W11 IBD, UC & Crohn's Disease Flashcards
What is IBD? (2)
Between what ages is it commonly diagnosed?
Inflammatory Bowel Disease
Collective term used to describe 2 conditions that cause inflammation of the GI tract
1. Ulcerative Colitis (UC) – Mostly affects colon and rectum
2, Crohn’s Disease (CD) – can affect anywhere in GI tract
* Can affect any age - mostly diagnosed between age 15-40
What are the symptoms of Inflammatory Bowel Disease? (6)
- Pain, swelling, cramping of the abdomen
- Recurring diarrhoea
- Bloody diarrhoea
- Weight loss
- Tiredness
- Also – Joint pain, red eyes, erythema nodosum, pyoderma gangrenosum, jaundice
- Symptom fluctuation – flare ups or periods of minimal/no symptoms (remission)
What are the Extra-intestinal Symptoms in IBD?
- Symptoms that manifest outside of the GI tract
-occur in roughly 30% of UC patients and 6% CD patients - More common in CD
- Can present before any GI symptoms
What are the Extra-intestinal Symptoms in IBD that are related to disease activity? (7)
- Pauci-articular arthritis
- Erythema nodosum -tender red bumps on shins
- Mouth Ulcers
- Episcleritis- a common condition affecting the episclera, the layer of tissue between the surface membrane (conjunctiva) and the firm white part of the eye (the sclera).
- Osteopenia, Osteoporosis,
- Osteomalacia-a metabolic bone disorder characterized by the inadequate mineralization of bone tissue
- VTE
What are the Extra-intestinal Symptoms in IBD that are NOT related to disease activity? (8)
- Axial arthritis
- Polyarticular arthritis
- Pyoderma gangrenosum
- Psoriasis
- Uveitis
- Hepatitis
- Liver Cirrhosis
- Gallstones
*rare condition that causes large, painful sores (ulcers) to develop on your skin, most often on your legs
What is Ulcerative colitis? (definition)
- Defined as – “chronic, relapsing-remitting, non-infectious inflammatory disease of the gastrointestinal tract” (NICE, 2019)
- Diffuse, continuous inflammation of intestinal mucosa in the colon and rectum
- Immune mediated, impaired epithelial barrier function, chronic inflammation
What can UC be classed as? (3)
Occurs in what areas?
- Ulcerative Proctitis – Inflammation in the rectum only, doesn’t extend to colon
- Left-sided colitis – Inflammation that doesn’t extend past the splenic flexure, a.k.a proctosigmoiditis
- Extensive colitis – Inflammation extends beyond the splenic flexure, can extend through the whole colon (pancolitis)
What are the risk factors and complications of Ulcerative colitis?
- Risk Factors – Family history, no appendicectomy, NSAIDs, Non-smoker
- Complications – Psychosocial impact, bowel obstruction, bowel perforation, intestinal stricture, fistula, iron deficiency, malnutrition, growth failure, pouchitis, colorectal cancer
What is toxic megacolon?
- Potential life-threatening complication
- Dilatation of the colon with increasing abdo. pain & systemic symptoms
- Colonectomy possibly required
- Abso x-ray shows dilatation of transverse colon
- Causes - relapse, infection, hypokalaemia, hypomagnesaemia, anti-diarrhoeal medication
What are the symptoms of UC?
➢ Bloody diarrhoea/rectal bleeding for more than 6 weeks
➢ Faecal urgency and/or incontinence
➢ Painful, persistent urge to pass stool even when rectum is empty (Tenesmus)
➢ Pain in lower left quadrant (LLQ) of abdomen
➢ Pain before passing stool – relieved after passing
➢ Fatigue, malaise, fever, anorexia
➢ Weight loss (unexplained), faltering growth, delayed puberty
➢ Family Hx of IBD, Coeliac or Colorectal Canc
What can be determined from examination of an UC patient?
➢ Pale ,finger clubbing, mouth ulcers
➢ Distension, feeling of a lump or tenderness in LLQ
➢ Signs of malnutrition or malabsorption
➢ Red eyes, skin rash, joint pain or swelling
➢ Physical exam may not be abnormal in mild or moderate disease
How to manage a patient with suspected UC?
