M104 Symposia Diarrhoea part 2 Flashcards
(130 cards)
1
Q
What conditions could cause chronic colonic diarrhoea?
A
Ulcerative & Crohn’s colitis
Microscopic colitis
Colorectal cancer
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
3
Q
What conditions could cause chronic pancreatic diarrhoea?
A
Chronic pancreatitis
Pancreatic cancer
Cystic fibrosis
4
Q
What conditions could cause chronic endocrine diarrhoea?
A
Hyperthyroidism
Diabetes
Addison’s disease
Hormone secreting tumours (e.g. Carcinoid, VIPoma)
5
Q
What are other factors that could cause chronic colonic diarrhoea?
A
Drugs
Alcohol
Factitious
6
Q
What is the normal Hb range for an adult male?
A
135 to 180 g / dL
7
Q
What disease does a negative tissue transglutaminase test exclude as a diagnosis?
A
celiac disease
8
Q
Is an anaemic person likely to have microscopic colitis?
A
no
9
Q
colonoscope
A
a long flexible video telescope
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
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
12
Q
What is a good light reflex?
A
when light reflects back in the colon in a colonoscope
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
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
15
Q
What is the first sign of Crohn’s disease?
A
aphthous ulcers
16
Q
What are aphthous ulcers caused by?
A
breaks in the lining of the intestine due to inflammation
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
18
Q
What is cobblestoned mucosa like?
A
islands of normal mucosa between large ulcers
19
Q
When is cobblestoned mucosa present?
A
in very severe colonic Crohn’s disease
20
Q
What are the main features of ulcerative colitis?
A
continuous mucosal inflammation of the
colon
no granulomas on biopsy
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
22
Q
Is ulcerative colitis continuous?
A
no, there are relapses and remits - flare ups
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
24
Q
What is the distribution of Crohn’s disease?
A
Terminal ileum – 30%
Colonic – 30%
Ileo-colic – 30%
Other
25
What are the main features of Crohn's disease?
often granulomatous
| transmural inflammation
26
What layers of the mucosa are affected by transmural inflammation from Crohn's disease?
the muscles, through to the serosa of the GI tract
27
Is transmural inflammation always present when assessing for Crohn's disease via biopsies?
no, but if they are present of discontinuous granulomatous transmural inflammation
28
What is the difference between the areas affected by Crohn's disease compared to ulcerative colitis?
crohn - can affect any area of the GI tract
| ulc - only affects the colon
29
What are the typical symptoms of ulcerative colitis?
Bloody diarrhoea, rectal bleeding
mucus
faecal urgency, abdominal pain, nocturnal defecation
30
What is the onset of ulcerative colitis?
insidious
31
What are the extraintestinal manifestations of ulcerative colitis?
```
arthritis
uveitis of the eye
erythema nodosum
pyoderma gangrenosum
primary sclerosing cholangitis
```
32
What % of patients with UC have primary sclerosing cholangitis?
3-7%
33
What material is excess mucus from ulcerative colitis made up of?
pus and shedded WBCs from the inflammation
34
When might mucus be a normal phenomena?
in small quantities
| the presence of true mucus in the rectum helps to lubricate the passage of stool
35
What is the difference between IBD and IBS?
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
36
What percecentage of patients with Primary sclerosing cholangitis will also have IBD?
about 80%
37
How is a dignosis of UC made?
using a mixture of history and examination
38
What examinations / investigations are made when diagnosing UC?
```
Stool cultures + CDT
Faecal calprotectin
CRP
FBC
Albumin
Flexible sigmoidoscopy/colonoscopy
```
39
Why are Stool cultures taken?
to exclude concomitant infection
40
Why are flexible sigmoidoscopies used more often than rigid colonoscopies?
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
41
Is bowel prep required for a flexible sigmoidoscopy in active ulcerative colitis?
not at all - it is done unprepared
42
Are there any risk factors for ulcerative colitis?
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)
43
What was the mortality in the first year after presentation in Birmingham in 1933?
75%
44
What was the mortality in the first year after presentation in Oxford in 1950?
22%
45
What was the mortality in the first year after presentation in Oxford in 1955?
7% mortality with corticosteroids
| 24% mortality with placebo
46
What is the mortality in the first year after presentation in 2012?
