Inflammatory Bowel Disease

Question 1

What is UC?

Answer 1

• Diffuse mucosal inflam limited to colon
• Affects rectum
• May involve all or part of rest of colon

Question 2

What is CD?

Answer 2

• Patchy transmural inflam

- Affects any part of GIT

Question 3

What is differences are seen between mild, moderate and severe UC?

Answer 3

• Mild = duller + redder with granular texture, vasc pattern obscures
• Moderate = gross pitting of mucosa + lining bleed @ lightest touch
• Severe = Micro-ulceration with mucopurulent exudate

Question 4

What are the symptoms of UC?

Answer 4

• Bleeding
• Diarrhoea (not present in proctitis)
• Urgency
• Abdominal pain

Question 5

What are the intestinal complications of UC?

Answer 5

1. TOXIC MEGACOLON
   - ulceration dissect deeply through wall of colon
   - accumulation of gas + protrusion soft tissue into lumen = early radiological sing of this
   - appearance of toxic dilation not until late stages -> already danger of perforation and/or peritonitis
   - most dilation in transverse colon
   - obliterate or accentuated haustra
2. PERFORAITON
   - most lethal
   - early sign = bowel necrosis + impending perforation = subserosal dissection
   - may be solent if patient on corticosteroids

Question 6

What does UC increase the risk of?

Answer 6

Increased risk colorectal cancer - for dysplasia to be reliable warning sign essential that finding made independent of ever inflam

Question 7

What extra-intestinal manifestations RELATED to disease activity are present in IBD?

Answer 7

• Aphthous stomatitis
• Epscleritis + uveitis
• Arthritis
• Vascular complications
• E. nodosum (esp in Crohn’s)
• P. gangrenosum (esp in UC)

Question 8

What does peripheral arthritis due to systemic complications of IBD present as?

Answer 8

• Most common in UC
• Affects knees, ankles, wrists + fingers
• Monoarticular
• Asymmetrical
• Large > small joints
• No synovial destruction
• No subcutaneous nodes
• Seronegative

Question 9

What extra-intestinal manifestation UNRELATED to disease activity are present in IBD?

Answer 9

1. Central arthropathy
   - ankylosing spondylitis - calcification + fusion of ligaments which join vertebrae = progressive kyphosis
   - sacroiliitis - scleoris + obstruction of sacroiliac joints
2. Liver disease
   - primary sclerosing cholangitis (jaundice, itching + cirrhosis)
   - steatosis (fatty liver)
   - chronic hepatitis
   - cirrhosis

Question 10

What does CD resemble?

Answer 10

Microperforation ressembles appendicitis

Question 11

What are the clinical patterns of CD?

Answer 11

1. Inflammation
   - ileocecal region
   - pain
   - tenderness
   - diarrhoea
   - low grade fever
   - weight loss
2. Obstruction
   - due to transmural inflam = fibromuscular prolif + collagen deposition in walls = narrowing
   - post-prandial cramps
   - distention
   - borborygmi (mumbling)
   - vomiting
   - weight loss
3. Fistulization
   - Enteroenteric - may be asymptomatic
   - Enterovesical - recurrent UTIs, pneumaturia
   - Retroperitoneal - psoas abscess signs
   - Enterocutaneous
   - Perianal
   - Rectovaginal

Question 12

What are the complications CD?

Answer 12

• ENTEROVESICAL FISTULA
  (earliest + most pathological sign = pneumaturia)
• PERIANAL FISUTLA + ABSCESS
  (arises from crypts of Morgagni in anus + spreads through internal sphincter muscle to give rise to abscess)

Question 13

What are distinguishing features of CD?

Answer 13

• Small bowel movement
• Non-bloody diarrhoea
• Perianal disease
• Skip + Focal lesions
• Granulomas
• Fistulisation

Question 14

What is the differential diagnosis between IBD and IBS?

Answer 14

Clinical features which are all ABSENT in IBS:

• Anaemia, increased platelets, increased sed rate, decreased albumin
• Weight loss, fever
• Perianal disease
• Bloody stools, tenesmus
• Fecal WBC, occult blood

Question 15

Which IBD are genetic influences greater in?

Answer 15

Crohns

Polygenic

Question 16

What are the environmental risk factors in IBD?

Answer 16

• Smoking protects in UC and worsens in CD
• Appendectomy protects in UC (prior to onset)
• High sanitation in childhood positively associated with Crohns

Question 17

How is UC treated?

Answer 17

ACTIVE:

• Mesalazine (5-aminosalicylic acid)
• Corticosteroid (ST)
• Anti-TNF

REMISSION:
- Mesalazine 
- Azathioprine (immunosuppressive) 
- Anti-TNF
- Vedolizumab (immunosupressive)
Tofactinib (immunosuppressive)

Question 18

How is Crohn’s treated?

Answer 18

ACTIVE:

• Budesonide (locally active corticosteroid)
• Dietary therapy (children)
• Antibiotics (perianal disease)
• prednisolone (sysemically active corticosteroid)
• Anti-TNF

REMISSION:

• Azathioprine
• Methotrexate (immunosuppressive)
• Anti-TNF
• Vedolizumab
• Ustekinumab (immunosupressive)

Question 19

What are the surgical options for UC?

Answer 19

Colectomy with:

1. Conventional ileostomy OR
2. Ileal pouch-anal anastomosis

Question 20

What are the surgical options for Crohn’s disease?

Answer 20

Resect diseases area if complications or failure to respond to drug therapy:

1. Ileocaecal resection - disease can recur, usually upstream of join
2. Colectomy - requires ileostomy = stoma