Inflammatory Bowel Disease (IBD)

Question 1

What is Inflammatory Bowel Disease?

Answer 1

Umbrella term for 2 main diseases causing inflammation of the GI tract : Ulcerative Colitis and Crohn’s disease. Both are associated with periods of exacerbation and remission.

Question 2

Key Features of Crohn’s Disease (5).

Answer 2

Mnemonic : Crows (Crohn’s) NESTS :

1. No Blood/Mucus (Less Common).
2. Entire GI Tract.
3. Skip Lesions on Endoscopy.
4. Transmural Inflammation / Terminal Ileum (most affected).
5. Smoking is a risk factor.

Question 3

Key Features of Ulcerative Colitis (7).

Answer 3

Mnemonic : CLOSE-UP :

1. Continuous Inflammation.
2. Limited to Colon and Rectum.
3. Only Superficial Mucosa is affected.
4. Smoking is a protective factor.
5. Excessive Blood/Mucus.
6. Use Aminosalicylates.
7. Primary Sclerosing Cholangitis.

Question 4

Epidemiology of Crohn’s Disease.

Answer 4

1. Peak Incidence : 20-40 years.

2. 3x commoner in smokers.

Question 5

Epidemiology of Ulcerative Colitis.

Answer 5

1. Peak Incidence : 15-25 years and 55-65 years.

2. 3x commoner in non-smokers.

Question 6

Aetiology of Inflammatory Bowel Disease.

Answer 6

Idiopathic.

Question 7

Common Extra-Intestinal Features in IBD (3).

Answer 7

1. Arthritis (commonest in both).
2. Episcleritis (commoner in CD).
3. Primary Sclerosing Cholangitis and Uveitis (commoner in UC).

Question 8

What is Erythema Nodosum?

Answer 8

Inflammation located in the fatty layer of the skin, presenting as red painful tender lumps (most commonly located in the anterior lower leg).

Question 9

What is Pauciarticular Arthritis?

Answer 9

Arthritis where 4 or fewer joints are affected by arthritis (commonest form is Juvenile Idiopathic Arthritis).

Question 10

What is the most prominent symptom of Crohn’s Disease in :
A. Adults?
B. Kids?

Answer 10

Adults : Diarrhoea.

Kids : Abdominal Pain.

Question 11

Give the criteria for a Mild Flare of Ulcerative Colitis (6).

Answer 11

1. Fewer than 4 Motions Per Day.
2. Little Rectal Bleeding.
3. Apyrexial.
4. HR < 70BPM.
5. Haemoglobin > 11.
6. ESR/CRP are Normal.

Question 12

Give the criteria for a Moderate Flare of Ulcerative Colitis (6).

Answer 12

1. 4-6 Motions Per Day.
2. Moderate Rectal Bleeding.
3. Intermediate Temperature.
4. 70-90BPM.
5. 10.5-11 Haemoglobin.
6. Intermediate ESR/CRP.

Question 13

Give the criteria for a Severe Flare of Ulcerative Colitis (6).

Answer 13

1. More than 6 Motions Per Day.
2. Large Amounts of Rectal Bleeding.
3. Temperature > 37.8C.
4. HR > 90BPM.
5. Haemoglobin < 10.5.
6. ESR > 30.

Question 14

Association of IBD and PSC.

Answer 14

5% of UC cases have PSC - increased risk of developing Cholangiocarcinoma (carcinoma of bile duct).

Question 15

Pathophysiology of Crohn’s Disease (5).

Answer 15

1. Patchy and Discontinuous Distribution.
2. Non-Caseating Granuloma Formation.
3. Increased Goblet Cells.
4. Strictures/Fistulae Formation.
5. Gallstones.

Question 16

Main Microscopic Features of Crohn’s Disease (2).

Answer 16

1. Deep Fissuring Ulcers (Penetrating Knife-like Clefts).

2. Cobblestone Appearance (linear fissuring ulcers may coalesce - cobblestones correspond to areas of surviving mucosa).

Question 17

What is a Granuloma?

Answer 17

An aggregate of activated epithelioid histiocytes.

Question 18

What is the significance of transmural inflammation in Crohn’s disease? (2)

Answer 18

1. It can extend to the serosal surface and cause adhesions to other loops of bowel and intra-abdominal organs.
2. Fistulae and Stricture Formation.

Question 19

Pathophysiology of Ulcerative Colitis (5).

Answer 19

1. Disease extends proximally in continuous distribution.
2. Never spreads beyond Ileocaecal Valve.
3. Inflammatory Cell Infiltrate in Lamina Propria and Neutrophils Migrate Through Gland Walls to Form Crypt Abscesses.
4. Depletion of Goblet Cells and Mucin (no Granulomas).
5. Inflammatory ‘Pseudopolyps’ = Not Dysplastic.

Question 20

Investigations of Inflammatory Bowel Disease (3).

Answer 20

1. CRP and Inflammatory Markers e.g. Faecal Calprotectin.
2. Stool Cultures (exclude Infection).
3. Diagnostic : Endoscopy with Biopsy.

Question 21

Crohn’s Disease : Investigations (3).

Answer 21

1. Endoscopy : ‘Skip Lesions’, ‘Cobblestone’ Appearance, Deep Ulcers.
2. Small Bowel Enema (Terminal Ileum) : Fistulae, Strictures (Kantor’s String Sign), Proximal Bowel Dilation and ‘Rose Thorn Ulcers’.
3. Colonoscopy : Investigation of Choice.

Question 22

Ulcerative Colitis : Investigations (2).

Answer 22

1. Endoscopy : Widespread ulceration with preservation of adjacent mucosa and ‘Pseudopolyps’.
2. Barium Enema : Loss of haustrations, Superficial Ulceration (Pseudopolyps), Drainpipe Colon (narrow and short colon in long-standing disease).

Question 23

How are drugs administered in Inflammatory Bowel Disease?

Answer 23

1. Per os if more extensive disease.

2. Per rectum if distal disease only.

Question 24

Management of Crohn’s Disease (3).

Answer 24

1. Induce Remission -
   1st Line : Steroids e.g. Oral Prednisolone or IV Hydrocortisone.
   2nd Line - Immunosuppressants.
2. Maintain Remission - Immunosuppressants.
3. Surgery - Distal Ileum Only Disease, Strictures, Fistulae (never curative, just prevent flares).

Question 25

Management of Ulcerative Colitis (3).

Answer 25

1. Induce Remission -
   MILD/MODERATE -
   1st Line : Aminosalicylates e.g. Mesalazine.
   2nd Line - Corticosteroids e.g. Prednisolone.
   SEVERE -
   1st Line : IV Corticosteroids e.g. Hydrocortisone.
   2nd Line : IV Ciclosporin.
2. Maintain Remission - Aminosalicylates or Immunosuppressants (Never Methotrexate).
3. Surgery - Panproctocolectomy (colon and rectum removal) is definitive. Patient is left with Permanent Ileostomy or J Pouch (Ileo-Anal Anastomosis).

Question 26

Complications of Crohn’s Disease (3).

Answer 26

1. Obstruction.
2. Fistulae.
3. Colorectal Cancer.

Question 27

Complication of Ulcerative Colitis.

Answer 27

Risk of Colorectal Cancer (higher than CD).

Question 28

What is a fistula?

Answer 28

Abnormal connection between two epithelial surfaces.

Question 29

What is a stricture?

Answer 29

Fibrotic healing resulting in bowel obstruction.