SM_164b: Clinical Features of IBD

Question 1

IBD includes ____ and ____

Answer 1

IBD includes ulcerative colitis and Crohn’s disease

(there is also indeterminate colitis, which is in between)

• Peak incidence in 2nd-3rd decades, female predominance for Crohn’s and male for UC, Caucasian, Jewish

Question 2

IBD pathogenesis involves an interaction between ____, ____, ____, and ____

Answer 2

IBD pathogenesis involves an interaction between genetics, immune response, environmental triggers, and microbial antigens

• Positive family history more common in Crohn’s disease

Question 3

NOD2/CARD15 on chromosome 16q12 is implicated in ____

Answer 3

NOD2/CARD15 on chromosome 16q12 is implicated in Crohn’s disease

• Nucleotide-binding oligomerization domain protein 2 / caspase recruitment domain protein 15)
• Accounts for 20% of Crohn’s diseaase seen in the Caucasian and Jewish populations
• Associated with ileal disease, fibrostenotic phenotype, and earlier age

Question 4

NOD2/CARD15 normally encodes a ____ which ____

Answer 4

NOD2/CARD15 normally encodes a protein that binds to bacterial cell wall (peptidoglycan) which activates NF-kB, stimulating the transcription of multiple pro-inflammatory and protective molecules

Question 5

Host-microbe interactions have shaped the genetic architecture of ____

Answer 5

Host-microbe interactions have shaped the genetic architecture of IBD

Question 6

Smokers are less likely to have ____ and more likely to have ____

Answer 6

Smokers are less likely to have ulcerative colitis and more likely to have Crohn’s disease

• More likely to have ileal disease rather than colonic or ileocolonic disease
• More likely to have disease recurrence
• Hygeine, smoking, infections, and diet influence IBD

Question 7

IBD diagnosis is made based on ____, ____, ____, and ____

Answer 7

IBD diagnosis is made based on history / exam, laboratory tests, radiology, and endoscopy / histology

Question 8

Describe clinical symptoms of IBD

Answer 8

Cinical symptoms of IBD

• Diarrhea
• Blood in stools
• Fecal urgency / incontinence
• Abdominal pain
• Abdominal mass
• Anal pain / drainage

Question 9

Extraintestinal manifestations of IBD are ____, ____, and ____

Answer 9

Extraintestinal manifestations of IBD are rash, joint pain, and eye problems

Question 10

Describe aspects of the history suggesting IBD

Answer 10

Aspects of the history suggesting IBD

• Acute or chronic symptoms
• PMHx: asthma, MS, T1DM, cecliac, autoimmune thyroid disorders, ankylosing spondylitis
• Meds: NSAIDs, antibiotics, immunosuppresants
• FMHx: IBD, cancers, RA, MS
• Smokign

Question 11

Describe aspects of the physical exam consistent with IBD

Answer 11

Aspects of the physical exam consistent with IBD

• Signs of anemia, malnutrition
• Red eye, aphthous ulcers
• Abdominal tenderness and mass
• Perianal fissure, fistula, skin tag
• Rash
• Joint swelling

Question 12

Crohn’s disease may involve ____ formation

Answer 12

Crohn’s disease may involve fistula formation

Question 13

IBD has many ____ manifestations

Answer 13

IBD has many extra-intestinal manifestations

• Eyes: episcleritis, uveitis
• Kidneys: stones (nephrolithiasis), hydronephrosis, fistulae, UTIs
• Skin: erythema nodosum, pyoderma gangrenosum
• Mouth: stomatitis, aphthous ulcers
• Liver: steatosis
• Biliary tract: gallstones, sclerosing cholangitis
• Joints: spondylitis, sacroiliitis, peripheral arthritis
• Circulation: phlebitis

Question 14

Bone and joint manifestations of IBD include ____ and ____

Answer 14

Bone and joint manifestations of IBD include spondyloarthropathy (axial, peripheral) and metabolic bone disease

• Axial spondyloarthropathy: sacroiliitis, ankylosing spondylitis
• Peripheral: type 1 (oligarticular, < 5 large joints), type 2 (polyarticular, small joints)
• Metabolic bone disease: osteoporosis / osteopenia, osteomalacia, osteonecrosis

