Inflammatory bowel disease Flashcards
1
Q
Describe ulcerative colitis?
A
- Relapsing, remitting inflammation of colonic mucosa
- Begins in rectum then spreads to the colon
- Cause:
- Inappropriate immune response against colonic flora
2
Q
Pathology of UC?
A
- Inflammation confined to mucosa
- Psuedopolyps form in long standing pancolitis
- Inflammarion of lamina propria and crypts (cryptitis)
- Crypt abscesses
- Goblet cells lose their mucus
3
Q
Major risk factor for UC?
A
UC is more common in smokers and ex-smokers
4
Q
Name some symptoms of UC?
A
- Cardinal features:
- Rectal bleeding with mucus + bloody diarrhoea
- Extra-intestinal manifestations
- Malaise, anorexia, abdominal pain
5
Q
Clinical signs of UC?
A
- Fever, tachycardia, tender abdo in severe UC
- Extraintestinal signs:
- Clubbing, aphthous oral ulcers, erythema nodosum
- Conjunctivitis, iritis, arthritis, sacroilitis
6
Q
Describe some tests for UC?
A
- FBC, ESR, CRP, U&E, LFT, blood culture
- Stool MC&S
- Exclude campylobacter, c. diff, salmonella/shigella, e.coli
- AXR
- No faecal shadows
- Colonic dilatation (lead pipe)
- Lower GI endoscopy
- Assess inflammation and biopsy
7
Q
How can UC be assessed in severity?
A
Truelove and Witts Criteria
8
Q
Name some complications of UC?
A
- Acute
- Toxic dilatation of colon with perforation risk
- Venous thromboembolism
- Chronic
- Colonic cancer
9
Q
Treatment for UC?
A
- 5-ASA (Mesalazine)
- +/- Topical steroid foams PR
- Immunomodulation if >=2 steroid courses required per year
- Patients intolerant of immunomodulation
- Biologic monoclonal antibodies (infliximab, adalimumab)
- Surgery if complete failure of medical therapy / complications
- Subtotal colectomy
- Terminal ileostomy
10
Q
SEs of mesalazine (5-ASAs)?
A
- Rash
- Haemolysis
- Hepatitis
- Pancreatitis
11
Q
Describe Crohn’s disease?
A
- Chronic inflammatory disesase:
- Transmural granulomatous inflammation
- Mouth to anus
- Skip lesions
- Inappropriate immune response against gut flora
12
Q
Associations of Crohns?
A
- Smoking increases risk
- NSAIDs can exacerbate the disease
13
Q
Symptoms of Crohns disease?
A
- Diarrhoea, abdo pain, weight loss
- Fatigue, fever, anorexia
- Ileal crohns disease can cause acute intestinal obstruction
14
Q
Clinical signs of Crohns disease?
A
- Bowel ulcereation
- Abdominal tenderness
- Anal strictures
- Clubbing, skin, joint and eye problems
15
Q
Complications of Crohns disease?
A
- Small bowel obstruction
- Toxic dilatiation (colonic diameter > 6cm)
- Abscess formation
- Perforation
- Colon cancer
16
Q
Diagnostic tests for Crohns disease?
A
- FBC, ESR, CRP, U&E, LFT, INR, ferritin, TIBC, B12, folate
- Stool MC&S
- Faecal calprotectin (GI inflammation with high sensitivity)
- Colonoscopy + biopsy
17
Q
Describe the treatment of Crohns disease?
A
- Optimize nutrition
- Mild: PO Prednisolone
- Severe:
- IV hydrocortisone / methylprednisolone
- Thromboembolism prophylaxis
- Azathioprine if refractory to steroids (alt: methotrexate)
- Biologics Anti-TNFa (infliximab/adalimumab
- Surgery: resection of affected areas, control fistulizing disease
18
Q
Describe the use of Anti-TNFa in Crohns disease?
A
- Infliximab/adalimumab
- Counter neutrophil accumulation and granuloma formation
- Cause cytotoxicity to CD4+ T cells
- CI: sepsis, TB
- SEs: rash, elevated LFTs
19
Q
Name some inflammatory mediators in IBD?
