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Yr3 Medicine- Gastroenterology > Inflammatory Bowel Disease > Flashcards

Inflammatory Bowel Disease Flashcards

1
Q

IBD is an umberella term for what two main diseases?

A
  • Ulcerative colitis
  • Crohn’s disease
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2
Q

At what age do pts with IBD commonly present?

A
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3
Q

Discuss whether smoking is associated with IBD

A
  • Crohn’s: smoking increases risk x3/4
  • UC: 3x more common in non-smokers
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4
Q

Compare and contrast crohn’s and UC, include:

  • Where it affects
  • Whether inflammation is continous or has skip lesions
  • Depth of inflammation
  • Colonscopy findings
  • Incidence in smokers
A
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5
Q

Which part of bowel is most commonly affected in crohn’s disease?

A

Terminal ileum

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6
Q

Does UC have perianal disease?

A

No, only crohn’s has perianal disease (inflammation at or near the anus including tags, fissures, fistulae, abscesses, or stenosis.)

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7
Q

State some risk factors for developing IBD

A
  • Age (15-40 or 60-80)
  • Family history of IBD
  • Family history of autoimmune diseases
  • White ethnicity
  • Smoking (ONLY IN CROHN’S)
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8
Q

Describe the symptoms of crohn’s and UC; highlighting any potential differences in symtpoms

A
  • Diarrhoea
  • Abdominal pain
  • Weight loss
  • Maleana
  • Steatorrhoea
  • Fatigue
  • Anorexia

Symptoms more likely in UC due to rectal involvement (but can occur in Crohn’s if there is rectal involvement):

  • Blood & mucus in stool
  • Tenesmus
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9
Q

State some clinical signs of IBD

A
  • Erythema nodosum
  • Pyoderma gangrenosum
  • Clubbing
  • Abdominal tenderness
  • Aphthous mouth ulcers
  • Conjunctivitis
  • Episcleritis
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10
Q

What does this image show?

A

Erythema nodosum: inflammation of fat cells under skin resulting in tender, erythematous paches or bumps on skin- most commmonly on anterior shins

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11
Q

What does this image show?

A

Pyoderma gangrenosum- painful inflammatory ulcers which most commonly develop on the legs

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12
Q

Discuss what investigations you would do if you suspect IBD, include:

  • Bedside
  • Bloods
  • Imaging
  • Others
A

Bedside

  • Faecal calportectin: marker of inflammation in intestines
  • Stool culture & sensitivity: exclude infection
  • DRE

Bloods

  • FBC: aneamia, infection, raised platelets
  • U&Es: renal func
  • LFTs: liver func
  • TFTs: thyroid func- hyperthyroidism can cause diarrhoea
  • CRP: inflammation
  • Ferritin, TIBC, transferrin saturation: Fe deficiency
  • B12: deficiency
  • Folate: deficiency

Imaging

  • AXR: check for signs of UC or crohns. Including complications
  • CT abdo: see above
  • MRI abdo: see above

Others

  • Colonoscopy, endoscopy, flexible sigmoidoscopy, capsule endoscopy, small bowel enema (crohns), barium enema (colitis) *Colonoscopy + biopsy often imaging of choice. I**n patients with severe colitis colonoscopy should be avoided due to the risk of perforation - a flexible sigmoidoscopy is preferred
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13
Q

Why is it important to check renal funcion in pts with IBD?

A

May hae deranged electrolytes or AKI due to GI losses

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14
Q

What is faecal calprotectin?

Is it specific to IBD?

A
  • Protein that is released by intestines when they are inflammed. Usually raised in active disease and negative in remission or in IBS.
  • Not specific to IBD
  • Shouldn’t be used in presence of blood as this requires further investigation. *Remember faecal occult test is test for blood in stool
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15
Q

Does a normal CRP exclude IBD?

A

NO

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16
Q

Why do you check for:

  • Fe studies
  • B12
  • Folate
  • … in suspected IBD?
A
  • Fe absorption occurs in duodenum & upper jejenum
  • B12 absorption occurs in terminal ileum
  • Folate absorption occurs in duodenum and jejenum

THEREFORE MORE LIKELY TO HAVE THESE DEFICIENCIES IN CROHN’S DISEASE

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17
Q

What investigations are used to diagnose IBD?

