Inflammatory Bowel Disease Flashcards
What is IBD [2]
Strong immune response against normal bacterial flora Unknown trigger - bacteria / virus / stress
What is ulcerative colitis [4]
Continuous inflammation and ulceration of rectum (proctitis) and colon (colitis) Localised in rectum and spreads proximally Never goes past ileocaecal valve Relapsing + remitting
Who is affected by UC [2]
F>M Peak at 20 + 50
What are the symptoms of UC [8]
Name 7 systemic symptoms
Describe relationship of symptom severity and extent of disease
- Bloody diarrhea
- Rectal bleeding
- Tenesmus suggests proctitis
- Fecal urgency
- Passage of mucus
- Cramping abdo pain LLQ
- Extra-intestinal bleeding
- Nausea and vomiting
- Systemic symptoms in attack - fever, malaise, anorexia. tachycardia
- Weight loss, Fatigue, Anaemia
- Dehydration, Malabsorption
- The severity of symptoms correlates with the extent of disease
Morphology in UC
Microscopic features [4] Macroscopic features [1] Pattern [2]
Microscopic
- Limited to mucosa and submucosa
- Crypt abscess
- Ulceration
- Goblet cell depletion
- Non caseating granuloma
Macroscopic:
- Pseudopolyps
Pattern:
- Starts in rectum and extends proximally
- Continuous lesion
What are the complications of IBD [6]
What are 3 complications outwith of the GI system?
Hypoalbuminemia
Colon cancer
Haemorrhage = anaemia
Electrolyte disturbances
Toxic dilatation with risk of perforation + peritonitis
Strictures / obstruction = unlikely (more common malignancy)
Spondyloarthropathy
Fatty liver
Cholangiocarcinoma
What are the differences between fulminating [3] and chronic UC [2]?
Fulminating
- >10 bowel movements in 24h
- Fever, tachycardia
- Continuous bleeding, anaemia, hypoalbuminemia, abdominal distention (toxic megacolon)
Chronic type
- Initial attack of mod severity then recurrent exacerbations
- Anaemic
- Malnourished
What are extra intestinal manifestations of UC
(MSK 3/ occular 4/ skin 2/ hepatobiliary 5 / other 6)
MSK
- think if back pain / check Vit D / ALP
- Arthritis = common
- Osteoporosis
- AS / sacroilitis
Occular
- Uveitis - common UC
- Episcleritis - common CD
- Conjunctivitis
- Sjogren’s
Skin
- Erythema nodosum
- Pyoderma gangrenous mouth
Hepatobiliary
- Fatty liver
- Cirrhosis
- Cholangiocarcinoma
- Gall stone
- PSC = UC
Other
- Mouth ulcers
- VTE
- Amyloidosis
- Myocarditis
- Vasculitis
- Clubbing
What are the differentials for UC [5]
Chronic diarrhoea
Ileus caecal
TB - Rx will worsen, Cambylobacter colitis / Salmonella Diverticulitis
Lymphoma
NSAID colitis - reduced prostaglandin = increased acid
What is Crohn’s [2]
Patchy granulomatous inflammation from mouth to anus Relapsing remitting
What does Crohn’s present like
Chronic with exacerbations
What are the symptoms of Crohn’s? What condition can Crohn’s mimic on presentation?
Symptoms
- Diarrhea/urgency +/- blood, N+V
- Abdominal pain - colicky
- Weight loss/FTT
- Fever, malaise, anorexia, anaemia
Signs - Apthous ulcerations
- Abdominal tenderness/mass, RIF
- Perianal abscess
- Fistula/skin tags
- Anal strictures
- Malnourished
- Extra-intestinal manifestations
Oral disease - orofacial granulomatosis
Malabsorption
Mouth ulcers / skin tags / anal stricutres/ fistula
Can present mimicking appendicitis
Morphology of Crohn’s Findings on endoscopy [7] Findings on histology [3]
Endoscopy
- Skip lesion
- Cobble stone appearance
- FIbrosis > Pseudopolyp
- Fistula, Ulcer
- Stricture, Adhesions
- Proximal dilatation
- Creeping fat
Histology
- Non-caseating Granuloma
- Whole thickness mucosa inflammation so more prone to fistula etc
- Goblet cell hyperplasia, crypt abscess
What are the complications of Crohn’s [8]
Extra-intestinal manifestations [5]
- Malabsorption, osteomalacia
- Strictures
- Small bowel obstruction
- Fissures leading to fistula
- Abscess formation
- Perforation
- Colon cancer
- Rectal hemorrhage
Extra-intestinal manifestations:
- Clubbing
- Erythema
- Gall stones, oxalate renal stone
- Cholangiocarcinoma - Spondyloarthropathy
What mimics Crohn’s [2]
Nicorandil (angina) toxicity NSAID can worsen as increase acid
How do you investigate IBD Lab workup [5] Imaging [4]
FBC (+ Ferritin, TIBC, B12, folate) CRP, ESR U&E, LFT, clotting
Stool culture neg, qFIT (blood)
Calprotectin (raised)
Imaging:
- Endoscopy/colonoscopy/ wireless capsules
- Barium follow through (string sign of Kantor)
- Small bowel MRI (avoids radiation)
- CT
What do you look for in the bloods [3]
Increased platelet
Increased WCC
Low serum albumin is related to a catabolic state and is a feature of severe disease.
