Inflammatory Bowel Diseases Flashcards
What is inflammatory bowel disease?
Chronic, relapsing, remitting inflammation of GIT
Chron’s disease and ulcerative colitis
Present mainly in teens and tweens
Where is Chron’s disease located?
Can be anywhere from mouth to anus
Is patchy
Where is Ulcerative Colitis located?
Starts at rectum then moves proximally
Only in colon
What are microscopic colitis?
Collagenous colitis - thickness of sub-epithelial collagen band increases
Lymphocytic colitis - increased lymphocytes
What is IBD-U?
IBD-unclassified
Mix of UC and CD
What causes for IBD?
Genomes, microbiota, medication, environment, smoking, diet and history of gastroenteritis
Explain genes and IBD
Is not Mendelian inherited
Genetic susceptibility - SNPs
Family trend
Offspring have 10% chance of developing
Genes effect epithelial barrier, immune responses and bacterial handling
How does host genetic and environmental factors affect the gut?
Altered microbiota - dysbiosis
Damages epithelial barrier and increased bacterial adherence
Chronic inflammation
What are the symptoms of ulcerative colitis?
Bloody diarrhoea, abdominal pain, weight loss and fatigue
Who does UC mainly affect?
Peak incidence at 20-40 years
More males over females
Explain Ulcerative Colitis
Continuous inflammation - only colon
Begins rectum and works proximally
Variable severity and distribution
What is proctitis?
Confined to rectum only
There is increased frequency, urgency, incontinence and tenesmus
Small volume mucus and blood
Constipation
What does proctitis respond to?
Topical therapy
What is acute severe colitis?
Life threatening medical emergency = appreciable mortality
Risk of colectomy
Patients often look well
Infection is main differential
How is ulcerative colitis scored?
Truelove and Witt’s criteria
Scores to put into categories - mild, moderate, severe and fulminant (continuous bleeding, toxicity..)
What investigations are used for ulcerative colitis?
Bloods for markers of inflammation - microcytic anaemia
Increased CRP/WCC/platelets
Decreased albumin
Stool culture, faecal calprotectin and colonoscopy
Explain faecal calprotectin
If activation of immune system then calprotectin released from epithelial cells, monocytes and neutrophils
High conc. does not equal IBD but shows inflammation
What is the name of the stool chart used?
Bristol stool chart
What should be done in the first 24hrs of acute severe colitis?
Blood tests, stool charts, 4 stool cultures, avoid/stop some drugs, IV hydration and glucocorticoids, LMWH, AXR
What drugs should be avoided or stopped for acute severe colitis?
Non steroidal analgesics
Opiates
Anti-diarrhoeas
Anti-cholinergic
What can be some features of UC on AXR?
Colon more than 5.5
Toxic megacolon
Mucosal thickening
Gaseous small bowel loops
Lead pipe appearance
What are the symptoms of Chron’s Disease?
Diarrhoea, abdominal pain, weight loss, malaise, lethargy, anorexia, malabsorption
What investigations are used for Chron’s Disease?
Bloods, stool culture, faecal calprotectin, colonoscopy, MRI small bowel study, capsule endoscopy and occasionally CT
How is Chron’s Disease different to ulcerative colitis?
Different histology
CD granulomas, transmural inflammation in CD
Goblet cells depleted in UC and more crypt abscesses
What are the complications of Chron’s Disease?
Inflammation, Stricture, Fistula, Abscess
Due to transmural inflammation and can cause connection to other organ
What are the symptoms for peri-anal Chron’s Disease?
Perianal pain, pus secretion and unable to sit down
What investigations are used for perianal Chron’s disease?
MRI pelvis
Examination under anaesthetic (EUA)
What is the treatment for perianal Chron’s disease?
Surgery to drain abscess and place seton stitch
Medical - antibiotics and biologic therapy (anti-TNF)
What are some extra-intestinal manifestations of IBD?
