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HMS Homeostasis II > Inflammatory Bowel Disease > Flashcards

Inflammatory Bowel Disease Flashcards

1
Q

The inflammation in ulcerative colitis is. . .

A

. . . limited to the mucosal layer of the colon. It often begins in the rectum and extends proximally in a continuous pattern. It may involve only a few centimeters of rectum/colon or may extend throughout the entire colon.

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2
Q

Ulceative colitis is described by. . .

A

. . . the extent of disease: ulcerative proctitis (inflammation limited the rectum), left-sided ulcerative colitis (extends to the splenic flexure) or pancolitis (the entire colon is involved).

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3
Q

The inflammation in Crohn’s disease is characterized by . . .

A

. . . transmural inflammation that can occur anywhere from the mouth to the anus. The inflammation often is not continuous, but instead is characterized by skip lesions. The ileum and colon are most frequently affected.

May be associated with fibrosis and occlusive luminal strictures, fistulas, micro-perforations, intramural abscesses, or phlegmons.

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4
Q

Phlegmon

A

An inflammation of soft tissue that spreads under the skin or inside the body.

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5
Q

Crohn’s disease is often described by. . .

A

. . .the segment(s) of the GI tract that are involved and also by the behavior of the disease: inflammatory, stricturing or penetrating/fistulizing.

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6
Q

A patient has a presentation that seems consistent with both Crohn’s and UC, however they are found to have a granuloma on biopsy. What is the diagnosis?

A

Crohn’s

Crohn’s presents with granulomas, UC doesn’t.

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7
Q

Treating someone who may have IBD and IBS

A

Determining if symptoms are from inflammation or from a functional disorder will guide therapy. For example, a gastroenterologist would not recommend immunosuppression for someone with IBD who has abdominal pain and diarrhea caused by IBS

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8
Q

Increasing incidence of immune disorders

A
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9
Q

Types of genes with alleles that predispose to IBD

A
  • Immune genes, especially type-17 cytokines
  • Genes regulating autophagy
  • Genes regulating epithelial barrier function
  • NOD2 specifically is very important
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10
Q

Tobacco and IBD

A

Smoking increases the risk of Crohn’s disease and exacerbates it.

However, weirdly, it actually protects against UC. Still net/net better quitting.

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11
Q

Infectious and antibiotic etiologies of IBD

A
  • Acute gastroenteritis is associated with development, but no causal link yet
  • Use of antibiotics associated with IBD development
  • It is believed that altering the microbiome predisposes to IBD, and the microbiomes of IBD patients and controls are markedly different, however no causal link has yet been shown
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12
Q

Links between medications and IBD development

A
  • Antibiotics (obviously)
  • Hormonal therapy (including oral contraceptives)
  • NSAIDs
  • Isotretinoin
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13
Q

Diet and IBD

A

Western, processed, fried, high-sugar diet is associated with development of IBD

higher intake of omega-3 fatty acids and lower intake of omega-6 fatty acids have been shown to reduce risk of UC

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14
Q

Omega fatty acids summary

A
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15
Q

Appendectomy and IBD

A

Appendectomy, especially before the age of 20, may be a protective factor against the development of ulcerative colitis.

The same has NOT been shown for Crohn’s

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16
Q

NEJM IBD summary image

A
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17
Q

Symptoms of Crohn’s

A
  • Abdominal pain, diarrhea, weight loss, rectal bleeding, fever
  • Rarer symptoms: fatigue, perianal disease, poor growth, joint pain, vomiting, nausea or oral aphthae
  • Physical manifestations: Mouth sores, mucogingivitis, deep ulcerations in the mouth, cobblestone appearance of the mucosa, lip swelling and pyostomatitis vegetans
    • Anal manifestations: Occlusion from skin tags, fistulae, abscesses
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18
Q

Pyostomatitis vegetans

A

Unusual inflammatory changes in gums and oral mucosa characterized by edema, erythema, and innumerable pustules

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19
Q

Clinical features in Crohn’s vs UC

A
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20
Q

Dermatalogic manifestations of IBD

A
  • Erythema nodosum and pyoderma gangrenosum are most common
  • EN: Occurs on the extensor surfaces, usually on the lower extremities. Skin lesions appear as raised, tender red/purple subcutaneous nodules and often correlate with IBD activity.
  • PG: Less common in Crohn’s. Skin lesions commonly manifest on the lower extremities, often at sites of trauma. Lesions often begin as a small red bump, but then expand into larger, painful open sores/ulcers.
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21
Q

Rheumatalogic manifestations of IBD

A
  • Joint pain associated with active inflammation
  • The larger joints (hips, knees, etc.) tend to be affected more frequently
  • Improves w/ treatment of gut inflammation
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22
Q

The caveat to saying that there are rheumatalogic manifestations of IBD

A

It is important to recognize that people with IBD are at higher risk for autoimmune diseases in general, and that while joint pain may be due to their IBD, the joint pain may also be due to other autoimmune rheumatologic conditions such as systemic lupus erythematous and rheumatoid arthritis.

