Inflammatory bowel disease (Crohns and UC) Flashcards
What is Crohn’s disease?
Chronic inflammatory disease
Transmural granulomatous inflammation
Affects whole GI tract but most commonly terminal ileum and proximal colon
Has skip lesions
How does UC differ from Crohn’s?
Extends from rectum up, never effects small bowel
No skip lesions
Mucosal ulcers, are more superficial
Smoking decreases risk of UC
More systemic features
Aetiology of Crohn’s?
Unknown
Mutations of the NOD2/CARD15 increases risk
Smoking = two-fold increased risk
Pathophysiology of crohns
Defective immune system producing an abnormal response to luminal antigens (e.g. bacteria) which enter the intestine via a leaky epithelium
Exaggerated immune response
Macroscopic:
Affects any part of GI tract
Discontinuous involvement (skip lesions)
Deep ulcers and fissures in mucosa – cobblestone appearance
Microscopic:
Transmural inflammation (inflammation spanning full depth of intestinal wall)
Granulomas present in 50%
What age does Crohns disease and UC usually present?
teens and twenties
Symptoms of Crohn’s
Diarrhoea/urgency- “I get up at 4am, go 5-6x in next 45 mins”
Abdo pain
Weight loss
fever, anorexia, malaise
Sign’s of Crohn’s
Mouth ulcers
Abdo tenderness/ mass
Perianal disease: abscess, skin tags, fistulas, anal strictures
Non GI: clubbing, skin joint and eye problems
Crohn’s complications?
Small bowel obstruction Toxic dilatation (toxic megacolon) Abscess formation Fistulae Perforation Rectal haemorrhage Colon cancer Fatty liver PSC (primary sclerosing cholangitis) Cholangiocarcinoma
Systemically: amyloidosis
Diagnostic tests for crohn’s disease?
Bloods
Stool sample
Colonoscopy + rectal biopsy
Small bowel enema (identifies ileal disease)
Microscopy of stool sample will help rule out bacterial causes of symptoms, what bacteria commonly cause symptoms?
C. diff,
Campylobacter,
E. coli
Crohn’s Treatment for mild attacks (symptomatic but systemically well)?
(optimise nutrition)
Oral prednisolone
Review in clinic – lower dose every couple of weeks if symptoms are improving
Crohn’s treatment for severe attacks?
IV steroids – hydrocortisone
Treat rectal disease – steroids
Metronidazole (antibiotic) oral/IV helps
Consider need for blood transfusion/parenteral nutrition
Treatment for perianal Crohn’s disease: abscess, skin tags, fistulas, anal strictures
Oral abx
Immunosuppressants ± infliximab
Local surgery
Other treatments for crohn’s?
Azathioprine – steroid sparing agent
TNFα inhibitors
TNFα has key role in Crohn’s pathogenesis
Infliximab, adalimumab
Surgical treatment of crohn’s?
50-80% require an operation in life
Not curative
Temporary ileostomy, resection of part of bowel
Bypass and pouch surgery NOT done in Crohn’s – widespread disease, so high risk of recurrence
What is Ulcerative colitis?
A relapsing and remitting inflammatory disorder of the colonic mucosa.
May affect:
Just the rectum – proctitis
Extend to involve part of the colon – left-sided colitis
Extend to the entire colon – pancolitis
Never goes beyond the ileocaecal valve
SMOKING IS PROTECTIVE
Describe pathology of UC
Hyperaemic/haemorrhagic granular colonic mucosa ± pseudopolyps formed by inflammation
Punctate (studded with tiny holes) ulcers- Mucosal disease
Macroscopic: Affects only the colon Begins in rectum and extends proximally Continuous involvement Red mucosa, bleeds easily Ulcers and pseudopolyps (regenerating mucosa) in severe disease
Microscopic: Mucosal inflammation No granulomata (granulation tissue) Goblet cell depletion Crypt abscesses
Symptoms of UC
Episodic or chronic diarrhoea ± blood and mucus in stool- Bowel frequency relates to severity
Crampy abdominal discomfort
Urgency = rectal UC
Systemic symptoms in attacks – fever, malaise, anorexia, weight loss
Signs of UC
In acute, severe UC – fever, tachycardia and a tender, distended abdomen
Extra intestinal signs:
Pretty much everything, UC has widespread extra-intestinal signs
e.g. clubbing, mouth ulcers, erythema nodosum and arthritis
Diagnostic test for UC?
Bloods
Stool sample
Abdo Xray
Colonoscopy
What would bloods show?
inflammatory signs and raised LFTS
Culture should be done to exclude infection
What tests and results on stool sample
MC&S/CDT (C. diff toxin)
To exclude Campylobacter, C. difficile, Salmonella, Shigella, E coli, amoebae
What would abdo Xray show?
No faecal shadows
Mucosal thicking/islands
Colonic dilatation
Colonic complications of UC?
Perforation and bleeding
Toxic megacolon venous thrombosis
Colonic cancer
Systemic complications of UC?
Joints- amyloidosis
Eyes- iritis, uveitis,
Skin, erythema nodosum
Liver changes— fatty change, schlerolosing cholangitis,
Treatment of UC to induce remission?
5 ASA (aminosalycilate acid (anti-inflammatory drug))
Steroids (predniolone)
If severe, Hydrocortisone IV
What topical therapies are offered for UC?
Proctitis responds to suppositories
Topical 5-ASAs are better than topical steroids
What surgery is offered?
20% needs surgery
proctocolectomy + terminal ileostomy
Coleostomy with ileo-anal pouch
