Inflammatory Bowel Diseases (Crohns + UC)

Question 1

What are the names of 2 inflammatory bowel diseases?

Answer 1

Crohns
Ulcerative colitis

Question 2

Which areas do they both affect?
What does that lead to?
Who are they most common in?
What are they associated with?
Ages affected?

Answer 2

Both are inflamed intestines
Results in malabsorption
MC in Jews
Associated with HLA B27 (seronegative spondylarthropathy)
Bimodal age (15-20, 55+)

Question 3

Crohns
what causes it to occur?

Answer 3

NOD 2 gene mutation (frameshift) + environment
(Autoimmune) Bacteria cause immune mediated response (T cell) –> TNF alpha, IL1, IL6

Question 4

Where does the inflammation occur?

Answer 4

Whole GIT (from mouth to anus)
Especially terminal ileum + proximal colon (usually rectum spared)

Question 5

RF for crohns

Answer 5

Family History, Jewish, Smoking (2x more likely)

Question 6

Pathology of Crohns

Answer 6

Defect in epithelial barrier allows bacteria through and immune system activated therefore unregulated inflammation & destruction deep in mucosa, form granulomas
Then ulcers form (craters In intestinal wall)

Question 7

How deep is the inflammation?

Answer 7

Transmural (all 4 layers, mucosa, submucosa, muscle, serosa)

Question 8

Symptoms of Crohns

Answer 8

Pain in right lower Quadrant (ileum)

Malabsorption (as small intestine affected) (colon = water absorption only) - B12, Folate, Fe deficiency

Watery diarrhoea + blood in stool (blood due to damaged intestinal wall & Large intestine damaged = no water absorption)

Gall stones and kidney stones

Failure to thrive and weight loss

Question 9

What are the extra intestinal symptoms?
They are mc in UC except which one*?

Answer 9

Apthous mouth ulcers*

Uveitis + Epislceritis (inflammation of uvea of eye)

Erythema Nodosum (red nodules/lumps - tender- inflamed fat cells) / pyoderma gangrenosum

Spondylarthiritis - Spine ache

Question 10

Diagnosis of Crohns
Tests and results?

Answer 10

pANCA (-ve) - marker for UC

(May be ASCA +ve - associated with Crohns)

High Fecal calprotectin (high in all IBD) - distinguishes between IBD and non inflammatory bowel diseases eg. Irritable bowel syndrome, released when intestines inflamed

Question 11

Which tests are done for Crohns?
What would be seen?

Answer 11

Endoscopy / XR:
Skip lesions, cobble stoning +/- structures ‘string sign’
(inflammation is patchy, normal gut inbetween)

Biopsy:
Transmural inflammation with non caseating granulomas

Question 12

Treatment for Crohns

Answer 12

1. For flares= Prednisolone (corticosteroid) + (Sulfasalazine - given as a suppository - rectal therefore less useful in Crohns than UC)
2. For Remission = Azathioprine, methotrexate
3. Biologics = Anti TNF alpha - Influximab
   IL 12 + 23 Inhibitor - Ustekinumab

Question 13

Is surgery a good option?

Answer 13

Surgery is not curative as entire bowel can be affected (cut out ‘x’ but ‘y’ may start to flare up)

Question 14

Complications of Crohns

Answer 14

Fistula, Strictures, Abcesses, small bowel obstruction

Question 15

Ulcerative colitis
What causes it to occur?

Answer 15

Autoimmune colitis associated with HLAB27 gene + pANCA

Question 16

Where does inflammation occur?

Answer 16

Colon only, starts at rectum (procitis) to sigmoid to proximal colon

Question 17

Rf of UC

Answer 17

family history
Jewish
Smoking = protective

Question 18

Specifically, where is the inflammation? which layers?

Answer 18

Confined to MUCOSA (+ submucosa)

Question 19

Symptoms of UC?

Answer 19

Pain in left lower quadrant
Tenesmus (rectal defecation pain) - feel need to pass stool when bowel empty
Bloody Mucusy Watery Diarrhoea

Question 20

What are some extra intestinal signs?

Answer 20

Uveitis + Epislceritis (inflammation of uvea of eye)

Erythema Nodosum (red nodules/lumps - tender- inflamed fat cells) / pyoderma gangrenosum

Spondylarthiritis - Spine ache

PSC (primary sclerosing cholangitis) - chronic liver disease, bile ducts in & out liver are enflamed and blocked
90% UC patients have PCS
(75% IBD Px have PCS)

Question 21

Diagnosis of UC

Answer 21

pANCA +ve (specific)
Fecal calprotectin high (non specific)

Colonoscopy/XR:
Continuous, ‘lead pipe’ sign

Biopsy:
Mucosal inflammation with crypt hyperplasia

Question 22

What do we use to classify the severity of flares?

Answer 22

use TRUELOVE + WITTS criteria
mild/moderate/severe

Question 23

Treatment of UC

Answer 23

1. Flares - Sulfalazine (v good) + prednisolone (give first if severe)
2. Remission - Azathioprine, Methotrexat ciclosporin (Calcineurin inhibitor)
3. Biologics - Anti TNF alpha - Infliximab

Question 24

Can surgery be used as a treatment?

Answer 24

Total/partial colonectomy
curative

Question 25

Complications of UC

Answer 25

Toxic megacolon (mc complication causing UC deaths)

Question 26

What happens when tissue flares and remission?

Answer 26

Flare = New damage
Remission = tissue heals