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MBBS IV - Junior Clerkship WCS > JC67 (Medicine) - Acute and Chronic Diarrhea - IBS and IBD > Flashcards

JC67 (Medicine) - Acute and Chronic Diarrhea - IBS and IBD Flashcards

1
Q

Ddx infective and non-infective causes of acute diarrhea

A 
Infective:
→ Gastroenteritis (vast majority)
→ C. difficile infection
→ Other GI infections, eg. diverticulitis
→ Malaria

GI non-infective:
→ IBD
→ CA colon

Metabolic:
→ DKA
→ Hypocalcaemia
→ Uraemia
→ Thyrotoxicosis
→ Neuroendocrine diseases

Drugs: antibiotics, NSAIDs, cytotoxic agents, PPI

Toxins: ciguatera fish poisoning, heavy metal poisoning

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2
Q

Acute diarrhea

4 pathological groups of infective causes + examples

A
  1. Food poisoning - preformed toxins:
    B. cereus
    S. aureus
    Clostridium perfringens
2. Non-inflammatory, small bowel: 
V. cholerae
Enterotoxigenic E. coli
Norovirus
Rotavirus (children)
Giardia lamblia
Cryptosporidium parvum
3. Inflammatory, large bowel: 
EHEC*
Shigella*
Campylobacter
Non-typhoidal Salmonella
Clostridium difficile
Entamoeba histolytica*
  1. Invasive:
    Salmonella typhi
    Salmonella paratyphi
    (Yersinia)
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3
Q

Infective food poisoning

  • Bacteriology
  • Pathogenesis
  • Incubation period
  • Presentation
A
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4
Q

Non-inflammatory acute GE

  • Bacteriology
  • Pathogenesis
  • Incubation period
  • Presentation
A
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5
Q

Inflammatory acute GE

  • Bacteriology
  • Pathogenesis
  • Incubation period
  • Presentation
A
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6
Q

Invasive acute GE

  • Bacteriology
  • Pathogenesis
  • Incubation period
  • Presentation
A
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7
Q

Acute GE in winter months, children predominant

Present with vomiting, diarrhea, prodromal features for few days

Most common pathogens

A

Viral causes: majority of acute GE, usually mild
□ Norovirus: accounts for >1/3 of outbreaks
→ Esp common in winter months

□ Other viruses: usually causes ds in children
→ Eg. rotavirus, adenovirus, astrovirus

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8
Q

Acute GE presents with severe watery diarrhea within hours of meal

Similar features in people who share meals

Most likely causative pathogens

A

□ Toxin-mediated: a/w food poisoning
→ S/S: prominent N/V w/ short incubation
→ Eg. B. cereus typically a/w rice
→ Eg. S. aureus typically a/w prepared food

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9
Q

Acute GE, presents with watery, large volume diarrhoea a/w abdominal cramping, bloating and gas

Over 3-5 days

No blood in stool or fever

Most likely causative agents

A

Non-inflammatory pathogens:

V. cholerae
Enterotoxigenic E. coli
Norovirus
Rotavirus (children)
Giardia lamblia
Cryptosporidium parvum
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10
Q

Acute GE, presents with frequent, regular, small volume and often painful bowel movements

a/w fever and bloody/mucoid stools

Most likely pathogens

A

Inflammatory pathogens

EHEC*
Shigella*
Campylobacter
Non-typhoidal Salmonella
Clostridium difficile
Entamoeba histolytica*
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11
Q

Define likely pathogens associated with following food:

Rice 
Seafood 
Raw eggs 
Uncooked meat, poultry 
Unpasteurized dairy products 
Canned food
A

Rice: Bacillus cereus
Seafood: Norovirus, Vibrio spp, hepatitis A
Raw eggs: Salmonella spp
Uncooked meat, poultry: Salmonella spp, Campylobacter spp, EHEC, C. perfringens
Unpasteurized dairy products: Salmonella spp, Campylobacter spp, EHEC, Yersinia enterocolitica
Canned food: C. botulinum

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12
Q

Outline history taking for acute diarrhea

A

□ Diarrhoea: syndrome, duration, amount, frequency, presence of blood, mucus or fat

□ Associating symptoms: abdominal pain, fever, N/V, poor appetite

□ Food history: intake, changes in preparation or content, unhygienic food

□ Travel, occupation, contact, cluster

□ Dehydration: frequent profuse watery diarrhoea, vomiting, poor fluid intake, concurrent fever, dry lips, oliguria

