must go through Flashcards
How can UC be managed?
Treatment can be divided into inducing and maintaining remission. NICE updated their guidelines on the management of ulcerative colitis in 2019.
The severity of UC is usually classified as being mild, moderate or severe:
mild: < 4 stools/day, only a small amount of blood
moderate: 4-6 stools/day, varying amounts of blood, no systemic upset
severe: >6 bloody stools per day + features of systemic upset (pyrexia, tachycardia, anaemia, raised inflammatory markers)
Inducing remission
Treating mild-to-moderate ulcerative colitis
proctitis
topical (rectal) aminosalicylate: for distal colitis rectal mesalazine has been shown to be superior to rectal steroids and oral aminosalicylates
if remission is not achieved within 4 weeks, add an oral aminosalicylate
if remission still not achieved add topical or oral corticosteroid
proctosigmoiditis and left-sided ulcerative colitis
topical (rectal) aminosalicylate
if remission is not achieved within 4 weeks, add a high-dose oral aminosalicylate OR switch to a high-dose oral aminosalicylate and a topical corticosteroid
if remission still not achieved stop topical treatments and offer an oral aminosalicylate and an oral corticosteroid
extensive disease
topical (rectal) aminosalicylate and a high-dose oral aminosalicylate:
if remission is not achieved within 4 weeks, stop topical treatments and offer a high-dose oral aminosalicylate and an oral corticosteroid
Severe colitis
should be treated in hospital
intravenous steroids are usually given first-line
intravenous ciclosporin may be used if steroid are contraindicated
if after 72 hours there has been no improvement, consider adding intravenous ciclosporin to intravenous corticosteroids or consider surgery
Maintaining remission
Following a mild-to-moderate ulcerative colitis flare
proctitis and proctosigmoiditis
topical (rectal) aminosalicylate alone (daily or intermittent) or
an oral aminosalicylate plus a topical (rectal) aminosalicylate (daily or intermittent) or
an oral aminosalicylate by itself: this may not be effective as the other two options
left-sided and extensive ulcerative colitis
low maintenance dose of an oral aminosalicylate
Following a severe relapse or >=2 exacerbations in the past year
oral azathioprine or oral mercaptopurine
Other points
methotrexate is not recommended for the management of UC (in contrast to Crohn’s disease)
there is some evidence that probiotics may prevent relapse in patients with mild to moderate disease
What scoring system is used?
true love and witt’s
How can Crohn’s be managed?
Crohn’s disease is a form of inflammatory bowel disease. It commonly affects the terminal ileum and colon but may be seen anywhere from the mouth to anus. NICE published guidelines on the management of Crohn’s disease in 2012.
General points
patients should be strongly advised to stop smoking
some studies suggest an increased risk of relapse secondary to NSAIDs and the combined oral contraceptive pill but the evidence is patchy
Inducing remission
glucocorticoids (oral, topical or intravenous) are generally used to induce remission. Budesonide is an alternative in a subgroup of patients
enteral feeding with an elemental diet may be used in addition to or instead of other measures to induce remission, particularly if there is concern regarding the side-effects of steroids (for example in young children)
5-ASA drugs (e.g. mesalazine) are used second-line to glucocorticoids but are not as effective
azathioprine or mercaptopurine* may be used as an add-on medication to induce remission but is not used as monotherapy. Methotrexate is an alternative to azathioprine
infliximab is useful in refractory disease and fistulating Crohn’s. Patients typically continue on azathioprine or methotrexate
metronidazole is often used for isolated peri-anal disease
Maintaining remission
as above, stopping smoking is a priority (remember: smoking makes Crohn’s worse, but may help ulcerative colitis)
azathioprine or mercaptopurine is used first-line to maintain remission
+TMPT activity should be assessed before starting
methotrexate is used second-line
5-ASA drugs (e.g. mesalazine) should be considered if a patient has had previous surgery
Surgery
around 80% of patients with Crohn’s disease will eventually have surgery
see below for further detail
Surgical interventions in Crohn’s disease
The commonest disease pattern in Crohn’s is stricturing terminal ileal disease and this often culminates in an ileocaecal resection. Other procedures performed include segmental small bowel resections and stricturoplasty. Colonic involvement in patients with Crohn’s is not common and, where found, distribution is often segmental. However, despite this distribution segmental resections of the colon in patients with Crohn’s disease are generally not advocated because the recurrence rate in the remaining colon is extremely high, as a result, the standard options of colonic surgery in Crohn’s patients are generally; sub total colectomy, panproctocolectomy and staged sub total colectomy and proctectomy. Restorative procedures such as ileoanal pouch have no role in therapy.
Crohn’s disease is notorious for the developmental of intestinal fistulae; these may form between the rectum and skin (perianal) or the small bowel and skin. Fistulation between loops of bowel may also occur and result in bacterial overgrowth and malabsorption. Management of enterocutaneous fistulae involves controlling sepsis, optimising nutrition, imaging the disease and planning definitive surgical management.
