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Year 3 > Inflammatory bowel disease (GI) > Flashcards

Inflammatory bowel disease (GI) Flashcards

1
Q

What does IBD consist of?

A
  • Crohn’s disease
  • ulcerative colitis
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2
Q

Define Crohn’s disease.

A

Disorder of unknown aetiology characterised by transmural inflammation of the GI tract

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3
Q

What parts of the GI tract can Crohn’s disease affect?

A

May involve any or all parts of the entire GI tract from mouth to perianal area, although usually seen in the terminal ileal and perianal locations

Most commonly ileum+colon, then just ileum, then just colon

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4
Q

What is Crohn’s disease characterised by?

A

Skip lesions (normal bowel mucosa between diseased areas, unlike ulcerative colitis)

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5
Q

What can the transmural inflammation in Crohn’s disease often lead to? (2)

A
  • fibrosis –> intestinal obstruction
  • sinus tracts that burrow through and penetrate serosa –> perforations and fistulae
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6
Q

What demographics does Crohn’s disease affect?

A
  • M=F
  • 2 age peaks: 15-40 years (main peak) and 60-80 years
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7
Q

Describe the aetiology of Crohn’s disease.

A
  • thought to be caused by an interaction of infectious, environmental, dietary, immunological features in a genetically susceptible person
    • genetic factors - CARD 15 which codes NOD2 pathogen recognition protein
    • environmental factors - smoking, OCP, high sugar diet, nutritional deficiencies (zinc), infections (measles)
  • breakdown of immune tolerance to normal gut microbiome –> unregulated inflammation
  • inflammatory infiltrate around intestinal crypts –> ulceration of superficial mucosa –> deeper layer penetration to form non-caseating granulomas (masses of immune cells)
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8
Q

What layers of the intestinal wall do granulomas involve in Crohn’s disease?

A

All layers of the intestinal wall (transmural) and mesentery and regional lymph nodes

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9
Q

What are the clinical features of Crohn’s disease? (8)

A
  • RLQ/peri-umbilical abdominal pain if ileitis is present, may be relieved by defecation
  • prolonged diarrhoea (usually non-bloody)
  • perianal lesions (skin tags, fistulae, abscesses, scarring, sinuses)
  • bowel obstruction (due to acute inflammatory oedema or chronic scarring and stricture)
  • blood in stools
  • fever
  • fatigue (due to malabsorption –> weight loss and anaemia too)
  • abdominal tenderness/mass
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10
Q

What features of bowel obstruction might you see in Crohn’s disease? (8)

A
  • bloating
  • distension
  • cramping
  • abdominal pain
  • loud borborygmi
  • vomiting
  • constipation
  • obstipation (severe constipation)
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11
Q

How does malabsorption show itself in Crohn’s disease?

A

Weight loss, anaemia and fatigue

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12
Q

What extraintestinal symptoms are seen in Crohn’s disease? (5)

A
  • oral lesions - mouth ulcers
  • arthropathy - joint pain
  • skin lesions - erythema nodosum (on shins) and pyoderma gangrenosum (ulcers on legs –> give prednisolone PO)
  • ocular symptoms - anterior uveitis (painful red eye with vision loss and photophobia) + episcleritis (painless red eye)
  • clubbing
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13
Q

What are some risk factors for Crohn’s disease? (7)

A
  • ethnicity: white, Jewish
  • age 15-40 or 50-60
  • Fx of Crohn’s disease
  • smoking (NB smoking reduces risk of UC)
  • diet: high refined sugar, low fibre, high ultra-processed foods
  • OCP
  • NSAIDs
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14
Q

What are the 1st line investigations for Crohn’s disease?

A
  • FBC
  • iron studies (serum iron, ferritin, TIBC, transferrin saturation)
  • serum vitamin B12
  • serum folate
  • comprehensive metabolic panel (CMP)
  • CRP & ESR
  • stool testing
  • plain abdominal x-ray
  • MRI abdomen/pelvis
  • CT abdomen
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15
Q

What would you see on colonoscopy and biopsy of Crohn’s disease? (6)

A
  • deep ulcers & rose-thorn ulcers
  • skip lesions
  • cobblestone appearance
  • increased goblet cells
  • lymphoid aggregates in mucosa
  • distortion of crypts
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16
Q

What would you see on histology of Crohn’s disease?