□ Other Hx: recent Antibiotics use, immunodeficiency

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13
Q

Clinical definition of diarrhea

A

Increase daily stool volume, frequency and fluidity

Stool weight > 250g/ 4h

> 2-3 times/ day or liquidity

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14
Q

First-line investigations for acute diarrhea

Indication for investigation

A

Basic metabolic panel: CBC, L/RFT, electrolytes ± blood culture

Stool examination:
→ Stool culture for bacterial pathogen
→ Stool microscopy for RBC, WBC, ova and cyst (if inflammatory or persistent)
→ Multipathogen panel for bacterial, viral and parasitEic pathogens (if inflammatory)
→ Specific toxin tests: E. coli O157:H7 test, Shiga toxin test, C. difficile toxin testing

Malaria workup: thick/thin blood smear if returning traveler

Indications:
severe illness, inflammatory diarrhea with high fever, persistent for > 1 week, high risk comorbidities and diseases

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15
Q

First-line management of acute diarrhea

A

Fluid: ORS or IV fluid if shock, unconscious

Antibiotics: ONLY FOR SEVERE or INFLAMMATORY DIARRHEA
Empirical Tx: azithromycin (if inflammatory) or fluoroquinolones
Specific Tx: metronidazole (C. dificile), amoxicillin/cotrimoxazole (Listeria)

Anti-diarrhoeal, eg. loperamide (Imodium), bismuth salicylate for inflammatory diarrhea

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16
Q

Clinical definition of chronic diarrhea

Categorize chronic diarrhea into 3 main pathophysiological groups

A

Definition: Loose stool > 4 weeks with >3 loose stools/ day

  1. Inflammatory: Inflammatory bowel diseases, chronic infections, colonic diseases
  2. Watery: Secretory, Osmotic and Motility problems
  3. Malabsorption
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17
Q

Inflammatory causes of chronic diarrhea

A

Inflammatory bowel ds:
Crohn’s disease
Ulcerative colitis

Chronic infections:
C. dificile
M. tuberculosis

Other colonic diseases:
CA colon
Chronic ischaemia

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18
Q

Malabsorptive causes of chronic diarrhea

A

Causes: small bowel diseases, gut resection, bacterial overgrowth, pancreatic diseases

e. g.Enteropathy: celiac disease, short gut syndrome, Crohn’s disease
e. g. Pancreatic insufficiency: chronic pancreatitis, CA pancreas

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19
Q

Secretory causes of chronic diarrhea

A

Endocrine tumours: VIPoma, carcinoid syndrome, Zollinger-Ellison syndrome

Bile salt malabsorption e.g. terminal ileum diseases/ resection

Laxative abuse

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20
Q

Osmotic causes of chronic diarrhea

A

Lactase deficiency
Osmotic laxative
(Malabsorption)

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21
Q

Hyper-motility causes of chronic diarrhea

A

IBS

Metabolic: hyperthyroidism

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22
Q

Chronic diarrhea presenting with Mucoid, bloody stools with PMN in stools

Most likely causes?

A

Inflammatory bowel ds
Crohn’s disease
Ulcerative colitis

Chronic infections
C. dificile
M. tuberculosis

Other colonic diseases
CA colon
Chronic ischaemia

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23
Q

Chronic diarrhea presenting with watery diarrhea that changes in fasting state, with no pus/blood/ fatty stool

Most likely causes
How to differentiate between causes?

A

Secretory - Persists with fasting
Endocrine tumours: VIPoma, carcinoid syndrome, Zollinger-Ellison syndrome
Bile salt malabsorption
Laxative abuse

Osmotic - Stops with fasting
Lactase deficiency
Osmotic laxative
(Malabsorption)

Motility
IBS
Metabolic: hyperthyroidism

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24
Q

Chronic watery diarrhea
+ steatorrhoea
+ weight loss
+ nutritional deficiency

Most likely causes

A

Malabsorptive: small bowel diseases, gut resection, bacterial overgrowth, pancreatic diseases

