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M104 Symposia > M104 Symposia Diarrhoea part 2 > Flashcards

M104 Symposia Diarrhoea part 2 Flashcards

1
Q

What conditions could cause chronic colonic diarrhoea?

A

Ulcerative & Crohn’s colitis
Microscopic colitis
Colorectal cancer

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2
Q

What conditions could cause chronic small bowel diarrhoea?

A 
Coeliac disease
Crohn’s disease
Bile salt malabsorption
Lactose deficiency
Small bowel bacterial overgrowth
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3
Q

What conditions could cause chronic pancreatic diarrhoea?

A

Chronic pancreatitis
Pancreatic cancer
Cystic fibrosis

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4
Q

What conditions could cause chronic endocrine diarrhoea?

A

Hyperthyroidism
Diabetes
Addison’s disease
Hormone secreting tumours (e.g. Carcinoid, VIPoma)

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5
Q

What are other factors that could cause chronic colonic diarrhoea?

A

Drugs
Alcohol
Factitious

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6
Q

What is the normal Hb range for an adult male?

A

135 to 180 g / dL

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7
Q

What disease does a negative tissue transglutaminase test exclude as a diagnosis?

A

celiac disease

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8
Q

Is an anaemic person likely to have microscopic colitis?

A

no

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9
Q

colonoscope

A

a long flexible video telescope

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10
Q

What is done to prepare the colon so that a colonoscope can be used effectively?

A

it is prepared with powerful laxatives to clean it out
if you don’t give bowel prep with laxatives, all you see is lots of diarrhoea stool
can’t make a good assessment

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11
Q

What are the features of a normal colon via a colonoscope?

A

looks healthy and pink
has a good vascular pattern
has a good light reflex - looks like lighter coloured patches

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12
Q

What is a good light reflex?

A

when light reflects back in the colon in a colonoscope

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13
Q

What are the features of a diseased colon with ulcerative colitis via a colonoscope?

A

loss of muscular pattern
granularity
mucopurulent exudate
erythematous, red mucosa

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14
Q

What are the distinct features of a diseased colon with Crohn’s disease via a colonoscope?

A

aphthops ulcers
patchy erythema with normal areas of colon mucosa in between
linear ulcer
cobblestoned mucosa

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15
Q

What is the first sign of Crohn’s disease?

A

aphthous ulcers

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16
Q

What are aphthous ulcers caused by?

A

breaks in the lining of the intestine due to inflammation

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17
Q

How do aphthous ulcers develop?

A

they become larger and deeper
with the expansion of the ulcers comes swelling of the tissue, and finally scarring of the intestine that causes stiffness and narrowing

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18
Q

What is cobblestoned mucosa like?

A

islands of normal mucosa between large ulcers

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19
Q

When is cobblestoned mucosa present?

A

in very severe colonic Crohn’s disease

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20
Q

What are the main features of ulcerative colitis?

A

continuous mucosal inflammation of the
colon
no granulomas on biopsy

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21
Q

What does ulcerative colitis affect?

A

the rectum and parts of the colon in
continuity and characterised by a relapsing
and remitting course

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22
Q

Is ulcerative colitis continuous?

A

no, there are relapses and remits - flare ups

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23
Q

What is a feature of skip lesions?

A

a wound / area of inflammation that is clearly patchy, “skipping” areas that thereby are unharmed

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24
Q

What is the distribution of Crohn’s disease?

A

Terminal ileum – 30%
Colonic – 30%
Ileo-colic – 30%
Other

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25
Q

What are the main features of Crohn’s disease?

A

often granulomatous

transmural inflammation

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26
Q

What layers of the mucosa are affected by transmural inflammation from Crohn’s disease?

A

the muscles, through to the serosa of the GI tract

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27
Q

Is transmural inflammation always present when assessing for Crohn’s disease via biopsies?

A

no, but if they are present of discontinuous granulomatous transmural inflammation

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28
Q

What is the difference between the areas affected by Crohn’s disease compared to ulcerative colitis?

A

crohn - can affect any area of the GI tract

ulc - only affects the colon

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29
Q

What are the typical symptoms of ulcerative colitis?

A

Bloody diarrhoea, rectal bleeding
mucus
faecal urgency, abdominal pain, nocturnal defecation

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30
Q

What is the onset of ulcerative colitis?

A

insidious

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31
Q

What are the extraintestinal manifestations of ulcerative colitis?

