Inflammatory bowel disease Flashcards
Which 2 diseases fall under the umbrella term Inflammatory bowel disease?
ulcerative colitis
Chron’s disease
At what age does IBD usually present?
teens and twenties
Define what IBD is?
chronic relapsing inflammatory conditions of the bowel
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
3 contributing factors that cause IBD
genome - own make up - hereditary conditions?
envirome - smoking, diet, drugs
microbiome ie in the gut
Which genetic alteration is related to IBD?
single nucleotide polymorphisms in a particular gene
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
What does dysbiosis of microbiota lead to
leaky epithelial barrier
which in turn causes disorded, perpetual innate and adaptive immune response
Ulcerative colitis info
can affect any age - peak 20-40 y/o
M=F
symptoms of ulcerative colitis (4)
Bloody diarrhoea
Abdominal pain
Weight loss
Fatigue
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
Where does ulcerative colitis begin?
begins in the rectum and works proximally - only affects the colon!
variable distribution and severity too
what procedure do patients who are diagnosed with ulcerative colitis usually require within the following 10 years?
colectomy
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
What size does the colon have to be to be conisdered as ‘toxic megacolon’
> 5.5cm
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
Clinical features of Chron’s disease (10)
Diarrhoea Abdominal pain Weight loss. Malaise, lethargy anorexia Nausea + vomiting low-grade fever Malabsorption Anaemia vitamin deficiency
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
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