Question 15

____ presents as low back pain and stiffness typically worse in the morning and with rest and may indicate ____

Answer 15

Sacroiliitis presents as low back pain and stiffness typically worse in the morning and with rest and may indicate IBD

• SI joint narrowing and sclerosis
• HLA-B27 association
• NOT associated with IBD activity

Question 16

____ presents as progressive stiffness and lordosis of the spine and may indicate ____

Answer 16

Ankylosing spondylitis presents as progressive stiffness and lordosis of the spine and may indicate IBD

• NOT associated with IBD activity
• Not associated with HLA-B27 activity

Question 17

Osteopenia or osteoporosis is usually ____ common in patients with ulcerative colitis than Crohn’s disease

Answer 17

Osteopenia or osteoporosis is usually less common in patients with ulcerative colitis than Crohn’s disease

• Induction of osteopenia by pro-inflammatory cytokine effects on osteoblasts and osteoclasts
• Risk factors: chronic inflammatory activity, chronic or recurrent corticosteroid use, malnutrition, BMI < 20 (low body weight), low intake or absorption of Ca and Vitamin D, hypogonadism

Question 18

____, ____, and ____ are common dermatologic manifestations of IBD

Answer 18

Pyoderma gangrenosum, erythema nodosum, and cutaneous (metastatic) Crohn’s disease are common dermatologic manifestations of IBD

• Erythema nodosum: pretibial, painful, tender, erythematous subcutaneous nodules, young women
• Pyoderma gangrenosum: pustular lesion evoving to ulcer with undermining borders, lower extremity and peristomal
• Aphthous stomatitis

Question 19

____, ____, and ____ are inflammatory ocular manifestations in IBD

Answer 19

Episcleritis / scleritis, anterior uveitis (iritis), and retinitis are inflammatory ocular manifestations in IBD

• Episcleritis: eye irritation (burning / itching) and conjunctival erythema
• Anterior uveitis: ocular pain, redness, photophobia, blurred vision (diagnose with slit lamp)

Question 20

Describe the hepatobiliary manifestations of IBD

Answer 20

Hepatobiliary manifestations of IBD

• Biliary: primary sclerosing cholangitis (large duct), small duct primary sclerosing cholangitis (pericholangitis), cholelithiasis / choledocholithiasis, cholangiocarcinoma, primary biliary cirrhosis
• Hepatic: fatty liver / steatohepatitis, autoimmune hepatitis

Question 21

____ is the most common hepatobiliary manifestation of IBD

Answer 21

Primary sclerosing cholangitis is the most common hepatobiliary manifestation of IBD

Question 22

___ are the most common kidney stones in people with IBD and are most common in people with Crohn’s with ileal disease

Answer 22

Calcium oxalate are the most common kidney stones in people with IBD and are most common in people with Crohn’s with ileal disease

• Intestinal: strictures, fistulas, perforation, toxic megacolon, short gut syndrome, colon cancer

Question 23

Describe differential diagnosis of IBD

Answer 23

Differential diagnosis of IBD

• Infectious diarrhea
• Medication induced colitis
• Celiac disease
• Behcet’s disease
• Eosinophilic gastroenteritis
• GVHD
• IBS
• Lactose intolerance

Question 24

Describe diagnosis of IBD

Answer 24

IBD diagnosis

• Blood tests: CBC, CMP, ESR, CRP, vitamins / minerals
• Stool tests: culture, C. difficile, ova and parasites, fecal leukocuytes
• Imaging: X-ray, CT, MRI
• Endoscopy: EGD, colonscopy, capsule endoscopy, double balloon / single balloon enteroscopy

Question 25

Describe pathological differences between ulcerative colitis and Crohn’s disease

Answer 25

Pathological differences between ulcerative colitis and Crohn’s disease

• Ulcerative colitis: mucosal depth, crypt abscesses and architecture distortion are seen
• Crohn’s disease: transmural, crypt abscesses and architecture distortion are seen, granuloma occurs