In addition, some therapies for inflammatory bowel diseases, also used to treat autoimmune disease, can trigger conditions such as drug-induced lupus.

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23
Q

Ophthalmalogic manifestations of IBD

A
  • Uveitis, scleritis, and episcleritis
  • Uveitis: Inflammation of the interior of the eye or any part of the uveal tract, presents with a change in vision or blurred vision, headaches and photophobia
  • Scleritis: Inflammation of the sclera. Often associated with an underlying systemic disease. Most common symptom is pain.
  • Episcleritis: Inflammation of the superficial conjunctiva. Usually mild and self-limiting and often recurs. Most cases of episcleritis are idiopathic, though up to one third may have an underlying systemic condition
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24
Q

What is going on in this photo?

A

Episcleritis

25
Q

What is going on in this photo?

A

Scleritis

26
Q

In prepubescent IBD, ___ often precedes development of GI symptoms

A

In prepubescent IBD, impeded growth often precedes development of GI symptoms

27
Q

Etiology of growth failure in IBD

A
28
Q

Clinical evaluation of IBD (excluding specific diagnostics)

A
  • Based on clinical and pathologic findings
  • Gold standard for diagnosis includes endoscopic and histologic findings for both Crohn’s disease and ulcerative colitis
  • Radiology often helps in Crohn’s to find an area of active transmural inflammation
  • UC will always be limited to the colon, making localizing much easier
  • Ruling out other etiologies is a big part
29
Q

Other diseases which present similarly to IBD

A
  • Ischemic colitis
  • Infectious colitis
    • Tuberculosis
    • Yersinia
  • IBS
30
Q

Fecal calprotectin or fecal lactoferrin

A

markers in the stool that are specific to gut inflammation

31
Q

Endoscopic features of Crohn’s vs UC

A
32
Q

What is going on in this CT scan?

A

Crohn’s ileitis

33
Q

What is going on in this axial CT scan?

A

Crohn’s ileitis

34
Q

Histopathology of UC

A

Characterized by expanded lamina propria with mixed inflammatory infiltrate; the bases of the crypts are separated from their normal position adjacent to the muscularis mucosae, and crypt branching may be present.

In addition to these changes that indicate chronic mucosal injury, neutrophilic inflammation of the colonic epithelium is also seen to a variable extent and severity.

35
Q

Histopathology of Crohn’s

A

Crohn’s ileitis is characterized by neutrophilic infiltration of the crypt epithelium and metaplasia, often of the pyloric-type.

Nonnecrotizing granulomata are highly specific for Crohn’s disease in the appropriate clinical context, and they can be seen anywhere in the gastrointestinal tract.

36
Q

Colectomy in treating IBD

A

Colectomy is a treatment for refractory ulcerative colitis or patients with dysplasia, and Crohn’s patients may have strictures or perforations requiring removal of diseased portions of the gastrointestinal tract.

37
Q

Generally speaking, ulcerative colitis is characterized by inflammation ___ whereas Crohn’s disease classically shows ___

A

Generally speaking, ulcerative colitis is characterized by inflammation restricted to the mucosa and submucosa whereas Crohn’s disease classically shows transmural chronic inflammation involving the muscularis propria and serosal tissues.

38
Q

The following biopsy sample is obtained from an individual presenting with clinical features of IBD. What is the diagnosis?

A

Crohn’s disease OR tuberculosis

The biopsy sample shows a non-necrotizing granuloma, indicating Crohn’s. However, gastrointestinal Tuberculosis infection may mimic IBD and will present with a mixture of necrotizing and non-necrotizing granulomas. Workup for TB is needed to differentiate the two.

39
Q

What does this colon histology show?

A

This is a deep transmural fissure, indicating pathology all along the wall of the GI tract. This is characteristic of Crohn’s disease.

40
Q

What does this colon histology show?

A

Crypt branching, a characteristic finding of ulcerative colitis.

There is also diffuse chronic inflammation in the lamina propria, and very irregular length and shape of crypts.

