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GI > Therapies and surgery for IBD > Flashcards

Therapies and surgery for IBD Flashcards

1
Q

what are 3 therapeutic strategies for IBD?

A
  • lifestyle advice
  • drugs
  • surgery
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2
Q

what is the most important lifestyle factor to stop if you have Crohn’s?

A

= stop smoking

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3
Q

What effect does diet have in IBD? (particularly in Crohn’s)

A

= not implicated in pathogenesis but can influence symptoms

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4
Q

what do all drugs aim to do?

A

= anti-inflammatory

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5
Q

how would you treat ulcerative colitis?

A 
- 5ASA
(= amino-salicyclic acid) (mesalazine)
- steroids
- immunosuppressants
- anti-TNF therapy
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6
Q

how would you treat Crohn’s disease?

A
  • steroids
  • immunosuppressants
  • anti-TNF therapy
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7
Q

how do 5ASA work?

A

= topical effect

  • anti-inflammatory properties
  • reduces risk of colon cancer
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8
Q

what are 2 side effects of 5ASA drugs?

A
  • diarrhoea

- idiosyncratic nephritis

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9
Q

describe the difference between oral and topical 5-ASA drugs?

A

Oral

  • prodrugs
  • pH dependent release
  • delayed release

Topical

  • suppositories
  • enemas
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10
Q

give 6 examples of 5-ASA?

A
  • sulphasalazine (sulphapyridine/5-ASA)
  • balsalazide (5-ASA inert carrier)
  • mezavant (5-ASA matrix carier)
  • mesalazine
  • pH release (asacol)
  • delayed release (pentasa)
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11
Q

describe the release of salazopyrin, balasalazide, asacol salofalk and pentasea.

A

Salazopyrin
= colon

Balsalazide
= colon

Asacol Salofalk
= ileum and colon

Pentasa
= duodenum, jejunum, ileum and colon

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12
Q

what are 2 examples of how topical therapies can be taken?

A

1) suppositories coat < 20c, but have better mucosal adherence than enemas

2) reflex contraction aids proximal spread of foam or liquid enemas
- <10% enemas remain in the rectum

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13
Q

what do corticosteroids do and give examples?

A

= systemic anti-inflammatory properties

Examples;

  • prednisolone (oral/topical)
  • budesonide

= induces remission
- usually short course, high dose initially reducing over 6-8weeks

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14
Q

what are side effects of steroids?

A

Musculoskeletal;

  • avascular necrosis
  • osteoporosis
GI;
- cutaneous 
= acne
= thinning of skin
= easy bruising

Metabolic;

  • gain weight (as it increases your appetite)
  • diabetes increased risk
  • hypertension

Neuropsychiatric
= cataracts
= growth failure

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15
Q

when are immunosuppressants used?

A

= when more potent suppression of inflammation is required

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16
Q

when should immunosuppressants be used in ulcerative colitis and Crohn’s?

A

Ulcerative colitis;
= steroid sparing agents

Crohn’s
= maintenance therapy

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17
Q

what are 3 examples of immunosuppressant drugs?

A
  • azathioprine / mercaptopurine

- methotrexate

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18
Q

describe the onset of azathioprine, an immunosuppressant?

A

= slow onset of action (16 weeks)

19
Q

when should you avoid co-prescription of azathioprine and what are side effects of it?

A

= avoid co-prescription of allopurinol (XO inhibitor)

  • regular blood monitoring required

Side effects;

  • pancreatitis
  • leucopenia
  • hepatitis
  • small risk of lymphoma, skin cancer
20
Q

what do anti-TNF therapies do?

A

TNF = tumour necrosis factor alpha which releases pro-inflammatory cytokine

therefore;
= you need an anti-TNF therapy

= promotes apoptosis of activated T-lymphocytes
(rapid onset of action)

21
Q

what are 2 antibodies to TNF?

A
  • chimeric (infliximab; IV infusion)

- humanised (adalimumab; S/C injection)

22
Q

what do anti-TNF therapies heal?

A

= mucosal healing

23
Q

describe the safety of anti-TNF alpha?

