Inflammatory Bowel Disease IBD - Chapter 326 Flashcards
These 2 countries have the highest IBD incidences in Asia.
India and China had the highest IBD incidences in Asia.
Differentiate UC vs CD in terms of age of onset
Ethnicity in which UC / CD are is most common
Effect of smoking on UC vs CD
Effect of oral contraceptives on UC vs CD
Effect of appendectomy on UC vs CD
Peak incidence of UC and CD is in what decades
Peak incidence of UC and CD is in the second to fourth decade
A second modest rise in incidence occurs between the seventh and ninth
A second modest rise in incidence of UC and CD occurs between the what decades of life.
A second modest rise in incidence occurs between the seventh and ninth decades of life.
IBD is not gender-specific.
true or false
True
differentiate the ff based on age
* early onset IBD
* very early onset IBD
* infantile IBD
part of the gut mainly affected in VEOIBD and infantile IBD
colon
VEOIBD and Infantile IBD are very sensitive to standard medications
True or false
False.
VEOIBD and Infantile IBD are resistant to standard medications
Rural areas have a higher prevalence of IBD than urban areas
True or false
False…
Urban areas have a higher prevalence of IBD than rural areas
high socioeconomic classes have a higher prevalence of IBD than lower socioeconomic classes.
true or false
True
Breast-feeding may also protect against the development of IBD.
true or false
True
Infectious gastroenteritis with pathogens (e.g., Salmonella, Shigella, Campylobacter spp., Clostridium difficile) increases IBD risk by two- to threefold.
true or false
True
Vitamin D has protective effect from UC.
True or false
False…
Vitamin D has protective effect from CD
the strongest risk factor for the development of IBD
the strongest risk factor for the development of IBD is a first-degree relative with the disease
how many times at risk to have UC ang kids na may mother or father na may UC
how many times at risk to have CD ang kids na may mother or father na may CD
most common CD phenotype in East Asians vs Latinx vs Blacks
all ileocolonic CD
predominant extraintestinal manifestation (EIM) of IBD among Blacks vs Latinx
Among blacks, joint involvement is the predominant extraintestinal manifestation (EIM)
vs
Dermatologic manifestations are the most common EIMs reported in Latinxs (10–13%).
mucosal disease that usually involves the rectum and extends proximally to involve all or part of the colon.
UC
in UC, how many % of patients have :
* disease limited to the rectum and rectosigmoid
* extends beyond the sigmoid but not involving the whole colon
* pancolitis
UC spreads distally.
True or False
Proximal spread occurs in continuity without areas of uninvolved mucosa.
backwash ileitis occurs in CD.
True or False
False.. it occurs in UC
in UC, although variations in macroscopic activity may suggest skip areas, biopsies from normal-appearing mucosa are usually abnormal
True or False
True
macroscopic appearance of UC with mild inflammation
macroscopic appearance of more severe UC
macroscopic appeaance of long-standing UC
in patients with many years of UC, the colonic mucosa appears atrophic and featureless
True or False
in patients with many years of UC, the colonic mucosa appears atrophic and featureless, and the entire colon becomes narrowed and shortened.
in patients with many years of UC, the entire colon becomes narrowed and shortened.
True or False
in patients with many years of UC, the colonic mucosa appears atrophic and featureless, and the entire colon becomes narrowed and shortened.
Patients with fulminant disease (UC) can develop ____ where the bowel wall becomes thin and the mucosa is severely ulcerated; this may lead to perforation
Patients with fulminant disease can develop a toxic colitis or megacolon where the bowel wall becomes thin and the mucosa is severely ulcerated; this may lead to perforation
In UC, the histologic findings correlate well with the endoscopic appearance and clinical course of UC.
True or False
True
in UC, the process is limited to WHAT LAYERS…., with deeper layers unaffected except in fulminant disease.
in UC, the process is limited to the mucosa and superficial submucosa, with deeper layers unaffected except in fulminant disease.
In UC, what are the two major histologic features that suggest chronicity
in UC, THESE CELLS invade the epithelium, usually in the crypts, giving rise to cryptitis and, ultimately, to crypt abscesses
in UC, the neutrophils invade the epithelium, usually in the crypts, giving rise to cryptitis and, ultimately, to crypt abscesses
CD can affect any part of the gastrointestinal (GI) tract from the mouth to the anus
True or False
True
How many CD patients…have
* small-bowel disease alone
* disease involving both the small and large intestines
* colitis alone
In the 75% of patients with small-intestinal disease in CD, the ____ is involved in 90%.
In the 75% of patients with small-intestinal disease in CD, the terminal ileum is involved in 90%.
Unlike UC, which almost always involves the rectum, the rectum is often spared in CD.
True or False
True
**but rectum can still be affected in CD
UC is often segmental with skip areas throughout the diseased intestine
True or False
False… kasi dapat…
CD is often segmental with skip areas throughout the diseased intestine
CD may also involve the liver and the pancreas
True or False
True
Unlike UC, CD is a transmural process
True or False
True
Difference between endoscopic appeaance of MILD CD vs MORE ACTIVE CD
“cobblestone” appearance is characteristic of CD
true or false
true
pseudopolyps can form in both UC and CD
true or false
true
in ACTIVE CD, projections of thickened mesentery known as “____” encase the bowel, and serosal and mesenteric inflammation promotes adhesions and fistula formation
Projections of thickened mesentery known as “creeping fat” encase the bowel, and serosal and mesenteric inflammation promotes adhesions and fistula formation
Granulomas are a characteristic feature of UC.
true or false
False… kasi dapat…
Granulomas are a characteristic feature of CD
transmural inflammation that is accompanied by fissures that penetrate deeply into the bowel wall and sometimes form fistulous tracts or local abscesses
CD or UC
CD
5 major symptoms of UC
The major symptoms of UC are
* Diarrhea
* Rectal bleeding
* Tenesmus
* Passage of mucus
* Crampy abdominal pain
in UC, the severity of symptoms correlates with the extent of disease.
