Session 8 - Take a (inflammatory) bow(el)

Question 1

Give five types of inflammatory bowel disease

Answer 1

• Ulcerative colitis • Crohn’s disease • Diversion colitis • Diverticular colitis Radiation, drugs, infectious diseases, ischaemic colitis

Question 2

What is ulcerative colitis?

Answer 2

• An inflammatory disorder that affects the rectum and extends proximally, in continuity (no breaks in inflammation!)

Question 3

Where is the incidence of ulcerative colitis the highest?

Answer 3

• US, UK and northen Europe • Presents in young adults, more commonly young women

Question 4

What inflammatory cells are found in the mucosa of patients with ulcerative colitis?

Answer 4

• T helper cells, which produce transforming growth factor (TGF and IL-5)

Question 5

What are the three main symptoms of ulcerative colitis?

Answer 5

• Rectal bleeding • Diarrhoea • Abdominal pain

Question 6

What is Chrohn’s disease?

Answer 6

• A condition of chronic inflammation involving any location of the GI tract from mouth to anus

Question 7

When are the two peaks of incidence of Chron’s disease?

Answer 7

• 1st at 15-30 • 2nd at 60 years

Question 8

What inflammatory cells are found in the mucosa of Chron’s disease patients?

Answer 8

• Th1 helper cells, which produce interferon gamma and IL-2

Question 9

What does the presentation of Chrohn’s disease depend on?

Answer 9

Diseases location

Question 10

What is the presentation of Chron’s disease in someone with upper GI tract involvement?

Answer 10

• Nausea and vomiting • Dyspepsia • Small bowel obstruction • Anorexia, weight loss • Loose stools

Question 11

What is the presentation of chron’s disease in someone with colonic diseasE?

Answer 11

• Diarrhoea • Passage of blood

Question 12

What happens if terminal ileum is involved in Chron’s disease?

Answer 12

• May be pernicous anaemia due to poor absorption of B12

Question 13

What is hypothesised to cause IBD (of which Chrohn’s and UC are two types)

Answer 13

• Genetic presdispostion • Environmental factors

Question 14

What genetic factors cause IBD?

Answer 14

• IBD1 • NOD2/CARD15 • Having one copy of a risk allele confers 2-4 fold risk for Crohn’s • Two couples of risk allele confers 20-40 fold risk for Crohn’s

Question 15

What environmental factors cause IBD?

Answer 15

• NSAIDs ○ Altered intestinal barrier due to decreased mucous production • Early Appendectomy ○ Increased UC incidence • Smoking ○ Protects against UC ○ Increases risk of CD

Question 16

Give 6 triggers of IBD

Answer 16

• Antibiotics ○ Gets rid of normal flora • Diet • Acute infections • NSAIDs • Smoking ○ Increase’s risk of Crohn’s • Stress

Question 17

Answer 17

Question 18

Give six methods of investigating inflmamtory bowel disease

Answer 18

• Colonoscopy ○ Biopsies of involved mucosa ○ Ulceration • Stool analysis ○ Parasites ○ Clostridium difficile toxin ○ Culture • Barium radiographs • CT scan • Capsule endoscopy Plain X-Ray if bowel obstruction or perforation suspected

Question 19

Outline the macroscopic changes found in Chrohn’s

Answer 19

• Involved bowel is usually thickened and is often narrowed • Deep ulcers and fissures in the mucosa may produce a cobblestone appearance Fistulae and abcesses may be seen

Question 20

Outline the macroscopic changes found in Ulcerative Colitis

Answer 20

• Mucosa looks reddened, inflamed and bleeds easily • In severe disease there is extensive ulceration with the adjacent mucosa appearing as inflammatory polyps

Question 21

Outline the microscopic changes found in chrohn’s

Answer 21

• Inflammation through all layers of the bowel (Transmural) • Increase in chronic inflammatory cells • Lymphoid hyperplasia • Granulomas (TH1 Response)

Question 22

Outline the microscopic changes found in Ulcerative Colitis

Answer 22

• Superficial inflammation • Chronic inflammatory cell infiltrate in the lamina propria • Crypt abscesses • Goblet cell depletion

Question 23

Outline three ways in which CD and UC can be separated

Answer 23

• Clinical • Radiological data • Histological differences seen in rectal mucosa

Question 24

When is it difficult to tell difference between CD and UC?

