Inflammatory Bowel Disease Flashcards by Lauren Horsburgh

What two disease are encompassed by inflammatory bowel disease?

Ulcerative colitis

Crohn’s disease

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What is the peak age incidence of inflammatory bowel disease?

15-30 years

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How does smoking affect the risk of inflammatory bowel disease?

Crohn’s disease - increased risk in smokers

UC - decreased risk in smokers

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What are the possible presenting signs and symptoms of inflammatory bowel disease?

Diarrhoea - can be bloody or chronic
Abdominal pain, distension, masses
Urgency or tenesmus
Proctitis
Perianal abscess and anal fissures / fistulae
Systemic upset during. an acute flare
Poor growth, delayed puberty and malnutrition in children

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What are the extra-intestinal manifestations of inflammatory bowel disease?

Mouth ulcers
Clubbing
Pyoderma gangrenous
Erythema nodosum
Conjunctivitis / iritis / episcleritis
Arthritis
Ankylosing spondylitis 
Sacroilitis
Fatty. liver
Primary sclerosing cholangitis
Cholangiocarcinoma
Renal stones
Osteomalacia
Amyloid

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What is pyoderma gangrenosum?

A condition which causes tissue to become necrotic, causing deep ulcers which usually occur on the legs
Ulcers usually initially look like small bug bites/papules and can progress to larger ulcers
They can cause pain and scarring

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What is erythema nodosum?

An inflammatory condition characterised by inflammation of the fat cells under the skin. Results in tender red nodules or lumps that are usually seen on both shins

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What are the differential diagnoses of inflammatory bowel disease?

Gastroenteritis
Infective colitis
Diverticulitis
Coeliac disease
Colorectal carcinoma
Ischaemic colitis
Radiation or drug induced colitis
Irritable bowel syndrome 
Acute appendicitis
Carcinoid syndrome
Amyloidosis
Intestinal lymphoma
Bechet's disease

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What blood tests should be used to investigate possible inflammatory bowel disease?

FBC
Haematinics
U&amp;Es
LFTs
ESR and CRP
Faecal calprotectin

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What tests should be used to rule out infection in possible inflammatory bowel disease?

Stool culture and microscopy

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What blood test can be used to differentiate inflammatory bowel disease from irritable bowel syndrome?

Faecal calprotectin

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What is the gold standard diagnostic test for inflammatory bowel disease?

Colonoscopy with biopsy

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When would AXR. be used to investigate inflammatory bowel disease?

In severe colitis to look for possible signs of toxic megacolon

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What investigative test can be used in place of colonoscopy in inflammatory bowel disease?

Flexible sigmoidoscopy

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Define Crohn’s disease?

A disorder of unknown aetiology characterised by transmural inflammation of the GI tract which can affect any/all parts of the GI tract from mouth the anus

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Which part of the GI tract is most commonly affected by Crohn’s disease?

Terminal ileum

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Which type of inflammatory bowel disease is characterised by skip lesions?

Crohn’s disease

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Why is it common for fibrosis and fistula formation to occur in Crohn’s disease?

Inflammation is transmural

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What environmental factors are implicated in the pathogenesis of Crohn’s disease?

Smoking
Oral contraceptive pill
Infectious agents
Nutritional deficiencies

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What endoscopic findings would you expect to see in Crohn’s disease?

Erythema
Oedema
Friability of the mucosa
Identification of fistula tract openings

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What histological features of Crohn’s disease can help distinguish it from UC?

Presence of non-caveating granulomas
Architectural change
Distribution of disease

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Explain how autoantibodies can help distinguish Crohn’s from UC?

In Crohn’s it is likely that ASCA will be positive and p-ANCA will be negative
The opposite is true of UC

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What scoring system is used to measure the severity of Crohn’s disease?

Crohn’s disease activity index

What is the main factor involved in lifestyle modification for Crohn’s disease?

Smoking cessation

What are the first line drugs for inducing remission of Crohn's disease?

Glucocorticoid | If this is not tolerated or is contraindicated, 5-ASA can be used

What add-on therapies can be used to induce remission of Crohn's disease?

Azathioprine / mercaptopurine | If TPMT activity deficient or if azathioprine not tolerated methotrexate can be used

What additional drugs can be induce remission of Crohn's disease?

