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Gastrointestinal 2 > Inflammatory Bowel Disease > Flashcards

Inflammatory Bowel Disease Flashcards

1
Q

Crohn’s Disease

A

Inflammatory bowel disease that causes inflammation and tissue destruction throughout the gastrointestinal tract (from mouth to anus).

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2
Q

What is the pathology of Crohn’s disease?

A

Considered to be immune related - triggered by a pathogen such as mycobacterium paratuberculosis, pseudomonas or listeria.

There is an immune response to these pathogens however the inflammatory response is large and uncontrolled, leading to destruction of cells in the gastrointestinal tract.

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3
Q

What is thought to cause Crohn’s disease?

A

Genetics - specifically mutation to the NOD2 gene.

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4
Q

What form in the deep mucosal layer of the bowel in someone with Crohn’s disease?
- what does this lead to.

A

Granuloma’s - collections of immune cells. This leads to continued inflammation and destruction of tissue, which can result in the formation of ulcers in the intestinal wall.

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5
Q

How do ulcers in Crohn’s disease differ to ulcers in ulcerative colitis?

A

In ulcerative colitis ulcer’s usually only extend through into the mucosa and submucosa. However in Crohn’s disease ulcers extend through the muscular and serosa layers aswell through the whole intestinal wall.

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6
Q

How the pattern of inflammation differ between Crohn’s disease and ulcerative collitis?

A

Inflammation in Crohn’s disease is scattered (inflamed tissue is interspersed with normal tissue).

Inflammation in ulcerative colitis is circumferential and continuous.

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7
Q

What is symptomatic of Crohn’s disease?

A

Pain in affected areas - specifically in the right iliac region - associated with the ilium.
Diarrhoea and blood in the stool.
Malnutrition.

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8
Q

What is the cause of the diarrhoea and blood in the stool in Crohn’s disease?

A

The blood is from damaged intestinal wall tissue and if the cells in the large intestine are damaged they lose their ability to absorb water - this leads to more water being excreted causing diarrhoea.

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9
Q

What is the treatment for Crohn’s disease?

A

Anti-inflammatory’s
Antibiotics - to control gut bacteria
Immunosupressant drugs in the form of corticosteroids.

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10
Q

Where does ulcerative colitis affect?

A

The large intestine only.

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11
Q

Ulcerative colitis

A

An inflammatory bowel disease that leads to the formation of ulcers along the large intestine.

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12
Q

Ulcerative colitis forms ulcers where specifically?

A

In the MUCOSA and SUBMUCOSA of the large intestine.

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13
Q

What is thought to be the origin of ulcerative colitis?

A

Autoimmune cause

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14
Q

What are the symptoms of ulcerative colitis?

A

Pain in the left lower quadrant.

Diarrhoea with blood - due to damage to the large intestine tissue (same as Crohn’s).

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15
Q

How is ulcerative colitis diagnosed?

A 
Colonoscopy - see ulcers and take a biopsy.
CT scan
Barium enema
X-ray
MRI

Used to look for abnormalities in the intestines.

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16
Q

What is the treatment for ulcerative colitis?

A

Anti-inflammatory’s
Immunosupressants
Colectomy

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17
Q

Diverticular disease

A

Diverticular disease is the general name for a common condition that causes small bulges (diverticula) or sacs to form in the wall of the large intestine.

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18
Q

Where do diverticula most commonly form?

A

Sigmoid colon

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19
Q

What is meant by true and pseudo diverticula?

A

True diverticula involve all layers of the colon, where as in pseudo diverticula the muscle layer is not included.
The mucosa and submucosa are only covered by serosa.

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20
Q

How are diverticula in the small intestine thought to form?

A

Diverticula are thought to form due to high pressure in the large intestine which push on the walls causing them to bubble out creating these sacs.
- thought to be due to abnormal exaggerated contractions of the smooth muscle of the large intestine.

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21
Q

What is Laplace’s law?

- what is the relevance of this regarding diverticula formation?

A

The pressure on the wall of a cylinder is proportional to the inverse of it’s diameter.
- as the sigmoid colon has the smallest diameter in the large intestine it’s subject to higher pressures - hence this is where most diverticula form.

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22
Q

Hematochezia

A

Rectal bleeding - blood in the stool.

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23
Q

What are risk factors that can increase the risk of diverticula formation?

A
  1. Low fibre diet
  2. Fatty foods and red meat
  3. Marfan syndrome and Ehler Danlos (affect connective tissue).
24
Q

Diverticulosis

- what are the symptoms?

A

Diverticulosis just means having diverticulum.

Usually no symptoms.
Sometimes stomach pain / bleeding.

25
Q

Diverticulitis

A

Inflammation of the diverticula

26
Q

What causes diverticulitis?

A

Diverticulitis occurs when faeces obstruct the neck of the diverticulum, causing stagnation and allowing bacteria to multiply and produce inflammation.

Erosion of the diverticular wall due to high pressures.

27
Q

What are the symptoms of diverticulitis?

A

Pain in the lower left quadrant.

Not associated with bleeding as the blood vessels become scarred from inflammation.

28
Q

What complications may the be with diverticulitis?

A

This can then lead to bowel perforation (peridiverticulitis), abscess formation, fistulae into adjacent organs, haemorrhage and even generalised peritonitis.

