Inflammatory Bowel Disease Flashcards
What is inflammatory bowel disease?
Chronic, relapsing, remitting inflammation of the GI tract
What are examples of inflammatory bowel disease?
Crohn’s disease
Ulcerative colitis
What do Crohn’s disease and ulcerative colitis differ in?
Location and inflammation
When does inflammatory bowel disease commonly present?
In the teens and twenties
What can IBD be due to?
Genome
Microbiome
Environment
Is IBD medelian inherited?
No, but has genetic susceptibility
What kind of genetic variation makes people genetically susceptible to IBD?
SNPs (single nucleotide polymorphisms)
What percentage of someones offspring who has IBD will also develop IBD?
10%
What do genes that cause inflammatory bowel disease regulate?
Epithelial barrier
Immune response
Bacterial handling
What is the pathogenesis of IBD?
Pathogenic gut causes altered microbiota
Damaged epithelial barrier increases bacterial adhesion and translocation
Chronic inflammation occurs
What is the ratio of microbial cells in the gut lumen to eukaryotic cells in the human body?
10:1
How many different species of bacteria are present in the gut?
At least 500 different species
What is the metabolic activity of all gut bacteria equivalent to?
That of the liver
What part of the gut contains the most bacteria?
Colon
What is different in the microbiota of people with IBD compared to those without?
In IBD there is a dysbosia in microbial communities
What kind of bacteria is massively more present in people with IBD than those who do not have it?
Proteobacteria
What is ulcerative colitis?
Chronic condition where the colon and rectum become inflammed
How does ulcerative colitis affect males compared to females?
Both affected the same
What are symptoms of ulcerative colitis?
Blood diarrhoea
Abdominal pain
Weight loss
Fatigue
What investigations are done for ulcerative colitis?
Bloods for markers of inflammation
Stool culture to rule out infection
Faecal calprotectin
Colonoscopy and colon mucosal biopsies
What are examples of markers of inflammation checked for in ulcerative colitis?
Normocytic anaemia
Increased CPR/platelets
Low albumin
What is considered normal faecal calprotectin?
<50ug/g of stool
What is considered elevated faecal calprotectin?
>200ug/g of stool
What is faecal calprotectin?
Substance that is released into the intestines when inflammation is present
Where in the GI tract is inflammation due to ulcerative colitis present?
Only in the colon, starting at the rectum and working proximally
What percentage of people with ulcerative colitis require a colectomy within 10 years of diagnosis?
20-30%
What are the different levels of severity of ulcerative colities?
Mild
Moderate
Severe
Fulminant
What are characteristics of mild ulcerative colitis?
<4 stools/day
With or without blood
Normal ESR
No signs of toxicity
What are characteristics of moderate ulcerative colitis?
4-6 stools/day
Occasional blood
Minimal signs of toxicity
CRP less than or equal to 30mg/L
What are characteristics of severe ulcerative colitis?
More than or equal to 6 blood stools/day
AND any of:
temperature > 37.8
tachycardia > 90bpm
anaemia (Hb < 105g/L)
ESR > 30mm/h, CRP > 30mg/L
What are characteristics of fulminant colitis?
10 stools/day
Continuous bleeding
Toxicity
Abdominal tenderness or distention
Transfusion requirement
Colonic dilation on x-ray
What is proctitis?
Condition where lining of tissue in inner rectum becomes inflammed
What is stool like with proctitis?
Frequency, urgency, incontinence
Small volume mucus, blood
Constipation
What does proctitis respond to?
Topical therapy
What percentage of mortality does acute severe colitis have?
2%, very serious condition
What percentage of people with acute severe colitis get an emergency colectomy at admission?
20-30%
What do patients with acute severe colitis often look like?
Well
Self-caring
Mobilising around ward
Often young with physiogical reserve
What is the main differential of acute severe colitis?
Infection
What must be done within the first 24 hours of a patient being admitted with acute severe colitis?
IV glucocorticosteroids
LMWH
Abdomen x-ray
IV hydration
Stop non-steroidal analgesics, opiates, anti-diarrhoels, anti-cholinergics
Stool chart
Stool culture for C. Difficile
Why are patients with acute severe colitis given LMWH?
They are at 3x increased risk of thromboembolism
What is Crohn’s disease?
Inflammatory bowel disease that causes inflammation in the digestive tract
Where can Crohn’s disease occur?
Anywhere in the GI tract from mouth to anus
Patchy disease (skip lesions)
Clinical features depend on regions involved
What are possible complications of Crohn’s disease?
Inflammation
Stricture
Fistula
What are clinical features of Crohn’s disease?
Diarrhoea
Abdominal pain
Weight loss
Malaise, lethargy, anorexa, nausea and vomiting, low grade fever
Malabsorption (anaemia, vitamin deficiency)
What investigations are done for Crohn’s disease?
Blood for markers of inflammation
Stool culture to rule out infection if dirrhoea
Faecal calprotectin
Colonoscopy with terminal ileum intubation and colon mucosal biopsies
MRI small bowel study
Capsule endoscopy
Occasionally CT if acutely unwell and want to rule out complications such as abscess
What are differences in the histology of Crohn’s disease and ulcerative colitis?
Granulomas in CD
Transmural inflammation in CD
Mucosal in UC
Goblet cells depleted in UC
Crypt abscesses more likely in UC than CD
What does PCD stand for?
Perianal Crohn’s disease
What is perianal Crohn’s disease?
Inflammation at or near the anus
What are symptoms of perianal Crohn’s disease?
Perianal pain
Pus secretion
Unable to sit down
What investigations are done for perianal Crohn’s disease?
MRI pelvis
Examination under anaesthetic
What is the treatment for perianal Crohn’s disease?
Surgery to drain abscess
Antibiotics and biological therapy (anti-TNF)
What must be considered by IBD differential diagnosis?
Chronic diarrhoea
Ileocaecal TB
Colitis must also be distinguished from infective and amoebic and ischaemic colitis
What does chronic diarrhoea cause?
Malabsorption
Malnutrition
What is a possible long term complication of colitis?
Colonic carcinoma
How do different kinds of colitis change the risk of colonic carcinoma?
Pancolitis 26x normal
Left colitis 6x normal
Proctitis minimal
What is done for IBD management?
Colorectal surgeon with IBD specialist interest
Weekly IBD MDT
Dedicated colonoscopy lists for surveillance
Direct communication between GP and consultant
IBD specialist nurse telephone hotline
Nurse led infusion clinic every 3 weeks
IBD pharmacist
What kind of approach does management of IBD use?
Step up approach
What medication is given to treat Crohn’s disease by reducing inflammation?
Aminosalicylates
What are aminosalicylates?
Family of medications with various formulations that deliver active ingredient, mesalamine, to target sites
What is the abbreviation for aminosalicylates?
5-ASA
How do amionsalicylates work?
Blocking prostaglandins and leukotrienes
Is 5ASA effective with both ulcerative colities and Crohn’s disease?
No, only with ulcerative colitis
When is rectal 5-ASA given?
For distal and left sided Crohn’s disease
What do steroids induce in Crohn’s disease and ulcerative colitis?
Remission
What are examples of steroids used to IBD?
Prednisolone
Budenoside
What is an example of an immunomodulation therapy for IBD?
Azathioprine
What are side effects of azithioprine?
Leucopenia
Hepatotoxicity
Pancreatitis
What biological agents are used for IBD?
Anti-ANFa antibodies
A4b7 integrin blockers
Explain each of the steps up in management of IBD?
1) 5-ASA
2) Steroids (prednisone or budesonide)
3) Immunomodulators
4) Biologic agents
5) Surgery
