Inflammatory Bowel Disease Flashcards
1
Q
what two conditions make up inflammatory bowel disease
A
- Crohns disease
- ulcerative colitis
2
Q
What is the definition of inflammatory bowel disease
A
- chronic condition
- idiopathic
- relapsing and remitting
- made up of inflammatory disorders of the GI tract
3
Q
Where does IBD tend to present in more developed or undeveloped countries
A
more in developed countries
4
Q
What is NOD2
A
- Immune cells in the body that protects against inflamming pathogens
5
Q
if you have a NOD2 mutation what are you at risk of
A
- developing IBD
6
Q
how is the hygiene hypothesis lead to IBD
A
- increase in hygiene has caused an rise in autoimmune conditions
- this is because we are not exposed to pathogens in the same way as we were before
7
Q
How is smoking related to IBD and what is its difference between crohns and UC
A
Crohns
- accelerates disease progression
- less likely to respond to treatment
- smoking cessation effective is an effective treatment
UC
- onset of UC follows smoking cessation
- nicotine patches are as effective as 5ASA
8
Q
What lifestyle intervention is effective for crohns
A
- smoking cessation is an effective treatment
9
Q
what can you take that is as effective as 5ASA in UC
A
nicotine patches are as effective as 5ASA
10
Q
describe the gut brain axis
A
- Brain and the gut are linked
- stress can play a role in gut disorders
- by reducing stress you can reduce the inflammatory response
11
Q
What are drugs that initiate relapse in IBD
A
- NSAIDs
- oral contraceptives
- opioids (loperamide, codeine)
- antibiotics
12
Q
how can diet effect IBD
A
- diet can play a role
- precise factors is unknown
- elemental/polymeric liquid diet is best
13
Q
what are the likely diet suspects in IBD which can cause IBD
A
- high animal fat diet
- low fibre intake
- emulsifiers and thickeners
- may alter gut microbiome
14
Q
How are physical inactivity and IBD linked
A
Regular active exercise reduces risk of
- developing crohns but not UC
- relapse of crohns and possibly UC
15
Q
what is the epidemiology of UC
A
- UK 13.9 per 100,000
- black SA 0.6 per 100,000
16
Q
What is the cause of ulcerative colitis
A
- inappropriate immune response against colonic flora in genetically susceptible individuals
17
Q
What is the onset of ulcerative colitis
A
- peak 20-40
- second peak is greater than 60
- both men and women get it equally
18
Q
describe the genetic component of UC
A
- monozygotic twins - 13%
- dizygotic twins - 2%
19
Q
what are the three types of ulcerative colitis
A
- left sided colitis
- pretosigmoiditis
- proctitis
20
Q
what area does ulcerative colitis affect
A
- colon and rectum only
- almost always rectum with variable proximal extent
21
Q
Where is the inflammation limited to in ulcerative colitis
A
- limited to the lamina propria
22
Q
What are the symptoms of UC
A
- Bloody and mucus diarrhoea
- Urgency
- Tenesmus - cramping rectal pain
- Abdominal pain particularly in the left lower quadrant
- Extra intestinal features
- Fever, malaise, weight loss
23
Q
what are the signs of UC
A
- tender abdomen - usually in the LIF generally mild
- pallor - anaemic
- tachycardia
- leuconychia - due to malnutrition
- extra intestinal manifestations
- fever
24
Q
How do you investigate UC
A
bloods
- anaemia - typically microcytic
- low ferritin
- low albumin
- raised inflammatory markers - CRP, ESR, Faceal calprotectin, thrombocytosis
plain AXR - shows dilated bowel and drainpipe colon
Lower GI endoscopy and then colonoscopy once patient stable
25
what is faceal calprotectin a marker for
inflammatory marker expressed by immune cells lining the cell wall that re expressed by neutrophils
26
what is the gold standard for diagnosis for IBD
endoscopy
27
Name the medications used in treatment of IBD
- steroids in the acute phase but never used as a maintenance
Maintenance
- 5ASA - mesalazine - 1st line
