surgery Management anal conditions – perianal disease Failure to thrive