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Pathology > Inflammatory Bowel Disease > Flashcards

Inflammatory Bowel Disease Flashcards

1
Q

types of IBD

A
  • Crohn’s
  • UC
  • indeterminate IBD (CUTE)
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2
Q

where do each of the IBD conditions affect?

A
  • Crohn’s: any part of GI

- UC: colon only

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3
Q

what is the difference between microscopic and macroscopic IBD

A
  • microscopic: absence of macroscopic evidence of inflammation whilst there is either lymphocytic or collagenous changes
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4
Q

which factors interact to make IBD?

A
  • environment
  • genetic susceptibility
  • intestinal microbiota
  • host immune response
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5
Q

which environmental factors contribute to IBD?

A
  • smoking
  • NSAIDs
  • hygiene (CD only)
  • nutritional factors
  • psychological factors (stress and depression)
  • appendectomy
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6
Q

where does Crohn’s mainly affect?

A

terminal ileum and ascending colon

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7
Q

pathogenesis of Crohn’s

A

The disease can involve one small area of the gut such as the terminal ileum, or multiple
areas with relatively normal bowel in between (skip lesions). It may also involve the whole of
the colon (total colitis) sometimes without macroscopic small bowel involvement.
- In Crohn’s disease, the involved bowel is usually thickened and often is narrowed
- Deep ulcers and fissures in the mucosa produce a cobblestone appearance.
- Fistulae and abscesses may be seen which reflect penetrating disease
- An early feature is aphthoid ulceration, usually seen at colonoscopy; later, larger and
deeper ulcers appear in a patchy distribution, again producing a cobblestone
appearance.
- Inflammation extends through all layers (transmural) of the bowel

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8
Q

features of UC

A

Ulcerative colitis can affect the rectum alone (proctitis), can extend proximally to involve
the sigmoid and descending colon (left-sided colitis), or may involve the whole colon
(extensive colitis).
- In ulcerative colitis, the mucosa looks reddened, inflamed and bleeds easily
(friability).
- In severe disease there is extensive ulceration with the adjacent mucosa appearing as
inflammatory (pseudo) polyps.
- In UC a superficial inflammation is seen

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9
Q

clinical features of UC

A
  • bloody diarrhoea with mucus
  • lower abdominal discomfort
  • pain (think of toxic megacolon)
  • malaise
  • lethargy
  • anorexia
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10
Q

clinical features of proctitis

A
  • frequent passage of blood and mucus
  • urgency
  • tenesmus
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11
Q

clinical features of Crohn’s

A
  • diarrhoea
  • mouth ulcers
  • abdominal pain
  • malabsorption
  • weight loss
  • malaise
  • lethargy
  • anorexia
  • nausea
  • vomiting
  • low-grade fever
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12
Q

what can be found in Crohn-small bowel disease?

A

steatorrhea

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13
Q

when is it more likely to pass blood with the stool?

A

colonic disease

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14
Q

ocular manifestations of IBD

A
  • uveitis
  • episcleritis
  • red eyes
  • problems with diplopia
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15
Q

rheumatological manifestations of IBD

A
  • arthropathy
  • arthralgia
  • ankylosing spondylitis
  • inflammatory back pain
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16
Q

dermatological manifestations of IBD

A
  • erythema nodosum

- pyoderma gangrenosum

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17
Q

hepatobiliary manifestations of IBD

A
  • sclerosing cholangitis
  • fatty liver
  • chronic hepatitis
  • cirrhosis
  • gallstones
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18
Q

what are the subdivisions of arthropathies?

A

Type 1: self-limiting and acute (happens in IBD relapses)

Type 2: takes longer, independent of IBD activity; associated with uveitis

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19
Q

investigations of IBD

A
  • bloods: CBC, CRP, ESR, renal profile, LFT, ferritin, B12, folate
  • stool
  • faecal calprotectin and lactoferrin (specific to colon not IBD)
  • AXR (toxic megacolon, obstruction, colonic dilatation)
  • endoscopy
  • biopsy
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20
Q

why do you look at the CBC in IBD?

A
  • anaemia of chronic disease
  • high WCC (could be low due to immunosuppressants)
  • folate and B12, ferritin low due to malabsorption
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21
Q

what feature can you find in biopsy of Crohn’s?

A

granulomas

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22
Q

endoscopy of Crohn’s vs UC

A
  • Crohn’s: affects mouth to anus, skip lesions, cobble stoning of mucosa, erythema with ulceration
  • UC: affects large intestine only from the rectum upwards
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23
Q

which IBD condition is transmural and fistulation?

A

Crohn’s

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24
Q

what would you ask in IBD history?