Anemic changes
What does calproctectin test show [3]
<50 = normal
50-200 = no active inflammation but IBD
>200 = active inflammation
Montreal classification Crohn’s [3] UC [2]
Crohns
- Age
- Behaviour
- Location
UC
- Extent - Severity
How do you treat IBD to maintain remission
5ASA
- monitor FBC + U+Es
Anti-inflammatory
Steroids
Immunosuppression
Biologics - if others don’t work
Surgery
What is as effective as steroids in children
Elemental feeding comprised of easily digestible formulas that come in liquid or powder form and provide all the nutrients your body needs.
When do you do surgery [2]
If still severe after steroids, biologics and immunosuppression
Max therapy / prolonged steroid
Effecting growth / puberty in child
What should you consider in Crohns if persistent abdominal pain? Presentation of Crohn’s can mimic…
Abdominal sepsis
Acute abdomen mimicking appendicitis
How do you manage severe attack and what is 1st line treatment [4]
Admit for IV hydration
IV steroids = 1st line IV ciclosporin if steroid CI
Thromboembolism prophylaxis
Biologics if all else fails Early surgeons
What biologics in IBD
Anti-TNF (Infliximab) If levels are therapeutic but stop working = diff mode of inflammation started rather than Ab
Why is it best to avoid steroids in children [3]
Growth
Adrenal
Infection
What is used to decrease need for steroid
Immune modulation - used for remission
Azahioprine / methotrexate / cyclosporin
Allopurinol + azathioprine (blocks XO which metabolises azatho so increases dose)
What are SE of immunosuppression [3]
Nausea
LFT Affects renal
Cyclosporin >steroids but need kidney function
What can’t you use in UC
Methotrexate
What is 1st line in Ulcerative colitis to induce remission [4]
Maintenance of remission [3]
When would you prescribe low maintenance dose? [2]
- If proctitis
- topical aminosalicylate
- Oral aminosalicylate if remission not achieved within 4w
- belcometasone propionate
- Oral CCS
Maintain remission:
- Topical aminosalicylate
- Topical + oral aminosalicylate
- Oral aminosalicylate alone
- Low maintenance dose of oral aminosalicylate if left-sided UC and extensive disease
What do you have to monitor with 5ASA [3]
FBC + U+E + trough level
Management for severe flareups in UC
Immediate management [2]
Monitoring [4]
No response after 3d [2]
Admit for NBM, IV fluids IV hydrocortisone (cyclosporin if CI)
Monitor: BP pulse, temp monitoring, BD abdo exam, daily blood
No response after 3d: Rescue therapy = cyclosporin or infliximab Colectomy
When do you do emergency surgery [2]
Acutely ill
Failure to respond to medical tx
Toxic dilatation / perforation - if no dramatic response to medical tx in 48h, then do surgery (cannot wait too long, unfit for surgery)
What other imaging options [3]
Abdo X-Ray = distention
CXR = free air if perforation or
AS Barium enema = loss of haustra
Rationale for surveillance in IBD? How is it carried out
Colonoscopy to reduce risk of bowel cancer Esp if PSC (primary sclerosis cholangitis)
Takes 4 random biopsies as intraepithelial neoplasia can occur in flat lesions
What type of anaemia [2]
Normochromic normocytic Iron or folate
What is an option for imaging small bowel in Crohn’s (gold standard now)
MR enterography or small bowel MRI
When would you need transvaginal ISS
Fistula
What investigation would be most helpful in dx in acute presentation?