A

Transmural inflammation with non-caseating granulomas

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17
Q

What would we see on a barium enema in Crohn’s disease? (2)

A
  • Kantor’s string sign
  • rose-thorn ulcers
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18
Q

What would we look for in bloods for Crohn’s disease? (6)

A
  • anaemia (due to chronic inflammation, chronic blood loss, iron and B12/folate malabsorption)
  • leukocytosis
  • thrombocytosis
  • increased CRP & ESR
  • raised serum vitamin B12 (absorbed in terminal ileum) and folate
  • raised faecal calprotectin
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19
Q

Why would we do stool MC&S in Crohn’s disease?

A

To exclude infections

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20
Q

What might we see on CT abdo/MRI for Crohn’s disease?

A
  • visualise skip lesions
  • bowel wall thickening
  • surrounding inflammation
  • abscess
  • fistulae
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21
Q

What stool test is important in Crohn’s disease?

A

Faecal calprotectin - looks for inflammation

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22
Q

What are some differential diagnoses for Crohn’s disease?

A
  • UC (left-sided abdo pain and bloody diarrhoea, no small bowel/oral/perineal disease, always rectum and is contiguous on endoscopy)
  • infectious colitis
  • pseudomembranous colitis (recent Abx, C. diff, no ulceration)
  • ischaemic colitis
  • radiation colitis
  • Yersinia enterocolitica
  • intestinal TB
  • amoebiasis
  • cytomegalovirus colitis
  • colorectal cancer
  • diverticular disease (L-sided pain)
  • acute appendicitis
  • ectopic pregnancy
  • PID
  • endometriosis
  • IBS (not bloody or nocturnal)
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23
Q

What should all patients with Crohn’s disease be advised to do?

A

Stop smoking

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24
Q

What does acute management of Crohn’s disease involve? (5)

A
  • fluid resuscitation
  • oral iron
  • analgesia
  • TPN or EN
  • monitor ESR/CRP, Hb, platelets
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25
Q

How do we induce remission in Crohn’s disease with 1st presentation/exacerbation?

A
  • 1st line: glucocorticoid (prednisolone, methylprednisolone or IV hydrocortisone)
  • 2nd line: budesonide (if non-severe) OR 5-ASAs (mesalazine and olsalazine)
  • 3rd line: add immunosuppressants/immunomodulators (azathioprine, mercaptopurine, methotrexate) - contraindicated by deficient thiopurine methyltransferase activity
  • 4th line (if refractory): anti-TNFa biologics (infliximab, adalimumab)
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26
Q

What do we use to induce remission in isolated peri-anal Crohn’s disease?

A

Metronidazole

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27
Q

How do we maintain remission in Crohn’s disease?

A
  • NO STEROIDS
  • 1st line: immunosuppressants/immunomodulators (azathioprine, mercaptopurine) - monitor FBC as can reduce WBC
  • 2nd line: methotrexate
  • 3rd line: 5-ASAs
  • smoking cessation
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28
Q

When is surgery done for Crohn’s disease?

A
  • medical treatment fails
  • failure to thrive in children with complications
  • involves resection of affected bowel and stoma formation
  • NB there is a risk of disease recurrence
29
Q

How are perianal abscesses in Crohn’s disease dealt with?

A
  • incision and drainage
  • uncomplex perianal fistula = Abx (oral metronidazole or ciprofloxacin)
  • complex perianal fistula = seton
30
Q

What may severe perianal or rectal Crohn’s disease require?

A

Proctectomy (ileoanal pouch not usually done)

31
Q

What are some complications of Crohn’s disease?

A
  • intestinal obstruction
  • pregnancy complications due to immunosuppressant therapy (do not continue methotrexate)
  • intra-abdominal sepsis
  • sinuses
  • toxic megacolon
  • anaemia (terminal ileum where B12 absorbed)
  • fistulas (perianal = fistulotomy or draining seton, MRI to visualise to treat)
  • strictures
  • malignancy & short-bowel syndrome
  • kidney stones & gallstones
  • abscess (incision and drainage)
32
Q

What is the prognosis of Crohn’s disease like?

A

Chronic disease with variable frequency of relapses and multiple possible complications. However, appropriate medical and surgical treatment may enable patients to have a reasonable QOL.

33
Q

Define ulcerative colitis.

A

Type of IBD that characteristically involves the rectum and extends proximally to affect a variable length of the colon

34
Q

What side of the GI tract does ulcerative colitis affect?