- probiotics - VSL, E.coli nissle
- azathioprine - moderate to severe
- methotrexate
Anti- TNF
- infliximab
- adalimumab
- Golimumab
Anti-intergrin
- vedolizumab
JAK inhibitors
- tofacitinib
surgery - lifetime risk of 15% in UC, 70% in crohn's - have to have the whole bowel removed
28
What is the first line treatment for UC
- 5ASA - mesalazine (aminosalicylate)
29
how do anti-intergrin work
- block homing molecules on peripheral lymphocytes which then bind to adhesion molecules within the endothelial layer of the blood vessel, blocks lymphocytes from going across the endothelial layer
30
Describe the treatment pyramid for UC (basic)
1st
- mesalazine - oral and topical
2nd
immunomodulators
- azathioprine and 6-mercaptopurine
3rd
- Anti- TNF = infliximab, adalimumab
- Anti-integrins - vedolizumab
- JAK inhibitors - Tofacitinib
31
describe the epidemiology of Crohn's disease
5.9-9.8 per 100,000
32
What is Crohn's disease
it is a chronic inflammatory disease characterised by transmural granulomatous inflammation affecting any part of the gut from out to anus
- especially affects terminal ileum in 70%
33
what is the average age of crohns disease
- Median age of onset is 30
- peak incidence is between 15-30
- men and women get it equally
34
What are the symptoms of crohns
- depends on where the disease is - large itnestine or terminal ileum
35
where is the most common area for crohns disease
terminal ileum
36
if crohns disease is in the terminal ileum what is the commonest symptom
pain
37
If crohns disease is in the colon what is the symptoms
diarrhoea and urgency
38
Why do you feel pain with crohns disease and whats the difference in ulcerative colitis
Transmural condition therefore there is nerve pain
- inflammation goes completely through the wall
- in ulcerative colitis the inflammation is limited to the epithelium and the lamina therefore nerve endings are not stimulated and pain is not felt
39
What are the symptoms of crohn's disease
Pain
Diarrhoea
- abdominal pain and diarrhoea
PR blood loss
weight loss
fistulae/abscesses
perianal disease
oral symptoms
EIM
fatigue, fever, malaise, anorexia
40
What are the signs of crohns
- abdominal tenderness
- bowel ulceration
- strictures
- mass
- scars
- stoma bag
- fistulae
- abscesses
- malnutrition
- (oral ulceration)
- clubbing, skin, joints and eye problems
41
how does crohns disease progress
- scaring and permanents scaring of the bowel
| - perforate the whole way through the wall
42
70% of crohns patients...
undergo surgery within the first 10 years
43
How do you investigate Crohns disease
Bloods
- anaemia - microcytic
- low ferritin, folate, B12
- raised inflammatory markers
- low albumin
faeces
- MC and S
- OC&P
- Faecal calprotectin
plain AXR
- loops of small bowel
- megacolon
barium following through
- stritures
- rose thorn ulcers
CT
- terminal ileal thickening
- abscesses. - think of the age of the patient
MRI
- small bowel
- pelvic/perianal sepsis
Endoscopy
44
What is the inflammation like in crohns
non caseaed granula
45
How do you induce remission in Crohn's disease
1st line
- Glucocorticoids (oral, topical or IV) are used to induce remission
- Eternal feeding can be used in addition
2nd line
- 5ASAs such as mesalazine are used as 2nd line as they are not as affective
Add on
- Azathioprine or mercaptopurine (methotrexate can be used as an addition to azathioprine)
- Infliximab is useful in refractory disease and fistulating Crohn’s
- Metronidazole is often used for isolated peri-anal disease
46
What are the extra-intestinal features of IBD
inflammation on
- skin
- eyes
- joints
- liver
complications
- anaemia
- thrombosis
- urinary stones
- gallstones
- osteoporosis
- liver complication - primary sclerosising cholangitis
47
Name some skin extra intestinal features of IBD
- erythema nodosum
| - pyoderma gangrenosum
48
Name some eye extra-intestinal features of IBD
- episcleritis