A
  • stool frequency and consistency
  • rectal bleeding
  • abdominal pain
  • weight loss
  • extraintestinal
  • family history
  • smoking (worsens Crohn’s, improves UC)
  • NSAIDs use (risk relapse)
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25
Q

features of IBS

A
  • no rectal bleeding
  • associated with stress
  • no unintentional weight loss
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26
Q

which of the IBD conditions is pANCA positive?

A

Ulcerative colitis

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27
Q

which type of anaemia is more common in which IBD condition?

A

UC: Fe-deficiency anaemia

Crohn’s: normocytic normochromic anaemia

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28
Q

what is a side effect of mesalazine?

A

nephritis

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29
Q

which medication can disturb the LFTs and in what way?

A

azothioprine

  • elevated ALP
  • elevated GGT
  • elevated bilirubin (jaundice)
  • different to hepatitis (elevated ALT and AST)
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30
Q

what is the gold standard investigation in IBD?

A

endoscopy with mucosal biopsy

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31
Q

what classification do you use for UC?

A

Montreal classification (proctitis, left sided colitis, pancolitis)

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32
Q

how do you classify Crohn’s?

A

Montreal classification (age, location, behaviour)

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33
Q

medical management of IBD

A
  • aminosalicylates (oral, suppository, topical)
  • corticosteroids
  • immunosuppressants
  • thiopurines
  • biological agents
  • antibiotics
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34
Q

side effects of 5-ASA

A
  • nausea
  • headache
  • rash
  • epigastric pain
  • diarrhoea
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35
Q

what are the different formulations of corticosteroids?

A
  • oral prednisolone
  • IV hydrocortisone
  • enemas colofam
36
Q

how can you stop medication?

A

you have to tail them down slowly

37
Q

adrenals side effects of corticosteroids

A
  • adrenal atrophy

- Cushing’s Syndrome

38
Q

cardiovascular side effects of steroids

A
  • dyslipidaemia
  • HTN
  • thrombosis
  • vasculitis
39
Q

neurological side effects of steroids

A
  • change in behavioural cognition
  • memory and mood
  • cerebral atrophy
40
Q

gastrointestinal side effects of steroids

A
  • GI bleeding
  • peptic ulcers
  • pancreatitis
41
Q

immunological side effects of steroids

A
  • immunosuppression

- activation of latent viruses

42
Q

integumental side effects of steroids

A
  • atrophy
  • delayed wound healing
  • erythema
  • hypertrichosis
  • perioral dermatitis
  • petechiae
  • GC induced acne
  • striae rubrae distensae
  • telengiectasia
43
Q

musculoskeletal side effects of steroids

A
  • bone necrosis
  • muscle atrophy
  • osteoporosis
  • retardation of longitudinal bone growth
  • increased bone resorption
  • decreased bone formation
44
Q

ocular side effects of steroids

A
  • cataracts

- glaucoma

45
Q

renal side effects of steroids

A
  • increased Na retention

- increased K excretion

46
Q

reproductive side effects of steroids

A
  • delayed puberty
  • foetal growth retardation
  • hypogonadism
47
Q

when do you use immunosuppression?

A
  • steroid resistance or unresponsiveness
  • frequent relapses
  • use of 2 or more courses of steroids in 12 months
  • relapse within 6 weeks of steroids
48
Q

how is thiopurine used?

A

steroid-sparing agent

49
Q

side effects of thiopurines

A
  • hepatitis
  • bone marrow suppression
  • pancreatitis
  • increased risk of infections
  • increased risk of melanomas
  • hepatosplenic T cell lymphoma
50
Q

side effects of azothiopurine

A
  • allergic reaction (rash, fever, arthralgia)
  • bone marrow toxicity/leucopenia
  • hepatitis
  • pancreatitis
51
Q

how do you manage a patient with bone marrow toxicity or leucopenia?

A
  • weekly CBC for 8 weeks and then, do 3x a month

- immediately report sore throat and other infections

52
Q

how is infliximab administered?

A

IV infusion given every 2 months

53
Q

how is adalimumab administered?

A

subcutaneous injection every 2 weeks

54
Q

when is adalimumab given?

A
  • antibodies to infliximab

- allergic reaction

55
Q

side effects of Anti-TNF medication

A
  • infections (vaccinate and check for the normal viruses)
  • infusion reaction due to antibody formation (treat with antihistamine and steroids)
  • demyelination
  • contraindication in severe CHF
56
Q

when do you use antibiotics in IBD?

A
  • perianal disease in Crohn’s

- alcohol intolerance, irreversible neuropathy

57
Q

when do the patient seek nutritional advice?

A
  • uncontrollable disease

- when there is an ileal resection (B12 deficiency; short bowel syndrome)

58
Q

what is TPN and when do you use it?

A

total parenteral nutrition; indicated in patients with obstruction and who have had surgery and need to rest their bowel

59
Q

which medication is substituted for a specific type of nutrition?

