Module 6.3 - Inflammatory Bowel Disease Flashcards
What is and what are the two types of inflammatory bowel disease?
Results from inappropriate mucosal immune responses to normal gut flora; comprises 2 disorders:
1. Ulcerative colitis (UC) – severe ulcerating inflammation extending into the mucosa and submucosa; limited to the colon and rectum; characterized by erosions with bleeding and friability
2. Crohn Disease (CD) – typically transmural inflammation and ulceration, structuring and fistula development with potential for abscess formation; occurring anywhere in the GI tract; increased risk for colon cancer, lymphoma and small bowel adenocarcinoma
What is ulcerative colitis?
A disease of continuity with NO skip lesions; involving the rectum and extending proximally in retrograde fashion to involve the entire colon; the distal ileus may also show inflammation.
What are the clinical features of ulcerative colitis?
- Bowel Region affected: Colon only
- Distribution: Diffuse
- Stricture: Rare
- Wall Appearance: Thin
- Inflammation: Limited to Mucosa
- Ulcers: Superficial, broad based
- Lymphoid Reaction: Moderate
- Fistulas: No
- Perianal fistula: No
- Fat/vitamin malabsorption: No
- Malignant potential: Yes
- Recurrence after surgery: No
- Toxic megacolon: Yes
What are the subjective/physical exam findings associated with ulcerative colitis?
- Bloody diarrhea – cardinal sign of UC
- Fecal urgency, tenesmus and abdominal cramping
- Weight loss, malnutrition, anemia and fever
- Joint pain- a common extra-intestinal complication of inflammatory bowel disease- affects approximately 30% of patients with both Crohn’s disease and ulcerative colitis
What are some lab tests/diagnostic tests used to diagnose Ulcerative Colitis?
Labs:
- Leukocytosis during inflammation
- Anemia
- Electrolyte abnormalities, such as hypokalemia
- May have elevated Liver Function Tests
Diagnostic Tests:
- Flexible Sigmoidoscopy/colonoscopy with biopsy- confirms extent of disease with histologic evidence; findings include hyperemic and friable rectal mucosa that bleeds easily on contact.
- Plan Abdominal X-rays – exclude dilatation of colon
- Colonoscopy and barium enema ARE NOT performed during an acute attack due to risk of colonic perforation.
How is mild to moderate active distal Ulcerative Colitis managed?
- First line therapy: oral or topical (enema/suppository) aminosalicylates or topical corticosteroids. Results in symptomatic improvement in 50-75% of individuals.
- 2nd line therapy: Individuals refractory to aminosalicylates and/or topical steroids may respond to mesalamine enemas.
- 3rd line therapy: treat with oral prednisone in doses up to 40-60mg per day or infliximab with an induction regimen
How is mild to moderate active extensive Ulcerative Colitis managed?
- First line therapy: Sulfasalzine (Azulfidine) drug therapy or an alternative aminosalicylate
- Dose is increased every few days until up to 4-6 grams/day for therapeutic dosing.
- Folate supplementation is recommended –to be started with sulfasalazine due to its inhibition of folate absorption
- Sulfa allergic individuals cannot use this regimen
- Consider combination oral and topical therapy for individuals with distal disease.
- If no improvement in 2-3 weeks, consider additional hydrocortisone enemas or systemic steroid therapy.
- If refractory to oral corticosteroids, treat with azathioprine or 6-mercaptopurine.
- If refractory to steroids, treat with infliximab
How is severe Ulcerative Colitis managed?
- If refractory to oral/topical corticosteroids, treat with 7-10 day course of IV corticosteroids.
- If refractory to IV corticosteroids, treat with IV cyclosporine
- May consider Infliximab , but long term efficacy is unknown
- If refractory to above therapies, refer to surgery for colectomy
- If toxic megacolon develops, treat with bowel decompression, broad spectrum antibiotics and possibly colectomy; develops in < 2% of patients
What are the indications for surgery in a patient with ulcerative colitis?
- Toxic megacolon
- Fulminant colitis
- Perforation
- Hemorrhage
- High grade dysplasia
- Carcinoma
- Refractory disease requiring high-dose steroids
What is Crohn’s Disease?
- Crohn’s disease is a type of inflammatory bowel disease (IBD) that may affect any part of the gastrointestinal tract from mouth to anus.
- Patients may present with a combination of issues: chronic inflammation, intestinal obstruction, fistula formation and abscess formation. Involves the small intestine along in 40% of cases, the small intestine and colon in 30% of cases and the colon alone in 30% of cases.
What are the clinical features of Crohn’s Disease?
- Bowel Region affected: Ileum and Colon
- Distribution: Skip Lesions
- Stricture: Yes
- Wall Appearance: Thick
- Inflammation: Transmural
- Ulcers: Deep, knife like
- Lymphoid Reaction: Marked
- Fistulas: Yes
- Perianal fistula: Yes - in colonic disease
- Fat/vitamin malabsorption: Yes
- Malignant potential: With colonic involvement
- Recurrence after surgery: Common
- Toxic megacolon: No
What are the risk factors for Crohn’s Disease?
- A family history of IBD
- Most common in whites and Ashkenazi Jewish descendants
- Often presents in patients in their early 20’s
What are the Subjective/Physical Exam Findings associated with Crohn’s Disease?
- Abdominal pain
- Watery diarrhea
- Low-grade fever
- Weight loss
- Obstruction
- Oral manifestations, including apthous ulcers
- Perianal fissures/fistulas
- Intra-abdominal abscess
How is Crohn’s Disease Diagnosed?
1. Barium enema
- Findings consist of deep transverse fissures, ulcers and edema of the bowel
2. Colonoscopy
- Findings consist of aphthoid, linear stellate ulcers, cobblestone mucosa, and skip lesions
3. Labs
- Findings consist of B12 deficiency, megaloblastic anemia, elevated homocysteine levels (increases the risk of thrombotic events)
How is Crohn’s Disease managed?
- Prednisone for acute exacerbation (flares are common during steroid tapering)
- Sulfasalazine/mesalamine
- Immunosuppression (if refractory to corticosteroids)
- Azathioprine
- Mercaptopurine
- Methotrexate – monitor CBC, renal function and liver function tests
- Anti-tumor necrosis factor therapies (if continued refractory disease)
- infliximab, adalimumab, and certolizumab injections/infusions
