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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
Q

Drug-induced diarrhea

Most common causative drugs?

A

□ 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

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26
Q

Outline P/E for chronic diarrhea

A

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
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27
Q

First-line blood and stool investigations for chronic diarrhea

A

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
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28
Q

Differentials of eosinophilia

A
  • Neoplasm
  • Allergy
  • Collagen vascular diseases
  • Parasite infestation
  • Eosinophilic gastroenteritis
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29
Q

Define spot stool analysis metrics and rationale

What’s tested and why?

A

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
Q

Fecal Calprotectin test

  • Function
  • MoA
A

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&raquo_space; indicate migration of neutrophils into gut mucosa

31
Q

First-line imaging investigations for chronic diarrhea

A

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
Q

Protein losing enteropathy

  • Disease entities
  • Workup
A

Diseases:
IBD, Whipple’s disease, Allergic gastroenteropathy, Intestinal lymphangiectasia…etc

Workup:
1. Labeled human serum scan (find source of protein pooling)

  1. Fecal alpha-1-antitrypsin concentration (excessive GI protein loss)
  2. Serum alpha-1-antitrypsin clearance
33
Q

Endoscopic investigation for chronic diarrhea

  • Modalities
  • Function
A

OGD, Capsule/ small bowel balloon enteroscopy, colonoscopy, sigmoidoscopy

obtain mucosal Bx for
→ IBD
→ Opportunitistic infections, eg. CMV colitis
→ Microscopic colitis

34
Q

Management plan for chronic diarrhea

List options for supportive treatment and malabsorption

A

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
Q

Irritable bowel syndrome

Demographic
Associated conditions

A

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
Q

Diagnostic criteria of IBS

A

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
Q

Alarming feature against diagnosis of IBS

A

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
Q

IBS

Clinical subtypes

A

□ 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
Q

IBS

Pathogenesis

A
  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
Q

IBS

Clinical features

A

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
Q

Ddx of IBS

A

□ 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
Q

IBS

Management plan outline

A

□ Reassurance and education
□ Dietary changes
□ Pharmacotherapy directed towards predominant symptoms
□ Psychotherapy if refractory to medications

43
Q

IBS

Treatment for diarrhea

A

Diet: Low FODMAP diet

Drugs: 
 Opioid agonist (loperamide)
 Bile salt sequestrants (cholestyramine)
 Probiotics
 Rifaximin
44
Q

IBS

Treatment for constipation

A

High fiber diet

 Dietary fibre (Psyllium)
 Laxative (PEG)
 Chloride channel activator (lubiprostone)*
 Guanylate cyclase C agonist (linaclotide)*

45
Q

IBS

Treatment for abdominal pain

A

 Peppermint oil
 Antispasmodics (otilonium, mebeverine)
 Tricyclic antidepressant (amitriptyline, desipramine)
 SSRI (citalopram, paroxetine, sertraline)

 Chloride channel activator (lubiprostone)*
 Guanylate cyclase C agonist (linaclotide)*

46
Q

IBD

Differentiate demographics between UC and CD

A

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
Q

IBD

Differentiate risk factors between UC and CD

A

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
Q

IBD

Differentiate extent of GIT involvement between UC and CD

A

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
Q

IBD

Differentiate endoscopic appearance between UC and CD

A

Crohn’s

  • Cobblestone appearance
  • Aphthous lesion
  • Solitary, deep ulcers w/ fissures

UC:

  • Pseudopolyps
  • Hyperemic mucosa
  • Shallow, diffuse ulceration
  • Diffusely granular appearance
50
Q

IBD

Differentiate histology between UC and CD

A

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
Q

Crohn’s disease

Major intestinal manifestations, S/S

A

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
Q

Ulcerative colitis

Major intestinal manifestations, S/S

A

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
Q

Extra-intestinal manifestations of IBD

  • Skin
  • Joints
A

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
Q

Extra-intestinal manifestations of IBD

  • Eyes
  • HBP
  • Haematological
  • Renal
A

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
Q

List complications + S/S of Crohn’s disease

A

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
Q

List complications of Ulcerative colitis

A

Severe hemorrhage

Toxic megacolon

Colorectal cancer

57
Q

Toxic megacolon in UC

  • Cause
  • S/S
  • Imaging features
  • Mx
A
  • 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
Q

CA colon and IBD

  • Typical onset after IBD?
  • Monitoring methods
A

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
Q

First-line serological investigations for IBD and typical findings

A

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
Q

First-line radiological investigation for IBD and typical findings

A

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
Q

Ddx for Crohn’s disease

A
  • 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
Q

Ddx of Ulcerative colitis

A
  • 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
Q

IBD treatment

Aims

2 approaches to treatment

A
  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
Q

Main treatment options for IBD - medical and surgical?

A

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
Q

IBD

Treatment for mild severity

A

Corticosteroids, eg. budesonide (1st line), prednisone

Antibiotics (Crohn’s only)

Aminosalicylates (ASA)

66
Q

IBD

Treatment for moderate severity

A

Immunomodulators, eg. thiopurines (azathioprine, 6-mercaptopurine), methotrexate

Biologics, eg. anti-TNF

Corticosteroids, eg. budesonide (1st line),

67
Q

IBD

Treatment for severe disease

A

Surgical resection

Bowel rest - defunctioning colostomy

Cyclosporine

Biologics, eg. anti-TNF

68
Q

5-aminosalicylic acid (5-ASA)

Examples
Indication 
MoA
RoA
S/E
A

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
Q

Corticosteroids for IBD

  • Indication
  • RoA
A

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
Q

Immunomodulators for IBD

  • Examples
  • Indications
  • Immediate or delayed onset?
  • S/E
A

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
Q

Biologics for IBD

  • Examples
  • Indication
  • C/I
  • Risks
A

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
Q

Surgical resection for IBD

  • Indications
  • Options
  • Curative or not?
A

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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