4 symptoms that lead to hosp admission?
Patient systemically unwell with symptoms and signs of severe disease – Hospital admission
➢ Fever
➢ Bloody diarrhoea
➢ Tachycardia
➢ Hypotension
- Admission not needed - refer urgently to gastroenterology (paeds or adult) for specialist investigations to confirm diagnosis
- Avoid anti-diarrhoeal treatment – toxic megacolon risk
- Refer to appropriate specialist if pt. has extra-intestinal symptoms e.g. Dermatology if has skin symptom
What is the Differential Diagnosis of UC?
- Crohn’s Disease
- Infective Colitis – Gastroenteritis, C.Diff
- Microscopic Colitis
- Intestine ischaemia
- Diverticulitis
- Coeliac Disease
- IBS, Laxative misuse/abuse
- Anal Fissure
- Colorectal Cancer
- Endometriosis
What investigations should be done on a patient with UC?
- FBC, LFT, TFT, CRP, ESR, U&E, Ferritin, B12,
Folate, Vit. D - Coeliac Serology
- Stool sample for microscopy & culture
- Faecal Calprotectin
- Colonoscopy/tissue biopsy-assess inflammation
Specialist Investigations/Studies
* Colonoscopy/tissue biopsies
* Assess inflammation and severity & extent of disease
* Upper intestinal endoscopy – helps differentiate between UC and CD
* Magnetic Resonance Enterography (MRE)
* Computed Tomography (CT)
* Abdominal X-Ray and Ultrasound Sca
What are the treatment options for UC? (7)
➢Corticosteroids
➢Aminosalicylates
➢Azathioprine & Mercaptopurine (immunosuppressants)
➢Methotrexate (MTX) – Poor evidence base for use
➢Ciclosporin (immunosuppressant)
➢Biologics
➢Surgery – Ileostomy, colostomy, stoma
What are the aims of treatment of UC? (3)
➢Treat active disease
➢Manage symptoms
➢Induce & maintain remission
What are examples of corticosteroids?
What are the types of formulation? (3)
What are the cautions? (8)
What are the contraindications? (6)
What are the side effects? (10)
Prednisolone, Hydrocortisone, Budesonide
- Topical – Foam, Enema, Suppository
- Oral – Tablets, Soluble Tablets, GR tablets, Oral
solution, sachets - Intravenous ( Topical & oral preparations used
in mild-moderate disease, IV treatment for severe acute disease (1st line) )
Cautions
* CHF, recent MI
* Diabetes including FH
* Diverticulitis
* Epilepsy
* Glaucoma
* Osteoporosis
* Peptic Ulcer
* Concurrent NSAID treatment
C/I
* Systemic infection
* Abdominal/local GI infection
* Bowel perforation
* Extensive fistulas
* Intestinal obstruction
* Recent intestinal surgery
SE
* Adrenal suppression
* Immunosuppression – inc. infection
susceptibility
* Increased appetite, weight gain
* Cushing’s Syndrome
* Fatigue
* Fluid retention
* GI discomfort
* Skin reactions
* Inc. risk of bone fractures
* Impaired growth (children)
Corticosteroids:
Counselling?
Monitoring?
Counselling - Take oral preps with food, monitor for signs of Cushing’s and infection, Gradual withdrawal from high dose, longer oral courses
Monitoring – Height & weight for children, CRP & ESR if on longer term oral course
- Add on therapy in mild – moderate disease (proctitis, proctosigmoiditis) to induce remission alongside aminosalicylate therapy
- “Time-limited course” – 4-8 weeks
Amino salicylates (5-ASAs)
What are some examples and routes of administration?
Side effects?
Mesalazine
* Oral
* 2.4g to 4.8g daily in divided doses - Acute
* 1.2-2.4g once daily –Remission
* Topical
* 1g to 2g daily – single dose or divided doses
Sulfasalazine
* Oral or Topical
* 1-2g daily – single dose or divided dose
Side Effects
* Joint Pain
* Cough
* GI – Diarrhoea, Nausea, Vomiting
* Dizziness, fever, headache
- Blood dyscrasis
➢ Leukopenia
➢ Agranulocytosis
➢ Bone marrow disorders
➢ Neutropenia
➢ Eosinophilia
Amino salicylates (5-ASAs)
Used to treat?