A 
arthritis
uveitis of the eye
erythema nodosum
pyoderma gangrenosum
primary sclerosing cholangitis
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32
Q

What % of patients with UC have primary sclerosing cholangitis?

A

3-7%

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33
Q

What material is excess mucus from ulcerative colitis made up of?

A

pus and shedded WBCs from the inflammation

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34
Q

When might mucus be a normal phenomena?

A

in small quantities

the presence of true mucus in the rectum helps to lubricate the passage of stool

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35
Q

What is the difference between IBD and IBS?

A

IBD - causes destructive inflammation and permanent harm to the intestines, can be seen during diagnostic imaging and there is an increased risk for colon cancer

IBS - uninflammatory, rarely requires hospitalization or surgery. There is no sign of disease or abnormality during colon examination and there’s no increased risk for colon cancer or IBD

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36
Q

What percecentage of patients with Primary sclerosing cholangitis will also have IBD?

A

about 80%

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37
Q

How is a dignosis of UC made?

A

using a mixture of history and examination

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38
Q

What examinations / investigations are made when diagnosing UC?

A 
Stool cultures + CDT
Faecal calprotectin
CRP
FBC
Albumin
Flexible sigmoidoscopy/colonoscopy
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39
Q

Why are Stool cultures taken?

A

to exclude concomitant infection

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40
Q

Why are flexible sigmoidoscopies used more often than rigid colonoscopies?

A

bc the goal of the flexible is to go up the left side of the colon only, so a full bowel prep is not required

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41
Q

Is bowel prep required for a flexible sigmoidoscopy in active ulcerative colitis?

A

not at all - it is done unprepared

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42
Q

Are there any risk factors for ulcerative colitis?

A

it can incur at any age, but generally it’s late teens / early adulthood
the male:female ratio is 1:1
being an ex-smoker - increased risk by 70%
Appendicectomy protective (before age 20)
10-15 fold risk in 1st degree relatives (2% lifetime risk)

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43
Q

What was the mortality in the first year after presentation in Birmingham in 1933?

A

75%

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44
Q

What was the mortality in the first year after presentation in Oxford in 1950?

A

22%

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45
Q

What was the mortality in the first year after presentation in Oxford in 1955?

A

7% mortality with corticosteroids

24% mortality with placebo

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46
Q

What is the mortality in the first year after presentation in 2012?

A

<1% mortality

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47
Q

What is the Truelove and Witts’ severity index?

A

a grading score that measures the severity of ulcerative colitis

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48
Q

What is the Truelove and Witts’ severity index named after?

A

after the two people who conducted a successful trial testing corticosteroids on patients with UC

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49
Q

What are the features of Truelove and Witts’ severity index?

A

no. of bloody stools / day

pulse, temperature, Hb

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50
Q

How are the results of Truelove and Witts’ severity index graded?

A

mild, moderate or severe UC

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51
Q

What is the goal of Truelove and Witts’ severity index?

A

to obtain a grade of UC severity

can be used when trying to make judgments on whether people should be admitted to hospital or not

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52
Q

What is a complication of severe UC?

A

a toxic megacolon

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53
Q

How does a bowel gas pattern work?

A

Gas within the bowel forms a natural contrast with surrounding tissues since it has a very low density
the bowels can only be seen if it contains air/gas. If it is completely fluid-filled, it is indistinguishable from its surroundings

54
Q

What is another turn for severe UC?

A

fulminant UC

55
Q

What is the potential effect of a toxic megacolon?

A

this distended colon can perforate and lead to peritonitis and death

56
Q

What might happen to a patient suffering from a toxin megacolon?

A

they might have to have their colon removed

57
Q

What are the symptoms of severe UC?

A

lots of bloody stools per day
possibly have a fever
anaemia
a raised CRP

58
Q

What are the symptoms of severe UC?

A

lots of bloody stools per day
possibly have a fever
anaemia
a raised CRP

59
Q

How is severe UC treated?

A

the patient is taken to hospital
100mg hydrocortisone IV x4/day
AXR

60
Q

What is the drug used to treat severe UC?

A

hydrocortisone

61
Q

How are severe UC patients monitored on a daily basis?

A

CRP is used to monitor for a response to hydrocortisone

the stool chart is used to see if stool frequency is declining

62
Q

What drugs should be avoided when treating severe UC?

A

NSAID’s
opiate analgesics
anti-motility agents
(anticoagulant heparins)

63
Q

What are three examples of NSAID’s?

A

ibuprofen, voltaren and naproxen

64
Q

Why are certain drugs avoided when treating severe UC?

