Inflammatory Bowel Disease Flashcards
What is the difference between Crohn’s and Ulcerative Colitis?
Crohn’s (crows NESTS)
N – No blood or mucus (less common)
E – Entire GI tract
S – “Skip lesions” on endoscopy
T – Terminal ileum most affected and Transmural (full thickness) inflammation
S – Smoking is a risk factor (don’t set the nest on fire)
Crohn’s is also associated with weight loss, strictures and fistulas.
Ulcerative Colitis (remember U – C – CLOSEUP)
C – Continuous inflammation
L – Limited to colon and rectum
O – Only superficial mucosa affected
S – Smoking is protective
E – Excrete blood and mucus
U – Use aminosalicylates
P – Primary Sclerosing Cholangitis
Clinical Features
Diarrhoea Abdominal pain Passing blood Weight loss Waking at night to pass stools (rarer)
Investigations
Routine bloods: FBC, U+Es, LFTs and CRP indicates inflammation and active disease
Faecal calprotectin (released by the intestines when inflamed) is a useful screening test (> 90% sensitive and specific to IBD in adults)
Endoscopy (OGD and colonoscopy) with biopsy is diagnostic
Imaging with ultrasound, CT and MRI can be used to look for complications such as fistulas, abscesses and strictures.
Management of Crohn’s
- Inducing Remission:
First line: Steroids (e.g. oral prednisolone or IV hydrocortisone)
If steroids alone don’t work, consider adding immunosuppressant medication under specialist guidance: Azathioprine Mercaptopurine Methotrexate Infliximab Adalimumab
- Maintaining Remission:
Tailored to individual patients based on risks, side effects, nature of the disease and patient’s wishes. It is reasonable not to take any medications whilst well.
First line:
Azathioprine
Mercaptopurine
Alternatives:
Methotrexate
Infliximab
Adalimumab
- Surgery:
When the disease only affects the distal ileum it is possible to surgically resect this area and prevent further flares of the disease but Crohns typically involves the entire GI tract
Surgery can also be used to treat strictures and fistulas secondary to Crohns disease.
Ulcerative Colitis
Management
- Inducing Remission
Mild to moderate disease =
First line: aminosalicylate (e.g. mesalazine oral or rectal)
Second line: corticosteroids (e.g. prednisolone)
Severe disease
First line: IV corticosteroids (e.g. hydrocortisone)
Second line: IV ciclosporin
- Maintaining Remission
Aminosalicylate (e.g. mesalazine oral or rectal)
Azathioprine
Mercaptopurine - Surgery:
Ulcerative colitis typically only affects the colon and rectum so remove the colon and rectum (panproctocolectomy) which leaves patient with:
i) permanent ileostomy or
ii) ileo-anal anastomosis (J-pouch): where the ileum is folded back in itself and fashioned into a larger pouch that functions a bit like a rectum and is then attached to the anus and collects stools prior to the person passing the motion.
(People with above surgery can be treated with metronidazole for pouch inflammation - side effects include peripheral neuropathy and caution with alcohol)
Primary Sclerosing Cholangitis
What is it?
Primary sclerosing cholangitis is a condition where the intrahepatic or extrahepatic ducts become strictured and fibrotic.
This causes an obstruction to the flow of bile out of the liver and into the intestines.
Sclerosis refers to the stiffening and hardening of the bile ducts, and cholangitis is inflammation of the bile ducts.
Chronic bile obstruction eventually leads to liver inflammation (hepatitis), fibrosis and cirrhosis.
Primary Sclerosing Cholangitis
Cause
The cause is mostly unclear although there is likely to be a combination of genetic, autoimmune, intestinal microbiome and environmental factors.
There is an established association with ULCERATIVE COLITIS with around 70% of cases being alongside established ulcerative colitis.
Primary Sclerosing Cholangitis
Risk factors
Male
Aged 30-40
Ulcerative Colitis
Family History
Primary Sclerosing Cholangitis
Clinical features
Jaundice Chronic right upper quadrant pain Pruritus Fatigue Hepatomegaly
Primary Sclerosing Cholangitis
Liver Function Test results
Liver function tests show a “cholestatic” picture = Alk Phos (alkaline phosphatase) is the most deranged LFT and may be the only abnormality at first.
+ there may be a rise in bilirubin as the strictures become more severe and prevents bilirubin from being excreted through the bile duct.
Other LFTs (i.e. transaminases: ALT and AST) can also be deranged, particularly as the disease progresses to hepatitis.
Primary Sclerosing Cholangitis
Autoantibodies
ANCA
Primary Sclerosing Cholangitis
Gold standard method of diagnosis
The gold standard investigation for diagnosis is an MRCP, which is short for magnetic resonance cholangiopancreatography, showing: multiple biliary strictures = BEADED appearance
This involves an MRI scan of the liver, bile ducts and pancreas.
Primary Sclerosing Cholangitis
Complications
Acute bacterial cholangitis CHOLANGIOCARCINOMA develops in 10-20% of cases Colorectal cancer Cirrhosis and liver failure Biliary strictures Fat soluble vitamin deficiencies
Primary Sclerosing Cholangitis
Management
- Liver transplant can be curative but is associated with its own problems (around 80% survival at 5 years).
- ERCP can be used to dilate and stent any strictures
- Ursodeoxycholic acid is used and may slow disease progression
- Colestyramine is a bile acid sequestrate in that it binds to bile acids to prevent absorption in the gut and can help with pruritus due to raised bile acids
- Monitoring for complications (such as cholangiocarcinoma, cirrhosis and oesophageal varices)
Inflammatory Bowel Disease
Extra-intestinal manifestations
Dermatological manifestations: ERYTHEMA NODUSUM (painful erythematous nodules/plaques on the shins), PYODERMA GANGRENOSUM (a well-defined ulcer with a purple overhanging edge).
Ocular manifestations: ANTERIOR UVEITIS (painful red eye with blurred vision and photophobia), EPISCLERITIS (painless red eye).