Enteropathy: celiac disease, short gut syndrome, Crohn’s disease

Pancreatic insufficiency: chronic pancreatitis, CA pancreas, CF

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25
Drug-induced diarrhea Most common causative drugs?
□ Acid-suppressing agents: antacids (esp Mg-containing), H2RA, PPI □ Alcohol □ Antibiotics □ Caffeine: coffee, tea, cola □ Sorbitol/mannitol: dietectic food, gums, mints (osmotic diarrhoea) □ Others: β-blocker, NSAID/5-ASA, colchicine, misoprostol, theophylline
26
Outline P/E for chronic diarrhea
General: - Dehydration: fluid and electrolyte depletion - Nutritional status/ weight loss/ vitamin deficiency: Malabsorptive causes Differentials: - Hyperthyroidism causing hyper-motility: goitre, thyrotoxic signs - IBD causing inflammation: episcleritis/uveitis, oral ulcers, arthritis, skin rashes, flushing - Crohn's or CA colorectal causing inflammation: PR exam Signs of toxicity - Fever - Abdominal distension, peritoneal signs
27
First-line blood and stool investigations for chronic diarrhea
Blood tests: - CBC: anaemia, leukocytosis, eosinophilia, thrombocytosis - APR: ESR, CRP - LFT: albumin (malabsorption, protein-losing enteropathy) - RFT: electrolyte disturbance, hydration - Serology: → AutoAb for IBD: p-ANCA (UC), ASCA (CD) → Serum Ig level: hypogammaglobulinaemia → recurrent GE → ± HIV Ab if noted lymphopenia - TFT for hyperthyroidism Stool tests: - Occult blood** - Na, K for osmolal gap - pH - Leucocytes, microbiology** - Fecal calprotectin
28
Differentials of eosinophilia
- Neoplasm - Allergy - Collagen vascular diseases - Parasite infestation - Eosinophilic gastroenteritis
29
# Define spot stool analysis metrics and rationale What's tested and why?
Stool for occult blood: GIB Stool for Na, K: → Stool osmolal gap: ↑ in osmotic, ↓ in secretory Stool for pH: → <5.6 → carbohydrate malabsorption Stool for leukocytes for inflammatory cause Stool for microbiology for infective vs inflammatory → C. dificile toxin → Culture for Aeromonas, Plesiomonas → Microscopy for ova and cyst for protozoan and parasites Fecal calprotectin: ↑ in inflammatory conditions
30
Fecal Calprotectin test - Function - MoA
Function: High in following causes of chronic diarrhea - Infectious diarrhea - Crohn's disease and Ulcerative colitis - Cancer MoA: 24kDa dimer of Ca binding proteins released by neutrophils >> indicate migration of neutrophils into gut mucosa
31
First-line imaging investigations for chronic diarrhea
AXR: calcifications in chronic pancreatitis Ba studies for mucosal abnormalities → Ba follow through/SB enema for SB mucosal abnormalities e.g. IBD, polyps, cancer USG for pancreatic disease CT/MR enterography for IBD and its complications Lymaphangiogram for lymphagiectasia Endoscopy
32
Protein losing enteropathy - Disease entities - Workup
Diseases: IBD, Whipple's disease, Allergic gastroenteropathy, Intestinal lymphangiectasia...etc Workup: 1. Labeled human serum scan (find source of protein pooling) 2. Fecal alpha-1-antitrypsin concentration (excessive GI protein loss) 3. Serum alpha-1-antitrypsin clearance
33
Endoscopic investigation for chronic diarrhea - Modalities - Function
OGD, Capsule/ small bowel balloon enteroscopy, colonoscopy, sigmoidoscopy obtain mucosal Bx for → IBD → Opportunitistic infections, eg. CMV colitis → Microscopic colitis
34
Management plan for chronic diarrhea List options for supportive treatment and malabsorption
Specific Tx for underlying cause of disease Supportive Tx: □ Antidiarrhoeal drugs, eg. Lomotil, Imodium □ Octreotide: ↓motility, useful in neuroendocrine tumour □ Intraluminal absorbants, eg. charcoal □ Bile acid-binding resin (cholestyramine) for bile acid malabsorption □ Bismuth compounds Treat malabsorption: □ Dietary supplements: Ca, Mg, Fe, folate, vitamin A, B12, D, K □ Pancreatic enzyme supplement, eg. pancreatin □ Enteral and parenteral supplementation
35
Irritable bowel syndrome Demographic Associated conditions
Demographics: ↑ in younger (<50y) and female (14% vs 9%) Associations: → Non-organic: eg. fibromyalgia, chronic fatigue syndrome, dysmenorrhea, functional dyspepsia, NCCP → Psychiatric: eg. depression, anxiety, somatization
