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Y4: Gastroenterology > Inflammatory bowel disease > Flashcards

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
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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
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3
Q

Major risk factor for UC?

A

UC is more common in smokers and ex-smokers

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4
Q

Name some symptoms of UC?

A
  • Cardinal features:
    • Rectal bleeding with mucus + bloody diarrhoea
  • Extra-intestinal manifestations
  • Malaise, anorexia, abdominal pain
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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
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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
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7
Q

How can UC be assessed in severity?

A

Truelove and Witts Criteria

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8
Q

Name some complications of UC?

A
  • Acute
    • Toxic dilatation of colon with perforation risk
    • Venous thromboembolism
  • Chronic
    • Colonic cancer
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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
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10
Q

SEs of mesalazine (5-ASAs)?

A
  • Rash
  • Haemolysis
  • Hepatitis
  • Pancreatitis
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11
Q

Describe Crohn’s disease?

A
  • Chronic inflammatory disesase:
    • Transmural granulomatous inflammation
    • Mouth to anus
    • Skip lesions
  • Inappropriate immune response against gut flora
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12
Q

Associations of Crohns?

A
  • Smoking increases risk
  • NSAIDs can exacerbate the disease
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13
Q

Symptoms of Crohns disease?

A
  • Diarrhoea, abdo pain, weight loss
  • Fatigue, fever, anorexia
  • Ileal crohns disease can cause acute intestinal obstruction
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14
Q

Clinical signs of Crohns disease?

A
  • Bowel ulcereation
  • Abdominal tenderness
  • Anal strictures
  • Clubbing, skin, joint and eye problems
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15
Q

Complications of Crohns disease?

A
  • Small bowel obstruction
  • Toxic dilatiation (colonic diameter > 6cm)
  • Abscess formation
  • Perforation
  • Colon cancer
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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
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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
Q

Name some differentials for IBD?

A
  • Salmonella, Shigella, Campylobacter, E. coli
  • HSV, CMV
  • Ischaemic colitis, collagenous colitis, colon cancer
26
Q

What are the complications of IBD?

A
  • Severe inflammation => toxic megacolon
  • Haemorrhage
  • Fistulae
  • Cancer
  • Extra-intestinal complications
27
Q

What is pictured in this AXR?

A
  • UC
    • Thumbprinting
    • Bowel wall thickening of the haustral folds
28
Q

What is the abnormality pictured here?

A
  • UC
    • Mucosal islands
    • Presence of pseudopolyps
29
Q

What is the abnormality pictured here?

A
  • UC
    • Toxic megacolon
    • Dilated colon with mucosal islands
30
Q

What blood test can be used to distinguish IBD from IBS?

A
  • Faecal calprotectin
    • Very sensitive for gastrointestinal inflammation
    • Can be raised even when CRP is normal
31
Q

Name the extraintestinal complications of IBD

A
32
Q

What are the key aims of medical therapy in IBD?

A
  • Treat acute attacks (induce remission)
  • Prevent relapses (maintain remission)
  • Prevent bowel damage
  • Detect dysplasia and prevent carcinoma
  • Select appropriate patients for surgery
33
Q

Treatment of Active proctitis UC?

A
  • Mesalazine (suppository/oral)
  • Glucocorticoids
  • Stool softener
34
Q

Treatment for Active left sided or extensive UC?

A
  • Combination of oral and topical 5-ASA
    • Top and tail approach
  • Prednisolone
    • Calcium and vitamin D supplementation for bone protection
35
Q

Management of severe UC?

A
  • 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
Q

Describe the maintenance of remission in UC?

A
  • 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
Q

Describe the induction of remission in Crohns disease?

A
  • Glucocorticoids
    • Budesonide, if no response, prednisolone
    • Calcium and vitamin D supplementation
  • If no response:
    • Infliximab or Adalimumab
38
Q

Describe the maintenance of remission in Crohns disease?

A
  • Immunosuppression with thipurines
    • Azathioprine and mercaptopurine
  • Methotrexate can also be used
  • Smoking cessation counselling
39
Q

Indications for surgery in UC?

A
  • Impaired QoL
    • Loss of job or education
    • Disrupted family life
  • Failure of medical therapy
  • Fulminant colitis
  • Colon cancer or severe dysplasia
40
Q

Surgical approaches to UC?

A
  • Panproctocolectomy with ileostomy
  • Proctocolectomy with ieal-anal pouch anastomosis
41
Q

Approaches to surgery in Crohns disease?

A
  • Resection of fistulae
  • Total colectomy
  • Avoid ileal-anal pouch formation due to recurrence risk
42
Q

Describe the association between IBD and pregnancy?

A
  • 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

Y4: Gastroenterology (14 decks)

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