A
  • OGD (also known as endoscopy)
  • Colonscopy
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18
Q

What would you find on OGD and colonscopy in Crohn’s disease?

A
  • Cobblestone apearance
  • Skip lesions
  • Strictures
  • Fistulaes
  • Ulcers
  • Hyperaemia (red & inflammed bowel)
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19
Q

What would you find on colonscopy in UC (macroscopically)?

A
  • Continuous inflammation confined to colon
  • Lack of haustra (most likely seen on imaging)
  • Pseudopolyps (areas that are healing after inflammation)
20
Q

Describe the microscopic pathological appearance of crohn’s

A
  • Granulomas
  • Increased number of goblet cells
21
Q

Describe the microscopic pathological appearance of UC

A
  • Crypt abcesses
    • Irregular shaped glands
    • Dysplasia of glands
    • Darker crowded nuclei
  • Reduced number of goblet cells
  • Increased number of paneth cells
22
Q

Describe the appearance of UC on AXR

A
  • Thumbprinting
  • Pseudopolyps
23
Q

Pts admitted to hospital with acute IBD are at high risk of what…?

A

VTE therefore need prophylactic heparin

24
Q

State some potential triggers for UC flare

A
  • Smoking cessation
  • Stress
  • NSAIDs
25
Q

Discuss the management of Crohn’s disease, include:

  • Inducing remission
  • Maintaining remission
  • Surgery
A

Treatment of IBD is about inducing and then maintaining remission. ALL SHOULD BE ADVISED TO STOP SMOKING.

Inducing remission:

  • First line= steroids e.g. oral prednisolone, oral budenoside (small bowel disease), IV hydrocortisone, rectal suppositories
  • Enteral feeding is alternative to steroids when there are concerns about ADRs of steroids (e.g. children)
  • Second line= 5ASA drugs are second line to steroids but not as effective
  • Add on therapy (e.g. in addition to steroids): immunosupressant medication e.g. azathioprine, mercaptopurine
  • Metronidazole for isolated perianal disease

Maintaining remission:

  • First line: azathioprine, mercaptopurine
  • Second line: methotrexate, infliximab, adalimumab

Surgery:

  • Used to remove strictures, fistulas or severely diseased parts of bowel
  • Not curative
  • ~50-80% of pts with crohn’s will need surgery at some point in their life
26
Q

Discuss the management of UC, include:

  • Inducing remission
  • Maintaining remission
  • Surgery
A

Inducing remission

  • Mild-mod disease:
    • First line: aminosalicylate
      • Proctitis: rectal (if in 4 weeks remission not achieved add PO ASA.)
      • Proctosigmoiditis: rectal (if in 4 weeks remission not achieved add HIGH dose PO ASA)
      • Extensive disease: rectal and high dose PO ASA
    • Second line: corticosteroids
  • Severe disease:
    • First line: IV steroids
    • Second line: IV ciclosporin
    • Third line: surgery

Maintaining remission

  • First line: aminosalicylates (rectal only, rectal and PO, PO only)
  • Second line following severe relapse or >2 exacerbations past year: azathioprine or mercaptopurine
  • Third line: biologics
  • NOTE METHOTREXATE NOT RECOMMENDED

Surgery

  • May be used to treat severe disease
  • Can be curative (if remove the colon and rectum)
27
Q

What medications are useful in crohns patients with perianal disease?

A
  • Isolated perianal disease can use metronidazole (most pts with perianal disease given metronidazole)
  • Biologics/anti-TNF e.g. infliximab
  • May also have draining seton
  • Perianal abscesses need incision & drainage
28
Q

What dose of IV steroids would you give in acute IBD flare?

A

~100mg hydrocortisone QDS

29
Q

Why do pts on azathioprine, mercaptopurine and biologics to maintain remission require frequent monitoring?

A

All immunosupressants hence require frequent monitoring of FBC, U&Es, LFTs

30
Q

Describe the mechanism of action of azathioprine?

A

Drug class: antiproliferative

  • Broken down by liver into 6-Mercaptopurine
  • 6-Mercaptopurine broken down into TIMP
  • TIMP then converted into either:
    • 6-MeMPN (by TPMT): inhibits de novo synthesis of purines
    • 6-TGN: incorporated into DNA
  • Limits DNA & RNA synthesis hence prevents immune cell production
31
Q

What must you check before starting a pt on azathioprine?