True or False
True
IN THIS VARIANT OF UC, patients usually pass fresh blood or blood-stained mucus, either mixed with stool or streaked onto the surface of a normal or hard stool
UC patients with proctitis
IN THIS VARIANT OF UC, patients have tenesmus, or urgency with a feeling of incomplete evacuation, but rarely have abdominal pain
UC patients with proctitis
in UC, when the disease extends beyond the THIS PART OF GUT, blood is usually mixed with stool or grossly bloody diarrhea may be noted
in UC, when the disease extends beyond the rectum, blood is usually mixed with stool or grossly bloody diarrhea may be noted
timinig of diarrhea in UC (2)
Diarrhea is often
* nocturnal and/or
* postprandial
3 physical signs of proctitis in UC
hepatic tympany is consistent with toxic colitis OR megacolon
severe pain and bleeding is consistent with toxic colitis OR megacolon
Both toxic colitis and megacolon may have signs of peritonitis
True or False
True
if perforation has occured
in UC, this is a highly sensitive and specific marker for detecting intestinal inflammation
fecal lactoferrin or fecal calprotectin
fecal lactoferrin
in active UC, these lab results are what… increased or decreased…
* CRP
* ESR
* platelet
* Hgb
in UC, levels of this marker correlate well with histologic inflammation, predict relapses, and detect pouchitis
fecal lactoferrin or fecal calprotectin
fecal calprotectin
in UC, fecal calprotectin detects what disease
pouchitis
in UC, Proctitis or proctosigmoiditis rarely causes a rise in CRP
True or False
True
This endscopic method is used to assess disease activity and is usually performed before treatment.
Sigmoidoscopy
In UC, if the patient is not having an acute flare, this endoscopy method is used to assess disease extent and activity
in UC, histologic features change FASTER than clinical features but can also be used to grade disease activity
True or False
False…. kasi dapat….
Histologic features change more slowly than clinical features but can also be used to grade disease activity
This classification system is used to describe extend and severity of UC
Differentiate differents extents of UC based from Montreal Classification
* E1
* E2
* E3
Differentiate differents severity of UC based from Montreal Classification
* S0
* S1
* S2
* S3
This is defined as a transverse or right colon with a diameter of >6 cm, with loss of haustration in patients with severe attacks of UC.
Toxic megacolon
Diameter of transverse or right colon in patients with toxic megacolon
transverse or right colon with a diameter of >6 cm
2 triggers of toxic megacolon
can be triggered by
* electrolyte abnormalities
* and narcotics
Management of toxic megacolon is always surgical. True or False
False….
About 50% of acute dilations will resolve with conservative management alone, but urgent colectomy is required for those who do not improve.
If surgery is needed for toxic megacolon, this procedure is done….
About 50% of acute dilations will resolve with conservative management alone, but urgent colectomy is required for those who do not improve.
most dangerous local complication of toxic megacolon
perforation
Strictures occur in 5–10% of patients and are always a concern in UC because of the possibility of underlying ____.
df
Neoplasia
Although benign strictures can form from the inflammation and fibrosis of UC, strictures that are ____should be presumed malignant until proven otherwise.
Although benign strictures can form from the inflammation and fibrosis of UC, strictures that are impassable with the colonoscope should be presumed malignant until proven otherwise.
A stricture that prevents passage of the colonoscope is an indication for surgery
True or False
True
UC patients occasionally develop anal fissures, perianal abscesses, or hemorrhoids, but the occurrence of extensive perianal lesions should suggest CD
True or False
True
two patterns of disease in CD
name of the classification system for CD
the Vienna and Montreal Classification Systems for CD are divided into what 3 parameters
most common site of inflammation in ileocolitis in CD
most common site of inflammation is the terminal ileum
usual presentation of ileocolitis in CD (2)
chronic history of recurrent episodes of right lower quadrant pain and diarrhea
Sometimes the initial presentation of this disease mimics acute appendicitis with pronounced right lower quadrant pain, a palpable mass, fever, and leukocytosis.
ileocolitis in CD
High-spiking fever in ileocolitis suggests what complication
High-spiking fever suggests intraabdominal abscess formation
The “string sign” on radiographic studies is seen in what disease
ileocolitis in CD
This finding in ileocolitis in CD is caused by incomplete filling of the lumen as the result of edema, irritability, and spasms associated with inflammation and ulcerations.
string sign
The string sign of ileocolitis in CD may be seen in both nonstenotic and stenotic phases of the disease.
True or False
True
Pellagra from ____ deficiency can occur in extensive small-bowel disease in jejunoileitis
Pellagra from niacin deficiency (Vitamin B3) can occur in extensive small-bowel disease
malabsorption of ____ in jejunoileitis can lead to megaloblastic anemia
Vitamin B 12
This symptom is characteristic of active disease in jejunoileitis in CD
Diarrhea
The third portion of the duodenum is more commonly involved than the bulb in CD
True or False
The second portion of the duodenum is more commonly involved than the bulb.
in CD, patients usually have a Helicobacter pylori–positive gastritis
True or False
False…
Patients usually have a Helicobacter pylori–negative gastritis
Fecal lactoferrin is a more sensitive marker of ileocolonic or colonic inflammation rather than isolated ileal inflammation.