Formation of a fistula.

29
Q

Fistula

A

Connection with an adjacent organ / structure.

30
Q

Colovesicular fistula

A

Fistula connecting the large intestine and bladder.

31
Q

What symptoms may be seen due to a colovesicular fistula?

A

Air or stool in the urine.

32
Q

What is the treatment for diverticulitis?

A

Antibiotics
High fibre diet
Surgery to remove affected areas.

33
Q

Where is the appendix attach?

A

Worm shaped structure attached to the end of the cecum.

34
Q

What is the most common cause of appendicitis?

A

Obstruction - commonly due to a faecolith.

35
Q

What are general causes of appendicitis?

A

Obstruction - e.g due to faecolith / undigested seeds.
Pinworm infection.
Lymphoid follicle growth.

36
Q

What are symptoms of appendicitis?

A

Right lower quadrant pain - at McBurney’s point
Fever
Nausea
Vomitting

37
Q

Rebound tenderness and abdominal guarding are suggestive of what?

A

Perforation of the appendix and subsequent infection of the peritoneum.

38
Q

What is the most common complication with a ruptured appendix?

A

Pus and fluid getting out and forming an abscess around the appendix.
- known as a periappendiceal abscess.

39
Q

How is appendicitis treated?

A

Appendectomy followed by antibiotics.

Any abscesses drained.

40
Q

What is the pathology of appendicitis?

A
  1. Obstruction due to faecolith.
  2. Bacterial multiplication takes place, mucus is secreted by lumen of the appendix, causing increased pressure and swelling.
  3. Blood supply is often then compromised as a result.
41
Q

Why do patients with IBD have an increased risk of developing gastrointestinal cancers?

A

In patients with IBD, chronic intestinal inflammation is the primary risk factor for the development of gastrointestinal malignancy.

42
Q

What cancers are commonly formed due to chronic intestinal inflammation in IBD’s?

A

Cancers as a result of chronic intestinal inflammation include CRC, small bowel adenocarcinoma, intestinal lymphoma, anal cancer, and cholangiocarcinoma.

43
Q

Features specific to Crohns (crows NEST)

A

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

Crohn’s is also associated with weight loss, strictures and fistulas.

44
Q

Features specific to Ulcerative Colitis (remember U – C – CLOSEUP)

A

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 & pseudopolyps

45
Q

Investigations for IBD

A

Routine bloods for anaemia, infection, thyroid, kidney and liver function.
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.

46
Q

What is used to induce remission in Crohn’s?

A

First line: Steroids (e.g. oral prednisolone or IV hydrocortisone).

47
Q

How is remission maintained in Crohn’s?

A

First line:
Azathioprine
Mercaptopurine

48
Q

Summary of surgery as a treatment for Croh’ns?

A

When the disease only affects the distal ileum it is possible to surgically resect this area and prevent further flares of the disease. Crohns typically involves the entire GI tract

Surgery can also be used to treat strictures and fistulas secondary to Crohns disease.

49
Q

What is used to induce remission in mild to moderate flare ups of UC?

A

First line: aminosalicylate (e.g. mesalazine oral or rectal)

Second line: corticosteroids (e.g. prednisolone)

50
Q

What is used to manage severe flare ups of UC?

A

First line: IV corticosteroids (e.g. hydrocortisone)

Second line: IV ciclosporin

51
Q

What is used to maintain remission in UC?

A

Aminosalicylate (e.g. mesalazine oral or rectal)
Azathioprine
Mercaptopurine

52
Q

Use of surgery to manage UC:

A

Ulcerative colitis typically only affects the colon and rectum. Therefore, removing the colon and rectum (panproctocolectomy) will remove the disease. The patient is then left with either a permanent ileostomy or something called an ileo-anal anastomosis (J-pouch). This is where the ileum is folded back in itself and fashioned into a larger pouch that functions a bit like a rectum. This “J-pouch” which is then attached to the anus and collects stools prior to the person passing the motion.

53
Q

Symptoms highly suggestive of IBS:

A

Abdominal pain / discomfort:

Relieved on opening bowels, or
Associated with a change in bowel habit
AND 2 of:

Abnormal stool passage
Bloating
Worse symptoms after eating
PR mucus

54
Q

In suspected IBS what investigations should be carried out in order to exclude other pathology?

A

Normal FBC, ESR and CRP blood tests
Faecal calprotectin negative to exclude inflammatory bowel disease
Negative coeliac disease serology (anti-TTG antibodies)
Cancer is not suspected or excluded if suspected

55
Q

IBS Management:

A

Reassurance
Adequate fluid intake
Regular small meals
Reduced processed foods
Limit caffeine and alcohol
Low “FODMAP” diet (ideally with dietician guidance)
Trial of probiotic supplements for 4 weeks

56
Q

What medications are used to manage IBS?

A

Loperamide for diarrhoea
Laxatives for constipation. Avoid lactulose as it can cause bloating. Linaclotide is a specialist laxative for patients with IBS not responding to first-line laxatives
Antispasmodics for cramps e.g. hyoscine butylbromide (Buscopan)

CBT and antidepressants second line.

Gastrointestinal 2 (24 decks)

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