Inflammatory Bowel Disease Flashcards
What is used to help classify IBD?
Montreal classification
What is the cause of IBD?
Unknown
What is the presentation of ulcerative collitis?
–Bloody diarrhoea
–Abdominal pain
–Weight loss
More common in females
Peak incidence is 20-40 years
What is the travel of inflammaiton in UC?
Inflammation travels from rectum proximmaly until it stops somewhere
What is the likelihood of surgical removal as a result of UC?
•Surgical Removal
–3% first attack
–8% at 5 years
•Mortality
–3% first attack
–23% severe attack
What are markers of a severe attack of ulcerative colitis?
•Markers of a severe attack
–Stool frequency: >6 stools/day with blood
–AND
- Fever: >37.5ºC
- Tachycardia: >90/min
- ESR(CRP): raised
- Anaemia: Hb <10g/dl
- Albumin: <30g/l
- Leucocytosis, thrombocytosis
What are the clinical features of Crohn’s disease?
- Diarrhoea
- Abdominal pain
- Weight loss.
- Malaise, lethargy, anorexia, N&V, low-grade fever
- Malabsorption
–Anaemia, vitamin deficiency
What are complications of Crohn’s disease?
What is the foecal calprotectin test?
Faecal calprotectin is a biochemical measurement of the protein calprotectin in the stool. Elevated faecal calprotectin indicates the migration of neutrophils to the intestinal mucosa, which occurs during intestinal inflammation, including inflammation caused by inflammatory bowel disease
What are the features of blood in patients with Crohn’s?
–High ESR & CRP
–High platelet count
–High WCC
–Low Hb
–Low albumin
What is the difference between histology of Crohn’s and UC?
CD = granulomas
Goblet cells are depleted in UC
Crypt abscesses are more common in Ulcerative colitis than crohn’s disease
What are the different features between Crohn’s and Ulcerative colitis?
Crohn’s: fistulae and perianal disease
Bloody diarrhoea: UC
Diarrhoea: Crohn’s
What are the extra-intestinal manifestations of IBD?
(EYES)
–uveitis, episcleritis, conjunctivitis
What are the extra-intestinal manifestations of IBD?
(JOINTS)
–sacroiliitis (inflammation of one or both of your sacroiliac joints) , monoarticular arthritis, ankylosing spondylitis (a form of spinal arthritis) eventually causes ankylosis of vertebral and sacroiliac joints.
Ankylosis abnormal stiffening and immobility of a joint due to fusion of the bones.
What are the IBD manifestations in the Kidney?
Crohn’s disease only: Renal calculi: kidney stones
What are the IBD extra intestinal manifestations?
(LIVER AND BILIARY TREE)
–Fatty change, pericholangitis, sclerosing cholangitis, gallstones
Pericholangitis: inflammation of the tissues surrounding the bile ducts.
What are the extra-intestinal manifestations of IBD?
(SKIN)
–pyoderma gangrenosum, erythema nodosum, vasculitis
Pyoderma gangrenosum: Pyoderma gangrenosum is a condition that causes tissue to become necrotic, causing deep ulcers that usually occur on the legs.
Erythema nodosum: Erythema nodosum is a type of skin inflammation that is located in a part of the fatty layer of skin. Erythema nodosum results in reddish, painful, tender lumps most commonly located in the front of the legs below the knees.
What are the IBD differential diagnosis’?
•Chronic diarrhoeas
–Malabsorption
–Malnutrition
- Ileo-caecal TB
- Colitis must be distinguished from
–infective, amoebic and ischaemic colitis
What are the associated liver diseases with IBD?
•Sclerosing Cholangitis
–Disease of the bile ducts
–Multiple strictures
–Slowly progressive, can lead to cirrhosis
What are Long-term complications of Colitis?
•Colonic carcinoma
–Risk Factors
•Extent
–Pancolitis 26 x normal
–Left colitis 8 x normal
–Proctitis minimal
•Duration
–< 10 yrs minimal risk
–- 20 yrs 23 x normal
–- 30 yrs 32 x normal
What is surveillance for patients with extensive collitis?