Cautions?
C/I?
Counselling & Advice?
- Treatment of mild - moderate disease
relapse and maintenance of remission - Initial topical treatment
- Oral treatment if remission not achieved within 4 weeks
Cautions
* Elderly
* Fluid intake
* Pulmonary disease
* Hx asthma
* Risk of liver toxicity
* Risk of blood toxicity
* G6PD deficiency
* Acute porphyria
* Hx allergy
Contraindications
* Blood clotting abnormality/disorder
Counselling & Advice
* Sulfasalazine can stain soft contact lenses
* Report any signs of
-Unexplained bruising
-Unexplained bleeding
- Purpura
- Sore throat
- Fever
- Malaise
Blood Monitoring of Aminosalicylates:
What should be monitored? (7)
When?
- Full Blood Count, Liver Function Tests, Renal Function – Urea, Electrolytes, Creatinine, EGFR
-Usually before starting treatment, after 3 months of treatment and then annually during treatment
Blood monitoring:
What is a shared protocol/agreement?
- Covers situations where primary care accepts transfer of prescribing responsibility from secondary care for medicines requiring
long-term monitoring - Set out the monitoring requirements and responsibilities i.e. highlights who does what and who is responsible for doing it
- e.g. Secondary care will do initial blood monitoring and prescribing of medication until patient is stable then transfer
responsibility to GP to continue prescribing and monitoring - GP signs the acceptance document if happy to accept or can decline transfer of responsibility e.g. if unable to conduct
monitoring - Overall responsibility for review of medication and follow ups remain with secondary care
- Blood monitoring is funded as part of a national enhanced service also i.e. the GP practice is paid to conduct the blood tests
- Covers when patients should be referred back to secondary care e.g. low WCC or platelet count
- CID642a Sulfasalazine Shared Care Protocol (Reviewed no changes - October 2022).pdf (Swansea Bay LHB Shared Care example)
Azathioprine/Mercaptopurine
(Thiopurines)
Side effects?
- Azathioprine is broken down into mercaptopurine within the body after administration
- Dose - 2-2.5mg/kg/day for remission of UC
- Mercaptopurine also available as
standalone drug for remission of maintenance in UC - Dose - 1-1.5mg/kg/day
- Also used in severe UC but unlicensed
Side effects
* Bone marrow
depression/disorders
* Inc. Infection risk
* Leukopenia
* Thrombocytopenia
* Neutropenia
* Pancreatitis
* Agranulocytosis
* Alopecia
* GI disorders
* SCARs
* Hypersensitivity (STOP
Azathioprine/Mercaptopurine
(Thiopurines)
Cautions
Contraindications
Blood Monitoring
Counselling & Advice
Cautions
* Reduce dose in the elderly
* Reduced TPMT activity
Contraindications
* Low TPMT activity
Blood Monitoring
* Weekly FBC for first 4 weeks then reduce to at least every 3 months
* Also covered under shared care
Counselling & Advice
* Report any signs of
-Unexplained bruising
-Unexplained bleeding
-Purpura
-Sore throat
-Fever
-Malaise
What is Thiopurine methyltransferase (TPMT)?
- Enzyme that metabolises thiopurine drugs
- Patients with reduced levels are at increased risk of myelosuppression
- TMPT test/screen must be conducted before treatment
- Reduced or low TPMT activity patients must be treated or remain under specialist supervision
- Reference ranges
Normal: 68 – 150 mU/L
Low: 20 – 67 mU/L
High: >150 mU/L
Acute – Severe UC
Where is pt referred to?
What medications are they given?
first and second line?
Which meds after 72 hours?
Step 1
* Hospital admission
* MDT Care – Gastroenterologist, colorectal surgeon, IBD Nurse, Stoma Nurse, Paediatric
Gastroenterologist if child, Obs. & Gynae. if pt. pregnant
* IV corticosteroid & assess for surgery
* IV ciclosporin if corticosteroid not tolerated, contraindicated or declined
Step 2
* Add IV ciclosporin to IV corticosteroid or consider surgery if:
* Little/no improvement within 72hrs of IV corticosteroids
* Symptoms worsening
* Infliximab if ciclosporin contraindicated or not appropriate – Risk v. Benefit
What is Crohn’s Disease?
