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CMPP > Inflammatory Bowel Diseases > Flashcards

Inflammatory Bowel Diseases Flashcards

1
Q

two major disorders of IBD

A 
Ulcerative colitis (UC)
Chrones disease (CD)
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2
Q

chronic inflammatory condition

A

CD and UC

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3
Q

relapsing and remitting episodes of inflammation

A

UC

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4
Q

inflammation limited to the mucosal layer of the colon

A

UC

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5
Q

transmural inflammation and what does it lead to

A

CD > fibrosis and obstructive clinical picture

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6
Q

involves rectum and colon preferably

A

UC

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7
Q

favors illeum but can go anywhere in GI tract

A

CD

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8
Q

may extend proximally and continuously to involve more of the colon

A

UC

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9
Q

skip lesions or cobble stone apearance

A

CD

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10
Q

age diagnosed for UC and CD

A

15-40 and 50-80

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11
Q

male predominance

A

UC

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12
Q

female predominance

A

CD

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13
Q

racial predominance for both

A

jewish, caucasian

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14
Q

percentage of CD and UC patients that have a 1st degree relative with IBD

A

10-25%

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15
Q

smoking is not a risk factor

A

UC

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16
Q

smoking is a risk factor

A

CD (cessation resulting in less flares)

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17
Q

3 main factors of IBD

A

genetic predisposition
altered dysregulation of immune response (helper T cells)
altered response to gut bacteria

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18
Q

clinical manifestations of UC

A 
diarrhea +/- blood
frequent and small BM
colicky periumbilical > LLQ abd pain
bowel urgency
tenesmus
incontinence
mucus from rectum
when rectum is involved, constipation
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19
Q

onset of symptoms in UC

A

gradual and progressive over a few weeks

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20
Q

severity of UC

A

10 stools daily with severe cramps and bleeding

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21
Q

how does physical exam help diagnosis of UC

A

it really doesnt

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22
Q

what causes UC?

A

inflammation of mucosa leading to ulceration, edema, bleeding, and fluid/electrolyte loss

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23
Q

what immune reaction is prompted

A

cytokines are released by macrophages and target Type2 helper T cells causing them to be cytotoxic to surrounding tissues > inflammation

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24
Q

microscopic level of UC

A

acute and chonic inflammatory changes to mucosa (lamina propria)
villous atrophy
discharge of mucus from goblet cells

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25
Q

signs of systemic toxicity

A

fever >99.5
tachy >90
anemia <10.5
elevated ESR

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26
Q

acute complications of UC

A

severe bleeding
fulminant colitis
toxic megacolon
perforation

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27
Q

fulminant colitis

A

> 10 stools per day with continuous bleeding
abd pain and distension
toxic symptoms

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28
Q

toxic megacolon

A

colonic diameter >6cm or >9 with toxicity
potentially deadly
can perforate

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29
Q

how many patients develop extraintestinal manifestations?

A

only 10%

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30
Q

when do extraintestinal manifestations most commonly occur>

A

following an episode of colitis

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31
Q

extraintestinal manifestations of UC

A

arthritis of large joints
uveitis
cholangitis (fibrosis of gallbladder)
unprovoked PE or DVT

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32
Q

when do you start a workup for UC

A

chronic diarrhea >4 weeks

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33
Q

what labs to order for UC

A

ESR: inflammation
CBC: WBC and hemoglobin
PANCA and ASCA: pANCA+ > UC

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34
Q

stool studies for UC, what to look out for

A 
salmonella
shigella
campylobacter
c.diff
ova/parasites
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35
Q

why is it important to take a good history for UC

A

rule out anal STDs

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36
Q

is imagine required to diagnose UC

A

no

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37
Q

imaging done to diagnose UC

A

endoscopy + biopsy

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38
Q

findings on endoscopy that indicate UC

A

bowel wall thickening
vascular markings due to engorgement of mucosa
edema, exudates, friability
pseudopolyps (more extensive UC)
erosions and ulcerations
continuous and circumfrential beginning at the anal verge

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39
Q

how likely is relapse in UC?

A

70% within the first 10 years

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40
Q

predictors of frequent relapse

A

disease flare within 2 years of diagnosis
presence of fever or weight loss upon diagnosis
active disease in preceding year

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41
Q

how likely is it for UC to extend up the colon?

