Inflammatory Bowel Disease

Question 1

What are the two forms of IBD?

Answer 1

Ulcerative colitis and Crohn disease.

Question 2

What are the differences between UC and Crohn disease regarding bowel involvement, tissue involvement, granulomas, and perianal disease?

Answer 2

UC: involves colon only, mucosa only (generally), does not have granulomas, and does not have perianal lesions. Crohn: can occur anywhere from mouth to anus, transmural disease, granulomas are likely, and perianal lesions are common.

Question 3

How does ulcerative colitis usually present?

Answer 3

Patients classically present with abdominal pain and bloody diarrhea; however, at onset, many patients have only nonbloody diarrhea.

Question 4

Describe the typical features of arthritis in patients with ulcerative colitis.

Answer 4

The arthritis is migratory, asymmetric, and mainly involves the hip and/or knee.

Question 5

List 6 potential extra-colonic manifestations of ulcerative colitis.

Answer 5

Arthritis, clubbing, seronegative spondyloarthropathies, erythema nodosum, pyoderma gangrenosum, and primary sclerosing cholangitis.

Question 6

How do you diagnose UC?

Answer 6

Diagnosis can be made with colonoscopy and upper endoscopy (to look for skip lesions). Both biopsy and characteristic endoscopic appearance will help make the diagnosis.

Question 7

Which is transmural - Crohn’s or UC?

Answer 7

Crohn disease is transmural. UC affects the mucosa only.

Question 8

Which drugs are used for both the remission and maintenance of UC?

Answer 8

5-aminosalicylic acid (5-ASA), which includes both sulfasalazine and mesalamine, and biologic agents (most commonly infliximab)

Question 9

What is the role of coticosteroids in treatment of ulcerative colitis?

Answer 9

Steroids may be used in acute exacerbations to induce remission, but should not be used for maintenance because they can be dangerous if used for long periods of time.

Question 10

When is 5-ASA typically used, in comparison with biologic agents, in the treatment of ulcerative colitis.

Answer 10

Most patients with mild-to-moderate UC respond well to 5-ASA, while biologic agents such as infliximab are commonly used in children with moderate-to-severe disease who are steroid dependent or refractory.

Question 11

What is the role of purine analogs (6-MP and azathioprine) in the treatment of ulcerative colitis?

Answer 11

These agents are very effective in maintaining remission for severe UC but do not have a role in inducing remission due to their slow onset of action (~3 months).

Question 12

What is the concern with use of antidiarrheal agents in patients with ulcerative colitis?

Answer 12

Antidiarrheal agents are not recommended in patients with UC due to the concern for development of toxic megacolon with their use.

Question 13

What are the (3) indications for urgent surgery in patients with ulcerative colitis?

Answer 13

Uncontrollable massive bleeding, perforation, and toxic megacolon.

Question 14

What is the most common reason for patients with ulcerative colitis to undergo surgery?

Answer 14

Surgery is most often done in these patients due to a failure of standard medical therapy.

Question 15

What is the risk of colon cancer in patients with ulcerative colitis?

Answer 15

UC predisposes to colon cancer at an increasing rate that is correlated with the duration of active disease. After 10 years of active disease, the yearly risk of colon cancer is ~1%.

Question 16

Which is more likely to cause weight loss and growth problems, Crohn’s or UC?

Answer 16

Crohn disease

Question 17

In which part of the GI tract does Crohn disease most commonly occur?

Answer 17

The terminal ileum is the most commonly involved site in patients with Crohn disease, with nearly 70% of pediatric patients also having some colonic involvement.

Question 18

Which form of IBD has a greater genetic association - UC or Crohn?

Answer 18

Crohn disease has a much greater genetic component than UC.

Question 19

What is the pathognomonic histological finding in Crohn disease?

Answer 19

On biopsy, noncaseating granulomas that contain multinucleated giant cells and epithelioid cells are pathognomonic of Crohn disease, though they are only seen 40% of the time.

Question 20

Is surgical therapy curative for Crohn disease?

Answer 20

No

Question 21

What is first-line therapy for inducing and maintaining remission in patients with Crohn disease?

Answer 21

Prednisone is usually given for 3-4 weeks until remission is achieved, and then gradually weaned. The puring analogs (6-MP and azathioprine) are generally used to then maintain remission.

Question 22

What is the role of nutrition therapy in patients with Crohn disease?

Answer 22

Unlike UC, Crohn disease responds to bowel rest. An exclusive elemental diet is recommended for one month at the start of therapy. Once remission has been achieved, an elemental diet is recommended 1 out of every 4 months.

Question 23

What dietary supplements are recommended for patients with Crohn disease?

Answer 23

Osteoporosis is a significant concern in children with Crohn disease, so supplementation with calcium and Vitamin D is recommended.

Question 24

What is the relationship between Crohn disease and colon cancer?

Answer 24

Patients with Crohn disease are much less likely than those with UC to develop colon cancer. However, the rate of colon cancer is still 20x higher in patients with Crohn than in the general population.