Revision - IBD & Coeliac Flashcards
What can LFTs show in severe IBD?
Low albumin (protein lost in bowel)
The severity of a UC flare is usually classified as being mild, moderate or severe.
Describe each
a) mild: <4 stools/day, only a small amount of blood
b) moderate: 4-6 stools/day, varying amounts of blood, no systemic upset
c) severe: >6 blood stools/day + systemic upset (fever, tachycardia, anaemia, raised inflammatory markers)
Mx of mild-mod flare of UC?
5-ASAs (topical or oral depending on location)
Mx of moderate/severe flare of UC?
IV steroids e.g. hydrocortisone
Treating mild-to-moderate UC: proctitis?
1) Topical ASA
2) Add oral ASA if remission not achieved in 4 weeks
3) Add oral/topical steroids if remission not achieved in 4 weeks
Treating mild-to-moderate UC: proctosigmoiditis and left-sided UC?
1) Topical ASA
2) Add high dose oral ASA or switch to high dose ASA + topical steroid if remission is not achieved within 4 weeks
3) Stop topical treatments and offer an oral ASA and an oral steroid if remission still not achieved
Treating mild-to-moderate UC: extensive disease?
1) Topical ASA + high dose oral ASA
2) Stop topical treatments and offer a high-dose oral ASA and an oral steroid if remission is not achieved within 4 weeks
Curative treatment for UC?
Panproctocolectomy –> removing the entire large bowel and rectum
1st line management of an exacerbation of Crohn’s?
Steroids (e.g., oral prednisolone or IV hydrocortisone)
What is an alternative to steroids in Crohn’s, particularly where there are concerns about steroids affecting growth?
Enteral nutrition –> a specially formulated liquid diet given orally or by NG feed that replaces the patient’s diet.
When steroids alone are inadequate in Crohn’s, what can be added?
Azathioprine
Mercaptopurine
Methotrexate
Infliximab
Adalimumab
1st line for maintaining remission in Crohn’s?
Azathiorpine / mercaptopurine
What is an alternative for maintaining remission in Crohn’s where 1st line options are not suitable?
Methotrexate
Where does Crohn’s disease most commonly affect?
Terminal ileum
What is the most common extra-intestinal feature in both CD and UC?
Arthritis
Is episcleritis more common in Crohn’s or UC?
Crohn’s
Is uveitis more common in Crohn’s or UC?
UC
Typical findings on coloscopy and biopsy in UC?
red, raw mucosa, bleeds easily
no inflammation beyond submucosa (unless fulminant disease)
widespread ulceration with preservation of adjacent mucosa which has the appearance of polyps (‘pseudopolyps’)
inflammatory cell infiltrate in lamina propria
neutrophils migrate through the walls of glands to form crypt abscesses
depletion of goblet cells and mucin from gland epithelium
granulomas are infrequent
What is 1st line anti-diarrhoeal indicated in IBS?
Loperamide
What is 1st line laxative indicated in IBS?
Bulk-forming (e.g. ispaghula husk)
What laxative is avoided in IBS?
Lactulose –> can cause bloating
Coeliac disease is associated with what 2 human leukocyte antigen (HLA) genotypes?
1) HLA-DQ2 (95%)
2) HLA-DQ8 (80%)
Rarely coeliac disease can present with neurological symptoms.
What are some of these symptoms?
1) Peripheral neuropathy
2) Cerebellar ataxia
3) Epilepsy
Gold standard for coeliac diagnosis?
Intestinal biopsy
Biopsy findings that support coeliac disease?
1) villous atrophy
2) crypt hyperplasia
3) increase in intraepithelial lymphocytes
4) lamina propria infiltration with lymphocytes
What infections are those with coeliac disease most at risk of?
Encapsulated bacteria such as Streptococcus pneumoniae –> due to hyposplenism
Complications of coeliac?
a
1) anaemia e.g. iron, folate and vitamin B12 deficiency
2) hyposplenism (with immunodeficiency, particularly to encapsulated bacteria such as Streptococcus pneumoniae)
3) osteoporosis, osteomalacia
3) lactose intolerance
4) enteropathy-associated T-cell lymphoma (EATL) of small intestine
5) subfertility, unfavourable pregnancy outcomes
6) rare: oesophageal cancer, small bowel adenocarcinoma
7) Non-Hodgkin lymphoma
8) Ulcerative jejunitis
Is folate deficiency or vitamin B12 deficiency more common in coeliac?
Folate
Patients with coeliac disease often have a degree of functional hyposplenism.
For this reason, all patients with coeliac disease are offered which vaccine?
Pneumococcal vaccine every 5 years
Give some general side effects of aminosalicylates
1) GI upset
2) Headache
3) Agranulocytosis
4) Pancreatitis
5) Interstitial nephritis
What is a key investigation in unwell patients taking aminosalicylates?
FBC –> risk of agranulocytosis
Is pancreatitis more common in patients taking mesalazine or sulfalazine?
7x more common with mesalazine
What are some associations with sigmoid volvulus?
- older patients
- chronic constipation
- Chagas disease
- neurological conditions e.g. Parkinson’s disease, Duchenne muscular dystrophy
- psychiatric conditions e.g. schizophrenia
What is a perianal fistula?
Inflammatory tract or connection between the anal canal and perianal skin.
What is the investigation of choice in a perianal fistula/
MRI
1st line management of patients with symptomatic perianal fistulae?
Oral metronidazole
Management of a perianal abscess?
Incision & drainage and abx
Best surgical management of severe rectal Crohns that has developed complications such as haemorrhage and multiple fistulae?
Proctectomy
What is maintenance treatment for patients with UC if they have had a severe relapse or ≥2 exacerbations in the past year?
Oral azathioprine or mercaptopurine to maintain remission
Mx of giardiasis?
Metronidazole
What medications are generally used to induce remission in Crohn’s?
Steroids
What can be used for complex perianal fistulae in patients with Crohn’s disease?
A draining seton
AXR features of UC?
Leadpipe colon
What type of IBD do crypt abscesses indicate?
UC
If a mild-moderate flare of ulcerative colitis does not respond to topical or oral ASAs, what should be added?
Oral steroids
Most common site affected in UC?
Rectum
What is fulminant UC?
The most severe type of UC, characterised by severe inflammation and sores in the colon lining that causes the colon walls to expand (toxic megacolon).
Mx of fulminant UC?
Subtotal colectomy –> rectum will be left in situ as resection of the rectum in these acutely unwell patients carries an extremely high risk of complications.
What may patients with UC wishing to avoid a permanent stoma be considered for?
Ileoanal pouch
What type of IBD is associated with gallstones?
Crohn’s –> can result in terminal ileitis.
This is the section of the bowel where bile salts are reabsorbed.
Loss of bile salts is a risk factor for gallstones.
