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Inflammatory Bowel Disease Flashcards

1
Q

What is IBD [2]

A

Strong immune response against normal bacterial flora Unknown trigger - bacteria / virus / stress

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2
Q

What is ulcerative colitis [4]

A

Continuous inflammation and ulceration of rectum (proctitis) and colon (colitis) Localised in rectum and spreads proximally Never goes past ileocaecal valve Relapsing + remitting

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3
Q

Who is affected by UC [2]

A

F>M Peak at 20 + 50

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4
Q

What are the symptoms of UC [8]

Name 7 systemic symptoms

Describe relationship of symptom severity and extent of disease

A
  • 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
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5
Q

Morphology in UC

Microscopic features [4] Macroscopic features [1] Pattern [2]

A

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
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6
Q

What are the complications of IBD [6]

What are 3 complications outwith of the GI system?

A

Hypoalbuminemia

Colon cancer

Haemorrhage = anaemia

Electrolyte disturbances

Toxic dilatation with risk of perforation + peritonitis

Strictures / obstruction = unlikely (more common malignancy)

Spondyloarthropathy

Fatty liver

Cholangiocarcinoma

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7
Q

What are the differences between fulminating [3] and chronic UC [2]?

A

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
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8
Q

What are extra intestinal manifestations of UC

(MSK 3/ occular 4/ skin 2/ hepatobiliary 5 / other 6)

A

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
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9
Q

What are the differentials for UC [5]

A

Chronic diarrhoea

Ileus caecal

TB - Rx will worsen, Cambylobacter colitis / Salmonella Diverticulitis

Lymphoma

NSAID colitis - reduced prostaglandin = increased acid

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10
Q

What is Crohn’s [2]

A

Patchy granulomatous inflammation from mouth to anus Relapsing remitting

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11
Q

What does Crohn’s present like

A

Chronic with exacerbations

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12
Q

What are the symptoms of Crohn’s? What condition can Crohn’s mimic on presentation?

A

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

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13
Q

Morphology of Crohn’s Findings on endoscopy [7] Findings on histology [3]

A

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
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14
Q

What are the complications of Crohn’s [8]

Extra-intestinal manifestations [5]

A
  • 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
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15
Q

What mimics Crohn’s [2]

A

Nicorandil (angina) toxicity NSAID can worsen as increase acid

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16
Q

How do you investigate IBD Lab workup [5] Imaging [4]

A

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
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17
Q

What do you look for in the bloods [3]

A

Increased platelet

Increased WCC

Low serum albumin is related to a catabolic state and is a feature of severe disease.

Anemic changes

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18
Q

What does calproctectin test show [3]

A

<50 = normal

50-200 = no active inflammation but IBD

>200 = active inflammation

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19
Q

Montreal classification Crohn’s [3] UC [2]

A

Crohns

  • Age
  • Behaviour
  • Location

UC

  • Extent - Severity
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20
Q

How do you treat IBD to maintain remission

A

5ASA

  • monitor FBC + U+Es

Anti-inflammatory

Steroids

Immunosuppression

Biologics - if others don’t work

Surgery

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21
Q

What is as effective as steroids in children

A

Elemental feeding comprised of easily digestible formulas that come in liquid or powder form and provide all the nutrients your body needs.

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22
Q

When do you do surgery [2]

A

If still severe after steroids, biologics and immunosuppression

Max therapy / prolonged steroid

Effecting growth / puberty in child

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23
Q

What should you consider in Crohns if persistent abdominal pain? Presentation of Crohn’s can mimic…

A

Abdominal sepsis

Acute abdomen mimicking appendicitis

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24
Q

How do you manage severe attack and what is 1st line treatment [4]

A

Admit for IV hydration

IV steroids = 1st line IV ciclosporin if steroid CI

Thromboembolism prophylaxis

Biologics if all else fails Early surgeons

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25
What biologics in IBD
Anti-TNF (Infliximab) If levels are therapeutic but stop working = diff mode of inflammation started rather than Ab
26
Why is it best to avoid steroids in children [3]
Growth Adrenal Infection
27
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)
28
What are SE of immunosuppression [3]
Nausea LFT Affects renal Cyclosporin \>steroids but need kidney function
29
What can't you use in UC
Methotrexate
30
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
31
What do you have to monitor with 5ASA [3]
FBC + U+E + trough level
32
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
33
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)
34
What other imaging options [3]
Abdo X-Ray = distention CXR = free air if perforation or AS Barium enema = loss of haustra
35
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
36
What type of anaemia [2]
Normochromic normocytic Iron or folate
37
What is an option for imaging small bowel in Crohn's (gold standard now)
MR enterography or small bowel MRI
38
When would you need transvaginal ISS
Fistula
39
What investigation would be most helpful in dx in acute presentation?
CT
40
What is diversion colitis
After stoma Distal bowel = no bacteria Causes colitis
41
When can't you anastomose
Above a stricture So if Crohn's = anal stricture have to take out colon as anastomoses would burst
42
What is radiation proctitis
After RT
43
What treatment for radiation proctitis
Transfusion if needed Argon phototherapy Hyperbaric oxygen Sulcrafate enema
44
What do you do for perforation
Stoma
45
What do you do for abscess
Ax USS / CT guided drainage
46
What do you do for fistula
Surgery
47
What are signs of perforation
Peritonitis SHock Ileus
48
What do mild and moderate attacks have
Increased stool frequency No systemic disturbance Mild \<4 stool Mod 4-6
49
What are strictures more likely to be in ulcerative colitis
Malignancy
50
What is tenesmus
Painful feeling of inability to evacuate bowel
51
What is toxic megacolon [3]
Loss of haustration Transverse or right colon with a diameter of \>6 cm Mucosal edema
52
How do you deal with toxic megacolon
Medical therapy Urgent colectomy if doesn't resolve
53
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
54
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)
55
Complications of surgery [5]
General Splenc injury Anastomotic injury Intra-abdominal abscess Poor function / failure of pouch
56
What is another type of colitis not related to IBD that can cause flares
Lymphocytic colitis
57
What is main am of IBD Rx [2]
Induce remission Maintain remission
58
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
59
How do you induce remission in extensive disease [2]
Topical + oral 5ASA Steroid if no improvement
60
What if severe attack
Hospital for IV
61
How do you maintain remission
Topical 5ASA / oral
62
What do you do if severe attack or \>2 exacerbations
Add azathioprine
63
Signs: UC What are two severity indexes used to assess patients
Truelove and Witt's severity index
64
Protective factors for UC vs risk factors of Crohns
Protective factors: - smoking - appendectomy for acute appendicitis before 20yo Risk factors: - Smoking worsens condition
65
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
66
Maintenance of remission UC [3]
1. 5-ASA 2. Immunotherapy: * Azathioprine * Mercaptopurine * Infliximab 3. Topical mesalazine or steroid (suppository)
67
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
68
Surgical management of Crohns (needed by 80% of pts w/ small bowel Crohn's) 1. Indications? 2. 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
69
Describe 4 types of acute presentations of Ulcerative Colitis
Proctosigmoiditis Left-sided colitis Pancolitis Backwash ileitis
70
Montreal classification for Crohns: Age [3] Location [4] Behaviour [3]
71
Montreal classification for UC Extent [3] Severity [4]
72
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 ().

Gastro (17 decks)

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