A
  • rectum and extends proximally to a variable length of colon
  • proctitis: when only rectum involved
  • pancolitis: entire colon involved
35
Q

What part of the bowel is most commonly affected in ulcerative colitis?

A

Rectum

36
Q

What layer of bowel walls does ulcerative colitis affect?

A

Colonic mucus only
(VS Crohn’s = transmural)

37
Q

What demographic does ulcerative colitis affect?

A

Peak incidence in 20-40 year olds
Another small one in >60

38
Q

What activity has a protective effect on ulcerative colitis?

A

Smoking

39
Q

Describe the aetiology of ulcerative colitis.

A
  • breakdown of immune tolerance to normal gut microbiome, occurring in genetically susceptible individuals with environmental triggers
  • thought to be autoimmune disease initiated by an inflammatory response to colonic bacteria and immune dysfunction
  • inflammation only of mucosa –> crypt abscesses and depletion of goblet cell mucosa
  • ulcerated areas become covered by granulation tissue which eventually forms inflammatory polyps or pseudopolyps
  • thin-walled dilated colon –> fulminant colitis/toxic megacolon –> perforation –> peritonitis
40
Q

What happens in fulminant colitis?

A

Rapid and extensive colonic dilatation –> toxic megacolon

41
Q

What is toxic megacolon?

A

Severe episode of colitis with segmental or total dilatation of the colon (result of fulminant colitis) –> nerves and muscles damaged so colon becomes dilated and atonic –> buildup of gas + faeces with ileus

42
Q

What can happen in chronic severe ulcerative colitis?

A

Precancerous changes e.g. carcinoma in situ or dysplasia

NB risk of cancer is higher in UC vs Crohn’s

43
Q

What are the clinical features of ulcerative colitis? (7)

A
  • rectal bleeding associated with mucus
  • diarrhoea (bloody)
  • blood in stool
  • abdominal pain (LLQ) & cramps
  • faecal urgency & tenesmus (suggestive of proctitis)
  • fever & weight loss
  • extra-intestinal symptoms
44
Q

What are the extra-intestinal symptoms of ulcerative colitis? (3)

A
  • joints - peripheral arthritis and ankylosing spondylitis
  • skin - erythema nodosum and pyoderma gangrenosum
  • ocular - episcleritis > uveitis
45
Q

How do we distinguish between mild, moderate and severe ulcerative colitis?

A
  • mild: <4 bowel movements per day, only small amount of blood
  • moderate: 4-6 bowel movements per day, varying blood, no systemic upset
  • severe: 6+ bowel movements per day + visible blood + systemic upset : pyrexia + HR>90 + anaemia + ESR>30
46
Q

What are the risk factors for ulcerative colitis? (6)

A
  • Fx of IBD
  • HLA-B27 association
  • infection
  • NSAIDs
  • non-smoker
  • white ethnicity / Jewish
47
Q

What are the 1st-line investigations for ulcerative colitis?

A
  • stool studies for infective pathogens
  • faecal calprotectin
  • FBC
  • comprehensive metabolic panel (CMP)
  • CRP & ESR
  • plain abdo x-ray
  • flexible sigmoidoscopy
  • colonoscopy
  • biopsies
48
Q

What would colonoscopy and biopsy show in ulcerative colitis? (5)

A
  • continuous distal disease (rectal)
  • absence of granulomas
  • crypt abscesses
  • depletion of goblet cells
  • loss of vascular markings
49
Q

What investigation do we use in severe colitis and why?

A

Flexible sigmoidoscopy - colonoscopy should be avoided due to risk of perforation

50
Q

What would bloods show for ulcerative colitis? (6)

A
  • deranged LFTs means primary sclerosing cholangitis - majority of PSC patients have underlying IBD
  • increased CRP & ESR
  • anaemia
  • leukocytosis
  • thrombocytopenia
  • may show positive ANCA (especially pANCA)
51
Q

What would AXR show for ulcerative colitis? (4)

A
  • toxic megacolon - transverse colon >6cm
  • loss of haustra
  • thumbprinting (large bowel wall thickening)
  • pseudopolyps
52
Q

What would barium enema show for ulcerative colitis?

A

Lead pipe appearance - smooth dilated large bowel (& thumbprinting - large bowel wall thickening in colitis)

53
Q

What are some differential diagnoses for ulcerative colitis?