A
  • infusion reactions
    = HACA +ve
  • infection
  • cancer
    = lymphoma
    = solid tumours
24
Q

when should anti-TNF alphas be used?

A
  • as part of long term strategy in combo with immune suppression, surgery (Crohn’s), supportive therapy
  • refractory/fistulating disease
25
Q

what are bio-similar anti-TNFs, give examples?

A

= approved subsequent versions of innovator bio-pharmaceutical products

Exampes of
- infliximab/remicade biosimilars;
= inflectra, remsima

26
Q

what are 2 types of surgery that may need to be done in IBD?

A

1) emergency
= failure to respond to medical therapy, small bowel obstruction, abscess, fistulae

2) elective
= failure to respond to medical therapy
= dysplasia of colon mucosa

27
Q

describe the surgery for Crohn’s?

A

= minimise amount of bowel resected

  • NOT CURATIVE
  • repeated resection of small intestine can result in short gut syndrome and requirement of lifelong total parenteral nutrition (reduced life expectancy)
28
Q

describe surgery for ulcerative colitis?

A

= CURATIVE

  • option of permanent ileostomy
    OR
  • restorative proctocolectomy and pouch
29
Q

Lecture 2 - surgery for IBD

A

Lecture 2 - surgery for IBD

30
Q

what are the 2 groups of emergency operations?

A

1) planned emergency
- sub-totally colectomy for UC
- resection of Crohn’s dosease

2) unexpected finding “surprise” operation
- diagnostic laproscopy
- rectal/anal disease

31
Q

list elective surgery for Crohn’s?

A
  • resection
  • stricturolplasty
  • fistulas
  • anal disease
32
Q

list elective surgery with people with ulcerative colitis?

A
  • proctolectomy with end ileostomy
  • proctocolectomy with ileorectal anastomosis
  • proctocolectomy with pouch
33
Q

what is an ileostomy?

A

(closed rose bud)

= where the small intestine is diverted through an opening in the tummy and a bag is placed externally to collect wast

34
Q

what is a colostomy?

A

(open rose bud)

= operation to divert one end of the colon (part of the bowel) through an opening in the tummy.

35
Q

when would surgery be given in people with ulcerative colitis?

A
  • medically unresponsive disease
  • intolerability
  • dysplasia/metaplasia
  • growth retardation in children
  • attempted resolution of extra-intestinal disease
36
Q

what are 3 possible options for ulcerative colitis?

A
  • end ileostomy
  • pouch (popular with younger patients - creates a reservoir)
  • ileorectal anastomosis
37
Q

what some complications that occur immediately early and late in surgery?

A

immediate;
Local - haemorrhage, enterostomy
Systemic - anaphylaxis

early;
Local - urinary dysfunction, wound infection, pelvic abscess, anastomotic leak
Systemic - atelectasis, ileus, portal vein thrombosis

Late;
Local - impotence, infertility (males & females), pouchitis
Systemic - small bowel obstruction

38
Q

describe sub-total colectomy?

A

= whole colectomy is cut out
- you keep the mesentery inside!!

= lap or open depending on expertise

  • rectal stump can be brought out as a mucous fistula
  • stapled and left in (riskier)
39
Q

what are the problems with the rectum?

A
  • Nervi erigenti
  • In acute flare up stay out of the rectum
  • When quiescent you can proceed
  • Removal of colon tends to settle rectal disease
  • No rush to deal with the rectum
  • Manage with meds (predfoam enemas etc)
40
Q

what does toxic megacolon result in?

A
  • sepsis
  • distension
  • pain
  • requires decompression
  • may perforate
  • can be fatal
41
Q

is surgery for ulcerative colitis well tolerated?

A

Yes - most live well with a stoma

42
Q

what are the indications for surgery in crohn’s?

A
  • stenosis causing obstruction
  • enterocutaneous fistulas
  • intra-abdominal fistulas
  • abscess
  • bleeding
  • free perfoation
43
Q

what is a pouch?

A

= loops of small intestine are folded and stapled on itself creating a reservoir, restoring normal function of rectum

GI (43 decks)

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