36
Diagnostic criteria of IBS
Rome IV criteria with no alarming features Recurrent abdominal pain on average ≥1 day/week A/w ≥2 of → Related to defecation → A/w change in frequency of stools → A/w change in form (appearance) of stools For the past 3 months With symptom onset ≥6mo before diagnosis
37
Alarming feature against diagnosis of IBS
PMH: features of malignancy - Weight loss - Rectal bleeding and anaemia - Age >50, Male sex - Family history of colon cancer or IBD Investigation results: - Positive fecal occult blood test - Anaemia with leukocytosis and high ESR - Abnormal biochemistry
38
IBS Clinical subtypes
□ IBS w/ diarrhoea (IBS-D): loose or watery stools ≥25% with hard stools <25% of bowel mov’t □ IBS w/ constipation (IBS-C): hard stools ≥25% with loose/watery stools <25% of bowel mov’t □ Mixed IBS (IBS-M): both hard + loose/watery stools ≥25% □ Unsubtyped IBS (IBS-U): insufficient abnormality to meet above criteria
39
IBS Pathogenesis
1. Altered bowel motility, visceral hypersensitivity, intestinal inflammation and Serotonin imbalance 2. Luminal factors: - Altered gut microbes - Small intestinal bacterial overgrowth - Post-GE - Gluten intolerance 3. CNS: autonomic nervous system and brain gut axis dysfunction 4. Psychosocial/ psychiatric comorbidities
40
IBS Clinical features
Recurrent abdominal pain: - Usu cramping/colicky pain ± bloating, flatulence or belching - ↑ by emotional stress, meals and throughout the day Altered bowel habits: - Diarrhoea: frequent loose stools of small to moderate volume - Constipation: infrequent passage of ‘pellety’ stools
41
Ddx of IBS
□ Coeliac disease: steatorrhoea, malabsorption (eg. Fe-def/megalob anaemia, weight loss), child-onset, hyposplenism, duodenal Bx □ IBD: constitutional Sx, inflammatory diarrhoea (S/S + Ix), characteristic colonoscopic appearance □ CA colon: bloody stool, tenesmus, pencil-thin stools, FHx+, elderly male
42
IBS Management plan outline
□ Reassurance and education □ Dietary changes □ Pharmacotherapy directed towards predominant symptoms □ Psychotherapy if refractory to medications
43
IBS Treatment for diarrhea
Diet: Low FODMAP diet ``` Drugs:  Opioid agonist (loperamide)  Bile salt sequestrants (cholestyramine)  Probiotics  Rifaximin ```
44
IBS Treatment for constipation
High fiber diet  Dietary fibre (Psyllium)  Laxative (PEG)  Chloride channel activator (lubiprostone)*  Guanylate cyclase C agonist (linaclotide)*
45
IBS Treatment for abdominal pain
 Peppermint oil  Antispasmodics (otilonium, mebeverine)  Tricyclic antidepressant (amitriptyline, desipramine)  SSRI (citalopram, paroxetine, sertraline)  Chloride channel activator (lubiprostone)*  Guanylate cyclase C agonist (linaclotide)*
46
IBD Differentiate demographics between UC and CD
Crohn's - Any, median age of onset 30 - Bimodal: 2nd-3rd decade + 7th decade - 65% male - ↑incidence UC: - Any, median age of onset 41 - Bimodal: 2nd-3rd decade + 7th decade - 56% male - Incidence static Both have family history in 3%
47
IBD Differentiate risk factors between UC and CD
Crohn's - ↑ w/ smoking - Defective innate immunity and autophagy (NOD2, ATG16L1, IRGM) UC - ↓ w/ smoking, ↓w/ appendicectomy - HLA-DR*103, colonic epithelial barrier function (HNF4a, LAMB1, CDH1)
48
IBD Differentiate extent of GIT involvement between UC and CD
Crohn's: Mouth to anus, skip lesions, rectal-sparing - Small intestines and colon (40-55%) - Small intestinal only (25-30%) - Colon only (20-25%) - Anorectal (30-40%) - Upper GI tract (3-5%) UC: Colon only, continuous, anus-sparing - Begins at anorectal margin - Proctitis alone (40-50%) - Lt colitis alone (30-40%) - Pancolitis (20%)
49
IBD Differentiate endoscopic appearance between UC and CD
Crohn's - Cobblestone appearance - Aphthous lesion - Solitary, deep ulcers w/ fissures UC: - Pseudopolyps - Hyperemic mucosa - Shallow, diffuse ulceration - Diffusely granular appearance
50
IBD Differentiate histology between UC and CD