Answer 24

Acute phase, tissues look very much the same

Question 25

What is CD/UC in acute phase called when it is difficult to tell the difference?

Answer 25

• Colitis of undetermined type and aEitology CUTE

Question 26

What serological tests can be used to distinguish UC from CD?

Answer 26

• Anti-neutrophil cytoplasmic antibodies in UC • Anti saccaromyces cervisiae antibodies in CD

Question 27

Give 5 ways in which abnormalities can be seen in Chrohn's disease

Answer 27

• Colonoscopy • Upper GI endoscopy • Small bowel imaging • Perianal MRI or endoanal Ultrasound • Capsule endocscopy

Question 28

What can a colonoscopy be used to see in Chrohn's disease?

Answer 28

• Performed if colonic involvement is suspected • Mild, patchy surface ulceration à Cobblestoning

Question 29

How does Upper GI Endoscopy do in a Chrohn's diagnosis?

Answer 29

• Required to exclude oesophageal and gastroduodenal disease in patients with relevant symptoms

Question 30

Outline the process of small bowel imaging in Crohn's

Answer 30

• Barium follow through • CT scan with oral contrast • Small bowel ultrasound • MRI • Asymmetrical alteration in the mucosal pattern with deep ulceration, and areas of narrowing or structuringr • String sign of Kantor

Question 31

What does perianal MRI or endoanal ultrasound do?

Answer 31

• Used to evaluate perianal disease

Question 32

What is capsule endoscopy used for in Chrohn's?

Answer 32

• Used in Chrohn's disease patients who have a normal radiological examination

Question 33

Give two tests used to define Ulcerative Colitis?

Answer 33

• Colonoscopy • Imaging

Question 34

What does colonoscopy do in UC?

Answer 34

• Allows biopsy, which is gold standard for UC diagnosis • Allows us to assess disease activity and extent

Question 35

What does imaging allow to see in UC?

Answer 35

• Plain Abdominal X-Ray to exclude colonic dilation • Other imaging techniques rarely used as endoscopy is preferred • Collar Button Ulcers ○ Ulcer through the bowel mucosa to the muscle, then up and down in a ‘T’ shape

Question 36

Give three overarching aims of Chrohn's disease treatment?

Answer 36

• Induction of remission • Maintenance of remission • Perianal disease

Question 37

How is induction of remission initiated in Chrohn's?

Answer 37

• Oral or IV Glucocorticosteroids • Enteral Nutrition • Anti-TNF antibodies (Infliximab)

Question 38

How is maintenance of remission achieved in Crohn's disease?

Answer 38

• Methotrexate, Azathioprine • Anti-TNF antibodies (Infliximab)

Question 39

How is perianal disease treated in Crohn's?

Answer 39

• Ciprofloxacin and Metrronidazole • Azathioprine • Anti-TNF antibodies (Infliximab)

Question 40

What do anti-TNF antibodies do?

Answer 40

• Bind to membrane bown TNF-a and induce immune cell apoptosis

Question 41

Outline the surgical management of crohn's

Answer 41

• Failure of therapy with acute or chronic symptoms • Complications, e.g. dilation, obstruction, perforation, abscesses • Failure to grow in children despite treatment • Colectomy and ileorectal anastomosis may be performed.

Question 42

Give three types of UC and their treatment

Answer 42

• Distal Disease (Proctitis) ○ Topical or suppository corticosteroids • Left Sided Colitis ○ Topical corticosteroid enema • Extensive Colitis ○ Oral corticosteroids ○ Infliximab

Question 43

Outline the surgical management of UC

Answer 43

• Patients with complications / Corticosteroids dependence • In acute disease, subtotal colectomy with end ileostomy and preservation of the rectum is the operation of choice.