A

they are thought to to worsen it

65
Q

What is an example of an opiate analgesic?

A

morphine for pain

66
Q

Why are opiate analgesics or anti-motility agents dangerous for UC patients?

A

bc they will slow down the bowel and theoretically could potentiate toxic megacolon

67
Q

What is an example of an anti-motility agent?

A

loperamide

68
Q

Why might you think anticoagulant heparins shouldn’t be given to people with UC?

A

they already have bloody diarrhoea, it might make them bleed more

69
Q

What are examples of conditions might develop from inflammatory diseases?

A

thromberpolin disease, DVT and PE

70
Q

Why are anticoagulant heparins given to people with UC?

A

it is prophylactic and will prevent DVT, thromberpolin disease or PE’s
these are conditions that are sometimes caused by inflammatory diseases such as UC, and so preventing them will not result in worsening the bleeding colitis

71
Q

What perentage of patients with severe UC will respond to steroids?

A

67%

72
Q

How is severe UC treated if there is a severe failure to respond to steroids?

A

Infliximab
Cyclosporin
Colectomy (not very useful)

73
Q

What is the effect of infliximab?

A

it is very useful as a rescue treatment - it can switch the disease off
but it doesn’t work on everybody

74
Q

What type of substance is infliximab?

A

an anti-TNF agent

75
Q

What substances are used to treat mild / moderate UC?

A 
Mesalazine 
Prednisolone 
Azathioprine
Biologics
Surgery (if all others don't work)
76
Q

Why is Infliximab used over Cyclosporin?

A

bc it is much easier to use and works more quickly

77
Q

How is Mesalazine administered?

A

orally - tablet form

topical - suppositories / enema

78
Q

What is the main substance used for maintenance treatment of mild / moderate UC?

A

Mesalazine

79
Q

In what situation is the adminsitration of Mesalazine via topical methods particularly useful?

A

for limited left sided disease

e.g. in the rectum sigmoid colon

80
Q

In what situation is the adminsitration of Mesalazine via topical methods particularly useful?

A

for limited left sided disease

e.g. in the rectum sigmoid colon

81
Q

What are two examples of Anti-TNF agents?

A

Infliximab, adalimumab

82
Q

What is an example of an a4b7 integrin blocker?

A

Vedolizumab

83
Q

What is an example of a Tyrosine kinase inhibitor?

A

Tofacitinib

84
Q

When is azathioprine used to treat UC patients?

A

as a step up treatment if people are requiring more than two courses of steroids per year

85
Q

What type of substance is azathioprine?

A

an immune modulating drug

86
Q

What is an advantage of tofacitinib over the other Biologics?

A

it can be administered orally, rather than need to be injected as the other biologics are

87
Q

Are there any risk factors for Crohn’s disease?

A

it can incur at any age, but generally it’s peak teens / early adulthood
the male:female ratio is 1:1
Smoking
Previous appendicectomy
Family history
Infectious gastroenteritis (increase risk in following year)

88
Q

How consistent are the symptoms between patients?

A

they can vary a lot from patient to patient

89
Q

What are some of the common presentations of Crohn’s disease?

A 
Chronic diarrhoea 
IBS type symptoms
Abdo pain
Weight loss 
Anaemia
Growth failure in children
Blood +/- mucus in stools (40-50% of Crohn’s colitis)
Perianal disease
Extraintestinal manifestations
90
Q

What is the most common presentation of Crohn’s disease?

A

Chronic diarrhoea

91
Q

What are some examples of extraintestinal manifestations in Crohn’s disease?

A

arthritis, uveitis, erythema nodosum

92
Q

What percentage of Crohn’s patients have abdominal pain?

A

70%

93
Q

What percentage of Crohn’s patients experience weight loss?

A

60%

94
Q

How can anaemia occur in Crohn’s patients?

A

via the shedding of enterocytes which contain iron
via blood loss
via the anaemia of chronic disease

95
Q

What is the mechanism by which Crohn’s disease results in anaemia of chronic disease?

A

a chronic inflammatory condition will suppress utilization of iron
leads to anaemia of chronic disease

96
Q

What is Anaemia of chronic disease otherwise known as?

A

anemia of inflammation

97
Q

What conditions can anemia of inflammation be associated with?

A

chronic illnesses
certain infections
autoimmune and inflammatory diseases

98
Q

What is a potential effect of anemia of inflammation on children?

A

growth failure

99
Q

What is a consequence of Crohn’s disease being a transmural condition?