| - uveitis - emergency
49
Name some joint features of extra-intestinal IBD
- Sacroilitis and ankylosing spondylitis
- large joint arthropathy
- small joint arthropathy
50
Name some liver features of extra-intestinal IBD
Primary sclerosing cholangitis
- itching, jaundice
- risk of cancer of bile duct and colon
- fatty liver
- autoimmune hepatitis
51
what is the risk of colon cancer with IBD
1-4 times increase in risk of CRC
52
How do you diagnose IBS
IBS should be considered if the paitent has had the following for at least 6 months
- Abdominal pain
- Bloating
- Change in bowel habit
Positive diagnosis should be made if
Patient has abdominal pain relieved by defecation in addition to 2 of the following:
- Altered stool passage (straining, urgency, incomplete evacuation)
- Abdominal bloating (more common in women than in men), distension, tension or hardness
- Symptoms made worse by eating
- Passage of mucus
53
What are the symptoms of IBS
- Diarrhoea or constipation or mixed
- Abdominal pain until defecation
- Bloating
54
What investigations are used in IBS
- FBC
- ESR/CRP
- Coeliac disease screen
55
What are the tests that happen in IBS
Normal everything
- Normal FBC
- CRP
- Coeliac screen
- haemetinics
- TFTs
- normal faecal calprotectin
56
what are the differntial diagnosis for IBD
- coeliac disease
- bile salt malabsorption
- parasitic infection
- small intestinal bacterial overgrowth
- NETs - fasting gut homrones
- hyperthyrodism
- carcinoid syndrome
57
How do you treat IBS
- Pain - antispasmodic agent
- Constipation – laxtatives
- Diarrhoea – loperamide
- Reassurance
- FODMAP
- Sparing use of anti spasmodics
- CBT
- Antibiotics in some
- Probiotics
- Anti-depressants
- Regular meals, avoid long gaps between eating, 8 cups of fluid a day
58
Describe the pathology for ulcerative colitis
- hyperaemic/haemorrhagic colonic mucosa and pseduopolyps formed by inflammation
- punctate ulcers may extend deep into lamina propriety - but is not transmural
- continuous inflammation limited to the mucosa differentiates from Crohn's disease
59
What are the extra intestinal manifestations for ulcerative colitis
Eyes
- anterior uveitis
- iritis
- episcleririts
- conjunctivitis
Joints
- type 1 (pauciarticular) arthropathy
- type II (Polyarticular) arthropathy
- arthralgia
- ankylosing spondylitis
- inflammatory back pain
Skin
- erythema nodosum
- pyoderma gangrenous
Liver and biliary tree
- sclerosing cholangitis
- fatty liver
- chronic hepatitis
- cirrhosis
- gallstones
- Venous thrombosis
60
What criteria is used to work out the severity of UC
- Truelove and Witts Criteria
61
describe the truelove and Witts criteria
- Motions/day
- rectal bleeding
- Temperature
- resting HR
- Hb
- ESR
Mild UC
- Motions/day = less than 4
- rectal bleeding = small
- Temperature = apyrexial
- resting HR = less than 70bpm
- Hb = >110 g/L
- ESR = <30
Moderate UC
- Motions/day = 5
- rectal bleeding = moderate
- Temperature = 37.1 - 37.8 degrees
- resting HR = 70-90bpm
- Hb = 105-110g/L
- ESR
Severe UC
- Motions/day = greater than 6
- rectal bleeding = large
- Temperature = >37.8 degrees
- resting HR = greater than 90bpm
- Hb = <105g/L
- ESR = >30 or (CRP >45mg/L)
62
What are the acute complications of UC
- toxic megacolon - mucosal islands, colonic diameter >6cm and risk of perforation
- VTE
- hypokalaemia
63
What are the chronic complications of UC
- Colon cancer - risk related to disease extent and activity - 5-10% with pancolitis for 20 years
- may occur in flat, normal looking mucosa
- to spot precursors of dysplasia, surveillance colonoscopy e.g. 1-5 years with multiple random biopsies or biopsies guided by differential uptake by abnormal mucosa of dye sprayed endoscopically
64
Describe the treatment for severe UC
Admit for:
1. IV hydration/electrolyte replacement
2. IV steroids, eg hydrocortisone 100mg/6h or methylprednisolone 40mg/12h