<1% mortality
47
What is the Truelove and Witts' severity index?
a grading score that measures the severity of ulcerative colitis
48
What is the Truelove and Witts' severity index named after?
after the two people who conducted a successful trial testing corticosteroids on patients with UC
49
What are the features of Truelove and Witts' severity index?
no. of bloody stools / day
| pulse, temperature, Hb
50
How are the results of Truelove and Witts' severity index graded?
mild, moderate or severe UC
51
What is the goal of Truelove and Witts' severity index?
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
52
What is a complication of severe UC?
a toxic megacolon
53
How does a bowel gas pattern work?
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
What is another turn for severe UC?
fulminant UC
55
What is the potential effect of a toxic megacolon?
this distended colon can perforate and lead to peritonitis and death
56
What might happen to a patient suffering from a toxin megacolon?
they might have to have their colon removed
57
What are the symptoms of severe UC?
lots of bloody stools per day
possibly have a fever
anaemia
a raised CRP
58
What are the symptoms of severe UC?
lots of bloody stools per day
possibly have a fever
anaemia
a raised CRP
59
How is severe UC treated?
the patient is taken to hospital
100mg hydrocortisone IV x4/day
AXR
60
What is the drug used to treat severe UC?
hydrocortisone
61
How are severe UC patients monitored on a daily basis?
CRP is used to monitor for a response to hydrocortisone
| the stool chart is used to see if stool frequency is declining
62
What drugs should be avoided when treating severe UC?
NSAID’s
opiate analgesics
anti-motility agents
(anticoagulant heparins)
63
What are three examples of NSAID’s?
ibuprofen, voltaren and naproxen
64
Why are certain drugs avoided when treating severe UC?
they are thought to to worsen it
65
What is an example of an opiate analgesic?
morphine for pain
66
Why are opiate analgesics or anti-motility agents dangerous for UC patients?
bc they will slow down the bowel and theoretically could potentiate toxic megacolon
67
What is an example of an anti-motility agent?
loperamide
68
Why might you think anticoagulant heparins shouldn't be given to people with UC?
they already have bloody diarrhoea, it might make them bleed more
69
What are examples of conditions might develop from inflammatory diseases?
thromberpolin disease, DVT and PE
70
Why are anticoagulant heparins given to people with UC?
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
What perentage of patients with severe UC will respond to steroids?
67%
72
How is severe UC treated if there is a severe failure to respond to steroids?
Infliximab
Cyclosporin
Colectomy (not very useful)
73
What is the effect of infliximab?
it is very useful as a rescue treatment - it can switch the disease off
but it doesn't work on everybody
74
What type of substance is infliximab?
an anti-TNF agent
75
What substances are used to treat mild / moderate UC?
```
Mesalazine
Prednisolone
Azathioprine
Biologics
Surgery (if all others don't work)
```
76
Why is Infliximab used over Cyclosporin?
bc it is much easier to use and works more quickly
77
How is Mesalazine administered?
orally - tablet form
| topical - suppositories / enema
78
What is the main substance used for maintenance treatment of mild / moderate UC?
Mesalazine
79
In what situation is the adminsitration of Mesalazine via topical methods particularly useful?
for limited left sided disease
| e.g. in the rectum sigmoid colon
80
In what situation is the adminsitration of Mesalazine via topical methods particularly useful?
for limited left sided disease
| e.g. in the rectum sigmoid colon
81
What are two examples of Anti-TNF agents?
Infliximab, adalimumab
82
What is an example of an a4b7 integrin blocker?
Vedolizumab
83
What is an example of a Tyrosine kinase inhibitor?
Tofacitinib
84
When is azathioprine used to treat UC patients?
as a step up treatment if people are requiring more than two courses of steroids per year
85
What type of substance is azathioprine?
an immune modulating drug
86
What is an advantage of tofacitinib over the other Biologics?
it can be administered orally, rather than need to be injected as the other biologics are
87
Are there any risk factors for Crohn’s disease?
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
How consistent are the symptoms between patients?
they can vary a lot from patient to patient
89
What are some of the common presentations of Crohn’s disease?
```
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
What is the most common presentation of Crohn’s disease?
