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Inflammatory Bowel Disease Flashcards

1
Q

what are the two forms of IBD?

A

Crohns Disease

Ulcerative Colitis

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2
Q

what is the inflammatory mechanism of IBD?

A

Antigens taken up by M cells, pass into lamina propria, taken up by APC causing release of TNF-a, IL12, IL18 and CD4+
TH1 is produced, secrete cytokines attracting more T cells

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3
Q

what is the mean onset of age of Crohns?

A

26, children, 60s

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4
Q

what is the mean onset of age of UC?

A

34

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5
Q

Crohns is more common in which gender?

A

Males

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6
Q

UC is more common in which gender?

A

Females

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7
Q

What part of the GI tract does Crohns affect?

A

Any part of GI-tract, most commonly the terminal ileum and colon

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8
Q

What part of the GI tract does UC affect?

A

Only colon/large intestine, usually more distal regions are worse affected

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9
Q

Skip lesions are present in…

A

Crohns

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10
Q

What layer of mucosa is affected in Crohns?

A

Deep/All layers

down to serosa (transmural)

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11
Q

What layer of mucosa is affected in UC?

A

superficial - mucosa and submucosa

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12
Q

What are the complications of Crohns?

A

Fistula, abscess, stricture. Most commonly the fistulae come from the anus to the peri-anal region and the produce pus

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13
Q

What are the complications of UC?

A

Rare. Toxic megacolon

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14
Q

Crohns is pANCA…

A

-ve

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15
Q

UC is pANCA…

A

+ve

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16
Q

what are protective factors of crohns?

A

High residue, low sugar diet,

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17
Q

what are protective factors of UC?

A

Smoking, appendicectomy, high reside low sugar diet

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18
Q

what is a strong risk factor of Crohns

A

FH

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19
Q

what are common symptoms of Crohns?

A 
RIF mass/pain
Abdominal discomfort
Bloody stool
Vit B12 and iron deficiency 
Malabsoprtion
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20
Q

What are common symptoms of UC?

A

Diarrhoea (+/- blood)

Abdo discomfort, bloating

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21
Q

What are common extraintestinal symptoms of IBD?

A

large joint arthritis, irisitis, erythema nodosum , ulcers on mucous membranes (mouth and vagina), cholangitis, pyoderma gangrenosum renal stones, gallstones

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22
Q

what will a barium swallow show in Crohns?

A

areas of stricture, shortening of small bowel, fistulas and abscesses

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23
Q

what will a PR in UC?

A

Blood

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24
Q

What will a CT show in Crohns?

A

areas of wall thickening, strictures and abscesses

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25
Q

What will a CT show in UC?

A

thickened bowel wall

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26
Q

What will a barium enema show in UC?

A

Reduced haustral folds due to fibrosis

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27
Q

what can colonoscopy be used for in Crohns?

28
Q

what is the management of crohns disease?

A

smoking cessation
Many require surgery
Metrondiazole
Infliximab

29
Q

what is the management of mild UC?

30
Q

what is the management of moderate UC?

A

steroid to initiate remission, then 5-ASA for maintenance

31
Q

what is the management of severe UC?

A

trial steroid for 5-7 days. If no remission, then operate immediately. Try to maintain remission with 5-ASA, if not then immunosuppressants may be used.

32
Q

what are the causes of Crohns disease?

A

• Genetic susceptibility – NOD2 gene, family history
Environmental factors
o Triggered by pathogen = mycobacterium paratuberculosis, pseudomonas, listeria
o Smoking, urban living
• Immune response

33
Q

what is the inflammatory process of crohns?

A

GI cells act as antigen presenting cells, TH1 cells attach and release cytokines, attract macrophages, release excess free radicals, proteases and platelet activating factor circulating causing damage to GI tissue
As more cells are damaged, immune cells enter deeper into the muscle
Form granulomas and ulcers form

34
Q

what is the macroscopic appearance of Crohns?

A

Gives cobblestone appearance – red, swollen, mucosal ulceration and intervening oedema

35
Q

what is the microscopic appearance of Crohns?

A

• Microscopic – fibrosis, lymphoedema, chronic inflammatory infiltrate through the whole thickness of the bowel with non-caseating foci of epithelioid and giant cells.

36
Q

what are the pathological consequences of Crohns?

A

Fistulas, abcesses
Bowel thickening = strictures
Fat wrapping - mesentery thickening and fat moves along bowel wall

37
Q

what are the types of crohns disease?

A
  • Colonic (25%)
  • Ileocaecal (40%)
  • Small intestine alone (30%)
38
Q

what are the symptoms of Crohns Disease?

A
  • Diarrhoea +/- blood
  • Abdominal Pain – RLQ
  • Weight loss
  • Fever, malaise, vomiting and anorexia may be present in active disease
  • Constipation
39
Q

what are the signs of Crohns Disease?

A
  • Abdominal tenderness
  • Right iliac fossa –
  • Perianal abscesses, fistulae, skin tags – cause secretions
  • Anal/rectal strictures
  • Systemic signs – clubbing, large joint arthritis, conjunctivitis, fatty liver, renal stones, pyoderma gangrenosum
  • Signs of B12 + Iron deficiencies
40
Q

What imaging is useful in Crohns diagnosis?

A 
o	Barium Swallow
o	Small bowel enema
o	Colonoscopy
o	CT
o	Stool samples 
o	Technetium labelled leuocyte scan
41
Q

What blood tests should be done in Crohns Investigations?