3. Rectal steroids, eg hydrocortisone 100mg in 100mL 0.9% saline/12h PR
4. VTE prophylaxis
5. Ensure multiple stool MC&S to exclude infection
Then:
- Monitor T°, HR and BP
- Record stool frequency/character on stool chart
- Twice-daily exam: document distension, bowel sounds, tenderness
- Daily FBC, ESR, CRP, U&E ± AXR
- Consider blood transfusion – eg if Hb<80g/L
- If on day 3-5 CRP>45 or >6 stools/d action is needed!= Rescue therapy with ciclosporin or infliximab – can avoid colectomy but involve surgeons early
- If improving, transfer to prednisolone 40mg/14h PO; schedule maintenance infliximab if used for rescue, or azathioprine if ciclosporin rescue
- If fails to improve then urgent colectomy by 7-10d = Challenge is to not delay surgery so long as to accumulate significant steroid exposure and debilitation that will delay post-surgical recovery
65
What are the side effects of azathioprine
- abdominal pain
- nausea
- pancreatitis
- leucopenia
- abnormal LFTs
66
Name the types of surgery that is used in UC
- total proctocolectomy
- restorative proctocolectomy with iliac pouch-anal anastomosis (IPAA)
- Abdominal colectomy with ileorectal anastomosis
- proctocolectomy and Kock pouch
67
describe a total proctocolectomy
- Curative – resection of the entire colon, rectum and anus
| - Patients will require a permanent ileostomy
68
Describe restorative proctocolectomy with ideal pouch-anal anastomosis
- Resection of the colon and rectum and the creation of an ileal pouch, which is then anastomosed to the anus to maintain faecal continence
- Favoured procedure in many patients
- Pouch opening frequency may still be around 6 times a day, and infections can occur causing pouchitis
69
Describe abdominal colectomy with ileorectal anastomosis
- abdominal colon with creation of an ileorectal anastomosis preserving sphincter control
- often preferred by patients wishing to avoid a permanent stoma and an IPAA
- Contraindicated in active rectal disease
70
Describe proctocolectomy and Kock pouch
- Creation of an ileal pouch with a valve to render the pouch continent, which has to be emptied 2-4 times daily but circumvents the need for an external appliance
- Mainly used in patients seeking an alternative to ileostomy, or after failed IPAA, and is also suitable for patients who have previously undergone ileostomy if they are unhappy with the permanent stoma
71
what urgent surgery is required in UC and preferred
- abdominal colectomy and Brooke ileostomy with rectal preservation (allowing subsequent IPAA) is the procedure of choice
72
What is the causes of Crohn's disease
- inappropriate immune response against colonic flora in genetically susceptible individuals
73
What is Crohn's disease associated with
- increase in smoking by 3-4 times
| - NSAIDs may exacerbate the disease
74
What are the complications of Crohn's disease
- small bowel obstruction
- toxic megacolon and risk of perforation
- Abscess formation - abdominal, pelvic, perianal
- fistula - e.g. enters-enteric, colovesical, colovaginal, perianal, enter-cutaneous
- colon cancer
- PSC
- malnutrition
75
what is the general management of Crohn's disease
- help quit smoking
- optimise nutrition
- assess severity
76
How do you treat severe Crohn's disease
Admit for:
1. IV hydration/electrolyte replacement
2. IV steroids, eg hydrocortisone 100mg/6h or methylprednisolone 40mg/12h
3. VTE prophylaxis
4. Ensure multiple stool MC&S to exclude infection
Then:
- Monitor T°, HR and BP
- Record stool frequency/character on stool chart
- Daily exam, FBC, ESR, CRP, U&E ± AXR
- Consider blood transfusion (eg if Hb<80g/L) and need for nutritional support
- If improving transfer to prednisolone 40mg/14h PO
- If not improving consider biologic therapies
- Consider abdominal sepsis complicating Crohn’s disease esp if abdo pain – US, CT, MRI used to assess this; seek surgical advice
77
What are the indications for Crohn's disease surgery to take place