True or False
False… kasi dapat …
Fecal calprotectin is a more sensitive marker of ileocolonic or colonic inflammation rather than isolated ileal inflammation.
Endoscopic features of CD (4)
Endoscopic features of CD include
* rectal sparing,
* aphthous ulcerations,
* fistulas,
* skip lesions.
Characteristics of strictures in CD that respond better to endoscopic dilation (2)
Strictures ≤4 cm in lengthand those at anastomotic sites respond better to endoscopic dilation.
This endoscopy method allows direct visualization of the entire small-bowel mucosa
Wireless capsule endoscopy (WCE) allows direct visualization of the entire small-bowel mucosa
In CD, early radiographic findings in the small bowel include (2)
- thickened folds
- aphthous ulcerations
The diagnostic yield of detecting lesions suggestive of active CD is higher with wireless capsule endoscopy (WCE) than CT or magnetic resonance (MR) enterography
True or False
True
in CD, “Cobblestoning” from longitudinal and transverse ulcerations most frequently involves the WHAT PART OF THE BOWEL
small bowel
The earliest macroscopic findings of colonic CD
The earliest macroscopic findings of colonic CD are aphthous ulcers.
This underutilized imaging study is at least as sensitive as MR enterography and CT enterography for detecting small-bowel CD
Small bowel ultrasound or SBUS is at least as sensitive as MR enterography and CT enterography for detecting small-bowel CD
SBUS is best suited for PROXIMAL small-bowel assessment
True or False
SBUS is best suited for distal small-bowel assessment, as the sensitivity of detecting lesions within the duodenum and proximal jejunum may be lower due to anatomic position.
Perforation occurs in 1–2% of CD patients, usually in the WHAT PART OF GUT
Ileum
anti–Saccharomyces cerevisiae antibody (ASCA) is more common in CD OR UC
perinuclear antineutrophil cytoplasmic antibody (pANCA) is more common in CD OR UC
.____measures a panel of serologic (S), genetic (G), and inflammatory (I) biomarkers, but the test is costly, and reliable results are based on the pretest probability of the patient having IBD
Prometheus IBD SGI Diagnostic blood test
.____is a validated web-based tool to display individual CD outcomes and considers multiple variables including disease location (large or small bowel, perianal), serologies (ASCA, CBir1, ANCA), and genetics (NOD2 frameshift mutation)
PROSPECT
Clinical factors described at diagnosis are more helpful than serologies at predicting the natural history of IBD.
True or FAlse
True
Once a diagnosis of IBD is made, distinguishing between UC and CD is impossible initially in up to 15% of cases.
These are termed WHAT
indeterminate colitis
This infectious disease can mimic the endoscopic appearance of severe UC and can cause a relapse of established UC.
This bacteria can cause watery or bloody diarrhea, nausea, and vomiting.
This infectious disease causes watery diarrhea, abdominal pain, and fever followed by rectal tenesmus and by the passage of blood and mucus per rectum.
This infection occurs mainly in the terminal ileum and causes mucosal ulceration, neutrophil invasion, and thickening of the ileal wall.
Yersinia enterocolitica infection
three categories of E. coli which can cause colitis
- enterohemorrhagic,
- enteroinvasive,
- enteroadherent E. coli
Gonorrhea, Chlamydia, and syphilis can also cause proctitis.
True or false
True
sites commonly affected in GI disease caused by mycobacterial infection
Distal ileal and cecal involvement
These viral diseases (2) cause proctitis and may occur in immunocompetent px
Although most of the patients with viral colitis are immunosuppressed, cytomegalovirus (CMV) and herpes simplex proctitis may occur in immunocompetent individuals.
How to diagnose CMV infection of GI tract vs Herpes simplex infection of the GI tract
- CMV: identification of characteristic intranuclear inclusions in mucosal cells on biopsy
- HSV: rectal biopsy with identification of characteristic cellular inclusionsand viral culture
Colonoscopy findings in entamoeba histolytica infection
focal punctate ulcers with normal intervening mucosa;
3 factors that favor CD over diverticulitis
Diverticular-associated colitis is similar to CD, but mucosal abnormalities are limited to the WHAT PARTS OF THE GUT (2)
Diverticular-associated colitis is similar to CD, but mucosal abnormalities are limited to the sigmoid and descending colon.
This DDx IBD…Patients usually present with sudden onset of left lower quadrant pain, urgency to defecate, and the passage of bright red blood per rectum.
ischemic colitis
This DDx of IBD….Endoscopic examination often demonstrates a normal-appearing rectum and a sharp transition to an area of inflammation in the descending colon and splenic flexure.
ischemic colitis
Endoscopy findings in GIT after undergoing radiotherapy
Solitary rectal ulcer syndrome is uncommon and can be confused with IBD. Ulceration, which may be as large as 5 cm in diameter, is usually observed AT WHAT PART OF THE GI TRACT
anteriorly or anterolaterally 3–15 cm from the anal verge
Examples of immune checkpoint proteins (2)
The most common clinical presentation of ICI-related colitis is…
The most common clinical presentation of ICI-related colitis is self-limited diarrhea that can be associated with frank colitis and can lead to significant morbidity and mortality if not managed appropriatel
Moderate to severe symptoms of ICI-related colitis usually require this DRUG CLASS
glucocorticoids
THESE DRUGS (2) are used in steroid- refractory cases of ICI-related colitis
biologics such as anti-TNF agents and integrin inhibitors are used in steroid- refractory cases of ICI-related colitis
Two atypical colitides—collagenous colitis and lymphocytic colitis have completely normal endoscopic appearances
True or False
True
what are the two atypical colitides
Two atypical colitides
* collagenous colitis and
* lymphocytic colitis
two main histologic components of collagenous colitis
two main histologic components of collagenous colitis
* increased subepithelial collagen deposition
* colitis with increased intraepithelial lymphocytes.
female-to-male ratio of collagenous colitis
female-to-male ratio is 9:1
Collagenous colitis present in what decade of life
present in the sixth or seventh decade of life
main symptom collagenous colitis
main symptom is chronic watery diarrhea.
