Therapies and surgery for IBD Flashcards
what are 3 therapeutic strategies for IBD?
- lifestyle advice
- drugs
- surgery
what is the most important lifestyle factor to stop if you have Crohn’s?
= stop smoking
What effect does diet have in IBD? (particularly in Crohn’s)
= not implicated in pathogenesis but can influence symptoms
what do all drugs aim to do?
= anti-inflammatory
how would you treat ulcerative colitis?
- 5ASA (= amino-salicyclic acid) (mesalazine) - steroids - immunosuppressants - anti-TNF therapy
how would you treat Crohn’s disease?
- steroids
- immunosuppressants
- anti-TNF therapy
how do 5ASA work?
= topical effect
- anti-inflammatory properties
- reduces risk of colon cancer
what are 2 side effects of 5ASA drugs?
- diarrhoea
- idiosyncratic nephritis
describe the difference between oral and topical 5-ASA drugs?
Oral
- prodrugs
- pH dependent release
- delayed release
Topical
- suppositories
- enemas
give 6 examples of 5-ASA?
- sulphasalazine (sulphapyridine/5-ASA)
- balsalazide (5-ASA inert carrier)
- mezavant (5-ASA matrix carier)
- mesalazine
- pH release (asacol)
- delayed release (pentasa)
describe the release of salazopyrin, balasalazide, asacol salofalk and pentasea.
Salazopyrin
= colon
Balsalazide
= colon
Asacol Salofalk
= ileum and colon
Pentasa
= duodenum, jejunum, ileum and colon
what are 2 examples of how topical therapies can be taken?
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
what do corticosteroids do and give examples?
= systemic anti-inflammatory properties
Examples;
- prednisolone (oral/topical)
- budesonide
= induces remission
- usually short course, high dose initially reducing over 6-8weeks
what are side effects of steroids?
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
when are immunosuppressants used?
= when more potent suppression of inflammation is required
when should immunosuppressants be used in ulcerative colitis and Crohn’s?
Ulcerative colitis;
= steroid sparing agents
Crohn’s
= maintenance therapy
what are 3 examples of immunosuppressant drugs?
- azathioprine / mercaptopurine
- methotrexate
describe the onset of azathioprine, an immunosuppressant?
= slow onset of action (16 weeks)
when should you avoid co-prescription of azathioprine and what are side effects of it?
= avoid co-prescription of allopurinol (XO inhibitor)
- regular blood monitoring required
Side effects;
- pancreatitis
- leucopenia
- hepatitis
- small risk of lymphoma, skin cancer
what do anti-TNF therapies do?
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)
what are 2 antibodies to TNF?
- chimeric (infliximab; IV infusion)
- humanised (adalimumab; S/C injection)
what do anti-TNF therapies heal?
= mucosal healing
describe the safety of anti-TNF alpha?
- infusion reactions
= HACA +ve - infection
- cancer
= lymphoma
= solid tumours
when should anti-TNF alphas be used?
- as part of long term strategy in combo with immune suppression, surgery (Crohn’s), supportive therapy
- refractory/fistulating disease
what are bio-similar anti-TNFs, give examples?
= approved subsequent versions of innovator bio-pharmaceutical products
Exampes of
- infliximab/remicade biosimilars;
= inflectra, remsima
what are 2 types of surgery that may need to be done in IBD?
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
describe the surgery for Crohn’s?
= 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)
describe surgery for ulcerative colitis?
= CURATIVE
- option of permanent ileostomy
OR - restorative proctocolectomy and pouch
Lecture 2 - surgery for IBD
Lecture 2 - surgery for IBD
what are the 2 groups of emergency operations?
1) planned emergency
- sub-totally colectomy for UC
- resection of Crohn’s dosease
2) unexpected finding “surprise” operation
- diagnostic laproscopy
- rectal/anal disease
list elective surgery for Crohn’s?
- resection
- stricturolplasty
- fistulas
- anal disease
list elective surgery with people with ulcerative colitis?
- proctolectomy with end ileostomy
- proctocolectomy with ileorectal anastomosis
- proctocolectomy with pouch
what is an ileostomy?
(closed rose bud)
= where the small intestine is diverted through an opening in the tummy and a bag is placed externally to collect wast
what is a colostomy?
(open rose bud)
= operation to divert one end of the colon (part of the bowel) through an opening in the tummy.
when would surgery be given in people with ulcerative colitis?
- medically unresponsive disease
- intolerability
- dysplasia/metaplasia
- growth retardation in children
- attempted resolution of extra-intestinal disease
what are 3 possible options for ulcerative colitis?
- end ileostomy
- pouch (popular with younger patients - creates a reservoir)
- ileorectal anastomosis
what some complications that occur immediately early and late in surgery?
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
describe sub-total colectomy?
= 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)
what are the problems with the rectum?
- 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)
what does toxic megacolon result in?
- sepsis
- distension
- pain
- requires decompression
- may perforate
- can be fatal
is surgery for ulcerative colitis well tolerated?
Yes - most live well with a stoma
what are the indications for surgery in crohn’s?
- stenosis causing obstruction
- enterocutaneous fistulas
- intra-abdominal fistulas
- abscess
- bleeding
- free perfoation
what is a pouch?
= loops of small intestine are folded and stapled on itself creating a reservoir, restoring normal function of rectum
