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Gastro > Inflammatory Bowel Disease > Flashcards

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
Q

What biologics in IBD

A

Anti-TNF (Infliximab) If levels are therapeutic but stop working = diff mode of inflammation started rather than Ab

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26
Q

Why is it best to avoid steroids in children [3]

A

Growth

Adrenal

Infection

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27
Q

What is used to decrease need for steroid

A

Immune modulation - used for remission

Azahioprine / methotrexate / cyclosporin

Allopurinol + azathioprine (blocks XO which metabolises azatho so increases dose)

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28
Q

What are SE of immunosuppression [3]

A

Nausea

LFT Affects renal

Cyclosporin >steroids but need kidney function

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29
Q

What can’t you use in UC

A

Methotrexate

30
Q

What is 1st line in Ulcerative colitis to induce remission [4]

Maintenance of remission [3]

When would you prescribe low maintenance dose? [2]

A
  • 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
Q

What do you have to monitor with 5ASA [3]

A

FBC + U+E + trough level

32
Q

Management for severe flareups in UC

Immediate management [2]

Monitoring [4]

No response after 3d [2]

A

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
Q

When do you do emergency surgery [2]

A

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
Q

What other imaging options [3]

A

Abdo X-Ray = distention

CXR = free air if perforation or

AS Barium enema = loss of haustra

35
Q

Rationale for surveillance in IBD? How is it carried out

A

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
Q

What type of anaemia [2]

A

Normochromic normocytic Iron or folate

37
Q

What is an option for imaging small bowel in Crohn’s (gold standard now)

A

MR enterography or small bowel MRI

38
Q

When would you need transvaginal ISS

A

Fistula

39
Q

What investigation would be most helpful in dx in acute presentation?

A

CT

40
Q

What is diversion colitis

A

After stoma Distal bowel = no bacteria Causes colitis

41
Q

When can’t you anastomose

A

Above a stricture

So if Crohn’s = anal stricture have to take out colon as anastomoses would burst

42
Q

What is radiation proctitis

A

After RT

43
Q

What treatment for radiation proctitis

A

Transfusion if needed Argon phototherapy Hyperbaric oxygen Sulcrafate enema

44
Q

What do you do for perforation

A

Stoma

45
Q

What do you do for abscess

A

Ax USS / CT guided drainage

46
Q

What do you do for fistula

A

Surgery

47
Q

What are signs of perforation

A

Peritonitis SHock Ileus

48
Q

What do mild and moderate attacks have

A

Increased stool frequency

No systemic disturbance

Mild <4 stool

Mod 4-6

49
Q

What are strictures more likely to be in ulcerative colitis

A

Malignancy

50
Q

What is tenesmus

A

Painful feeling of inability to evacuate bowel

51
Q

What is toxic megacolon [3]

A

Loss of haustration Transverse or right colon with a diameter of >6 cm Mucosal edema

52
Q

How do you deal with toxic megacolon

A

Medical therapy

Urgent colectomy if doesn’t resolve

53
Q

What surgery for UC [2] Options following recovery from emergency surgery [2]

A

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
Q

Indications [2] and contraindications [2] of ileal pouch

What is important to communicate in counseling of patient going for ileal pouch?

A

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
Q

Complications of surgery [5]

A

General

Splenc injury

Anastomotic injury

Intra-abdominal abscess

Poor function / failure of pouch

56
Q

What is another type of colitis not related to IBD that can cause flares

A

Lymphocytic colitis

57
Q

What is main am of IBD Rx [2]

A

Induce remission

Maintain remission

58
Q

How do you induce remission in proctitis / L sided colitis [3]

A

Topical 5ASA

Oral if no improvement after 4 weeks

Add topical or oral steroid if no improvement

59
Q

How do you induce remission in extensive disease [2]

A

Topical + oral 5ASA Steroid if no improvement

60
Q

What if severe attack

A

Hospital for IV

61
Q

How do you maintain remission

A

Topical 5ASA / oral

62
Q

What do you do if severe attack or >2 exacerbations

A

Add azathioprine

63
Q

Signs: UC What are two severity indexes used to assess patients

A

Truelove and Witt’s severity index

64
Q

Protective factors for UC vs risk factors of Crohns

A

Protective factors:

  • smoking
  • appendectomy for acute appendicitis before 20yo

Risk factors:

  • Smoking worsens condition
65
Q

Sulfasalazine SE [5] Mesalazine SE [5]

A

Sulfasalazine

  • Headache, anorexia,
  • Nausea, rashes
  • Oligospermia
  • Heinz body anaemia, megaloblastic anaemia
  • Lung fibrosis

Mesalazine

  • GI upset
  • Headache
  • Agranulocytosis
  • Pancreatitis
  • Interstitial nephritis
66
Q

Maintenance of remission UC [3]

A
  1. 5-ASA
  2. Immunotherapy:
  • Azathioprine
  • Mercaptopurine
  • Infliximab
  1. Topical mesalazine or steroid (suppository)
67
Q

Crohns management Induction of remission [3]

How to manage severe cases [5]

A
  • 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
Q

Surgical management of Crohns (needed by 80% of pts w/ small bowel Crohn’s)

  1. Indications?
  2. Type of interventions [4]
A

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
Q

Describe 4 types of acute presentations of Ulcerative Colitis

A

Proctosigmoiditis

Left-sided colitis

Pancolitis

Backwash ileitis

70
Q

Montreal classification for Crohns:
Age [3]
Location [4]
Behaviour [3]

A
71
Q

Montreal classification for UC

Extent [3]

Severity [4]

A
72
Q

Microscopic colitis

A

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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