A

TPMT levels

32
Q

Describe the mechanism of action of ciclosporin

A

Drug class: calcineurin inhibitor

  • Enter helper T cell
  • Bind to certain protein in cell
    • Ciclosporin bind to cyclophilin
    • Tarcolismus bind to tacrolismus binding protein
  • Drug-protein complexes bind to calcineurin and inhibit its phosphatase activity
  • Calcineurin would usually dephosphorylate cytoplasmic component of nuclear factors that in activated T cells would migrate to nucleus and induce transcription of genes such as IL2
  • If calcineurin phosphate activity inhibited then it can’t make cytoplasmic nuclear factor into a form that can cross nuclear membrane hence IL2 production inhibited
33
Q

Describe the mechanism of action of methotrexate

A

Mechanism of action in non-malignant disase unclear but we know it is not via usual folate mechanism. Possible mechanism include:

  • Inhibition of accumulation of adenosine
  • Inhibition of T cell activation
  • Supression of intracellular adhesion molecule expresin by T cells
34
Q

What must you give to pts who are prescribed methotrexate for non-malignant reasons?

A

Folate supplement

35
Q

What antibiotic can you NOT prescribe for someone on methotrexate?

A

Trimethoprim (both inhibit folate)

36
Q

Describe the mechanism of action of aminosalicyclates e.g. mesalazine

A

NOTE: mesalazine is also called 5ASA

  • Poorly absorbed
  • Anti-inflammatory effect in lumen

*IN IMAGE, ignore sulfapyridine part. Only have that part if you give sulfasalazine (which has both parts)

37
Q

Describe the mechanisms of biologics such as infliximab & adalimumab

A
  • Anti-TNF
  • Block actions of TNF-alpha (which is a proinflammatory cytokine)
38
Q

What must you test for before prescribing anti-TNF treatment?

A

TB (TST and IGRA) as TNF is required to maintain granulomas

39
Q

If a pt is having flare of UC and they are receiving rescue therapy (with ciclosporin or steroids) why is it important to involve surgical team and discuss surgery?

A

Around 50% pts receiving rescue therapy for acute UC won’t respond and will need surgery

40
Q

Discuss the surgery options for someone with UC if they wish to cure their disease

A
  • Panproctocolectomy: remove entire colon & rectum. Pt left with either ileostomy or an ileo-anal anastomosis (J-pouch)- ileum is folded back in on itself to form a larger pouch that fashions like a rectum. The pouch is then attached to anus and collects stools prior to passing a motion
41
Q

What is meant by IBD-U?

A
  • IBD unclassified
  • Inflammation only in colon but not sure if it is crohn’s or UC
  • Commoner in children. Usually becomes apparent later in life which it is: crohn’s or UC
42
Q

State some potential complications of IBD- think about which are more common in crohn’s and which are more common in UC

A

Crohn’s

  • Bowel obstruction (strictures)
  • Abscess formation
  • Fistulae
  • Malnutrition
  • Toxic megacolon
  • Anaemia

UC

  • Toxic megacolon- perforation- sepsis

Both

  • Gastro cancer
  • Other cancer (immunosupressants)
  • Infection (immunosupressants)
  • VTE
  • CVD
43
Q

IBD requires MDT management; state some members of MDT invovled

A
  • Gastro team: consultant, IBD nurse
  • Dietician
  • Dermatologist
  • Gynaecologist
  • Mental health team
44
Q

State two scoring systems used in Crohn’s disease

A
  • CDAI: crohn’s disease activity index
  • ECCO: European crohn’s & colitis organisation
45
Q

Why would you use the CDAI score?

What is included in scoring system?

A
  • Help assess disease severity and quality of life
  • Includes:
    • Weight
    • Ideal weight
    • Number of stools per day
    • Abdo pain
    • General wellbeing
    • Extra-GI manifestations
  • Score between 0-600+
46
Q

What scoring system is used for UC?

When would you use it?

What are some components of the scoring system?

A
  • Truelove & Witts
  • Help classify severity of UC
  • Patients with severe disease should be admitted to hospital

*Can think of severe as having features of systemic upset

Yr3 Medicine- Gastroenterology (8 decks)

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