A

steroids can be replaced by the elemental diet (satches mixed with water); indicated in active inflammation

60
Q

treatment of UC

A
  • mild/moderate: 5-ASA
  • proctitis: 5-ASA suppositories and if more severe, oral 5-ASA; if resistant to this, use prednisolone as well
  • left-sided colitis: topical 5-ASA enemas; if more severe, oral 5-ASA, if worse, add prednisolone
  • pancolitis: oral 5-ASA, if worse add prednisolone
61
Q

what happens if the patients do not respond to prednisolone?

A
  • admitted and treated with hydrocortisone
  • SC LMWH to prevent thromboembolism
  • if these do not work, salvage medical therapy or emergency surgery is needed
  • they should start a long-term therapy with a thiopurine
62
Q

which medications can be used to induce remission?

A
  • glucocorticoids (in moderate/severe CD) - if they resolve, decrease prednisolone to 5mg every 2-4 weeks and stop them when the parameters are normal
  • antibiotics (secondary complications of CD)
63
Q

which medications do you use to maintain remission?

A
  • people with good prognosis might not need this course of medication
  • thiopurines
  • Anti-TNF agents
64
Q

what is the aim of surgery in Crohn’s?

A

limit the extent of the Crohn’s, risk of malignancy due to dysplasia in the colon

65
Q

when do you do surgery in UC?

A
  • noncompliance to medication
  • persistent inflammation
  • chronic disease and risk malignancy
66
Q

indications of surgery in CD?

A
  • failure of medical therapy
  • complications of IBD
  • failure to grow in children despite the medical treatment
  • presence of perianal sepsis
67
Q

what are the complications of CD

A
  • toxic megacolon
  • obstruction
  • perforation
  • abscesses
  • enterocutaneous fistula
68
Q

what do you do in patients with small bowel disease?

A
  • strituroplasty (these are widened)

- resection and anastomosis

69
Q

what do you when CD affects the colon, sparing the rectum?

A

subtotal colectomy and ileorectal anastomosis

70
Q

what do you do when both the colon and rectum are involved?

A

panproctocolectomy with an end ileostomy (the opening is in the RIF); patients wears an ileostomy bag; not done in CD because high risk of this recurring in the pouch

71
Q

problems associated with ileostomies

A
  • mechanical problems
  • dehydration
  • psychosexual problems
  • erectile dysfunction
  • recurrence of CD
72
Q

indications for surgery in UC

A
  • failure of medical treatment
  • toxic dilatation
  • haemorrhage
  • imminent perforation
  • incomplete response to medical treatment/steroid dependent (chronic)
  • dysplasia on surveillance colonoscopy
73
Q

which surgery do you do in acute UC?

A

subtotal colectomy with end ileostomy and preservation of the rectum
- proctectomy with a permanent ileostomy or ileo-anal anastomosis (if you don’t want the ileostomy)

74
Q

what is pouchitis?

A

inflammation of the pouch mucosa signified by diarrhoea, bleeding, fever, exacerbation of extracolonic manifestations

75
Q

risk factors for developing pouchitis

A
  • primary sclerosing cholangitis
  • positive ANCA
  • backwash ileitis prior to colectomy
76
Q

how do you treat pouchitis?

A

antibiotics (metronidazole/ciprofloxacin)

77
Q

clinical features of microscopic colitis

A

chronic of fluctuating watery diarrhoea; macroscopic features are fine whilst the problem can be found histologically

78
Q

3 types of microscopic colitis

A
  • ulcerative
  • lymphocytic
  • collagenous
79
Q

characteristics of microscopic ulcerative colitis?

A
  • chronic inflammatory cell infiltrate in the lamina propria
  • deformed crypt architecture
  • goblet cell depletion with/out abscesses
  • treat like UC (most need only 5-ASA)
80
Q

characteristics of microscopic lymphocytic colitis

A
  • surface epithelial injury
  • prominent lymphocytic infiltration in the surface epithelium
  • increased lamina propria mononuclear cells
81
Q

characteristics of microscopic collagenous colitis

A
  • thickened subepithelial collagen layer adjacent to the basal membrane
  • increased infiltration of the lamina propria with lymphocytes and plasma cells
  • surface epithelial cell damage
82
Q

which population is more prone to microscopic collagenous colitis?

A
  • mainly found in elderly/middle aged women
83
Q

which autoimmune disorders is microscopic collagenous colitis associated to?

A
  • arthritis
  • thyroid disease
  • limited cutaneous scleroderma
  • primary biliary cirrhosis
84
Q

which types of microscopic colitis is more likely to happen in Coeliac patients?

A

lymphocytic and collagenous

85
Q

treatment of microscopic lymphocytic and collagenous colitis

A

budesonide (steroids)

86
Q

which drugs do you use if the microscopic colitis is refractory?

A
  • aminosalicylates
  • bismuth-containing preparations
  • prednisolone
  • azothioprine

Pathology (21 decks)

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