Complications of Crohn’s disease
As well as the well-documented complications described above, patients are also at risk of: small bowel cancer (standard incidence ratio = 40) colorectal cancer (standard incidence ration = 2, i.e. less than the risk associated with ulcerative colitis) osteoporosis
*assess thiopurine methyltransferase (TPMT) activity before offering azathioprine or mercaptopurine
celiac disease features?
Collective activation of both the innate and adaptive immune responses leads to chronic inflammation and damage to enterocytes, resulting in three classical features:
Villous atrophy (reduced absorptive surface). Crypt hyperplasia (increased cellular proliferation). Inflammatory infiltration (increased IEL, influx of immune cells into lamina propria)
refferal criteria for colorectal cancer?
Patients with features suggestive of colorectal cancer should be referred for further review or investigation on an two-week wait basis.
The majority of cases can be sent ‘straight to test’ for a colonoscopy after review of the GP referral by a specialist nurse. Patients in whom colonoscopy may be complicated or who have a contraindication should be reviewed in colorectal clinic first. This may include patients with dementia, learning difficulties, physical impairments, on anticoagulation or with anal pathology.
NICE guidance Suspected cancer: recognition and referral advise patients should be referred on a target (two week wait) pathway if:
Aged 40 and over with unexplained weight loss and abdominal pain
Aged 50 and over with unexplained rectal bleeding
Aged 60 and over with:
Iron-deficiency anaemia or
Changes in their bowel habit
Tests show occult blood in their faeces
A rectal or abdominal mass
bowel screening?
The NHS runs a national screening programme for CRC.
Traditionally, there were two aspects to the NHS screening programme: Bowel scope screening and FIT testing. However, since the COVID-19 pandemic and difficulties with rolling out services across the country, bowel scope screening has since stopped.
Bowel scope screening (One-off flexible sigmoidoscopy): People aged 55 will be invited for a one-off (unless abnormalities are found) screening with flexible sigmoidoscopy. This service is not available everywhere. Approximately 95% will have a normal exam, whilst 5% will be found to have polyps. If polyps are found a completion colonoscopy will likely be organised. Around 1% of people will be found to have cancer. Now stopped.
Faecal immunochemical test (FIT): People aged 60-74 will be invited to complete a home test kit consisting of a FIT. After the age of 75, people can request further tests every two years. Approximately 98% have a normal result. Those with abnormal results will be invited for colonoscopy.
pancreatitis scoring systems?
Glasgow score
The Glasgow score, completed in the first 48hrs, helps to assess the severity of acute pancreatitis.
Glasgow score
What is the criteria for sacrolitis?
Low back pain ≥ 3 months, improved by exercise and not relieved by rest
Limitation of lumbar spine in sagittal and frontal planes
Limitation of chest expansion (relative to normal values corrected for age and sex)
RADIOLOGICAL CRITERIA
Bilateral grade 2-4 sacroiliitis, or;
Unilateral 3-4 sacroiliitis
REQUIREMENTS
bilateral grade 2-4 or unilateral grade 3-4 sacroiliitis AND any clinical criteria (see X-Ray Grading of SI joints).
REFERENCE
Van der Linden et al. Arthritis Rheum 1984; 27:361.
EULAR criteria for RA?
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Diagnostic criteria for psoriatic arthritis
3 0r more points on casters criteria
types of psoriatic presentations?
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What are the risk factors for pseudo gout?
Advanced age
Injury or previous joint surgery
Hyperparathyroidism
Haemochromatosis
Hypomagnesaemia
Hypophosphataemia
What is the kings college criteria for emergency transplant
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bp targets in ckd
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How can complications of liver disease be managed
There are many complications of cirrhosis - it is a serious condition that can affect all other main organ systems and has an overall 5-year mortality of 50%.
Ascites - this results from portal hypertension and hypoalbuminaemia. It gives rise to other complications such as spontaneous bacterial peritonitis.
Spontaneous bacterial peritonitis (SBP) - sudden peritonitis can occur in patients with ascites. It may present atypically (often with no abdominal tenderness or guarding) and should be suspected in patients who deteriorate suddenly with no other obvious cause. An ascitic tap with neutrophils >250mm³ indicates SBP. Patients with a low ascitic albumin are especially at risk and should be treated with prophylactic antibiotics.
Liver failure - with its sequelae of hepatic encephalopathy and coagulopathy. The former can result in cerebral oedema progressing to raised intracranial pressure and death, and the latter can contribute to life-threatening bleeds in those with a source of bleeding.
Hepatocellular carcinoma - patients with cirrhosis are at significantly increased risk, especially those with Hepatitis B and C.
Oesophageal varices ± haemorrhage - the development of portal hypertension in cirrhosis leads to dilatation of oesophageal veins. These are liable to rupture and this can be fatal, especially in patients with coagulopathy.
Renal failure - cirrhosis and ascites with renal failure is known as hepatorenal syndrome if other causes of acute kidney injury have been ruled out. Abnormal haemodynamics in liver disease cause renal vasoconstriction which makes the kidneys more susceptible to injury. It has a very poor prognosis.