What is the medical management of IBD for outpatient?
–5ASA (aminosalicylates)
–Steroids
–Immunosuppression
- Azathioprine
- Mercaptopurine
- Methotrexate
- Infliximab
What is the therapy for IBD in hospital?
–Steroids
–Anticoagulation
–Rest
–Other
- Cyclosporin
- Infliximab
- Surgery
Give examples of aminosalicylates
Mesalazine
•Pro-drugs
–Balsalazide
–Olzalazine
–Sulfasalazine
Pro-drugs deliver to the distal bowel better
What are the effects of 5ASA in UC?
First line therapy for induction and maintenance of remission
Reduces risk of CRC
What is the effect of 5ASA on Crohn’s?
- Widely used but limited evidence
- Induction of remission
–Mildly active ileocolonic disease
•Maintenance of remission
Only if medical remission induced by 5ASA
Give examples of steroids used to treat IBD?
Prednisolone
Budenoside (better side effect profile, ileal and ascending colon disease only)
What are the side effects of Azathiopurine / 6 mercaptopurine?
–Leucopenia
–Hepatoxicity
•Requires Blood Monitoring
–Weekly for 8 weeks and then every 8 weeks
–Patients must see GP if sore throat/infection
–Pancreatitis
–Possible long term lymphoma risk
–Up to 28% intolerant
What type of drugs are
Azathioprine
Mercaptopurine
Methotrexate
Immuno-suppressants
What are the biologics medications available for IBD patients?
•Anti-TNFa antibodies
–Infliximab (Remicade)
•8 weekly IV infusion
–Adulimumab (Humira)
- 2 weekly SC injections
- a4b7 Integrin Blockers
–Vedolizumab
- 8 Weekly IV Infusions
- IL12/IL23 Blockers
–Ustekinumab
•IV loading followed by SC 8-12 weekly
TNF -alpha explanation
https://www.youtube.com/watch?v=rBfjfwQ45ZU
Elemental feeding
- Exclusive elemental feeding can be as effective as steroids
- More efficacious in children
- Compliance difficult
What are antibiotics used for?
–Crohn’s peri-anal disease
–Small bowel bacterial over growth
What can cause failure of medical therapy?
- Relapse prior to or shortly after stopping therapy
- Failure to control symptoms
- Unacceptable complications of steroids:
–Diabetes
–Severe osteoporosis
–Psychosis
What can result from poor response to medical therapy?
- Fistulas
- Fibrotic strictures
- Peri-anal disease
- Severe fulminating disease
What are the surgical options for severe colitis?
Total colectomy
What are the required surgical procedures after a colectomy?
End ileostomy: Illeostomy: a surgical operation in which a damaged part is removed from the ileum and the cut end diverted to an artificial opening in the abdominal wall.
AND
Rectal Stump: The rectal stump is the sack left behind after the colon is diverted surgically to open at the abdominal wall ( a colostomy).
What is meant by the pouch procedure?
When the colon and rectum are removed (due to ulcerative colitis or familial adenomatous polyposis), another reservoir must be created for bowel contents (stool) to exit the body. Surgically creating a “J” shaped reservoir (called a J-pouch) is an option for selected patients to store and pass stool.
Small bowel is mobilised and lengthened and used to construct a pouch.
Stoma bag still exits in this circumstance - 60% of people chose not to do this
Where does Crohn’s affect the GI tract?
Small intestine 30%
Ileocaecal area 40%
Colon and rectum 30%
Anus
How does crohn’s affect the anus?
fissures, abscesses, fistulas, skin tags
(non-ulcerating vs severe ulcerating disease)
What are the surgical indications for Crohn’s disease?
- Failure of medical management
- Relief of obstructive symptoms (small bowel)
- Management of fistulae - e.g. bowel to bladder
- Management of intra-abdominal abscess
- Management anal conditions
- Failure to thrive
50% need another operation by 10 years