A

it can fistulate between different organs

can cause perianal disease

100
Q

What are examples of fistulations associated with Crohn’s disease?

A

enteroenteric fistula between different parts of the bowel
to the vagina and / or bladder
fistulating disease out on the skin surface - perianal fistula = perianal disease

101
Q

Which disease is associated with perianal disease?

A

Crohn’s disease, not UC

102
Q

What are the different subtypes of Crohn’s disease?

A

Purely Inflammatory disease
Stricturing disease
Fistulating disease
Perianal disease

103
Q

What is an effect of Purely Inflammatory disease?

A

if the disease burns out through the healing process, it can leave fiberoptics strictures

104
Q

What is the difference between the treatments of an inflamamtory stricture compared to that of a fibroptic stricture with a scar tissue?

A

a - might be amenable to anti-inflammatory treatments

b - would not, and might need a surgical approach instead

105
Q

What is an example of an anti-inflammatory treatment?

A

Infliximab

106
Q

What are the two types of Stricturing disease?

A

infammatory or fibrotic

107
Q

What disease can Purely Inflammatory disease lead on to?

A

Stricturing disease

108
Q

What have barium enemas been replaced with?

A

colonoscopies and C.T. scans

109
Q

What happens during a barium enema?

A

barium is put into the rectum and then on a tilt table, is moved around all over the place to wash this around the colon
x-rays are then taken

110
Q

What is the main type of investion, imaging-wise, in the small bowel for Crohn’s disease?

A

an MRI of the small bowel

111
Q

What are the main treatments for Crohn’s disease?

A 
corticosteroids
purine analogues
Methotrexate
Nutritional therapy (elemental diet)  
Biologics
Surgery
112
Q

What is a type of drug treatment for Crohn’s disease that is not very helpful?

A

5 ASA preparations

113
Q

What are the two types of corticosteroids used to treat Crohn’s disease?

A

Prednisolone and Budesonide

114
Q

What is the difference between 6-Mercaptopurine and Azathioprine?

A

mer is a metabolite, like azathioprine, but can be given in its own right as a drug

115
Q

What are the two types of purine analogues used to treat Crohn’s disease?

A

Azathioprine and 6-Mercaptopurine

116
Q

How does Methotrexate work?

A

by inhibiting folic acid metabolism in its role as a metabolite

117
Q

What is an example of a consituent part of the elemental diet?

A

a milkshake diet of elements of carbohydrates, nuts and amacs

118
Q

What is the diet used as a form of nutritional therapy when treating Crohn’s disease?

A

elemental diet

119
Q

How effective is the elemental diet when treating Crohn’s disease?

A

it can be as effective as steroids

120
Q

What are the disadvantages of the elemental diet when treating Crohn’s disease?

A

it’s very difficult to adhere to this diet

adults almost always refuse to have it or don’t do well on it because they can’t continue with it

121
Q

When is it advantageous to prescribe the elemental diet when treating Crohn’s disease?

A

in children bc you don’t want to give steroids to children if it can be prevented bc it inhibits growth, as does the disease itself

122
Q

Are antibiotics widely used to treat Crohn’s disease?

A

less so now

with the exception of perianal disease where a trial of them can be very useful

123
Q

What disease are antibiotics effective against?

A

perianal disease

124
Q

Which biologics are used when treating Crohn’s disease?

A

anti-TNF agents
Vedolizumab
Ustekinumab (IL-12 &IL-23 inhibitor)

125
Q

What are two examples of anti-TNF agents used when treating Crohn’s disease?

A

Infliximab

adalimumab

126
Q

What type of substance is Ustekinumab?

A

an IL-12 &IL-23 inhibitor

127
Q

What do interleukin-12 & 23 have in common?

A

they are both cytokines that are a part of the inflammatory cascade
nhibiting these seems to be very beneficial in Crohn’s disease

128
Q

How often is surgery used when treating Crohn’s disease compared to when treating UC?

A

much more common

129
Q

What are the main differences between UC and Crohn’s disease?

A

UC is a mucosal disease, it only affects the surface layer of bowel muscoa
Crohn’s is transmural across the whole wall of the bowel - causes deep ulcers and the wall can fistulate

UC is a continuous disease - it only affects the colon
Crohn’s is patchy - it can affect any part of the GI tract

130
Q

What does UC being a continuous disease mean?

A

it only affects the colon, not multiple areas like Crohn’s

is - it can affect any part of the GI tract

M104 Symposia (11 decks)

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