Chronic diarrhoea
91
What are some examples of extraintestinal manifestations in Crohn’s disease?
arthritis, uveitis, erythema nodosum
92
What percentage of Crohn's patients have abdominal pain?
70%
93
What percentage of Crohn's patients experience weight loss?
60%
94
How can anaemia occur in Crohn's patients?
via the shedding of enterocytes which contain iron
via blood loss
via the anaemia of chronic disease
95
What is the mechanism by which Crohn's disease results in anaemia of chronic disease?
a chronic inflammatory condition will suppress utilization of iron
leads to anaemia of chronic disease
96
What is Anaemia of chronic disease otherwise known as?
anemia of inflammation
97
What conditions can anemia of inflammation be associated with?
chronic illnesses
certain infections
autoimmune and inflammatory diseases
98
What is a potential effect of anemia of inflammation on children?
growth failure
99
What is a consequence of Crohn's disease being a transmural condition?
it can fistulate between different organs
| can cause perianal disease
100
What are examples of fistulations associated with Crohn's disease?
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
Which disease is associated with perianal disease?
Crohn's disease, not UC
102
What are the different subtypes of Crohn's disease?
Purely Inflammatory disease
Stricturing disease
Fistulating disease
Perianal disease
103
What is an effect of Purely Inflammatory disease?
if the disease burns out through the healing process, it can leave fiberoptics strictures
104
What is the difference between the treatments of an inflamamtory stricture compared to that of a fibroptic stricture with a scar tissue?
a - might be amenable to anti-inflammatory treatments
| b - would not, and might need a surgical approach instead
105
What is an example of an anti-inflammatory treatment?
Infliximab
106
What are the two types of Stricturing disease?
infammatory or fibrotic
107
What disease can Purely Inflammatory disease lead on to?
Stricturing disease
108
What have barium enemas been replaced with?
colonoscopies and C.T. scans
109
What happens during a barium enema?
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
What is the main type of investion, imaging-wise, in the small bowel for Crohn's disease?
an MRI of the small bowel
111
What are the main treatments for Crohn's disease?
```
corticosteroids
purine analogues
Methotrexate
Nutritional therapy (elemental diet)
Biologics
Surgery
```
112
What is a type of drug treatment for Crohn's disease that is not very helpful?
5 ASA preparations
113
What are the two types of corticosteroids used to treat Crohn's disease?
Prednisolone and Budesonide
114
What is the difference between 6-Mercaptopurine and Azathioprine?
mer is a metabolite, like azathioprine, but can be given in its own right as a drug
115
What are the two types of purine analogues used to treat Crohn's disease?
Azathioprine and 6-Mercaptopurine
116
How does Methotrexate work?
by inhibiting folic acid metabolism in its role as a metabolite
117
What is an example of a consituent part of the elemental diet?
a milkshake diet of elements of carbohydrates, nuts and amacs
118
What is the diet used as a form of nutritional therapy when treating Crohn's disease?
elemental diet
119
How effective is the elemental diet when treating Crohn's disease?
it can be as effective as steroids
120
What are the disadvantages of the elemental diet when treating Crohn's disease?
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
When is it advantageous to prescribe the elemental diet when treating Crohn's disease?
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
Are antibiotics widely used to treat Crohn's disease?
less so now
| with the exception of perianal disease where a trial of them can be very useful
123
What disease are antibiotics effective against?
perianal disease
124
Which biologics are used when treating Crohn's disease?
anti-TNF agents
Vedolizumab
Ustekinumab (IL-12 &IL-23 inhibitor)
125
What are two examples of anti-TNF agents used when treating Crohn's disease?
Infliximab
| adalimumab
126
What type of substance is Ustekinumab?
an IL-12 &IL-23 inhibitor
127
What do interleukin-12 & 23 have in common?
they are both cytokines that are a part of the inflammatory cascade
nhibiting these seems to be very beneficial in Crohn's disease
128
How often is surgery used when treating Crohn's disease compared to when treating UC?
much more common
129
What are the main differences between UC and Crohn's disease?
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
What does UC being a continuous disease mean?
it only affects the colon, not multiple areas like Crohn's
| is - it can affect any part of the GI tract
