Inflammatory Bowel Disease

Question 1

What is the likelihood a parent with IBD passes it on to their children?
What are the types of genes affected?

Answer 1

10%

Epithelial barrier, immune response and bacterial handling gene mutations can cause IBD

Question 2

Describe the relationship of bacteria in the colon in a person with IBD. Effect of this?

Answer 2

The bacteria is in “dysbiosis” (imbalanced)

This causes chronic inflammation of the gut

Question 3

Symptoms of ulcerative colitis?

Answer 3

Bloody diarrhoea 
Abdominal pain
Weight loss
Tiredness / fatigue
Rectal bleeding

Question 4

Investigations for suspected ulcerative colitis?

Answer 4

Bloods (markers of inflammation - CRP/ESR/low albumin)
Stool culture (to rule out infection)
Faecal calprotectin (>200microg/g)
Colonoscopy + colon mucosal biopsy
pANCA

Question 5

Where is UC localized? How does it spread?

Answer 5

It is localized in the colon

Starts at rectum and spread proximally

Question 6

Do many UC patients require colectomy?

Answer 6

20-30% require colectomy within 10 years of diagnosis

Question 7

Signs that UC is severe?

Answer 7

Blood in stools 
>6 stools per day 
Anaemia 
Abdominal tenderness or dilatation
Increased temp/HR

Question 8

What is proctitis?

How is it treated?

Answer 8

Inflammation of the lining of the rectum

Anti-inflammatories / Corticosteroids

Question 9

Symptoms of proctitis?

Answer 9

Frequency 
Urgency/tenesmus 
Incontinence
Mucus + blood in stool
Constipation

Question 10

What is acute severe colitis?

Answer 10

An acute exacerbation of ulcerative colitis

Characterized by:
>6 bloody stools/day
Increased HR + Temperature 
Anaemia 
Raised CRP/ESR

Question 11

Necessary interventions within first 24 hours of acute severe colitis?

Answer 11

LMWH
IV glucocorticoids
Abdominal X-Ray (dilatation? Oedema? Faecal loading?)
IV hydration & correction of electrolytes (low K/Mg can precipitate toxic megacolon)

Question 12

How is Crohn’s localized? How does it present?

Answer 12

Anywhere from mouth to anus - patchy disease with skip lesions between affected areas

Clinical features depend on affected area

Question 13

Clinical features of Crohn’s?

Answer 13

Diarrhoea 
Abdominal pain
Weight loss
Malabsorption (anaemia/vit deficiency)
Mouth ulceration
Malaise/lethargy/anorexia/nausea & vomiting/low-grade fever

Question 14

Investigations for Crohn’s disease?

Answer 14

Bloods (inflammation markers)
Stool culture (rule out infection)
Faecal calprotectin (>200, won’t be elevated in small bowel disease)
Colonoscopy + biopsy
MRI small bowel
Capsule endoscopy
CT scan (if acutely unwell - want to rule out abscessed)

Question 15

Histological differences between Crohn’s and UC?

Answer 15

Crohn’s gut will have granulomas, UC won’t
Goblet cells are depleted in UC
Crypt abscesses in UC > Crohn’s
Transmural inflammation in CD, Mucosal in UC

Question 16

Symptoms and investigations for perianal Crohn’s disease?

Answer 16

Perianal pain
Pus Secretion
Inability to sit down

MRI pelvis
Clinical examination under anaesthetic

Question 17

Treatment of perianal Crohn’s disease?

Answer 17

Surgery to drain the abscess

Antibiotics if infected

Question 18

What are some things that commonly occur in perianal Crohn’s disease?

Answer 18

Ulceration
Fistula’s
External openings (can become inflamed)

Question 19

How often are colonoscopies given to patients with colitis?

Answer 19

Depends on severity of colitis
Low risk colitis - every 5 years
Intermediate risk - every 3 years
Higher risk - every 1 year

Question 20

Drugs used to treat IBD? (step up approach)

Answer 20

1. 5-ASA or sulfasalazine
2. Prednisone or budesonide
3. Immunomodulators (AZA or 6-MP or MTX)
4. Biologic agents
5. Surgery

Question 21

How do aminosalicylates (5-ASA) work? When are they indicated?

Answer 21

Block prostaglandins and leukotrienes
1st line therapy for mild-moderate UC
Used to be used for maintenance of Crohn’s remission but not anymore

Question 22

When are steroids indicated in IBD cases? Examples of steroids?

Answer 22

They are used to induce remission in CD & UC

1. Prednisolone
2. Budenoside (less effective, only used in ileal & asc. colon disease - better side effect profile though)

Question 23

Examples of immunomodulators for UC and Crohn’s? When are they indicated?

Answer 23

Indicated to maintain UC & Crohn’s - stop exacerbation/progression

Azathioprine
Methotrexate (CD)

Question 24

Side effects of Azathioprine (6-Mercaptopurine)?

Answer 24

Leucopenia (low WBC)
Hepatotoxicity (requires blood monitoring every 8 weeks)
Pancreatitis
Possible lymphoma and melanoma risk

Question 25

What are the biologic agent drugs? Examples?

Answer 25

They are monoclonal antibodies

Infliximab
Adulimumab
Vedolizumab

Often have to be administered at x weekly intervals (eg. once every 6 weeks)

Question 26

What non-pharmacological intervention can be effective in managing IBD?

Answer 26

Elemental feeding (ingestion/IV administration of liquid nutrients in an easily assimilated form)

More efficacious in children, can be as effective as steroids

Question 27

Surgical options for drug resistant IBD?

Answer 27

Partial colectomy
Total proctocolectomy + ileostomy
Total colectomy + pouch procedure

Question 28

What is an ileostomy?

Answer 28

Surgical procedure that can be necessary after a colectomy + proctectomy
In an ileostomy the small intestine is diverted through an opening in the abdomen

Question 29

What is a pouch procedure?

Answer 29

Procedure that involves the lengthening and folding of the small intestine into a pouch and then attaching it to the rectum
Done when colon needs to be removed but rectum can be salvaged

Question 30

What is a proctectomy?

Answer 30

Surgery to remove all or part of the rectum