A

20% of pts in the first 5 years

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42
Q

what does repeated inflammation prompt in UC

A

benign strictures only in 10% of patients
rectosigmoid colon
evaluate on endoscopy and biopsy to rule out cancer

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43
Q

is there increased risk for cancer with UC?

A

yes, colorectal cancer.

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44
Q

greatest risk factors for colorectal cancer and UC?

A

extent of colitis (how much of the GI tract)

duration of the disease (how long they’ve been diagnosed)

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45
Q

highest risk for colorectal cancer of UC patients

A

pancolitis

46
Q

when does the risk start for colorectal cancer?

A

8-10 years after pancolitis diagnosis

47
Q

step 1 therapy for proctitis or proctosigmoiditis

A

5-ASA
Mesalanine (Canasa) BID topical for rectal (suppository)
Mesalanine (Rowasa) BID topical for >colon (enema)

48
Q

with topical therapy how soon will relief and bleeding subside in UC?

A

a few days

49
Q

how long must UC pts stay on topical mesalanine for complete healing

A

6-8weeks –> gradual taper

50
Q

step 2 therapy for UC

A

5-ASA topical + oral if they don’t respond

or if they refuse topical

51
Q

5-ASA PO drugs

A

Sulfalazine (azulfidine)

mesalanine (asacol, lialda,pentasa, apriso)

52
Q

sulfalazine mechanism

A

prodrug splits into sulfapyridine and mesalanine by bacteria in the colon

53
Q

MOA of sulfasalazine

A

blocks prostaglandin production in the colon and inhibits inflammations

54
Q

S.E. of sulfasalazine

A

due to sulfapyridine component
nausea, headache, rash, fever
leukopenia in first 3 months + fever and rash
inhibits folic acid transport across cell membrane
watery diarrhea, abd pain, pancreatitis

55
Q

monitoring while on 5-ASA therapy for UC

A

baseline CBC and LFTS
continue q2w x3m
qmonth x3m
q3m after

56
Q

what do you need to prescribe with sulfasalazine

A

1mg Folic acid qd

57
Q

when don’t we recommend maintenance 5-ASA therapy

A

patient with first episode of mild ulcerative proctatitis that responds to treatment

58
Q

when do we recommend maintence therapy for UC

A

pts with >1 relapse per year

ALL patients with proctosigmoiditis

59
Q

when can we consider taking a pt off maintenance therapy for UC

A

when they’ve been on meds for 2+ years and get clearance from GI specialist

60
Q

pts on topical therapy for induction of remission

A

1 5-ASA suppository QHS with proctiits
1 5-ASA enema QHS with proctosigmoiditis
possible they need sulfasalazine to remain in remission

61
Q

first line therapy for left sided colitis or pancolitis

A

combo of oral and topical 5-ASA (enema)

62
Q

second line therapy for left sided colitis or pancolitis

A

no remission in 2-4 weeks or systemic symptoms
GLUCOCORTICOIDS (prednisone)
only for pts with systemic symptoms, toxicosis, tachycardic

63
Q

which patients with left colitis or pancolitis need maintenance therapy?

A

all of them
can taper down from BID enemas to QHS
no glucocorticoids, taper after pt stable for 2-4 weeks

64
Q

when can we use supportive treatment for UC?

A

in those with MILD disease and without SYSTEMIC TOXICITY

65
Q

diarrhea support in UC

A

loperamide (immodium)

66
Q

abdominal cramping support in UC

A

anticholinergic medicines like

hyoscamine (Levsin)

67
Q

avoid what med while treating UC

A

NSAIDs

opiates

68
Q

surgical treatment for UC

A

total colectomy

69
Q

when are total colectomies most commonly done in UC

A

intractable disease
dependence upon steroids to maintain remission
progression of dx with worsening symptoms
major complications with medications

70
Q

when to conduct colorectal screenings in UC

A

after 8 years in pancolitis
after 15 years in left colitis
repeat every 1-2 years regardless of reults

71
Q

when to perform osteoporosis screening in UC pts

A 
all UC patients who are
postmenopausal
>60 y.o
ongoing corticosteroid use >3m
history of low-trauma fractures
72
Q

where does chrones occur?

A 
anywhere in the the GI tract
80% most commonly in the distal ileum
50% in the ileum and colon
20% in colon
5-10% in mouth, esophagus, or duodenum
73
Q

what do the cytokines target in CD?

A

type 1 helper T cells

just like UC, cytotoxic effect on surrounding tissues > villous atrophy

74
Q

why does diarrhea occur in CD?

