Lecture 8: Inflammatory Bowel Disease Flashcards
What are 4 extraintestinal manifestations of the skin associated with IBD?
- Erythema nodosum
- Apthous (oral) ulcers
- Pyoderma gangrenosum
- Cutaneous CD vasculitis
What are 4 extraintestinal manifestations of the eye associated with IBD?
- Conjunctivitis
- Episcleritis
- Iritis
- Uveitis
What are 5 extraintestinal manifestations of the liver associated with IBD?
- Fatty liver
- Pericholangitis (intrahepatic sclerosis cholangitis)
- Primary Sclerosis Cholangitis
- Cholangiocarcinoma
- Chronic hepatitis
Which extraintestinal manifestation of the kidney is associated specifically with Chron Disease?
Nephrolithiasis w/ urate or calcium oxalate stones
What are some of the hematologic extraintestinal manifestations associated with IBD?
- Hemolytic anemia
- Phlebitis
- Thromboembolic events (DVT)
- Pulmonary embolus (PE)
Can infectious enterocolitis be distinguished clinically and endoscopically from UC?
- NO!
- Need stool studies and biopsy
What are some diseases other than Chron Disease that have non-caseating granulomas?
- Sarcoid
- PBC
- Vasculidites (giant cell arteritis, “Wegener’s”)
- Fungus
- Hypersensitivity pneumonitis
Erythema nodosum is an extraintestinal manifestation most commonly seen in which form of IBD?
UC > CD
What are some of the potential complications associated with UC?
- Toxic megacolon
- Colonic perforation
- Cancer risk –> related to extent and duration of colitis
Which procedure before the age of 20 is associated w/ reduced risk for developing UC?
Appendectomy
How does location of UC affect the risk of developing colon cancer?
Increased risk in disease proximal to rectum
What is the recommendation for colonoscopies in a person w/ UC?
Every 1-2 years, beginning 8 years after diagnosis
What is the key diagnostic modality used for diagnosis of UC?
How will the mucosal surface appear?
- Sigmoidoscopy
- Edematous, friable, mucopus, and eroded
Which type of IBD can present with acute ileitis sometimes mimicking appendicitis?
Chron Disease
Anorectal fissure, fistulas and abscesses are all associated with what form of IBD?
Chron Disease
Patients with Chron Disease are at risk for what type of cancers?
- Colonic carcinoma
- Lymphoma and Small Bowel Adenocarinoma (both are rare)
Which imaging modality is usually performed first with suspect Chron Disease?
Colonoscopy –> to evaluate the colon and terminal ileum and to obtain mucosal biopsies
What are the typical endoscopic findings in someone with Chron Disease?
- Apthoid linear or stellate ulcers
- Strictures
- Segmental involvement or normal-appearing mucosa adjacent to inflammed mucosa
*Granulomas on biopsy are highly suggestive of Chron disease
In patients with fulminant disease associated with UC, which imaging modality should not be performed?
Why not?
Colonoscopy due to risk of perforation
In patients with severe UC, barium enemas may precipitate which complication?
Otherwise this imaging modality will show what characterisitc sign?
- Toxic megacolon
- Otherwise show –> “lead pipe” = loss of haustra in UC
In a patient with Chron Disease a tender abdominal mass with fever and leukocytosis suggest what complication?
What is needed to confirm this diagnosis?
- Abscess
- Emergent CT of abdomen needed to confirm
In patient with Chron Disease that has developed an abscess what is the treatment?
- Broad-spectrum antibiotics
- Percutaneous drainage or sugery
A patient with CD presenting with an intestinal obstruction should be treated how?
Placed on what type of diet?
- IV fluids w/ nasogastric suction
- Placed on a low-roughage diet (i.e., no raw fruits/vegetables, popcorn, nuts, etc.)
A fistula in CD between the small intestine and the colon is called what?
Enterocolonic fistula
A fistula in CD between the colon and bladder is called what?