- drug failure
- GI obstruction from stricture
- perforation
- fistulae
- abscess
78
What are the surgical aims of Crohn's disease
- resection of affected areas - but beware of short bowel syndrome
- control perianal or fistulising disease
- defunction (rest) distal disease e.g. with temporary ileostomy
79
What are poor prognosis indicators of Crohn's disease
- Age <40 years old
- steroids needed at 1st presentation
- perianal disease
- isolated terminal ileitis
- smoking
80
what is the treatment for perianal disease
- oral antibiotics
- immunosuppressant therapy +/- anti- TNF alpha
- and local surgery +/- seton insertion
81
What is a toxic megacolon
- this occurs when the swelling and inflammation spread into the deeper layers of the colon, therefore the colon stops working and widens, it can rupture in serve cases
82
Define acute flare
- period of active disease within an IBD
- time of active disease can vary and you also have periods of remission when the disease is not active between flare ups
83
What is the pain management for IBD
- consider paracetamol first line
- avoid NSAIDs as they may aggravate colitis symptoms
- be aware that opiate analgesia may increase the risk of developing a toxic megacolon
84
What monitoring takes place of UC and Crohn's disease
- colorectal cancer surveillance - has a colonoscopy screening if diagnosed 10 years or more ago
- children and young people have their growth and pubertal development monitored regularly
- monitor serum ferritin, B12 and folate, vitamin D
- ensure they receive appropriate vaccinations
85
What is the most common affected site of UC
the rectum
86
When should you use oral azathioprine in UC
Follow a severe relapse or >=2 exacerbations in the past year
- Oral azathioprine or oral mercaptopurine
87
describe the NICE guidelines for the treatment for UC for:
- Proctitis
- proctosigmviditis and left sided ulcerative colitis
- extensive disease
Proctitis
- Topical (rectal) aminosalicylate = mesalazine (5ASA)
- If remission still not achieved then add a topical or oral corticosteroid
Proctosigmoiditis and left sided ulcerative colitis
- Topical (rectal) aminosalicylate = mesalazine (5ASA)
- If remission not achieved within 4 weeks then add a high dose oral aminosalicylate or switch to a high dose oral aminosalicylate and a topical corticosteroid
- If remission still not achieved then stop topical treatments and offer oral aminosalicylate and an oral corticosteroid
Extensive disease
- Topical (rectal) aminosalicylate = mesalazine (5ASA) and a high dose oral aminosalicylate
- If remission still not achieved within 4 weeks then stop topical treatments and offer oral aminosalicylate and an oral corticosteroid
88
Describe the NICE guiltiness for the maintenance of remission in UC for:
- Procitits and proctosigmviditis
- left sided and extensive ulcerative colitis
Proctiits and proctosigmoiditis
- Topical (rectal) aminosalicylate alone or
- An oral aminosalicylate plus a topical aminosalicylate
- An oral aminosalicylate by itself
Left sided and extensive ulcerative colitis
- Low maintenance dose of an oral aminosalicylate
89
What is the microscopic pathology for UC
- Red raw mucosa that bleeds easily
- No inflammation beyond submucosa
- Widespread ulceration with preservation of adjacent mucosa which has appearance of polyps
- Inflammatory cells infiltrate into lamina propria
- Neutrophils migrate through the walls of glands to form crypt abscesses
- Depletion of goblet cells
- Granulomas are infrequent
- Drainpipe colon
90
What medication is used in the maintenance of remission in Crohn's disease
- Stopping smoking
1st line
- Azathioprine or mercaptopurine is 1st line
2nd line
- Methotrexate
Others
- 5ASA should be considered if patient has had previous surgery
91
What is faecal calprotectin used to test for
tests for inflammation in the bowel such as IBD
