Inflammatory Bowel Diseases Flashcards by Sophie Pitcairn

What is inflammatory bowel disease?

Chronic, relapsing, remitting inflammation of GIT
Chron’s disease and ulcerative colitis
Present mainly in teens and tweens

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Where is Chron’s disease located?

Can be anywhere from mouth to anus
Is patchy

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Where is Ulcerative Colitis located?

Starts at rectum then moves proximally
Only in colon

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What are microscopic colitis?

Collagenous colitis - thickness of sub-epithelial collagen band increases
Lymphocytic colitis - increased lymphocytes

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What is IBD-U?

IBD-unclassified
Mix of UC and CD

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What causes for IBD?

Genomes, microbiota, medication, environment, smoking, diet and history of gastroenteritis

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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

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How does host genetic and environmental factors affect the gut?

Altered microbiota - dysbiosis
Damages epithelial barrier and increased bacterial adherence
Chronic inflammation

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What are the symptoms of ulcerative colitis?

Bloody diarrhoea, abdominal pain, weight loss and fatigue

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Who does UC mainly affect?

Peak incidence at 20-40 years
More males over females

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Explain Ulcerative Colitis

Continuous inflammation - only colon
Begins rectum and works proximally
Variable severity and distribution

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What is proctitis?

Confined to rectum only
There is increased frequency, urgency, incontinence and tenesmus
Small volume mucus and blood
Constipation

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What does proctitis respond to?

Topical therapy

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What is acute severe colitis?

Life threatening medical emergency = appreciable mortality
Risk of colectomy
Patients often look well
Infection is main differential

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How is ulcerative colitis scored?

Truelove and Witt’s criteria
Scores to put into categories - mild, moderate, severe and fulminant (continuous bleeding, toxicity..)

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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

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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

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What is the name of the stool chart used?

Bristol stool chart

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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

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What drugs should be avoided or stopped for acute severe colitis?

Non steroidal analgesics
Opiates
Anti-diarrhoeas
Anti-cholinergic

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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

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What are the symptoms of Chron’s Disease?

Diarrhoea, abdominal pain, weight loss, malaise, lethargy, anorexia, malabsorption

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What investigations are used for Chron’s Disease?

Bloods, stool culture, faecal calprotectin, colonoscopy, MRI small bowel study, capsule endoscopy and occasionally CT

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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