Risk factors of collagenous colitis (3)
Risk factors of collagenous colitis :
* smoking;
* use of NSAIDs, proton pump inhibitors, or beta blockers;
* and a history of autoimmune disease.
Lymphocytic colitis has features similar to collagenous colitis, including age at onset and clinical presentation but it is different in 2 clinical aspects
Both collagenous colitis and lymphocytic colitis have increased intraepithelial lymphocytes
True or False
True
Use of of THIS DRUG is an additional risk factor for lymphocytic colitis
Use of sertraline (but not beta blockers) is an additional risk factor for lymphocytic colitis
The frequency of ____disease is increased in lymphocytic colitis and ranges from 9 to 27%
The frequency of celiac disease is increased in lymphocytic colitis and ranges from 9 to 27%
This is an inflammatory process that arises in segments of the large intestine that are not continuous with the fecal stream.
Diversion colitis
Diversion colitis usually occurs in patients with…
It usually occurs in patients with ileostomy or colostomy when a mucus fistula or a Hartmann’s pouch has been created.
Crypt architecture in diversion colitis is normal, which differentiates it from UC but not necessarily CD.
True or False
True
____ may help in diversion colitis but the definitive therapy is surgical reanastomosis
Short-chain fatty acid enemas
Short-chain fatty acid enemas may help in diversion colitis but the definitive therapy is____
surgical reanastomosis
Mycobacterial diseases that can mimic IBD. Give 2
Viral diseases that can mimic IBD. Give 3
Fungal diseases that can mimic IBD. Give 3
Parasitic diseases that can mimic IBD. Give 3
Drugs/chemicals that can mimic IBD. Give 3
Mild UC based from Montreal Classification is defined as…
Moderate UC based from Montreal Classification is defined as…
Severe UC based from Montreal Classificatio is defined as…
This extraintestinal dermatologic manifesation of IBD has the ff characteristics:
* Lesions are hot, red, tender nodules measuring 1–5 cm in diameter
* Lesions are found on the anterior surface of the lower legs, ankles, calves, thighs, and arms.
Erythema nodosum (EN)
in Erythema nodusoum, skin lesions develop after the onset of bowel symptoms, and patients frequently have concomitant ____ (disease)
active peripheral arthritis
EN parralels bowel activity. True or False
True
only 2 dermatologic manifestation of IBD that does not parallel bowel activity
Pyoderma gangrenosum and Psoriasis
Treatment of pyoderma gangrenosum
They are sometimes very difficult to treat and often require IV antibiotics, IV glucocorticoids, dapsone, azathioprine, thalidomide, IV cyclosporine (CSA), infliximab, or adalimumab.
Pyoderma gangrenosum may occur years before the onset of bowel symptoms,
True or False
True
Pyoderma gangrenosum is usually associated with mild disease.
True or False
False…. kasi dapat…
It is usually associated with severe disease.
Difference of Pyoderma vegetan vs Pyostomatitis vegetans in terms of location
This dermatologic EIM of IBD is a neutrophilic dermatosis
This dermatologic EIM of IBD is a rare disorder defined by cutaneous granuloma formation.
only rhematologic EIM of IBD that parralels bowel activity
Rheumatologic EIM of IBD with the ff characteristics:
* Asymmetric, migratory
* Parallels bowel activity
Rheumatologic EIM of IBD with the ff characteristics:
Rheumatologic EIM of IBD with the ff characteristics:
* Symmetric: spine and hip joints
* Independent of bowel activity
Rheumatologic EIM of IBD with the ff characteristics:
* Gradual fusion of spine
* Independent of bowel activity
* Two-thirds have HLA-B27 antigen
Treatment of periphral is directed at ____
reducing bowel inflammation
About one-thirds of IBD patients with AS express the HLA-B27 antigen.
True or false
False… kasi dapat…
About two-thirds of IBD patients with AS express the HLA-B27 antigen.
In severe UC, colectomy frequently cures the arthritis.
True or False
True
About two-thirds of IBD patients with AS express THIS ANTIGEN
About two-thirds of IBD patients with AS express the HLA-B27 antigen.
Ankylosing spondylitis does not remit with glucocorticoids or colectomy.
True or false
True
THIS therapy in AS
* reduces spinal inflammation
* and improves functional status and quality of life.
Anti-TNF therapy in AS
* reduces spinal inflammation
* and improves functional status and quality of life.
