Station 5 Paces Flashcards
Taking history of bloody diarrhoea
Presenting complaint
Systemic symptoms (fever, anorexia, weight loss, rash, arthralgia, aphthous ulcers)
PMHx and PSHx
Meds history
FH, SHx
Examination findings for ?IBD dx
Pallor
Nutritional status
Pulse and BP
Oral ulceration
Surgical scars/stomas
Tenderness
Palpable mass
Perianal disease
Steroid side effects
Gum hypertrophy from ciclosporin
Investigating IBD
Stool MC&S
FBC, UE, CRP, electrolytes
AXR
Flexi sig
Treatment for Crohns
Mild- moderate: oral steroids and mesalazine
Severe disease: IV steroid, IV infliximab
Maintenance therapy: oral steroids, aza, infliximab, adalimimab
Metronidazole in Crohns with orrianal infection/fistula/small bowel bacterial over growth
Nutritional support
Treatment for UC
Mild to mod: Oral or rectal steroids and mesalazine
Severe: IV steroids, IV ciclosporin
Maintainence therapy: oral steroids, mesalazine, azathioprine
Surgical management of IBD
Crohns: used for strictures, fistula or perianal disease that fails to respond to medical management
UC: emergency surgery for severe refractory disease or symptomatic relief of chronic disease or carcinoma
Complications of Crohns
Malabsorption
Anaemia
Abscess
Fistula
Obstruction
Complications of UC
Anaemia
Toxic dilatation
Perforation
Colonic carcinoma
- higher risk in patients with pancoitis and PSC
- surveillance colonoscopy 3 yearly in patients with pancolitis >10 years, increasing frequency with every decade form diagnosis
Extra- intestinal manifestations of IBD
Aphthous ulcers*
Erythema nodosum*
Pyoderma gangrenosum*
Finger clubbing*
Large joint arthritis*
Seronegative arthritis
Uveitis*
Episcleritis*
Iritis*
PSC
Systemic amyloidosis
- related to disease activity
What is dermatitis herpetiformis?
Itchy blistering rash usually in extensor surfaces secondary to an insensitivity to gliadin in gluten (hence commonly associated with coeliac disease
Diagnosis of dermatitis herpetiformis
Skin biopsy
Screen for coeliac disease:
FBC, iron, b12/folate, calcium
IgA TTG
Anti- endomysial antibodies
Small intestinal biopsy
Management of coeliac disease and dermatitis herpetiformis
Gluten free diet + dietitian referral
Oral dapsone
Aetiology of rhuematoid arthritis
Combination of genetic and environmental factors
Association with HLA-DR4
Association with smoking
Pathophysiology of RA
Disease exclusively of synovial joints
Inflammation of the synovial membranes due to the presence of immune complexes in these joints which leads to activation of the immune system and synovitis
Clinical presentation of RA
Symmetrical MCP, PIP and wrist joint synovitis
Joint pain, stiffness, swelling of joints and erythema
Cervical spine involvement
Characteristic dermformities:
- ulnar deviation of MCP joints
- boutnonniere deformities of fingers
- swan neck deformities
- Z deformity of thumbs
Extra articular features:
- rhuematoid nodules
- episcleritis
Diagnosis of RA
X-rays- periarticular osteopenia, symmetrical joint space loss, deformities, erosions, nodules)
RF (+ve in 70%)
Anti- CCP (+ve in 60%, more specific than RF)
ANA (+ve in 30%)
ESR and CRP
FBC (? Anaemia)
U&E (renal involvement and before NSAIDs)
Synovial fluid - raised wcc, raised protein, low glucose
Urine dip and PCR
ACR/ EULAR 2011 classification criteria (>6 points)
Management of RA
MDT approach
Disease education
Smoking cessation
Physiotherapy
NSAIDs with stomach protection
Steroids
Methotrexate + DMARD
Occasionally surgery
Features associated with poor prognosis in RA
Rhuematoid factor or anti- CCP antibodies
Smoking
Extra- articular features
HLA-DR4
Female
Early erosions
Severe disability at presentation
Systemic manifestations of RA
Pulmonary:
- fibrosis
- effusions
- fibrosing alveolitis
- obliterative bronchiolitis
- caplans nodules
Eyes:
Scleritis/episcleritis
Neurological:
- carpal tunnel syndrome
- Atlanto- axial subluxation
- peripheral neuropathy
Haematological:
- Feltys (RA+ splenomegaly+ neutropenia)
Skin: palmar erythema, Raynauds, pyoderma
Renal: glomerulonephritis
Aetiology of Ehlers Danlos Syndrome
Faulty genes in EDS result in abnormal phenotypical expression owing to defective collagen and extra cellular matrix proteins.
Hypermobile, classical, vascular EDS have an autosomal dominant inheritance pattern
Kyphoscoliotic, classical- like and cardio- valvular are autosomal recessive
Clinical presentation of EDS
Hyperflexible joints
Increased skin elasticity
Bruising
Joint dislocations
Widespread pain
Aortic aneurysm
Mitral valve prolapse
Blue sclera, tinnitus, hernias, prolapse
Investigation of EDS
Echo
CT
Molecular genetic testing
Management of EDS
Physiotherapy
Analgesia
CBT
Genetic counselling
Cardiovascular screening
What is the Pathophysiology of sarcoidosis?
Granulomas composed of macrophages, lymphocytes, epethelioid histiocytes fuse to form a multinucleotide giant cell