Colovesical fistula
A fistula in CD between the bladder and small intestine is called what?
Enterovesical fistula
Fistulas to the skin in CD occurring at sites of surgical scars can be of what 2 types?
1) Enterocutanous
2) Colocutaneous
Which type of fistula seen in CD is manifested by fever, chills, a tender abdominal mass, and leukocytosis?
Retroperitoneal phlegmon or abscess
What is the treatment for symptomatic fistulas associated with CD?
After percutaneous drainage, a long-term antibiotic is administered until the fistula is closed or surgically resected
What are the manifestations of perianal disease associated with CD?
Large painful skin tags, anal fissures, perianal abscesses, and fistulas
Specific treatment of perianal disease associated with CD is best approached jointly with whom?
Colorectal surgeon
What is the best noninvasive study for evaluating perianal fistulas?
Pelvic MRI
Which 2 oral antibiotics can be given for perianal disease?
1) Metronidazole
2) Ciprofloxacin
Refractory anal fissues may benefit from which treatments?
- Mesalamine suppositories, or…
- Topical tacrolimus ointment
Severe hemorrhage is a complication most often seen in which form of IBD?
UC
Often the terminal ileum must be resect in patients with CD, malabsorption may result from removal of how much?
What are the recommendations to deal with the malabsorption issues in these patients?
- More than 100 cm of terminal ileum resected
- Low-fat diet
- Parenteral vitamin B12
Reduced absorption of bile acids due to involvement of the terminal ileum in patients with CD may cause what type of diarrhea?
Secretory
In CD patients with severe bile salt malabsorption w/ steatorrhea, which agents should not be given as they will exacerbate the diarrhea?
Bile-salt binding agents
All of the unabsorbed fatty acids in a CD patient with severe ileal involvement or ileal resection can lead to what complication?
- Unabsorbed FA’s bind w/ Ca2+, reducing its absorption and enhancing the absorption of oxalate
- Oxalate kidney stones may develop
Which drugs are given for severe cases of IBD?
*This will likely be on exam!!!
Glucocorticoids –> Prednisone PO or IV hydrocortisone
What are the adverse effects associated with short-term glucocorticoid administration for severe IBD?
- Mood changes
- Insomnia
- Buffalo hump + Weight gain (striae) + Acne + Moon facies
- Edema
- Increase serum glucose levels
5-ASA drugs are given for mild to moderate UC and may have what adverse effects?
- Nausea
- Rash
- Diarrhea
- Pancreatitis
- Acute interstitial nephritis
AZO compounds (Sulfasalazine) used in the treatment of IBD are always administered with what?
Folate
What type of surgery is done for UC and is it curative?
Procto-Colectomy w/ ileostomy (curative)
Is surgery as a treatment for CD usually done?
Indicated when?
- Rarely, as recurrence = likely at site of surgery
- Sometimes NEEDs to be done (i.e., resection for fixed obstruction, abscesses, persistent symptomatic fistulas, intractability)
What are the indications for surgery in pt w/ UC?
- Intractability
- Fulminant colitis and Toxic Megacolon (if no improvement w/ aggressive med therapy in 24-48 hrs)
- Cancer, dysplasia, severe hemorrhage, or perforation
- Ileal pouch - anal anastomosis is operation of choice
Prior to the use of anti-TNF agents for IBD what do the patients need to be screened for?
During therapy what must be monitored?
- Screened for latent TB w/ PPD testing and CXR
- During tx liver biochemical tests should be monitored routinely
Anti-TNF agents increase the risk for what types of cancers?
- non-melanoma skin cancer
- non-Hodgkin lymphoma
Measurement of the functional activity of what is recommended prior to initiation of Azathioprine or 6-mercaptopurine?
Thiopurine methyltransferase (TPMT)
Why should prophylaxis be administered to all hospitalized IBD patients?
Due to high risk of venous thromboembolic disease