Mouth ulcers, skin rashes/lesions (erythema nodosum), musculoskeletal, eye, primary sclerosing cholangitis
What are some differential diagnoses of IBD?
Other causes of chronic diarrhoea - malabsorption, IBS and overflow diarrhoea
Ileo-caecal TB and colitis type
What is the long term complications of colitis?
Colonic carcinoma
What are the risk factors for developing colonic carcinoma from colitis?
Pancolitis 26x, left colitis 8x and proctitis minimal
Over 10years is minimal risk then 20 and 30 years gets to 30x normal
Describe colitis surveillance
If have colitis then need observation
Screening at 10 years then after can be low risk, intermediate and higher risk
Low - 5years
Intermediate - 3 years
High - 1year
Who is involved in IBD management?
OP clinics, IBD nurses, pharmacist, nurse led infusion clinic, colorectal surgeon, GP, MDT meetings
What are the aims of treatment for IBD?
Maintenance
Steroids needed at flares
Can have periods of remission
What approach is used for IBD?
Step up vs top down approach
5ASA then prednisolone/ budesonide then immunomodulators then biologic agents then surgery
Explain amino-salicylates
Work by blocking prostaglandins and leukotrienes
Topical to colonic mucosa
Release mechanisms lead to colonic delivery ex pH responsive
What are the two types of 5-ASAs
Mesalazine - pentasa
Prodrugs - balsalazide, olzalazine
What is 5-ASAs used for?
Induction of remission - 1st line treatment
Used in UC not in CD
Can be given orally or rectal
Describe 5ASAs and mild moderate UC
Maintenance of remission
Reduced number and severity of relapses
Reduced colorectal risk
What are steroids used for?
Induce remission UC and CD
Not for long term use as have adverse side effects
What steroids are used for treatment?
Prednisolone - calcium/ vit D supplementation
Budesonide - slightly less effective but has better side effect profile
When are Thiopurines -immunomodulation used for treatment?
Used for maintenance in UC and CD
Azathioprine
Has significant side effects
What are some side effects of Azathioprine?
Leukopenia
Hepatoxicity
Pancreatitis
Possible lymphoma risk and non melanoma skin cancers
Check TPMT to access
When is Methotrexate - immunomodulation used for treatment?
Unlicensed use
For Chron’s only - induction and maintenance of remission
Require specialist follow up
What are some biologics - monoclonal antibodies used for treatment?
Anti-TNF alpha antibodies
Alpha 4b7 integrin blockers
IL12/IL23 blockers
What are some Anti-TNF alpha antibodies?
Infliximab - 8 weekly IV infusion
Adalimumab - 2 weekly SC injection
What is a alpha 4b7 integrin blocker used?
Vedolizumab - 8 weekly IV infusion
What is a IL12/IL23 blocker used?
Ustekinumab - IV loading then SC 8-12 weekly
What is a newer treatment?
Tofacitinib
Small molecule
Pan JAK inhibitor and oral
Describe elemental feeding
Liquid food and no other oral diet
More efficacious in children
Compliance difficult but can be as effective as steroids
When is it an emergency to operate?
Acute severe colitis not responding to high dose IV steroids and maybe anti-TNF biologics
Complications like perforation, obstruction and abscess
What are some elective reasons to operate?
Frequent relapses despite medical therapy
Not able to tolerate medical therapy
Steroid dependant
Patient choice
What is the surgery for acute severe colitis?
Subtotal colectomy
Rectal preservation
Ileostomy
What is left after subtotal colectomy?
End ileostomy and rectal stump
Describe pouch surgery
Mobilise and lengthen small bowel
Construct pouch then staple
Recommended in UC
What are surgical indication for surgery in Chron’s disease?
Failure of medical management
Relief of obstructive symptoms
Management of fistulae, intra-abdominal abscess and anal conditions
Failure to thrive
Is surgery in Chron’s disease curative?
No - half need further surgery in 10 years