A

excessive fluid secretion bc of inflammed bowel, but atrophy doesn’t allow the bowel to reabsorb

bile salts aren’t absorbed by terminal ileum

75
Q

describe abd pain in CD

A

crampy
periumbilical > RLQ
transmural involvement
relieved with BM

76
Q

diarrhea in CD

A

common at presentation
NOT usually bloody
may include mucus or pus

77
Q

how does CD in only the colon present?

A

just like UC

78
Q

evidence of malabsorption in CD

A

weight loss, anorexia, NV

79
Q

complication of deepening transmural involvement in CD

A

fistula formation in bladder, skin, bowel, and vagina

increasing chances longer diagnosed

80
Q

if a sinus tract does not extend all the way to another organ in CD it forms an…

A

abscess

81
Q

extraintestinal manifestations of CD

A

same as UC (more frequent if colonic involvement of a flare)

82
Q

labs for diagnosis

A

ESR: inflammation
Iron: deficiency due to bleeding or poor absorption of Fe
B12: ileum absorption
CBC: hemoglobin, white count
pANCA and ASCA: + ASCA > CD
(if colon involed, pANCA might be positive

83
Q

stool studies look out

A

same as UC

84
Q

endoscopic findings

A

aphthous ulcers
cobblestoning
linear ulcers
discontinuous lesions

85
Q

CD disease course

A

remission followed by exacerbation

active disease in past year > 70% chance having disease active 1 year later

86
Q

patients who go in remission for 1 year

A

80% chance of remaining in remission another year

only 13% of CD pts

87
Q

pts who have annual relapses

A

20%

88
Q

pts who go in and out of remission?

A

70%

89
Q

predictors of more severe disease cours

A 
>40y.o @ diagnosis
perianal or rectal disease
smoking
low education level
initial requirements of glucocorticoids
90
Q

choice of treatment for CD depends on

A

anatomic location of disease
severity
goal of therapy

91
Q

treatment for oral lesion

A

triamcinolone oral gel

92
Q

first line therapy for Ileitis and colitis with CD

A

glucocorticoids (prednisone) + immunomodulators or biological agents

93
Q

glucocorticoids in CD

A

60-80% respondance in 10-14 days
taper drug after condition improves
not long term

94
Q

support in CD for diarrhea

A

immodium (loperamide)

95
Q

immunomodulators

A

Azathioprine (imuran)

Methotrexate (CHEAPER!!!)

96
Q

azathioprine (imuran) MOA

A

inhibits an enzyme needed for DNA synthesis

affects proliferating cells especially T and B cells

97
Q

how long does it take for Azathioprine to be effective

A

3-6 months

98
Q

role of azathioprine

A

to get people into remission who have symptoms even on chronic steroid therapy

99
Q

risks of azathioprine

A

secondary infection
malignancy
leukopenia (long term)
thrombocytopenia (long term)

100
Q

methotrexate mOA

A

interferes with DNA synthesis, repair, cellular replication
rapidly dividing cells are more sensitive to this effect (malignant cells, bone marrow, fetal cells, intestinal mucosa, bladder cells)

101
Q

role of methotrexate

A

induction and maintenance of CD remission

102
Q

risk of methotrexate

A

teratogenic
males should not try to get pregnant until 3 months after stopping medication
females should not try to get pregnant until they have one full ovulatory cycle after stopping medication

103
Q

unexpected severe symptoms of methotrexate

A

bone marrow suppression, aplastic anemia (WITH NSAIDs)

104
Q

biological agents, when do we use them?

A

Inflizimab (remicade)

when you fail prednisone + methotrexate

105
Q

how is inflizimab given?

A

IV

106
Q

MOA of infliximab

A

antibody against TNF > blocks it in the serum and cell surface causing lysis of macrophages and T cells

107
Q

role of infliximab

A

induction of remission (if it works stay on it for maintenace)

108
Q

risks of infliximab

A

increased risk of opportunisitc infections
test for TB prior to prescribing
higher rates of Hodgkin’s and non-Hodgkin’s lymphoma in those who started therapy <18 y.o occuring 1-84 months post start of therapy (most prescribed concomitant immunosuppressants)
Heart Failure: do not use with pts with moderate to severe heart failure

109
Q

who needs surgery for CD?

A

intracable symptoms
obstruction
perforation

110
Q

colorectal screening for CD?

A

same as UC

CMPP (17 decks)

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