Crohn's - Patchy, transmural infl’n - Abscesses and fistulas often present - Glands relatively preserved - Granulomas common - Goblet cells present UC: - Continuous, superficial infl’n - Cryptitis ± cryptal abscesses - Gland atrophy in chronic cases - Granulomas rarely seen - Goblet cells depleted
51
Crohn's disease Major intestinal manifestations, S/S
Crohn’s ileitis (commonest) - Episodic colicky abdominal pain - Watery, fatty or inflammatory (less common) diarrhoea - Malabsorptive features - ± subacute/acute IO (fibrotic strictures) - ± RLQ mass (Crohn’s abscess) Crohn’s colitis (similar to UC) - Mucoid and bloody diarrhoea - A/w episodic colicky abdominal pain
52
Ulcerative colitis Major intestinal manifestations, S/S
Proctitis - Rectal bleeding with mucus discharge - A/w urgency, tenesmus, incontinence and changes in bowel habits Left and extensive colitis - Mucoid and bloody diarrhoea - A/w episodic colicky abdominal pain - ± toxic megacolon
53
Extra-intestinal manifestations of IBD - Skin - Joints
Dermatological: □ Erythema nodosum (3-15%): raised, tender, red/violet non-ulcerative subcutaneous nodules □ Pyoderma gangrenosum (0.75%): deep, necrotic ulcers, usually on leg, a/w sterile abscess on Bx Joints: acute pauciarticular peripheral arthritis (IBD-associated SpA) □ polyarthritis (3-4%), sacroiliitis (4-18%), AS, enthesitis and dactylitis
54
Extra-intestinal manifestations of IBD - Eyes - HBP - Haematological - Renal
Ocular: uveitis, episcleritis, scleritis HBP: Fatty liver, liver abscess, liver amyloidosis, granulomatous hepatitis Haematological: DVT, mesenteric or portal vein thrombosis Renal: ureteric calculi (oxalate, urate), renal amyloidosis
55
List complications + S/S of Crohn's disease
Malnutrition: - Cause: poor intake, protein-losing enteropathy, malabsorption - S/S: weight loss, deficiency anaemias, coagulopathy, osteomalacia, hypoCa Abscesses and fistula: - Transmural inflammation forms sinus tracts - e.g. Enteroenteric fistula: diarrhoea, malabsorption; Enterovesical fistula: recurrent UTI, pneumaturia Strictures and obstruction: - S/S: partial (colicky abd pain) or frank IO ``` Perianal disease (>1/3): - Anal fissure, perianal fistula, anorectal abscess ``` CA colon
56
List complications of Ulcerative colitis
Severe hemorrhage Toxic megacolon Colorectal cancer
57
Toxic megacolon in UC - Cause - S/S - Imaging features - Mx
- Cause: severe colitis → massive colon dilatation → bacterial toxin pass freely through mucosa into blood - S/S: Severe colitis, bleeding diarrhea, abd pain with distension - Systemic: dehydration, hypotension, fever, tachycardia - Imaging features: AXR: grossly dilated colon (3-6-9 rule) with thumbprinting, multiple fluid levels - Mx: Avoid colonscopy, anti-diarrhea and anti-spasmodic drugs Resuscitation, NG tube decompression, IV steroids, Broad-spectrum antibiotics Urgent colectomy if refractory
58
CA colon and IBD - Typical onset after IBD? - Monitoring methods
Time frame: ~8-10y after onset in extensive disease, ~10-15y after onset in limited or L-sided disease Surveillance colonoscopy (AGA): every 1-2y after 8y for pan-colitis and 15y for left-sided colitis
59
First-line serological investigations for IBD and typical findings
CBC with differential: anaemia + lymphocytosis APR: ESR, CRP ↓serum Fe, vitamin D, B12 Stool: ↑WBC/calprotectin, -ve for culture, ova/parasite and C. difficile toxin Serology: - Crohn's: ASCA +ve, pANCA –ve - UC: ASCA –ve, pANCA +ve
60
First-line radiological investigation for IBD and typical findings
Crohn's: - Small bowel imaging: narrowed lumen (‘string sign’), bowel wall thickening with ‘rose-thorn’ ulcers, mucosal nodular filling defects with cobble-stoning, ± fistulas - CT ± enteroclysis: screen complications (eg. abscess, perforation) - MRI: thickened, hyperintense bowel wall UC: - Colonoscopy - AXR for toxic megacolon - Double contrast enema: ‘carpeting’ diffuse involvement with button-shaped ulcers or pseudopolyp, lead-pipe sign - CT colonoscopy
61
Ddx for Crohn's disease
