Inflammatory Bowel Disorder

Question 1

Describe Crohn’s Disease

Answer 1

• Chronic progressive patchy inflammation of the gut wall
• May occur anywhere along the GIT (more in ileum and colon)
• Transmural, chronic inflammation
• Hyperplasia and luminal invasion
• Patchy ulceration
• Strictures
• Fistulae
• Perianal disease
• RLO masses occur

Question 2

Describe Ulcerative Colitis

Answer 2

• Continuous progressive generalised epithelial ulceration
• Inflammation limited to colon
• Distal disease (rectum or sigmoid colon) our more extensive (L-sided colitis)
• Superficial continuous inflammation (mucosa only)
• Inflammation limited to colon and starting at anus
• Most limited to the left side
• No perianal disease (fistulae, fissures and perforation)

Question 3

What are the key clinical differences between CD and UC?

Answer 3

• CD:
• Acute or insidious onset of symptoms
• Abdominal pain
• Weight loss/anorexia
• Palpable tender mass (lower abdomen)
• Malabsorption, hypovitaminosis
• Frequently perianal disease
• UC:
• Often abrupt onset with some chronic symptoms
• Left sided pain
• Anaemia
• Dehydration
• Lower abdominal cramps
• Pain on defecation

Question 4

What are the main complications associated with IBD?

Answer 4

• Strictures
• Dietary restrictions
• Vitamin deficiencies
• Anaemia
• Fistulae
• Dehydration
• Surgery

Question 5

How should you manage UC?

Answer 5

• Mild:
• Inducing remission = oral 5-ASA and/or topical steroid e.g. prednisolone
• Maintenance = oral 5-ASA and oral azathioprine/mercaptopurine
• Moderate:
• Inducing remission = oral 5-ASA and/or topical steroid e.g. prednisolone (tacrolimus if inadequate response to oral prednisolone)
• Maintenance = oral 5-ASA and oral azathioprine/mercaptopurine
• Severe:
• Inducing remission = IV corticosteroids (hydrocortisone) and IV cyclosporin or infliximab or surgery
• Maintenance = infliximab, adalimumab or golimumab and consider adding oral azathioprine or mercaptopurine

Question 6

How should you manage CD?

Answer 6

• Mild:
• Inducing remission = oral steroids or budesonide/5-ASA if prednisolone not tolerated
• Maintenance = azathioprine/mercaptopurine or methotrexate
• Moderate:
• Inducing remission = glucocorticosteroids and consider using infliximab
• Maintenance = infliximab potentially with azathioprine or methotrexate
• Fistulating disease:
• Inducing remission = antibiotics/drainage and consider infliximab
• Maintenance = infliximab potentially with azathioprine/mercaptopurine or methotrexate

Question 7

Acute treatment vs Chronic treatment

Answer 7

• Acute treatment (fast onset):
• Steroids
• 5-ASA
• Anti-TNFs
• Ciclosporin
• Chronic treatment (slow onset):
• Azathioprine/mercaptopurine/methotrexate
• 2-3 months for onset of action

Question 8

What should you consider when selecting treatment?

Answer 8

• Can you wait for the slow drugs to take effect?
• Is the drug cost effective
• Is treatment suitable for long-term treatment?
• Aim to wean off steroids once in remission
• Ciclosporin is not for long terms use

Question 9

What are the associated co-morbidities?

Answer 9

• Heart failure:
• Steroids (fluid retention)
• Infliximab (worsens heart failure)
• Diabetes:
• Steroids (can affect glycemic control)
• Osteoporosis:
• Avoid repeated courses of steroids
• Pregnancy:
• Azathioprine/mercaptopurine/methotrexate
• Infliximab/adalimumab