41
Q

Step-up vs Top-down approaches to treating IBD

A
42
Q

General principles of IBD treatment

A
  1. Disease location, severity, and for Crohn’s disease the phenotype (stricturing vs penetrating vs inflammatory) are important to selecting therapy
  2. Timing of therapy (induction during flares to control them, then maintenance)
  3. A top-down regimen intensity is generally favorable in moderate to severe cases, but surgery should be avoided if possible.
43
Q

Importance of adherence in IBD treatment

A
44
Q

Immunomodulators in treating IBD

A
  • 6-mercaptopurine, azathioprine, methotrexate, tacrolimus, cyclosporine
  • Azathioprine and 6-mercaptopurine (6-MP) are purine analogs. Methotrexate is a folic acid antagonist
  • Tacrolimus and cyclosporine are calcineurin inhibitors that impair T cell proliferation.
  • Inhibit leukocyte proliferation
  • Side effects include leukopenia, infection, hair loss
  • Increased cancer risk
45
Q

Most commonly used anti-TNFs

A

Inflixumab and Adalimumab

46
Q

Tofacitinib

A
  • First-in-class JAK3 inhibitor
  • Used in IBD treatment
  • Side effects include increased risk for opportunistic infections, blood dyscrasias, malignancy, and thrombotic events.
47
Q

IBD therapeutic summary

A
48
Q

Role of surgery in Crohn’s

A

In Crohn’s disease, the role of surgery is to resect bowel that cannot be treated medically, either because it is refractory to medical treatment, or because there are areas of bowel with irreversible fibrosis causing stenosis and obstruction, or because there is perforation with abscess that is not responding to acute medical therapy

49
Q

Role of surgery in UC

A

Surgery in ulcerative colitis is curative, as UC only affects the colon, and thus with a colectomy, all disease is removed. Surgery for ulcerative colitis often includes removal of the entire colon and creation of a J pouch with small bowel.

Patients with ulcerative colitis should still be monitored for pouchitis (inflammation of the pouch). The small amount of rectum, known as the rectal cuff, also needs to be monitored for dysplasia. About 20-30% of patients with ulcerative colitis eventually require surgery.

50
Q

Result of total colectomy and ileum-anal canal anastamosis

A
51
Q

Specific carbohydrate diet

A

Diet that has received the most recognition and anecdotally has been the most effective at inducing and maintaining remission in IBD

There has not been an RCT proving it is effective yet.

52
Q

Exclusive Enteral Diet

A

Dietary approach to treating IBD that is used more commonly in pediatrics

Consists of a completely liquid diet, often using elemental formula. While this can be difficult to maintain, it is often effective therapy to induce remission in small intestinal Crohn’s disease.

53
Q

IBD patients are constantly at risk for developing ___.

A

IBD patients are constantly at risk for developing nutrient deficiencies and colon cancer.

If the ileum is involved, especially B12

54
Q

Is colon cancer always preceded by a polyp in IBD patients?

A

NO

This is why histopathologic samples are routinely sampled during endoscopy of IBD patients.

55
Q

Chromoendoscopy

A

Special endoscopy where a blue dye is sprayed throughout the colon or with using high resolution endoscopes, allowing for better inspection of the mucosa to identify areas of dysplasia

Patients who have highgrade dysplasia are often recommended to have colectomy, as they are at increased risk for developing cancer, and because areas of high grade dysplasia may already have cancer cells within the lesion.

56
Q

IBD medications that must be stopped prior to becoming pregnant

A
  • Methotrexate
  • Some biologics (namely those that cross the placenta)
57
Q

Considerations for female IBD patients who are planning to become pregnant

A
  • Some medications may need to be stopped
  • The majority of women with IBD who conceive when they are in remission will remain in remission throughout the duration of their pregnancy, and seeking remission prior to becoming pregnant is advantageous
  • Obstetritians involved in pregnancy management should be trained in managing IBD pregnancies specifically, as they are high-risk
  • A history of inflammatory bowel disease is not an indication for cesarean section, though there are certain contraindications to vaginal delivery among women with IBD (perianal disease or fistulas in the rectal/vaginal/perineal area)
58
Q

Common initial presentation of Crohn’s

A

Crohn’s disease commonly presents with terminal ileitis. This could cause irritation of the parietal peritoneum in this location, resulting in well-defined, localized pain and tenderness in this location.

Thus, the presenting symptom would be RLQ pain, mimicking appendicitis.

HMS Homeostasis II (35 decks)

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