Lecture 25 Inflammatory Bowel Disease Flashcards by Jessica Eze

What is the definition of IBD

• Chronic, relapsing, remitting inflammation of gastrointestinal tract

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What are the 2 main IBDs

Crohn’s and Ulcerative colitis

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What group is microscopic colitis found in and how is it diagnosed

Middle aged woman

Histology

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What type of inheritance is IBD

Multi-factorial
Not-medelian
• Genetic susceptibility – SNPs (single nucleotide polymorphisms)- 1bp switch in genetic sequence- which may affect the function of the gene

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What does increase permeability in the epithelium barrier lead to

Dysbosis and chronic inflammation

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Microbiota metabolic function

Production of vitamins
Digestion of dietary carcinogens
Fermentation of non-degradable substrates
Production of SCFAs- energy source

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Microbiota structural function

sIgA production
Intestinal villi and crypts
Mucous Layer
TJs

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Microbiota protective function

Colonisation resistance
Innate and adaptive immunity
Inflammatory cytokine oversite

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Extra-intestinal manifestation of IBD

Erythema nodusom
Ulcers on leg- PG (Crohn’s disease)
Arthritis in large joints
Sacroiliitis
Associated liver disease- sclerosing cholangitis
Gall stones and renal stones

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Symptoms of Ulcerative colitis

o Bloody diarrhoea
o Abdominal pain
o Weight loss
o Fatigue

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Whats a distinctive feature of UC

only colon

• Begins rectum and works proximally

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Investigations for UC

Bloods for markers of inflammation (normocytic anaemia, increased CRP/platelets, low albumin)
Stool culture to rule out infection
Faecal Calprotectin-non-invasive marker of inflammation in GI mucosa

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Mild UC

Less than 4 stools a day +/-blood
Normal ESR
No signs of toxicity

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Moderate UC

4-6 stools/day
Occasional blood
Minimal signs od toxicity
CRP<= 30mg/L

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Severe UC

More than 6 stills a day and:
Temp over 37.8
Tachycardia
Anaemia 
ESR>30mm/h
CRP>30mg/L

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Filmiant UC

10 stools a day, continuous bleeding
Toxicity
Abdominal tenderness or distention
Transfusion requirement
Colonic dilatation (Xray)

What is proctitis

UC confined to the rectum

What are the features of proctitis

Frequency, urgency, incontinence- constant stimulation of pressure receptors, tenesmus
Small volume mucus and blood
Proximal faecal stasis (constipation)

What is the treatment for proctitis

topical therapy via depository

Interventions for acute severe colitis

Stool chart
3-4 serial stool cultures for C. difficile- conditions increases susceptibility to infection
IV glucocorticoids- dampen down inflammation
LMWH- 3X increased risk of thromboembolism (anticoagulants)
Avoid/Stop non-steroidal analgesics, opiates, anti-diarrhoeals, anti-cholinergic
IV hydration, careful correction of electrolytes low potassium or magnesium can precipitate toxic megacolon
AXR – toxic dilatation, extent of disease – mucosal odema, lead pipe, proximal faecal loading

Toxic megacolon

Dilated colon filled with air >5.5cm

Clinical features of Crohn’s disease

•	Patchy disease  
–	mouth to anus 
–	skip lesions
–	clinical features 
depend on regions involved

Clinical Features of CD

•	Diarrhoea
•	Abdominal pain
•	Weight loss. 
•	Malaise, lethargy, anorexia, N&amp;V, low-grade fever
•	Malabsorption
–	Anaemia, vitamin deficiency

Investigations for CD

Bloods for markers of inflammation
Stool culture to rule out infection if diarrhoea
Faecal Calprotectin (0-50ug/g stool=normal, 50-200=equivocal, >200 elevated) – may not be high if just small bowel disease
Colonoscopy with terminal ileum intubation and colon/TI mucosal biopsies
MRI small bowel study
Capsule endoscopy- tablet with camera within it
Occasionally CT scan if acutely unwell and want to rule out complication eg abscess

Different in histology of UC and CD

``` – CD granulomas – Goblet cells depleted in UC – Crypt abscesses: UC > CD – Transmural inflammation in CD – Mucosal in UC ```

Symptoms of perianal Crohn's disease

Perianal pain Pus secretion Unable to sit down

Investigation of Perianal Crohn's disease

MRI pelvis | Examination under anaesthetic

Treatment for perianal Crohn's disease

Surgery to drain abscess | Medical – antibiotics and biologic therapy (anti-TNF)

Describe the step up approach for the treatment for UC

``` Aminosalicylates (5-ASA) Steroids-Prednisone/Budesonide Immunomodulators Biologic agents Surgery ```

Main Aminosalicylates (5-ASA)

Mesalazine • Work by blocking prostaglandins and leukotrienes • Topical to colonic mucosa can be taken orally

Can Aminosalicylates (5-ASA) work for Crohn's

What is Immunomodulation

– Thiopurines used for maintenance for UC and Crohn’s disease

Significant side effects of Immunomodulation

– Leucopenia (supress bone marrow function) more susceptible to infection – Hepatoxicity • Requires Blood Monitoring – Pancreatitis – Possible long-term lymphoma risk and non-melanoma skin cancers

Name biologics used

``` Monoclonal Antibodies • Anti-TNF antibodies – Infliximab (Remicade) • 8 weekly IV infusion – Adulimumab (Humira) • 2 weekly SC injections • 4b7 Integrin Blockers – Vedolizumab • 8 Weekly IV Infusions • IL12/IL23 Blockers – Ustekinumab • IV loading followed by SC 8-12 weekly ```

UC definition of failed medical therapy

* Recurrent courses of steroid (>2 courses a year) * Relapse prior to or shortly after stopping therapy * Unacceptable side effects * Acute severe colitis not responding to 72 hours high dose IV steroids +/- anti-TNF biologic ‘rescue’ therapy

Surgery for acute sever colitis

``` • Total colectomy o Create a rectal stump o Bring out end of small intestine in iliac fossa (end ileostomy) • Rectal preservation • Ileostomy ```

Surgical indicators for Crohn's disease

* Failure of medical management * Relief of obstructive symptoms (small bowel)- if there is development of a stricture * Management of fistulae - e.g. bowel to bladder * Management of intra-abdominal abscess * Management anal conditions * Failure to thrive