This rhuematologic EIM of IBD
* is symmetric,
* occurs equally in UC and CD
True or False
Sacroiliitis
Sacroiliitis
* is often asymptomatic,
* and does not always progress to AS
True or false
True
This ocular EIM of IBD has the ff characteristics
* Ocular pain, photophobia, blurred vision, headache
* Independent of bowel activity
Uveitis
This ocular EIM of IBD has the ff characteristics
* Mild ocular burning
* Parallels bowel activity
This ocular EIM of IBD parallels bowel activity
Common treatment for the 2 ocular EIM of IBD
____is detectable in about one-half of the abnormal liver biopsies from patients with CD and UC; patients usually present with hepatomegaly
Hepatic steatosis is detectable in about one-half of the abnormal liver biopsies from patients with CD and UC; patients usually present with hepatomegaly
____is a disorder characterized by both intrahepatic and extrahepatic bile duct inflammation and fibrosis, frequently leading to biliary cirrhosis and hepatic failure
Primary sclerosing cholangitis (PSC)
Although it can be recognized after the diagnosis of IBD, PSC can be detected earlier or even years after proctocolectomy
True or False
True
both IBD and PSC are commonly pANCA negative
True or false
false…. kasi dapat…
both IBD and PSC are commonly pANCA positive
traditional gold standard diagnostic test for PSC
traditional gold standard diagnostic test is endoscopic retrograde cholangiopancreatography (ERCP)
In patients with PSC, both ERCP and MRCP demonstrate multiple bile duct strictures alternating with relatively normal segments.
True or False
True
Gallbladder polyps in patients with PSC have a high incidence of malignancy, and cholecystectomy is recommende
True or False
True
How often should GB ultrasound be done in px with GB polyp and IBD
Gallbladder surveillance with ultrasound should be performed annually
Patients with IBD and PSC are at increased risk of colon cancer and should be surveyed ( HOW OFTEN ) by colonoscopy and biopsy.
yearly
cholangiography is normal in a small percentage of patients who have a variant of PSC known as ____.
cholangiography is normal in a small percentage of patients who have a variant of PSC known as small duct primary sclerosing cholangitis (AKA pericholangitis)
hepatobiliary EIM of IBD with the ff characteristics
* Secondary to chronic illness, malnutrition, steroid therapy
hepatobiliary EIM of IBD with the ff characteristics
* Intrahepatic and extrahepatic
* Inflammation and fibrosis leading to biliary cirrhosis and hepatic failure
* 7–10% cholangiocarcinoma
* Small-duct PSC involves small-caliber bile ducts and has a better prognosis
hepatobiliary EIM of IBD with the ff characteristics
* Patients with ileitis or ileal resection
* Malabsorption of bile acids, depletion of bile salt pool, secretion of lithogenic bile
The highest frequency of nephrolithiasis (10–20%) occurs in this subset of CD patients
The highest frequency of nephrolithiasis (10–20%) occurs in patients with CD following small-bowel resection.
Calcium oxalate stones develop secondary to ____
Calcium oxalate stones develop secondary to hyperoxaluria, which results from increased absorption of dietary oxalate
Patients with IBD have an increased risk of both venous and arterial thrombosis even if the disease is not active.
True or False
True
The renal disease in secondary or reactive amyloidosis can be successfully treated with WHAT DRUG
Colchicine
5-ASA are effective at inducing and maintaining remission in UC.
True or False
True
____ is effective treatment for mild to moderate UC, but its high rate of side effects limits its use.
Sulfasalazine
Sulfasalazine is effective treatment for mild to moderate UC, but its high rate of side effects limits its use.
Although sulfasalazine is more effective at higher doses, at ____g/d, up to 30% of patients experience allergic reactions or intolerable side effects
6 or 8 g/day
This vitamin should be given when admnistering sulfasalazine
Sulfasalazine can also impair folate absorption, and patients should be given folic acid supplements.
This contains an azo bond binding mesalamine to the carrier molecule 4-aminobenzoyl-β-alanine; it is effective in the colon.
Balsalazide
Balsalazide is effective at what part of the gut
colon
These are enteric-coated forms of mesalamine (2) with the 5-ASA being released at pH >7.
Delzicol and Asacol HD (high dose)
This is a once-a-day formulation of mesalamine (Multi-Matrix System [MMX]) designed to release mesalamine in the colon.
Lialda
The ____incorporates mesalamine into a lipophilic matrix within a hydrophilic matrix encapsulated in a polymer resistant to degradation at a low pH (<7) to delay release throughout the colon.
MMX technology
is a formulation containing encapsulated mesalamine granules that delivers mesalamine to the terminal ileum and colon via a proprietary extended-release mechanism (Intellicor).
Apriso
This is another mesalamine formulation that uses an ethyl cellulose coating to allow water absorption into small beads containing the mesalamine.
Pentasa
This an unencapsulated version of mesalamine,
It has been in use in Europe for induction and maintenance of remission for several years.
Salofalk Granu-Stix
Dosing per day of Sulfasalazine (Acute vs Maintenance)
Examples of different kinds of Mesalazine
* Delayed-release
* Controlled-release
* Delayed- and Extended-release
5-ASa agents that are delivered to the colon only (2)
5-ASa agents that is delivered to the distal ileum-colon only (2)
5-ASA agents that are delivered to the ileum-colon (2)
iba pa yung dital ileum-colon
5-ASA agents that is delivered to the stomach-colon (1)
Renal function tests and urinalysis in px taking 5-ASA should be checked HOW OFTEN
yearly
These enema enemas are composed of mesalamine
and are effective in mild-to-moderate distal UC.
Topical Rowasa enemas
____ suppositories composed of mesalamine are effective in treating proctitis.
Canasa
Canasa suppositories composed of mesalamine are effective in treating ____.
proctitis
for active UC that is unresponsive to 5-ASA therapy * Prednisone is usually started at what dose…
Prednisone 40–60 mg/d
A newer glucocorticoid for UC, ____, is released entirely in the colon and has minimal to no glucocorticoid side effects.
