Inflammatory Bowel Disease (Crohn's and Ulcerative Collitis)

Question 1

What is UC?

Answer 1

UC is a relapsing and remitiing inflammatory disorder of the colonic mucosa.

• proctits (rectum)
• left sided colitis
• entire colon (pancolitis)

Question 2

What percentage of UC is limited to the rectum (proctitis)?

Answer 2

50%

Question 3

What % of UC is left sided colitis?

Answer 3

30%

Question 4

What % of UC involves the whole colon - pancolitis?

Answer 4

20%

Question 5

What is the prevalence of UC?

Answer 5

100-200 per 100, 000

Question 6

what is the male: female ratio of UC?

Answer 6

1:1

Question 7

at what age does UC present?

Answer 7

15 - 30 yrs

Question 8

Smoking is a protective risk factor for which IBD condition? crohn’s or UC?

Answer 8

Smoking reduces risk of UC

Smoking increases risk of crohns

Question 9

What are the symptoms of UC?

Answer 9

• episodic diarrhoea (with or without blood or mucus)
• crampy abdo pain
• increased bowel frequency –> increased severity of UC
• urgency / tenesmus = rectal UC
• systemic symptoms during attack : fever, malaise, anorexia, weight loss.

Question 10

What are the signs of UC?

Answer 10

• may be no signs OR:
• sever UC - fever, tachycardia, tender distended abdo

Extraintestinal signs

• clubbing
• oral ulcers
• erythema nodosum (red lumps under skin)
• pyoderma gangrenosum
• conjuctivitis
• episcleritis
• iritis
• large joint arthritis
• sacroiliitis
• ankylosing spondylitis
• fatty liver
• cholangiocarcinoma
• amyloidosis

Question 11

what are the extraintestinal eye signs of UC?

Answer 11

• conjunctivitis
• episcleritis
• iritis

Question 12

what are the extraintestinal MSK signs of UC?

Answer 12

• large joint arthritis
• sacroiliitis
• ankylosing spondylitis

Question 13

What tests would you do for UC?

Answer 13

Bloods:

• FBC
• CRP / ESR
• U&E
• LFT
• blood culture

Stools to exclude:

• campylobacter
• c.diff
• salmonella
• shigella
• E.coli
• amoebae

AXR:

• no faecal shadows
• mucosal thickening
• colonic dilatation (toxic mega colon)

Chest Xray:
-perforation

Colonoscopy:

• biopsy
• Histology : look for inflammation, goblet cell depletion, glandular distortion, mucosal ulcer, crypt abscesses.

Question 14

What are the complications of UC?

Answer 14

• Toxic megacolon (colon dilated to >6cm)

- venous thrombosis

Question 15

What drugs are used to induce remission in mild UC?

Answer 15

1) 5-ASA e.g. sulfasalazine or mesalazine.
2) Steroids e.g. prednisolone 20mg PO twice daily OR PR foams e.g. hydrocortisone OR prednisolone retention enema 20mg.

**if improving after 2 weeks reduce steroids slowly

Question 16

What drugs are used to induce remission in moderate UC?

Answer 16

• Oral prednisolone (40mg/d for 1 wk), then 30mg/d for 1 wk then 20mg/d for 4 more wks.
• AND a 5ASA
• AND twice daily steroid enemas

**decrease steroids gradually if improving

Question 17

What is classed as severe UC?

Answer 17

unwell and 6+ motions a day

Question 18

How do we treat severe UC?

Answer 18

1) admit for nil by mouth and IV hydration
2) IV Steroids : Hydorcortisone 100mg/6h IV
3) Rectal steroids (hydrocortisone 100mg in 100ml 0.9% Nacl every 12 hrs
4) monitor bp, pulse, temperature, stool freq/character
5) If not improving then either colectomy surgery OR rescue infliximab / ciclosporin

Question 19

What are the indications for surgery in UC?

Answer 19

• perforation
• massive haemorrhage
• toxic megacolon
• failed medical therapy

Question 20

What immunomodulants are used in UC?

Answer 20

• Azathioprine
• methotrexate
• infliximab
• adalimumab
• calcineurin inhibitors e.g. ciclosporin / tacrolimus

Question 21

What is the dose of azathioprine for UC?

Answer 21

2.5mg /kg/d PO after food

Question 22

What is crohns disease?

Answer 22

Inflammation of the GI tract that can occur anywhere from mouth to anus. characterised by transmural skip lesions.

Question 23

What are is affected in 70% of crohn’s?

Answer 23

terminal ileum

Question 24

what is the prevalence of crohn’s

Answer 24

0.5-1 / 1000 (crohn’s)

1-2/1000 (UC)

Question 25

What age does crohn's present at?

Answer 25

20 - 40s

Question 26

what increases the risk of crohn's?

Answer 26

- smoking increases risk by 3-4X | - NSAIDs exacerbate disease

Question 27

What are the symptoms of crohns?

Answer 27

- Diarrhoea - urgency - abdo pain - weight loss - fatigue - fever, malaise, anorexia

Question 28

What are the signs of crohns?

Answer 28

- oral ulcers - abdo tenderness/ mass - perianal abscess - fistulae - skin tags - anal strictures -clubbing, skin, joint, eye problems (same as UC)

Question 29

What are the complications of crohns?

Answer 29

- small bowl obstruction - toxic megacolon - abscess formation - fistulae - perforation - rectal haemorrhage - colon cancer - fatty liver - primary sclerosing cholangitis - cholangiocarcinoma - renal stones - osteomalacia - malnuitrition - amyloidosis

Question 30

What tests are done for crohn's disease?

Answer 30

Blood: -FBC, ESR, CRP, U&E, LFTs, INR, Ferritin, B12, Folate Stool to exclude: C.diff, campylobacter, salmonella, e.coli Colonoscopy and rectal biopsy Small bowel enema (detects ileal disease) Capsule endoscopy Barium enema MRI to assess pelvic disease and fistulae

Question 31

What is the treatment for mild crohn's attacks?

Answer 31

1) Prednisolone 30mg/d for 1 week, then reduce to 20mg/d for 4 weeks. (if symptoms resolve decrease predisolone by 5mg every 2-4 weeks)

Question 32

What is the treatment for sever crohn's attacks?

Answer 32

- admit for IV steroids (hydrocortisone 100mg/6h IV) - IV fluids -

Question 33

What is the treatment for perianal disase (50%) in crohns?

Answer 33

Assess via MRI. | treat with oral abx, immunosuppressant therapy +/- infliximab