Anti-TNF drugs - infliximab, adalimumab | If this fails or there are contraindications vedolizumab and ustekinumab can be used

What drugs can be used to maintain remission in Crohn's disease?

Azathioprine | IM methotrexate

Why should glucocorticoids not be used for maintenance therapy in Crohn's disease?

Glucocorticoids are not effective for maintaining remission and can cause unwanted adverse effects

After surgery for Crohn's disease, what drugs should be used?

Azathioprine plus metronidazole for 3 months

What are the possible complications fo Crohn's disease?

``` Colorectal cancer Strictures Fistulae Perforation Haemorrhage Osteoporosis Renal disease Anaemia Delay growth and puberty in children Miscarriages, stillbirths and IBD exacerbation in pregnancy ```

What is the term from ulcerative colitis which only involves the rectum?

Ulcerative proctitis

What is the term from ulcerative colitis which only involves the rectum and sigmoid colon?

Ulcerative proctosigmoiditis

What is the term from ulcerative colitis which affects the rectum, sigmoid colon and colon up to the splenic flexure?

Distal ulcerative colitis

What is the term from ulcerative colitis which affects the rectum, sigmoid colon and colon up to but not including the caecum?

Extensive colitis

What is the term from ulcerative colitis which affects the entire colon including the caecum?

Pancolitis

What scale is used to measure the severity of disease in ulcerative colitis in adults?

Truelove and Witt's index

What scale is used to measure the severity of disease in ulcerative colitis in children?

PUCAI severity index

In the Truelove and Witt's index for severity of ulcerative colitis, what are the criteria for mild UC?

``` <4 stools/day No more than a small amount of blood in stools No anaemia HR <90 No fever Normal ESR and CRP ```

In the Truelove and Witt's index for severity of ulcerative colitis, what are the criteria for moderate UC?

``` 4-6 stools/day More blood in stools No anaemia HR <90 No fever Normal ESR and CRP ```

In the Truelove and Witt's index for severity of ulcerative colitis, what are the criteria for severe UC?

>6 stools/day Visible blood in stools ``` + one of: >37.8 degrees C HR >90 Anaemia ESR >30 ```

Which patients with ulcerative colitis require urgent hospital referral?

Severe colitis or moderate disease which doesn't respond to steroids within 2 weeks

How is medication administered for ulcerative proctitis?

Suppositories

How is medication administered for ulcerative proctosigmoiditis?

Foams

How is medication administered for distal ulcerative colitis?

Enemas

How is medication administered for extensive UC / pancolitis?

Oral medications

When can mesalazine (5-ASA) be used to treat ulcerative colitis?

For induce and maintenance of remission in mild to moderate UC

When can corticosteroids be used in ulcerative colitis?

To induce remission

When should azathioprine be used in ulcerative colitis?

Patients who are intolerant of corticosteroids Patients who need >2 corticosteroids a year Patients who have disease relapses when corticosteroids are reduced or within 6 weeks of stopping steroids

Levels of which enzyme need to be checked before starting azathioprine?

TPNT enzyme

Anti-TNF drugs can be used for patients with ulcerative colitis who have failed therapy with conventional agents. Give examples of these agents?

Infliximab Adalimumab Golimumab

Colectomy is curative in ulcerative colitis. T/F?

True

Which patients with ulcerative colitis are at an increased likelihood of requiring surgery?

Stool frequency >8 a day Pyrexia Tachycardia Colonic dilatation on AXR

What are the complications of ulcerative colitis?

``` Colorectal cancer Other bowel complications - toxic megacolon, perforation, haemorrhage, polyps, pouchitis, post-IPAA leakage and pelvic abscess Osteoporosis Anaemia Psychosocial and sexual problems ```

Given than patients with inflammatory bowel disease are at increased risk of colorectal cancer, what precautions should be taken?

Regular colonoscopy for colorectal cancer screening

Why is toxic megacolon (a possible complication of inflammatory bowel disease) particularly dangerous?

It can lead to perforation and peritonitis

Toxic megacolon is characterised by a dilated colon. What diameter is required for diagnosis?

>5.5cm