Inflammatory bowel disease (Crohns and UC)

Question 1

What is Crohn’s disease?

Answer 1

Chronic inflammatory disease

Transmural granulomatous inflammation

Affects whole GI tract but most commonly terminal ileum and proximal colon

Has skip lesions

Question 2

How does UC differ from Crohn’s?

Answer 2

Extends from rectum up, never effects small bowel

No skip lesions

Mucosal ulcers, are more superficial

Smoking decreases risk of UC

More systemic features

Question 3

Aetiology of Crohn’s?

Answer 3

Unknown

Mutations of the NOD2/CARD15 increases risk

Smoking = two-fold increased risk

Question 4

Pathophysiology of crohns

Answer 4

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%

Question 5

What age does Crohns disease and UC usually present?

Answer 5

teens and twenties

Question 6

Symptoms of Crohn’s

Answer 6

Diarrhoea/urgency- “I get up at 4am, go 5-6x in next 45 mins”
Abdo pain
Weight loss
fever, anorexia, malaise

Question 7

Sign’s of Crohn’s

Answer 7

Mouth ulcers
Abdo tenderness/ mass
Perianal disease: abscess, skin tags, fistulas, anal strictures

Non GI: clubbing, skin joint and eye problems

Question 8

Crohn’s complications?

Answer 8

Small bowel obstruction
Toxic dilatation (toxic megacolon)
Abscess formation
Fistulae
Perforation
Rectal haemorrhage
Colon cancer
Fatty liver
PSC (primary sclerosing cholangitis)
Cholangiocarcinoma

Systemically: amyloidosis

Question 9

Diagnostic tests for crohn’s disease?

Answer 9

Bloods
Stool sample
Colonoscopy + rectal biopsy
Small bowel enema (identifies ileal disease)

Question 10

Microscopy of stool sample will help rule out bacterial causes of symptoms, what bacteria commonly cause symptoms?

Answer 10

C. diff,
Campylobacter,
E. coli

Question 11

Crohn’s Treatment for mild attacks (symptomatic but systemically well)?

Answer 11

(optimise nutrition)

Oral prednisolone

Review in clinic – lower dose every couple of weeks if symptoms are improving

Question 12

Crohn’s treatment for severe attacks?

Answer 12

IV steroids – hydrocortisone
Treat rectal disease – steroids
Metronidazole (antibiotic) oral/IV helps
Consider need for blood transfusion/parenteral nutrition

Question 13

Treatment for perianal Crohn’s disease: abscess, skin tags, fistulas, anal strictures

Answer 13

Oral abx
Immunosuppressants ± infliximab
Local surgery

Question 14

Other treatments for crohn’s?

Answer 14

Azathioprine – steroid sparing agent
TNFα inhibitors
TNFα has key role in Crohn’s pathogenesis
Infliximab, adalimumab

Question 15

Surgical treatment of crohn’s?

Answer 15

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

Question 16

What is Ulcerative colitis?

Answer 16

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

Question 17

Describe pathology of UC

Answer 17

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

Question 18

Symptoms of UC

Answer 18

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

Question 19

Signs of UC

Answer 19

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

Question 20

Diagnostic test for UC?

Answer 20

Bloods
Stool sample
Abdo Xray
Colonoscopy

Question 21

What would bloods show?

Answer 21

inflammatory signs and raised LFTS

Culture should be done to exclude infection

Question 22

What tests and results on stool sample

Answer 22

MC&S/CDT (C. diff toxin)

To exclude Campylobacter, C. difficile, Salmonella, Shigella, E coli, amoebae

Question 23

What would abdo Xray show?

Answer 23

No faecal shadows
Mucosal thicking/islands
Colonic dilatation

Question 24

Colonic complications of UC?

Answer 24

Perforation and bleeding
Toxic megacolon venous thrombosis
Colonic cancer

Question 25

Systemic complications of UC?

Answer 25

Joints- amyloidosis
Eyes- iritis, uveitis,
Skin, erythema nodosum
Liver changes— fatty change, schlerolosing cholangitis,

Question 26

Treatment of UC to induce remission?

Answer 26

5 ASA (aminosalycilate acid (anti-inflammatory drug))
Steroids (predniolone)
If severe, Hydrocortisone IV

Question 27

What topical therapies are offered for UC?

Answer 27

Proctitis responds to suppositories

Topical 5-ASAs are better than topical steroids

Question 28

What surgery is offered?

Answer 28

20% needs surgery
proctocolectomy + terminal ileostomy
Coleostomy with ileo-anal pouch