Inflammatory bowel disease Flashcards
Definition of ulcerative colitis
The most common form of chronic inflammatory bowel disease with a relapsing and remitting course, that typically affects the rectum and extends proximally.
Epidemiology of ulcerative colitis
- Consistent incidence of 10 per 100.000
- May affect any age group but has a bimodal distribution - first peak at 15-30 and the second at 55-65
- Equal gender preponderance
Clinical features of ulcerative colitis
- Diarrhoea (+/- blood & mucus)
- Colicky abdominal pain and tenesmus may also be present
- Increased frequency of bowel movements
- Systemic symptoms: fever, malaise, anorexia, weight loss
Investigations for ulcerative colitis
- Arrange blood tests - FBC (↓Hb, ↑WCC), LFTs (↓albumin is an important marker of severity), inflammatory markers (↑CRP/ESR)
- Arrange stool testing
- Stool MC&S should be performed on all patients to exclude an infective cause
- Faecal calprotectin can be used to support a diagnosis of IBD
- Obtain radiological imaging
- Abdominal xray +/- an erect xray should be obtained to assess for the presence of complications (eg megacolon, perforation)
- Arrange a full colonoscopy with biopsies at a minium of 5 sites
Why is colonoscopy containdicated in acute colitis and what can be used instead to confirm the diagnosis?
Colonoscopy is contraindicated in acute colitis as it is associated with a high risk of perforation. In such cases, a flexible sigmoidoscopy may be performed instead to confirm the diagnosis.
Which criteria is used to evaluate the severity of an acute exacerbation of ulcerative colitis?
Truelove and Witts criteria
Truelove and Witts criteria uses:
- Movements/day
- Bleeding
- Pyrexia (T >37.8)
- Pulse (HR >90)
- Anaemia (Hb <10)
- ESR (>30)
Inducing remission is severe ulcerative colitis
- Urgent hospital admission
- IV corticosteroids (or cyclosporin if steroids are contraindicated)
- Offer VTE prophylaxis (patients are pro-coagulopathic)
- Add on IV cyclosporin if unresponsive to corticosteroids after 72 hours (consider infiximab if cyclosporin contraindicated)
- Consider urgent surgery in patients with acute complications (eg megacolon, perforation) or if they have failed to respond to medical therapy
Inducing remission in mild/moderate ulcerative colitis
- Topical aminosalicylates (eg mesalazine) are preferred over steroids as first line agents
- Add oral aminosalicylates if no remission after 4 weeks
- Consider oral corticosteroids
- if aminosaliclates contraindicated or
- as add on if no improvement with aminosalicylates
- Tacrolimus may be added to corticosteroids in the event of inadequate response
- Consider adalimumab as an alternative agent to conventional therapy
Maintaining remission in ulcerative colitis
- Oral or topical aminoslicylates are recommended first-line agents (after 1 mild to moderate exacerbation)
- Consider azathioprine or mercaptopurine (6-MP) in patients who
- have ≥2 exacerbations in a year, requiring corticosteroid therapy
- have a single episode of acute severe ulcerative colitis
- are unresponsive to oral aminosalicylates
- Consider elective surgery
- may be offered to patients who are chronically symptomatic and fail to resond to medical therapy
Definition of Crohn’s disease
Crohn’s is a form of chronic inflammatory bowel disease of unknown aetiology, characterised by transmural involvement and may affect any part of the GI tract.
Epidemiology of Crohn’s disease
- Increasing incidence of 6-7 per 100,000
- May affect any age group but has a bimodal distribution - first peak at 15-20 and the second at 60-80
- Slight female preponderance
Clinical features of Crohn’s disease
- Diarrhoea is a common symptom; often not bloody
- Abdominal discomfort, weight loss may also be present
- Apthous ulcers, glossitis and fistulae are common manifestations
- Systemic symptoms: malaise, fever, anorexia
Investigations for Crohn’s disease
- Arrange blood tests - FBC (↓Hb, ↑WCC, ↑platelets), LFTs (↓albumin), ↑CRP/ESR, haematinics (may show ↓Fe, B12, folate secondary to malabsorption depending on the site of disease)
- Arrange stool testing
- Stool MC&S to rule out infection
- Faecal calprotectin is recommended
- Obtain radiological imaging
- AXR +/- erect CXR to look for complications (eg obstruction secondary to strictures, perforation)
- MRI pelvis is useful in perianal disease to evaluate the extent of disease and look for fistulae
- MRI enterography or capsule endoscopy may be used to assess for small bowel disease
- Arragne endoscopy
- Ileocolonoscopy with visualisation of the terminal ileum and biopsies is recommended to establish a histological diagnosis
- An upper GI endoscopy may also be warranted in patients with UGI symptoms
Inducing remission in Crohn’s disease
- Offer oral or IV corticosteroids as first line agents
- Consider budesonide or aminosalicylate (5-ASA) therapy
- in patients with distal ileal or right sided colonic disease as an alternative to steroids
- should not be used in severe disease
- Azathioprine or 6-MP may be used as an add on therapy in resistive cases
- or methotrexate if contraindicated or intolerant
- Consider biologic agents
- such as infliximab and adalinumab for patients who are unresponsive to conventional therapy
- Consider surgery as an alternative to medical therapy in patinets with localised distal ileal disease
