Ulcerative Colitis & Crohn's

Question 1

Ulcerative Colitis Definition/Pathophysiology

Answer 1

Chronic idiopathic immune-mediated inflammatory condition of large intestine. Frequently associated with inflammation of rectum & often extends proximally to involve colon. Relapsing & remitting, with symptoms of active disease alternating with periods of remission.

Question 2

UC Risk factors/prevention

Answer 2

Onset peaks between 15-30 years of age. Recent smoking cessation, NSAIDs, C.diff

Question 3

UC Clinical Manifestations

Answer 3

Inflamed rectum (bleeding, urgency, tenesmus-sense of pressure)
abdominal cramping
weight loss

Question 4

UC Diagnosis

Answer 4

Infectious etiology should be ruled out (C.diff)
Colonoscopy to include ileum & biopsies of affected/unaffected areas

Question 5

UC Endoscopic Index of Severity looks at what 3 descriptors?

Answer 5

Vascular pattern
Bleeding
Erosions and ulcers

Question 6

UC Management
Induction of remission: (Mild)

Answer 6

rectal 5-aminosalicylate 1g/d (+ po 5-aminosalicylate 2g/d if left-sided UC)
PO 5-aminosalicylate 2g/d if extensive UC
PO steroids if no remission (budesonide MMX 9mg/d)

Question 7

UC Management
Maintenance (Mild)

Answer 7

rectal 5-aminosalicylate 1g/d
PO 5-aminosalicylate 2g/d if extensive UC or left-sided UC

Question 8

UC Management
Induction of remission (Mod-Severe)

Answer 8

PO budesonide MMX
5-ASA (not in severe cases)
anti-TNF therapy
Vedolizumab (monoclonal Ab)
tofacitinib 10mg po BID x 8 weeks

Question 9

anti-TNF therapy ioncludes what drugs?

Answer 9

adalimumab
golimumab
infliximab + thiopurine

Question 10

UC Management
Maintenance (Mod-Severe)

Answer 10

thiopurines if used steroids for induction (azathioprine, mercaptopurine)
anti-TNF therapy
Vedolizumab
tofacitinib

Question 11

UC Management (acute, hospitalized)

Answer 11

DVT prophylaxis
C. Diff testing
Vanco if C.diff
methylprednisolone 60mg/d or hydrocortisone 100 mg TID/qid to induce remission

Question 12

UC prevention of colon cancer

Answer 12

colonoscopies q 1-3 years beginning 8 years after initial dx

Question 13

Poor prognostic factors for UC

Answer 13

Age < 40 at dx
Extensive colitis
Severe endoscopic disease
Hospitalization for colitis
Elevated CRP
Low Serum Albumin

Question 14

Crohn’s Definition/Pathophysiology

Answer 14

Idiopathic inflammatory d/o of UK etiology with genetic, immunologic, & environmental influences. Chronic, intermittent, progressive, destructive. Most present with non-penetrating, non-stricturizing dz. 50% develop intestinal comps (stricture, abscess, fistula, phlegmon) w/n 20 yrs of dx. Extensive anatomic involvement & deep ulcerations are other risk factors for progression to comps.

Question 15

Crohn’s Risk Factors/prevention

Answer 15

Smoking & NSAIDs may exacerbate disease activity

Question 16

Crohn’s Clinical Manifestations

Answer 16

abdominal pain (RLQ)
diarrhea
fatigue
weight loss
fever
growth failure
anemia
recurrent fistulas

Question 17

Crohn’s Extraintestinal manifestations include
ocular?
derm?
hepatobiliary dz?
thromboembolic?

Answer 17

uveitis, scleritis
pyoderma gangrenosum & erythema nodosum
PSC
venous & arterial

Question 18

Crohn’s Extraintestinal manifestations (other) include?

Answer 18

arthopathy
metabolic bone dzs
osteonecrosis
cholelithiasis
nerpholithiasis
asthma
chronic bronchitis
pericarditis
psoriasis
celiac disease
RA
MS

Question 19

Crohn’s Dx:
Clinical Dx On Endoscopy

Answer 19

discontinuous involvement with skip areas,
sparing of rectum,
deep/linear/serpiginous ulcers of colon
strictures
fistulas
granulomatous inflammation

Question 20

What can help differentiate b/t inflammatory bowel dz & irritable bowel?

Answer 20

Fecal Calpropectin

Question 21

Crohn’s Dx:
if suspicion of small bowel involvement use what imaging?
What imaging modalities should be used if patient is < 35?
Endoscopy provides opportunity to obtain what?

Answer 21

video capsule endoscopy
CT enterography of small bowel; MR enterography
Bx

Question 22

Risk factors for progressive course of Crohn’s include?

Answer 22

younger age at dx
initial extensive bowel involvement (ileal/ilealcolonic, perianal/severe rectal dz, penetrating or stenosis dz)

Question 23

Crohn’s Management (mild-mod)

Answer 23

sulfasalazine for treating symptoms
controlled ileal release budesonide 9mg/d for induction of remission
anti-diarrheals diet mod

Question 24

Crohn’s Management (Mod-Severe)
use what for treating symptoms?

Answer 24

Short term PO steroids

Question 25

Crohn’s Management (Mod-Severe)
consider what instead of steroids? or for maintenance of remisson?

Answer 25

thiopurines

Question 26

Crohn’s Management (Mod-Severe)
Use what for S&S of steroid dependent Crohn’s & maintaining remission?

Answer 26

methotrexate

Question 27

Crohn’s Management (Mod-Severe)
Use what if steroid, thiopurine, and methotrexate resistant?

Answer 27

Anti-TNF

Question 28

Crohn’s Management (Mod-Severe)
What combination treatment is more effective than single agents if niave to both?

Answer 28

infliximab + thiopurine

Question 29

Crohn’s Management (Mod-Severe)
What combination treatment can be considered for induction of remission?

Answer 29

vedolizumab +/- thiopurine, natalizumab

Question 30

Crohn’s Management (Severe/Fullminant)

Answer 30

IV steroids
Anti-TNFs can be considered to treat active dz

Question 31

Crohn’s Management (Fistulas)

Answer 31

infliximab, thiopurines, tracrolimus, abx (imidazoles), surgical drain can be considered

Question 32

Crohn’s Management (Fistulas)
Use for maintenance?

Answer 32

Methotrexate or thiopurines

Question 33

Crohn’s Management (Fisutlas)
Use for maintenance if used for induction?

Answer 33

Anti-TNF
Vedolizumab

Question 34

Crohn’s Management (Abscesses)

Answer 34

Abx & Drainage