A newer glucocorticoid for UC, budesonide (Uceris), is released entirely in the colon and has minimal to no glucocorticoid side effects.
dose and duration of Budesonide in UC
Hydrocortisone enemas are significantly absorbed from the rectum and can lead to ____ with prolonged administration
adrenal suppression
Topical steroid therapy is more effective than topical 5-ASA therapy in the treatment of distal UC.
True or false
False… kasi dapat…
Topical 5-ASA therapy is more effective than topical steroid therapy in the treatment of distal UC.
Glucocorticoids play no role in maintenance therapy in either UC or CD.
True or False
True
Glucocorticoids have many side effects. Which adverse effect is not related to the dose and duration of therapy
Osteonecrosis
Antibiotics have no role in the treatment of active or quiescent UC.
True or False
True
Antibiotics have no role in the treatment of active or quiescent UC. However, pouchitis, which occurs in ~30–50% of UC patients after colectomy and IPAA, usually responds to treatment with a variety of antibiotics including ____ and ____
metronidazole and ciprofloxacin.
Antibiotics have no role in the treatment of active or quiescent UC. However,____, which occurs in ~30–50% of UC patients after colectomy and IPAA, usually responds to treatment with a variety of antibiotics including metronidazole and ciprofloxacin.
pouchitis
These are purine analogues used concomitantly with biologic therapy or, much less often, as the sole immunosuppressants for IBD
Azathioprine and mercaptopurine (MP
____ is rapidly absorbed and converted to MP, which is then metabolized to the active end product, thioinosinic acid, an inhibitor of purine ribonucleotide synthesis and cell proliferation.
Azathioprine
Azathioprine is rapidly absorbed and converted to MP, which is then metabolized to the active end product, ____, an inhibitor of purine ribonucleotide synthesis and cell proliferation.
Azathioprine is rapidly absorbed and converted to MP, which is then metabolized to the active end product, thioinosinic acid, an inhibitor of purine ribonucleotide synthesis and cell proliferation.
Adherence to azathioprine and mercaptopuirine can be monitored by measuring the levels of ____ and ____, the end products of MP metabolism.
Adherence can be monitored by measuring the levels of 6-thioguanine and 6-methylmercaptopurine, end products of MP metabolism.
Dose of azathioprine vs mercaptopurine
Although azathioprine and MP are usually safe, THIS ADVERSE EFFECT occurs in 3–4% of patients, typically presents within the first few weeks of therapy, and is completely reversible when the drug is stopped.
Although azathioprine and MP are usually safe, pancreatitis occurs in 3–4% of patients, typically presents within the first few weeks of therapy, and is completely reversible when the drug is stopped.
in Azathioprine and MP, Bone marrow suppression (particularly thrombocytopenia) is dose-related and often delayed
True or False
False… kasi dapat…
Leukopenia
enzyme responsible for drug metabolism to inactive end products 6-methylmercaptopurine
thiopurine methyltransferase
Age with highest risk for thiopurine-associated lymphoma
vs moderate risk
- highest risk –patients >65 years old actively using thiopurines
- moderate risk – ages of 50 and 65
IBD patients on azathioprine and MP have fourfold risk of THIS CANCER
lymphoma
____inhibits dihydrofolate reductase, resulting in impaired DNA synthesis.
Methotrexate
Intramuscular (IM) or subcutaneous (SC) doses of MTX range from ___ to ___mg/week.
Intramuscular (IM) or subcutaneous (SC) doses range from
15 to 25 mg/week
Potential toxicities of methotrexate include ____and ____ necessitating periodic evaluation of CBCs and liver enzymes.
Potential toxicities include leukopenia and hepatic fibrosis, necessitating periodic evaluation of CBCs and liver enzymes.
Hypersensitivity pneumonitis is a rare but serious complication of therapy of what IBD drug
Methotrexate
CSA is a lipophilic peptide with inhibitory effects on both the cellular and humoral immune systems.
True or False
True
CSA has a more rapid onset of action than MP and azathioprine.
True or False
True
This drug most effective when given at 2–4 mg/kg per day IV in severe UC that is refractory to IV glucocorticoids, with 82% of patients responding.
Cyclosporine
This drug can be an alternative to colectomy.
Cyclosporine
Cyclosporine levels as measured by monoclonal radioimmunoassay or by the high-performance liquid chromatography assay should be maintained between ____ and ____ ng/mL.
Levels as measured by monoclonal radioimmunoassay or by the high-performance liquid chromatography assay should be maintained between 150 and 350 ng/mL.
gingival hyperplasia and hypertrichosis are common side effects of this IBD drug
Cyclosporine
Seizures may also complicate therapy using cyclosporine , especially if the patient has these 2 low lab values (2)
Seizures may also complicate therapy, especially if the patient is
* hypomagnesemic or
* if serum cholesterol levels are <3.1 mmol/L (<120 mg/dL)
antibiotic prophylaxis with ____ should be given in patients taking Cyclosporine
trimethoprim-sulfamethoxazole
____ is a macrolide antibiotic with immunomodulatory properties similar to CSA but 100 times as potent
Tacrolimus
Tacrolimus is a macrolide antibiotic with immunomodulatory properties similar to CSA but 10 times as potent
True or False
False…
100 times as potent
tacrolimus has poor oral absorption because of proximal small-bowel Crohn’s involvement
True or False
False… kasi dapat…
tacrolimus has good oral absorption despite proximal small-bowel Crohn’s involvement
Tacrolimus is effective in these 4 subset of populations
Tacrolimus is effective
* in children with refractory IBD
* in adults with extensive involvement of the small bowel
* in adults with glucocorticoid-dependent or refractory UC and CD
* in adults with refractory fistulizing CD
High-risk patients with UC who are more likely to require biologics (3)
High-risk patients with CD who are more likely to require biologics
Four TNF inhibitors are currently approved for the treatment of IBD
- infliximab
- adalimumab
- certolizumab pegol
- golimumab
first biologic therapy approved for moderately to severely active inflammatory and fistulizing CD and UC
Infliximab
a chimeric IgG1 antibody against TNF-α
Infliximab
This trial compared infliximab plus azathioprine, infliximab alone, and azathioprine alone in immunomodulator- and biologic therapy–naive patients with moderate to severe CD.
