Inflammatory bowel disease Flashcards
Describe ulcerative colitis?
- Relapsing, remitting inflammation of colonic mucosa
- Begins in rectum then spreads to the colon
- Cause:
- Inappropriate immune response against colonic flora
Pathology of UC?
- Inflammation confined to mucosa
- Psuedopolyps form in long standing pancolitis
- Inflammarion of lamina propria and crypts (cryptitis)
- Crypt abscesses
- Goblet cells lose their mucus
Major risk factor for UC?
UC is more common in smokers and ex-smokers
Name some symptoms of UC?
- Cardinal features:
- Rectal bleeding with mucus + bloody diarrhoea
- Extra-intestinal manifestations
- Malaise, anorexia, abdominal pain
Clinical signs of UC?
- Fever, tachycardia, tender abdo in severe UC
- Extraintestinal signs:
- Clubbing, aphthous oral ulcers, erythema nodosum
- Conjunctivitis, iritis, arthritis, sacroilitis
Describe some tests for UC?
- 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
How can UC be assessed in severity?
Truelove and Witts Criteria
Name some complications of UC?
- Acute
- Toxic dilatation of colon with perforation risk
- Venous thromboembolism
- Chronic
- Colonic cancer
Treatment for UC?
- 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
SEs of mesalazine (5-ASAs)?
- Rash
- Haemolysis
- Hepatitis
- Pancreatitis
Describe Crohn’s disease?
- Chronic inflammatory disesase:
- Transmural granulomatous inflammation
- Mouth to anus
- Skip lesions
- Inappropriate immune response against gut flora
Associations of Crohns?
- Smoking increases risk
- NSAIDs can exacerbate the disease
Symptoms of Crohns disease?
- Diarrhoea, abdo pain, weight loss
- Fatigue, fever, anorexia
- Ileal crohns disease can cause acute intestinal obstruction
Clinical signs of Crohns disease?
- Bowel ulcereation
- Abdominal tenderness
- Anal strictures
- Clubbing, skin, joint and eye problems
Complications of Crohns disease?
- Small bowel obstruction
- Toxic dilatiation (colonic diameter > 6cm)
- Abscess formation
- Perforation
- Colon cancer
Diagnostic tests for Crohns disease?
- FBC, ESR, CRP, U&E, LFT, INR, ferritin, TIBC, B12, folate
- Stool MC&S
- Faecal calprotectin (GI inflammation with high sensitivity)
- Colonoscopy + biopsy
Describe the treatment of Crohns disease?
- 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
Describe the use of Anti-TNFa in Crohns disease?
- Infliximab/adalimumab
- Counter neutrophil accumulation and granuloma formation
- Cause cytotoxicity to CD4+ T cells
- CI: sepsis, TB
- SEs: rash, elevated LFTs
Name some inflammatory mediators in IBD?
- TNF-α
- IL-12
- IL-23
What are the different patterns of UC?
- Proctitis
- Left-sided colitis
- Extensive colitis (up to pancolitis)
What are the different patterns of Crohns disease?
- Ileal or ileocolonic
- Small intestinal
- Crohns colitis
- Perianal disease alone
Describe the histology of UC?
- Surface ulceration and inflammation confined to mucosa
- Excess inflammatory cells in lamina propria, loss of goblet cells and crypt abscesses
Describe the histology of Crohns disease?
- Inflammation is transmural
- Inflammation extends into submucosa
- Non-caseating granulomas
What is the Truelove-Witts criteria for acute severe ulcerative colitis?
- 6 or more bloody stools in the last 24 hours
- Plus one or more of:
- Fever
- Anaemia
- Tachycardia
- High inflammatory markers
Name some differentials for IBD?
- Salmonella, Shigella, Campylobacter, E. coli
- HSV, CMV
- Ischaemic colitis, collagenous colitis, colon cancer
What are the complications of IBD?
- Severe inflammation => toxic megacolon
- Haemorrhage
- Fistulae
- Cancer
- Extra-intestinal complications
What is pictured in this AXR?
- UC
- Thumbprinting
- Bowel wall thickening of the haustral folds
What is the abnormality pictured here?
- UC
- Mucosal islands
- Presence of pseudopolyps
What is the abnormality pictured here?
- UC
- Toxic megacolon
- Dilated colon with mucosal islands
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
Name the extraintestinal complications of IBD
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
Treatment of Active proctitis UC?
- Mesalazine (suppository/oral)
- Glucocorticoids
- Stool softener
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
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
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
- Thiopurines
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
Describe the maintenance of remission in Crohns disease?
- Immunosuppression with thipurines
- Azathioprine and mercaptopurine
- Methotrexate can also be used
- Smoking cessation counselling
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
Surgical approaches to UC?
- Panproctocolectomy with ileostomy
- Proctocolectomy with ieal-anal pouch anastomosis
Approaches to surgery in Crohns disease?
- Resection of fistulae
- Total colectomy
- Avoid ileal-anal pouch formation due to recurrence risk
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