A
  • Crohn’s disease - perianal involvement, rectal sparing, fistulae, endoscopy&biopsy
  • indeterminate colitis
  • radiation colitis
  • infectious colitis
  • diverticulitis
  • IBS
  • mesenteric ischaemia/ischaemic colitis
  • vasculitis
  • prolonged use of cathartics
  • lymphogranuloma venereum
54
Q

What is mild ulcerative colitis?

A

<4 stools/day, only a small amount of blood

55
Q

What is moderate ulcerative colitis?

A

4-6 stools/day, varying amounts of blood, no systemic upset

56
Q

What is severe ulcerative colitis?

A

> 6 bloody stools/day + features of systemic upset (pyrexia, tachycardia, anaemia, raised inflammatory markers)

57
Q

How do we induce remission in mild-moderate ulcerative colitis - proctitis?

A
  • 5-ASAs (mesalazine - an aminosalicyclate) –> topical (rectal) for distal colitis
  • if remission not achieved in 4wk: add oral ASA for more severe colitis
  • if still not achieved, add topical or oral corticosteroid
58
Q

How do we induce remission in mild-moderate ulcerative colitis - proctosigmoiditis and left-sided ulcerative colitis?

A
  • topical (rectal) aminosalicyclate (mesalazine)
  • if remission not achieved in 4wk: add high-dose oral aminosalicyclate OR switch to a high-dose oral aminosalicyclate and a topical corticosteroid
  • if still not achieved: stop topical treatments and offer an oral aminosalicyclate and an oral corticosteroid
59
Q

How do we induce remission in mild-moderate ulcerative colitis - extensive disease?

A
  • topical (rectal) 5-ASA + high-dose oral 5-ASA
  • if remission not achieved in 4wk: stop topical treatments and offer a high-dose oral 5-ASA + oral corticosteroid
60
Q

How do we induce remission in severe ulcerative colitis?

A
  • should be treated in hospital
  • IV steroids 1st-line (IV ciclosporin may be used if steroids contraindicated)
  • if after 72h there has been no improvement, consider adding IV ciclosporin to IV corticosteroids or consider surgery
  • IV fluids + NBM
  • rescue therapy: infliximab
  • if still fails to improve: urgent subtotal colectomy with end ileostomy
61
Q

How do we maintain remission following a mild-moderate ulcerative colitis flare?

A

Proctitis and proctosigmoiditis:

  • topical (rectal) 5-ASA alone OR
  • oral 5-ASA + topical (rectal) 5-ASA OR
  • oral 5-ASA by itself (less effective)

Left-sided and extensive ulcerative colitis: low maintenance dose of oral 5-ASA

62
Q

How do we maintain remission in ulcerative colitis following a severe relapse or >/=2 exacerbations in the past year?

A

Oral azathioprine / mercaptopurine (immunosuppressants)

63
Q

What drug is not recommended for management of ulcerative colitis (vs Crohn’s)?

A

Methotrexate

64
Q

What issue can 5-ASA cause and how can we monitor it?

A

Agranulocytosis = monitor via FBC

65
Q

How do we treat toxic megacolon (ulcerative colitis)? (5)

A
  • NBM
  • IV fluids
  • NGT
  • avoid colonoscopy due to perforation risk
  • avoid sulfasalazine and other 5-ASA
66
Q

What surgery can we do in longstanding ulcerative colitis with risk of malignant transformation?

A

Proctocolectomy (with ileostomy - surgical removal of colon, rectum and anal canal)

Ileo-anal pouch formation

67
Q

What are some complications of ulcerative colitis? (4)

A
  • fulminant colitis –> toxic megacolon –> perforation –> peritonitis
  • primary sclerosing cholangitis (PSC) - inflammation and fibrosis of intra and extra hepatic bile ducts
  • colonic adenocarcinoma (in 3-5%)
  • infections - CMV, C. diff
68
Q

What is primary sclerosing cholangitis (complication of ulcerative colitis)?

A

Inflammation and fibrosis of intra and extra hepatic bile ducts (UC + cholestasis –> jaundice + pruritus with raised ALP + GGT) –> can lead to cholangiocarcinoma of bile duct

69
Q

What is the prognosis of ulcerative colitis?

A

Overall mortality of UC patients not increased compared to general population

Year 3 (145 decks)

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