SONIC trial…
Study of Biologic and Immunomodulator-Naive Patients with Crohn’s Disease
Hospitalized patients with acute severe glucocorticoid refractory UC have a high inflammatory burden and may develop a ____, leading to an accelerated consumption, excessive fecal wasting, and low serum concentrations of infliximab.
Hospitalized patients with acute severe glucocorticoid refractory UC have a high inflammatory burden and may develop a protein-losing enteropathy, leading to an accelerated consumption, excessive fecal wasting, and low serum concentrations of infliximab.
This is a recombinant human monoclonal IgG1 antibody containing only human peptide sequences and is injected subcutaneously.
Adalimumab
ADA is approved for treatment of both moderate to severe CD and UC.
True or False
True
____ is an ADA maintenance study in patients who responded to ADA induction therapy.
CHARM (Crohn’s Trial of the Fully Human Adalimumab for Remission Maintenance)
the remission rate in both CD and UC patients taking ADA increases with a dose increase to 40 mg weekly instead of every other week.
True or False
True
This is a pegylated form of an anti-TNF Fab portion of an antibody administered SC once monthly.
Certolizumab Pegol
SC certolizumab pegol was effective for induction of clinical response in patients with active inflammatory UC and CD.
True or False
Fasle…
CD lang dapat
another fully human IgG1 antibody against TNF-α and is currently approved for the treatment of moderately to severely active UC.
Golimumab
Golimumab is used for CD
True or False
False…
it is used for UC only
anti TNF agents given via SC route (3)
- ADA
- certolizumab
- golimumab
If a patient has high anti-infliximab antibodies and a low trough level of infliximab, it is best to switch to another anti-TNF therapy.
True or Flase
True
If a patient has a therapeutic anti-TNF level and active inflammatory symptoms, the drug should be switched to a different class of biologic.
True
Most acute infusion reactions and serum sickness secondsry to biologics can be managed with THESE 2 DRUGS
Most acute infusion reactions and serum sickness can be managed with glucocorticoids and antihistamines.
It is now common practice to add ____ to anti-TNF therapy to help prevent antibody formation
It is now common practice to add an immunomodulator such as azathioprine, MP, or MTX to anti-TNF therapy to help prevent antibody formation
The baseline risk of THIS MALIGNANCY in CD patients is 2 in 10,000, slightly higher than in the general population.
Azathioprine and/or MP therapy increases the risk to ~4 in 10,000.
Non Hodgkin’s lymphoma
____ is a nearly universally fatal lymphoma in patients with or without CD.
Hepatosplenic T-Cell Lymphoma (HSTCL)
Patients with IBD may have a slight, unexplained, intrinsic higher risk of developing THIS SKIN CANCER
Patients with IBD may have a slight, unexplained, intrinsic higher risk of developing melanoma.
The risk of melanoma is increased almost twofold with anti-TNF and not thiopurine use.
True or False
True
The risk of nonmelanoma skin cancer is increased with thiopurines and biologics, especially with ≥1 year of follow-up.
Patients on Biologics should have a skin check at least how many times a yeae
once a year
All of the anti-TNF drugs are associated with an increased risk of infections
True or False
True
Patients should have a purified protein derivative (PPD) or a QuantiFERON-TB Gold test before initiation of anti-TNF therapy.
True or False
True
Patients ____ years old have a higher rate of infections and death on infliximab or ADA than those ____ years old.
Patients >65 years old have a higher rate of infections and death on infliximab or ADA than those <65 years old.
Anti integrin that is a recombinant humanized IgG4 antibody against α4-integrin
Monoclonal antibody directed against a4B7-integrin specifically
Vedolizumab
Anti integrin thatg is a fully human IgG1 monoclonal antibody,
blocks the biologic activity of IL-12 and IL-23 through their common p40 subunit
Natalizumab is no longer widely used for CD due to the risk of ____
Natalizumab is no longer widely used for CD due to the risk of progressive multifocal leukoencephalopathy (PML).
This anti integrin has the ability to convey gut-selective immunosuppression.
Vedolizumab
This anti integrin may be prescribed as a first-line biologic or after failure of a TNF antagonist in patients with CD or UC.
Vedolizumab
This trial suggests that among patients with UC, VDZ should be considered as first-line therapy and before treatment with ADA
VARSITY trial
This trial evaluated ustekinumab as 8-week induction and 44-week maintenance therapy in moderate to severe UC.
UNIFI trial
This trial showed that the remission rate for the highest 6 mg/kg IV induction dose of Ustekinumab followed by a dose of 90 mg every 8 weeks was 41.7%, compared with 27.4% for placebo, at 22 weeks in patients with CD no longer responding to anti-TNF therapy
UNITI trial
This drug is another option for the treatment of moderate to severe CD and UC and is particularly appealing for use in patients with concomitant psoriatic arthritis.
Ustekinumab
new class of orally administered medications developed for IBD that lack the immunogenicity associated with monoclonal antibodies
small molecules
____ is a reversible and competitive JAK inhibitor used for the treatment of moderate to severe UC refractory to conventional therapy.
