Inflammatory Bowel Disease Flashcards
Two types of extra-intestinal manifestations of IBD?
Type 1: pauciarticular(4 or less joints involved)
Type 2: polyarticular
Describe Type 1 of extra-intestinal manifestations of IBD?
Attacks are acute and self-limiting (<10 weeks), associated with other extra-intestinal manifestations of IBD activity
Describe type 2 of extra-intestinal manifestations of IBD?
Arthropathy lasts longer (months to years), is independent of IBD activity and usually associated with uveitis
Eye manifestations of IBD?
Uveitis
Episcleritis, conjunctivitis
Joint manifestations of IBD?
Arthritis
Seronegative arthropathy
Skin manifestations of IBD?
Erythema nodosum
Pyoderma gangrenosum
Clubbing
Liver and biliary tree manifestations of IBD?
Primary sclerosing cholangitis Fatty liver Chronic hepatitis Cirrhosis Gallstones
What is Crohn’s disease?
Chronic inflammatory condition which may affect the whole git but tends to affect the terminal ileum and ascending colon.
Can involve 1 small area of gut or have skip lesions or whole colon
Histology of bowel involved in Crohn’s disease?
Bowel normally thickened and narrowed
Cobblestone appearance
Inflammation is transmural: extends all area of the bowel
Who gets Crohn’s disease?
- Jewish people
- White people
- Young people
- 1/4 diagnosed are kids
- People with family history
- Smokers
- NSAIDs
- Appendectomy increases risk
How does Crohn’s generally present?
Diarrhoea (containing blood if colonic disease)
Abdominal pain
Perianal disease
How does Crohn’s of small intestine present?
- Abdominal cramps
- Diarrhoea
- Wt loss
How does Crohn’s in the colon present?
Abdominal cramps
Diarrhoea with blood
Wt loss
Mouth crohn’s presents as?
Painful ulcers
Swollen lips
Angular chellitis
Anus Crohn’s presents as?
Peri-anal pain and abscesses
When should Crohn’s be considered?
Should be considered in all individuals with evidence of vitamin malabsorption and children with reduced growth velocity and diarrhoea
Clinical evidence for Crohns?
Evidence of weight loss
RIF mass
Peri-anal signs
Blood tests for Crohn’s?
Anaemia Raised ESR and CRP Hypoalbuminaemia Liver biochem Blood cultures (suspected septicaemia) Serological tests
Stool tests for Crohn’s?
Diarrhoea- C. Difficile toxin assay should be done
Microscopy for parasites in patients with travel
Faecal calprotectin and lactoferrin
Imaging tests for Crohn’s?
- Colonoscopy
- Upper GI endoscopy (to exclude oesophageal and gastroduodenal disease) define extent
- Small bowel imaging (mandatory)
- US scanning
- Perianal MRI
- Capsule endoscopy
Severity of CD can be assessed with?
Haemoglobin
WCC
Inflammatory markers (ESR, CRP, platelets)
Serum albumin
lifestyle Treatment of CD?
Lifestyle
STOP SMOKING it aggravates
Diet
Medical treatment of CD?
Oral or IV glucocorticosteroids (pred, budesonide)
Enteral nutrition
Immunosuppressants
Anti tumour necrosis factor (TNF) antibodies: promote apoptosis of activated T lymphocytes
IV fluids
Examples of anti tumour necrosis factor (TNF) antibodies?
Infliximab IV
Adalimumab SC
Certolizamub pegol
Maintenance of remission of CD?
Azathioprine
Mercaotopurine (all immunosuppressants)
Methotrexate
Anti- TNF antibodies
Perianal disease management?
Surgical drainage of sepsis
Ciprofloxacin & metronidazole
Azathioprine
Surgical treatment of Crohn’s?
Should be avoided as not curative Indications for surgery: -Failure of medical therapy -Failure to grow in children -peri-anal sepsis
Type of surgeries for CD?
Stricturoplasty- widening of strictures
Resection
Anastamosis
Ileocolonoscopy to prevent disease recurrence
Problems with ileostomy?
Mechanical problems Dehydration Psychosexual problems Erectile dysfunction Recurrence of CD
Risk of CD?
Gallstones
Malabsorption
Bowel obstruction
Increased risk of colorectal cancer & oestoporosis
Anal and peri-anal complications of CD?
Fissure in ano Haemorrhoids Skin tags Perianal abscess Ischiorectal abscess Fistula in ano Anorectal fistulae
What is Ulcerative Collitis?
IBD which affects the colon, can affect the rectum alone or can extend proximally to involve the different parts of the colon up to the whole colon + possible terminal ileum
Histology of UC?
Inflammation is superficial, limited to the mucosa, including chronic inflammatory cell infiltrate in the lamina propria
NO SKIP LESIONS
Granulomas are very rare in UC
What is UC inflammation mediated by?
TH1/TH2 natural killer cells
Who gets UC?
People with Fam history NSAIDs Appendectomy decreases risk Young people NON SMOKERS
How does UC present?
DIARRHOEA WITH BLOOD + MUCOUS Lower abdo pain Malaise/fatigue Lethargy Anorexia Wt loss Aphthous ulceration Less severe symptoms than CD Slightly distended abdomen Tachycardia & pyrexia (if severe) Rectal exam shows blood
How is UC diagnosed?
Severe: 6 stools with a lot of blood, fever>37.5, >90bpm, erythrocyte sedimentation rate >30mm/h, <100g/L haemoglobin and <30g/L albumin
Blood tests for UC?
WCC & platelet counts
ESR and CRP- raised, liver biochemistry abnormal, hypoalbuniaemia
pANCA- positive contrary to CD
Albumin
Gold standard for UC?
Endoscopy with mucosal biopsy
How is severe UC treated?
Exclude enteric infection Admit to hospital Confirm diagnosis sigmoidoscopy Assess fluid status Prophylactic anticoagulation (LMWH) IV hydrocortisone Monitor daily
Treating general UC?
Corticosteroids for acute attacks Aminosalicylates IV Fluids Immunosuppressants Anti-TNF therapy
Treating proctitis?
Rectal 5-ASA suppositories = first line
Topical steroids
Oral 5-ASA prednisalone
Oral pred for those who don’t respond
Surgical management of UC?
Can be curative
Laproscopic surgery
Permanent ileostomy & ileo-anal pouch
Risk factor of severe colitis?
Toxic Megacolon
- abdominal x ray will show dilated thin-walled colon with a diameter >6m, which is gas filled and has mucosal islands
HIGH RISK OF PERFORATION AND DEATH
Other risks of UC?
Primary sclerosing cholangitis
Prognosis?
1/3 patients will undergo colectomy within 20 years of diagnosis
Mouth manifestations of IBD?
Ulcers
Stomatitis
Where can Crohn’s affect?
Anywhere from mouth to anus
What is different about treatment of UC and CD?
CD you do not use 5 ASA in
IV steroids are used to?
Reduce severe flares
General medications for IBD?
Corticosteroids
Immunosuppression
Anti-TNF
Surgery