A
- TNF-α
- IL-12
- IL-23
20
Q
What are the different patterns of UC?
A
- Proctitis
- Left-sided colitis
- Extensive colitis (up to pancolitis)
21
Q
What are the different patterns of Crohns disease?
A
- Ileal or ileocolonic
- Small intestinal
- Crohns colitis
- Perianal disease alone
22
Q
Describe the histology of UC?
A
- Surface ulceration and inflammation confined to mucosa
- Excess inflammatory cells in lamina propria, loss of goblet cells and crypt abscesses
23
Q
Describe the histology of Crohns disease?
A
- Inflammation is transmural
- Inflammation extends into submucosa
- Non-caseating granulomas
24
Q
What is the Truelove-Witts criteria for acute severe ulcerative colitis?
A
- 6 or more bloody stools in the last 24 hours
- Plus one or more of:
- Fever
- Anaemia
- Tachycardia
- High inflammatory markers
25
Name some differentials for IBD?
* Salmonella, Shigella, Campylobacter, E. coli
* HSV, CMV
* Ischaemic colitis, collagenous colitis, colon cancer
26
What are the complications of IBD?
* Severe inflammation =\> toxic megacolon
* Haemorrhage
* Fistulae
* Cancer
* Extra-intestinal complications
27
What is pictured in this AXR?
* UC
* Thumbprinting
* Bowel wall thickening of the haustral folds
28
What is the abnormality pictured here?
* UC
* Mucosal islands
* Presence of pseudopolyps
29
What is the abnormality pictured here?
* UC
* Toxic megacolon
* Dilated colon with mucosal islands
30
What blood test can be used to distinguish IBD from IBS?
* Faecal calprotectin
* Very sensitive for gastrointestinal inflammation
* Can be raised even when CRP is normal
31
Name the extraintestinal complications of IBD
32
What are the key aims of medical therapy in IBD?
* Treat acute attacks (induce remission)
* Prevent relapses (maintain remission)
* Prevent bowel damage
* Detect dysplasia and prevent carcinoma
* Select appropriate patients for surgery
33
Treatment of Active proctitis UC?
* Mesalazine (suppository/oral)
* Glucocorticoids
* Stool softener
34
Treatment for Active left sided or extensive UC?
* Combination of oral and topical 5-ASA
* Top and tail approach
* Prednisolone
* Calcium and vitamin D supplementation for bone protection
35
Management of severe UC?
* Those meeting the Truelove-Witt criteria
* Best managed in hospital
* Fluids and nutrition PRN
* IV glucocorticoids
* Methylprednisolone
* If not responding:
* Rescue therapy: Ciclosporin or Infliximab
* If colonic dilation \>6cm and not responding =\> Subtotal colectomy
36
Describe the maintenance of remission in UC?
* For those with left-sided or extensive disease (not always proctitis)
* Once-daily oral 5-ASA
* If patients frequently relapse:
* Thiopurines
* Azathioprine or 6-mercaptopurine
37
Describe the induction of remission in Crohns disease?
* Glucocorticoids
* Budesonide, if no response, prednisolone
* Calcium and vitamin D supplementation
* If no response:
* Infliximab or Adalimumab
38
Describe the maintenance of remission in Crohns disease?
* Immunosuppression with thipurines
* Azathioprine and mercaptopurine
* Methotrexate can also be used
* Smoking cessation counselling
39
Indications for surgery in UC?
* Impaired QoL
* Loss of job or education
* Disrupted family life
* Failure of medical therapy
* Fulminant colitis
* Colon cancer or severe dysplasia
40
Surgical approaches to UC?
* Panproctocolectomy with ileostomy
* Proctocolectomy with ieal-anal pouch anastomosis
41
Approaches to surgery in Crohns disease?
* Resection of fistulae
* Total colectomy
* Avoid ileal-anal pouch formation due to recurrence risk
42
Describe the association between IBD and pregnancy?
* Active IBD impairs woman's ability to get pregnant
* Methotrexate should be stopped 3 months prior to conception
* Anti-TNF should be withheld in 3rd trimester due to placental transfer of antibody
