Inflammatory Bowel Disease

Question 1

Inflammatory bowel disease mainly comprises of two idiopathic chronic inflammatory diseases - what are they?

Answer 1

Crohn’s disease

Ulcerative colitis

Question 2

Which 3 factors link together in the pathogenesis of IBD?

Answer 2

Genetic predisposition
Impaired mucosal immunity
Environmental triggers

Question 3

There is a stronger genetic link in UC than Crohn’s disease. True/False?

Answer 3

False

Stronger genetic link in Crohn’s (36%) than UC (16%)

Question 4

Which gene is susceptible to mutation which causes inflammatory bowel disease?

Answer 4

NOD2 (IBD-1) on chromosome 16

Encodes protein involved in bacterial recognition

Question 5

Crohn’s disease a TH1/TH2/TH1+TH2 mediated disease

Answer 5

TH1-mediated disease

Question 6

UC is a TH1/TH2/TH1+TH2 mediated disease

Answer 6

(mixed) TH1 + TH2 -mediated disease

Question 7

Smoking aggravates Crohn’s disease + UC. True/False?

Answer 7

False

Aggravates Crohn’s but no effect on/may even protect UC

Question 8

Which age range is typical peak incidence of UC?

Answer 8

20-40s but variable

Question 9

Where does the inflammation start in UC?

Answer 9

Rectum

Question 10

Does UC produce skip lesions?

Answer 10

No

Continuous proximal inflammation from rectum to stop point

Question 11

List typical symptoms of UC

Answer 11

Diarrhoea + bleeding
Increased bowel frequency
Urgency, tenesmus, incontinence
Night rising
Lower abdo pain (LIF)

Question 12

Define severe UC

Answer 12

>6 bloody stools/day + 1 of:
Fever
Tachycardia
Anaemia
Elevated ESR

Question 13

What is the classic sign of mucosal inflammation/oedema on an AXR?

Answer 13

Thumbprinting

Question 14

How does toxic megacolon arise?

Answer 14

Persistent inflammation causes loss of muscle tone of the colon, resulting in distention

Question 15

What are some extra-intestinal manifestations of UC?

Answer 15

Primary sclerosing cholangitis
Apthous ulcers
Erythema nodosum
Uveitis

Question 16

Which age range is typical for Crohn’s disease?

Answer 16

Young children to 40 year olds

Question 17

The inflammation in Crohn’s and UC is transmural, i.e. it breaches the mucosa and goes beyond muscle layer. True/False?

Answer 17

False

Inflammation in Crohn’s is transmural; inflammation in UC is confined to mucosa/submucosa

Question 18

Does Crohn’s disease produce skip lesions?

Answer 18

Yes

Can affect anywhere from mouth to anus

Question 19

Can fistulas occur in Crohn’s and UC?

Answer 19

Yes

Leads to abscess formations, especially peri-anally

Question 20

Symptoms of Crohn’s disease are dependent on where the disease occurs. List some common symptoms

Answer 20

Abdominal cramps
Diarrhoea
Weight loss
Painful ulcers
Abscesses

Question 21

How common is granuloma in Crohn’s disease?

Answer 21

50% of patients

Question 22

Where does Crohn’s disease most commonly occur?

Answer 22

Terminal ileum

Colon

Question 23

Fissures are associated with which IBD - Crohn’s or UC?

Answer 23

Crohn’s disease

Deep, knife-like fissures

Question 24

List some complications of Crohn’s disease

Answer 24

Malabsorption
Short bowel syndrome
Vitamin deficiencies, anaemia
Fistulas

Question 25

What are the 4 treatments available (excluding surgery) for UC and Crohn's disease, in order of step-up therapy?

Answer 25

5-ASA (mesalazine - UC ONLY) Steroids Immunosuppression Anti-TNF drugs

Question 26

How can mesalazine be administered?

Answer 26

Orally | Topically as a rectal suppository/enema

Question 27

What is the main action of mesalazine?

Answer 27

Anti-inflammatory

Question 28

Mesalazine can be given in an oral form that is "pH-dependent" - what does this mean?

Answer 28

Only activates at a certain pH; in this case, would only activate in the presence of the pH of the colon

Question 29

What is the advantage of a mesalazine topical enema over a suppository?

Answer 29

Enema extends action to sigmoid colon

Question 30

What is the advantage of a mesalazine topical suppository over an enema?

Answer 30

Suppository has better mucosal adherence

Question 31

If mesalazine is ineffective/patient continues to experience symptoms, which class of drugs is prescribed? Give an example of the class of drug used

Answer 31

Steroids | Oral/topical prednisolone/budesonide

Question 32

Steroids are given for a long course in IBD. True/False?

Answer 32

False

Question 33

Is increasing or reducing dosage of steroids given for IBD?

Answer 33

``` Reducing dose (start high and reduce over 6-8 weeks) ```

Question 34

When a more potent suppression of inflammation than steroids is required, which class of drugs is prescribed? Give an example of this class of drug

Answer 34

Immunosuppression | Azathioprine, Methotrexate

Question 35

Which class of drug is used after immunosuppression? Give an example of a drug of this class

Answer 35

Anti-TNF drugs | IV Infliximab

Question 36

Anti-TNF has become the mainstay of treating Crohn's disease. When is it mainly used, according to NICE?

Answer 36

Long-term management Refractory/fistulating disease BUT NOT IN PRESENCE OF TB

Question 37

What are "planned" surgical procedures for IBD in cases of emergency?

Answer 37

``` Subtotal colectomy (leave rectum) in UC Resection in Crohn's disease ```

Question 38

List elective surgery for Crohn's disease

Answer 38

Resection Stricturoplasty Fistula repair

Question 39

List elective surgery for UC

Answer 39

Proctocolectomy with end ileostomy Proctocolectomy with ileorectal anastomosis Proctocolectomy with pouch

Question 40

What is an ileostomy?

Answer 40

Small intestine is diverted to an opening in the abdomen and a bag is placed externally to collect waste products

Question 41

What is a pouch? (AKA ileo-anal pouch; J/W/S pouch)

Answer 41

Loops of small intestine are folded and stapled on itself to create a reservoir, restoring normal function of the rectum

Question 42

Surgery for UC is well tolerated. True/False?

Answer 42

True | Most live well with a stoma

Question 43

Surgery for Crohn's is well tolerated. True/False?

Answer 43

False