CT
What is diversion colitis
After stoma Distal bowel = no bacteria Causes colitis
When can’t you anastomose
Above a stricture
So if Crohn’s = anal stricture have to take out colon as anastomoses would burst
What is radiation proctitis
After RT
What treatment for radiation proctitis
Transfusion if needed Argon phototherapy Hyperbaric oxygen Sulcrafate enema
What do you do for perforation
Stoma
What do you do for abscess
Ax USS / CT guided drainage
What do you do for fistula
Surgery
What are signs of perforation
Peritonitis SHock Ileus
What do mild and moderate attacks have
Increased stool frequency
No systemic disturbance
Mild <4 stool
Mod 4-6
What are strictures more likely to be in ulcerative colitis
Malignancy
What is tenesmus
Painful feeling of inability to evacuate bowel
What is toxic megacolon [3]
Loss of haustration Transverse or right colon with a diameter of >6 cm Mucosal edema
How do you deal with toxic megacolon
Medical therapy
Urgent colectomy if doesn’t resolve
What surgery for UC [2] Options following recovery from emergency surgery [2]
Total Colectomy, ileostomy & Closure of the rectal stump
OR Total Colectomy, ileostomy & rectosigmoid mucous fistula
Options following recovery from emergency surgery
- Excision of the rectum and the patient is left with permanent ileostomy
- OR Formation of ileal pouch
Indications [2] and contraindications [2] of ileal pouch
What is important to communicate in counseling of patient going for ileal pouch?
Indications
- Ulcerative colitis
- Familial adenomatous polyposis
Contraindications
- Crohn’s disease
- Significant anal incontinence
Counseling:
- 4-5x bowel movements, 1-2x night time, light incontinence (mucous, fluid stool consistency), sexual dysfunction
- retrograde ejaculation, risk of infertility (pelvic adhesions)
Complications of surgery [5]
General
Splenc injury
Anastomotic injury
Intra-abdominal abscess
Poor function / failure of pouch
What is another type of colitis not related to IBD that can cause flares
Lymphocytic colitis
What is main am of IBD Rx [2]
Induce remission
Maintain remission
How do you induce remission in proctitis / L sided colitis [3]
Topical 5ASA
Oral if no improvement after 4 weeks
Add topical or oral steroid if no improvement
How do you induce remission in extensive disease [2]
Topical + oral 5ASA Steroid if no improvement
What if severe attack
Hospital for IV
How do you maintain remission
Topical 5ASA / oral
What do you do if severe attack or >2 exacerbations
Add azathioprine
Signs: UC What are two severity indexes used to assess patients
Truelove and Witt’s severity index
Protective factors for UC vs risk factors of Crohns
Protective factors:
- smoking
- appendectomy for acute appendicitis before 20yo
Risk factors:
- Smoking worsens condition
Sulfasalazine SE [5] Mesalazine SE [5]
Sulfasalazine
- Headache, anorexia,
- Nausea, rashes
- Oligospermia
- Heinz body anaemia, megaloblastic anaemia
- Lung fibrosis
Mesalazine
- GI upset
- Headache
- Agranulocytosis
- Pancreatitis
- Interstitial nephritis
Maintenance of remission UC [3]
- 5-ASA
- Immunotherapy:
- Azathioprine
- Mercaptopurine
- Infliximab
- Topical mesalazine or steroid (suppository)
Crohns management Induction of remission [3]
How to manage severe cases [5]
- Oral prednisolone if symptomatic, systemically well
- Metronidazole
- isolated perianal disease
- TNF alpha + azathioprine/methotrexate if refractory/fistulating
Admit for NBM, IV fluids
IV hydrocortisone +/- azathioprine or mercaptopurine or methotrexate
Surgical management of Crohns (needed by 80% of pts w/ small bowel Crohn’s)
- Indications?
- Type of interventions [4]
Indications: ONLY on onset of complications (strictures, fistula, abscess, intestinal obstruction)
Abscess drainage: can cause fistula
Excisional surgery: resection of affected bowel segment with end to end anastomosis
Strictureplasty: for multiple relatively short strictures
Bypass surgery: for duodenal disease
Describe 4 types of acute presentations of Ulcerative Colitis
Proctosigmoiditis
Left-sided colitis
Pancolitis
Backwash ileitis
Montreal classification for Crohns:
Age [3]
Location [4]
Behaviour [3]
Montreal classification for UC
Extent [3]
Severity [4]
Microscopic colitis
Microscopic colitis is a syndrome of chronic watery diarrhoea with characteristic histological features. It occurs more frequently in middle-aged women. The diagnosis is made with colonic biopsies; macroscopic appearances at endoscopy are normal.
Clinical presentation
* Non-bloody diarrhoea, which can be frequent (>5 times per day). * Abdominal cramping.
* Weight loss, likely due to significant fluid losses.
Investigations
* Colonoscopy with mucosal biopsies. Treatment
* Medications such as NSAIDS, ranitidine, PPIs and selective serotonin re-uptake inhibitors are associated with microscopic colitis and should be avoided.
* First-line treatment in patients that do not respond to standard anti-diarrhoeal agents is budesonide ().