A 
o	Serum iron and B12 if you suspect anaemia
o	CRP 
o	LFT, U+E, FBC
o	ESR 
o	WCC 
o	Hb
o	Albumin
42
Q

what will blood tests show in active crohns disease?

A 
o	CRP raised 
o	ESR raised
o	WCC raised 
o	Hbdecreased 
o	Albumin decreased
43
Q

what is the management of a mild crohns attack?

A

prednisolone

44
Q

what is the management of a severe crohns attack?

A 
o	Admit, IV fluids, nil by mouth
o	Hydrocortisone 100mg
o	Rectal disease – hydrocortisone
o	Anal disease – metrondidzole 
o	If no improvement after 5 days – prednisolone or infliximab or adalimumab
45
Q

what are the additional aspects of crohns management?

A
  • Perianal disease – antibiotics, immunosuppressants +/- inflimumab
  • Smoking cessation
  • Assess risk of osteoporosis
  • Additional Therapies: Azaithropine, Sulfasalzine, TNFa inhbitors, Methotrexate, Nutrition – eternal, TPN last resort, Antibiotics – such as rifaximin, IV immunoglobulin
  • Surgery – non curative
46
Q

what are the complications of crohns disease?

A
  • Increased risk of malignancy
  • Renal calculi-
  • Biliary calculi
  • Primary sclerosing cholangitis, sacroiliitis, pyoderma gangrenosum, uveitis
47
Q

what are the causes of UC?

A

Genetic
Environmental
Immune response to bacteria

48
Q

what is the immune response involved in UC?

A

o Epithelial barrier impaired, synthesis of mucin 2 is decreased
o Dendritic cell number reduced
o Exaggerated T cell (TH2) response
o Autoimmune – pANCA antibodies target neutrophils (gut bacteria cross reacts with neutrophils) = immune response

49
Q

what is the pattern of disease in UC?

A

o Circumferential and continuous – no skip leisions

o Starts in rectum and continues around colon

50
Q

what is proctitis?

A

UC that occurs only in the last 6 inches of the rectum. It also refers to any form of inflammation in the rectum

51
Q

What is proctocolitis?

A

inflammation in the colon and rectum – i.e. more generalised than proctitis

52
Q

what is pan colitis?

A

inflammation affecting the whole of the colon.

53
Q

what are the macroscopic features of UC?

A
  • Oedematous islands of mucosa between the ulcers form pseudopolyps
  • Wall of colon oedematous and fibrotic and therefore rigid with loss of its normal haustrations. Inflamed colon does not become adherent to its neighbouring intra-abdominal viscera
54
Q

what are the microscopic features of UC?

A

o small abscesses form within the mucosal crypts
o abscess break down ulcers whose base is lined with granulation tissue
o walls of colon infiltrated wth polymorphs and round cells; there is oedema and submucosal fibrosis

55
Q

what affect does chronic UC have on the bowel?

A

mucosa is smooth and atrophic, bowel wall is thinned

56
Q

What are the clinical features of the bowel in UC?

A

Bloody diarrhoea
Pain in LLQ
Tenesmus if rectum involved
Malaise, anorexia, clubbing

57
Q

what are the non-bowel clinical features of UC?

A

ulcers in mouth and vagina, arthralgia/arthritis, iritis, erythema nodosum, pyoderma grangrenosum, cholangitis

58
Q

what are the clinical features of an acute UC attack?

A

o Bloody diarrhoea, up to 20x day

o Systemic signs – fever, tachycardia, ESR>30mm/hour, anaemia <10, albulin <30g/L

59
Q

what investigations are done for UC?

A
  • PR exam
  • Rigid sigmoidoscopy
  • Blood tests in acute attacks
  • Stool samples
  • Plain AXR
  • US
  • CT – acute attacks
  • Colonoscopy – not in acute attack
  • Barium enema
  • Rectal biopsy
60
Q

what will blood tests in acute attack of UC show?

A 
o	Raised white cell count
o	Raised platelets
o	Iron deficiency anaemia
o	Raised ESR
o	Raised CRP
o	Hypoalbuminaemia (in more severe disease)
o	pANCA may be positive
61
Q

what will a plain AR in UC show?

A

presence of air in colon, colonic dilatation

62
Q

what will a US in UC show?

A

thickening of the wall, free fluid in abdominal cavity

63
Q

what is the management of mild UC?

A

o 5-ASA e.g. sulfasalazine or mesalazine or olsalazine

o Steroids e.g. prednisolone +/- hydrocortisone

64
Q

What is the management of moderate UC?

A

Oral prednisolone + 5-ASA + steroid enema

65
Q

what is the management of severe UC?

A 
o	Nil by mouth + IV hydration
o	Hydrocortisone 
o	Rectal steroids
o	Monitor NEWs and stool chart
o	Twice daily exam
o	Daily blood tests – blood transfusion
o	Parenteral nutrion rarely required
o	If improving prednisolone with 5-ASA 
o	If no improvement – colectomy or rescue therapy with ciclosporin or infliximab
66
Q

is surgery curative in UC?

67
Q

what are the complications of UC?

A
  • Perforation
  • Bleeding
  • Toxic megacolon
  • Venous thrombosis
  • Colon cancer

Gastroenterology (4 decks)

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