It competes with ATP to bind to the ATP-docking site of the kinase domain of JAK.
Tofacitinib
Although tofacitinib is a pan-JAK inhibitor, it has higher specificity for JAK2 and TYK2
True or False
False… kasi dapat…..
Tofacitinib is a pan-JAK inhibitor, it has higher specificity for JAK1 and JAK3 than for JAK2 and TYK2.
This drug is potent sphingosine-1-phosphate (S1P1) receptor modulator that binds selectively with high affinity to the S1P receptor subtypes S1P1 and S1P5, both of which are involved in immune regulation. By preventing trafficking of disease-exacerbating lymphocytes to the gut, this drug may provide immunomodulatory effects and moderate disease processes.
Ozanimod
Because UC is a mucosal disease, the rectal mucosa can be dissected and removed down to WHAT LEVEL (2)
Because UC is a mucosal disease, the rectal mucosa can be dissected and removed down to :
* dentate line of the anus
* or ~2 cm proximal to this landmark
The part of the gut is fashioned into a pouch that serves as a neorectum.
The ileum is fashioned into a pouch that serves as a neorectum.
The most frequent complication of IPAA is ____
pouchitis
Patients with IPAA usually have____ bowel movements a day.
Patients with IPAA usually have ~6–10 bowel movements a day.
____is the most frequently performed operation, and in most cases, primary anastomosis can be done to restore continuity
Surgical resection of the diseased segment
An end-to-end anastomosis may provide the best opportunity for an optimal functional outcome, compared to an anti-peristaltic side-to-side anastomosis
True or False
True
Most surgeons believe that an IPAA is contraindicated in UC due to the high incidence of pouch failure.
True or False
False… kasi dapat CD
Patients with quiescent UC and CD have normal fertility rates;
True or False
True
Infertility in men can be caused by this IBD DRUG but reverses when treatment is stopped.
Infertility in men can be caused by sulfasalazine but reverses when treatment is stopped.
LEft side of fallopian tube is usually scarred in IBD. True or False
the fallopian tubes can be scarred by the inflammatory process of CD, especially on the right side because of the proximity of the terminal ileum.
why are women with IPAA have decreased fertility
Women with an IPAA have decreased fertility due to scarring or occlusion of the fallopian tubes secondary to pelvic inflammation and adhesions
Mild or quiescent UC or CD has no effect on birth outcomes.
True or False
True
Patients should be in remission for UC or CD for HOW MANY months before conceiving.
6 months remission dapat
all mesalamines are safe for use in pregnancy and nursing
True or False
True
This vitamin must be given for pregnant patients receiving sulfasalazine
Folic acid (vitamin B9)
Topical 5-ASA agents are safe during pregnancy and nursing.
true or false
True
Glucocorticoids are generally safe for use during pregnancy
True or False
True
The safest antibiotics to use for CD in pregnancy for short periods of time (weeks, not months) are…. (2)
ampicillin and cephalosporins
Metronidazole can be used in what trimester of pregnancy
Metronidazole can be used in the second or third trimester.
____ causes cartilage lesions in immature animals and should be avoided because of the absence of data on its effects on growth and development in humans
Ciprofloxacin causes cartilage lesions in immature animals and should be avoided because of the absence of data on its effects on growth and development in humans
MP and azathioprine pose minimal or no risk during pregnancy.
True or False
True
MTX is teratogenic and should be discontinued at least HOW MANY months before conception
MTX is teratogenic and should be discontinued at least 3 months before conception
Infants can have serum levels of infliximab and ADA up to 12 months of age, and live vaccines should be avoided during this time.
True or False
true
no increased risk of stillbirths, miscarriages, or spontaneous abortions was seen with infliximab, ADA, or certolizumab
true or false
true
this anti TNF drug crosses the placenta by passive diffusion, and infant serum and cord blood levels are minimal.
Certolizumab crosses the placenta by passive diffusion, and infant serum and cord blood levels are minimal.
VDZ and ustekinumab appear safe during pregnancy
True or False
True
Tofacitinib can be safely used during pregnancy.
True or False
Tofacitinib should not be used during pregnancy.
For Tocatinib, A washout period of at least HOW LONG is recommended before conception.
A washout period of at least 1 week is recommended before conception.
The best time to perform surgery in UC is in WHAT trimester if necessary.
The best time to perform surgery is in the second trimester if necessary.
Patients with IPAAs have increased nighttime stool frequency during pregnancy that resolves postpartum
True or False
True
Patients with long-standing UC are at increased risk for developing colonic epithelial dysplasia and carcinoma
True or False
True
Annual or biennial colonoscopy with multiple biopsies is recommended in UC
True or False
True
International guideline societies have recommended ____ for dysplasia surveillance in IBD
International guideline societies have recommended chromoendoscopy for dysplasia surveillance in IBD
In real-life settings, the practice has been to use standard-definition ____endoscopy with surveillance biopsies in patients with chronic colitis at average risk and ____endoscopy in higher-risk patients including those with a history of dysplasia, PSC, or family history of colorectal cancer.
In real-life settings, the practice has been to use standard-definition white light endoscopy with surveillance biopsies in patients with chronic colitis at average risk and chromoendoscopy in higher-risk patients including those with a history of dysplasia, PSC, or family history of colorectal cancer.
the same endoscopic surveillance strategy used for UC is recommended for patients with chronic Crohn’s colitis.
True or False T
True
Usual treatment if If flat high-grade dysplasia is encountered on colonoscopic surveillance in
* CD vs
* UC
usual treatment if flat lowgrade dysplasia is found