- Defined as – “chronic, relapsing-remitting, non-infectious inflammatory disease of the gastrointestinal tract” (NICE, 2019)
- Inflammation can be anywhere in the GI tract - discrete areas
- Inflamed areas with normal areas inbetween – “skip lesions”
- Thickening and inflammation of the intestinal wall, compared to only intestinal mucosa affected in UC
What are the risk factors and complications in Crohn’s disease?
- Risk Factors – Family Hx, Smoking, Hx infective gastroenteritis, Appendectomy, Drugs (NSAIDs)
- Complications - Psychosocial, intestinal stricture, fistula, perianal disease, dilation and
perforation of the GI tract, haemorrhage, malnutrition, vitamin and mineral deficiencies, cancer
Diagnosing CD:
What are the symptoms?
-Unexplained persistent diarrhoea for more than 4-6 weeks, inc. at night
-Faecal urgency
-Urge to pass stool even when rectum is empty (Tenesmus)
-Blood or mucous in stool
-Abdom. Pain/discomfort
-Fatigue, malaise, fever, anorexia
-Weight loss (unexplained), faltering growth, delayed puberty
-Family Hx of IBD, Coeliac or Colorectal Cancer
Symptoms during Patient examination in Crohn’s disease?
- Pale ,finger clubbing, mouth ulcers
- Feel of abdominal mass or tenderness
- Perianal pain
- Anal/perianal skintag, fissure, fistula or abscess
- Signs of malnutrition or malabsorption
- Extra-intestinal symptoms – in joints, skin eyes or liver
What are the differential diagnosis for Crohn’s disease?
- Crohn’s Disease
- Infective Colitis – Gastroenteritis, C.Diff
- Microscopic or Pseudomembranous colitis
- Intestine ischaemia, appendicitis
- Diverticulitis
- Coeliac Disease
- IBS, Laxative misuse/abuse
- Anal Fissure
- Cancer – colorectal, small bowel, lymphoma
- Endometriosis
What are the investigations to be done in diagnosing CD?
- FBC, LFT, TFT, CRP, ESR, U&E, Ferritin, B12, Folate, Vit. D
- Coeliac Serology
- Stool sample for microscopy & culture
- Faecal Calprotectin
- Colonoscopy/tissue biopsy-assess inflammation
- Results can show as normal
Suspected CD
What symptoms lead to hosp referral? (4)
What shouldnt be prescribed?
- Patient systemically unwell with symptoms and signs of severe disease – Hospital admission
-Fever
-Bloody diarrhoea
-Tachycardia
-Hypotension - Admission not needed - refer urgently to gastroenterology (paeds or adult) for specialist investigations to confirm diagnosis
- Avoid anti-diarrhoeal treatment if diagnosis uncertain – may precipitate toxic megacolon
- Refer to appropriate specialist if pt. has extra-intestinal symptoms e.g. Dermatology if has skin symptoms
Treatment of CD
What are the aims of treatment?
- Relieve/reduce symptoms
- Maintain and improve QoL
- Limit drug related toxicity
Induce & maintain remission
Treatment of CD
What are the treatment options? (7)
Glucocorticoids & Budesonide
Aminosalicylates
Azathioprine & Mercaptopurine
Methotrexate (MTX) – Poor evidence base for use in UC
Ciclosporin
Biologics
Surgery – Ileostomy, colostomy, stoma
Ulcerative colitis vs Crohn’s disease:
Location, Pattern and Appearance of Inflammation?
Location of Pain?
Bleeding?
Ulcerative Colitis:
Inflammation:
Location= limited to colon (large int)
Pattern= Inflamed areas are continuous with no patchiness. Typically in the lower left abdomen
Appearance= Ulcers penetrate the inner lining of the abdomen only.
Bleeding= Common during bowel movements
Crohns:
Location= Anywhere in GI tract (from gum to bum)
Appearance= Patches of inflammation found in large sections of the bowel lower right abdomen
Pattern= Typically in the lower right abdomen
Location of pain= ulcers penetrate the entire thickness of the abdo lining
Bleeding= Uncommon