- IBS: never PR bleed, no constitutional features, normal ileocolonoscopy, imaging, stool markers - Lactose intolerance: diarrhoea, abd pain and flatulence a/w ingestion of milk-related products - Infective enteritis: esp Yersinia and TB - UC: ↑bleeding and ↓constitutional Sx, limited to colon with rectal involvement sparing anus, continuous lesion with no granuloma and limited to mucosa
62
Ddx of Ulcerative colitis
- Infectious colitis (bacterial, amoebic, TB, CMV): may have similar clinical and endoscopic findings, excluded with stool/tissue culture, stool studies, colonic biopsy - Crohn's disease: no gross bleeding, perianal involvement, fistulating disease - Radiation colitis: may have similar endoscopic appearance, histology with eosinophilic infiltrates, epithelial atypia - Others: solitary rectal ulcer syndrome, GVHD of GIT, diverticular colitis, NSAID colitis
63
IBD treatment Aims 2 approaches to treatment
1. Induction of remission during acute flare 2. Maintenance of remission 3. Modify clinical course: reduce complications, surgery, cancer; improve QoL, nutrition Choice of treatment: based on treatment hierarchy and disease severity → Top-down approach for moderate to severe disease → Step-up approach for mild disease
64
Main treatment options for IBD - medical and surgical?
5-aminosalicylic acid (5-ASA), eg. sulphasalazine (prodrug), mesalazine, osalazine (analogues) Corticosteroids, eg. budesonide (1st line), prednisone Immunomodulators, eg. thiopurines (azathioprine, 6-mercaptopurine), methotrexate Biologics, eg. anti-TNF (infliximab, adalimuab, etanercept, certolizumab), natalizumab, vedolizumab Surgical therapy: bowel resection
65
IBD Treatment for mild severity
Corticosteroids, eg. budesonide (1st line), prednisone Antibiotics (Crohn's only) Aminosalicylates (ASA)
66
IBD Treatment for moderate severity
Immunomodulators, eg. thiopurines (azathioprine, 6-mercaptopurine), methotrexate Biologics, eg. anti-TNF Corticosteroids, eg. budesonide (1st line),
67
IBD Treatment for severe disease
Surgical resection Bowel rest - defunctioning colostomy Cyclosporine Biologics, eg. anti-TNF
68
5-aminosalicylic acid (5-ASA) ``` Examples Indication MoA RoA S/E ```
5-aminosalicylic acid (5-ASA), eg. sulphasalazine (prodrug), mesalazine, osalazine (analogues) □ Indications: induction + maintenance in mild-moderate UC (± CD) □ MoA: local anti-inflammatory action □ RoA: PO, topical (suppository, enema) (mesalazine only) □ S/E for sulphasalazine: skin rash, haemolysis, neutropenia, male infertility, pancreatitis
69
Corticosteroids for IBD - Indication - RoA
Corticosteroids, eg. budesonide (1st line), prednisone □ Indications: induction in mild-moderate CD or UC, NOT for long-term use □ RoA: PO (enteric coated), topical (suppository for proctitis, foam/enema for distal colitis)
70
Immunomodulators for IBD - Examples - Indications - Immediate or delayed onset? - S/E
Immunomodulators, eg. thiopurines (azathioprine, 6-mercaptopurine), methotrexate Indications: induction + maintenance for both CD and UC → Frequently relapsing disease → Steroid-sparing therapy → Fistulating Crohn's disease Effect: delayed onset for 3mo S/E: well-tolerated, 10% may have S/E incl. BM suppression, allergy, hepatotoxicity, pancreatitis
71
Biologics for IBD - Examples - Indication - C/I - Risks
Biologics, eg. anti-TNF (infliximab, adalimuab, etanercept, certolizumab), natalizumab, vedolizumab Indications: induction + maintenance for both CD and UC if → Refractory to standard treatment → Fistulizing CD → Extra-intestinal manifestations, eg. pyodermal gangrenosum, uveitis, severe arthritis C/I: Sepsis, TB, Optic neuritis, Infusion reaction, Cancer Risks: → Infections: reactivation of latent TB and viral infections (eg.HBV) → Malignancies: eg. lymphoma → Autoimmunity: haemolytic anaemia, lupus-like disease, anti-dsDNA or ANA positive
72
Surgical resection for IBD - Indications - Options - Curative or not?
Indications: severe UC/ Crohn's - Severe bleeding - Severe fistula, strictures, perforation, abscess - Failed medical treatment Options: - Resect diseased intestine - Stricturoplasty - Colectomy, proctocolectomy Not curative, disease recur close to anastomosis

MBBS IV - Junior Clerkship WCS (131 decks)

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