Inflammatory Bowel Disease Flashcards

1
Q

What are the features of IBD in childhood

A

Approximately 1/4 of patients present in childhood or adolescence
Crohn’s disease is more common in childhood than ulcerative colitis (unlike in adults)
Can cause poor general health, growth restriction, and have an adverse effect on psychological wellbeing

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2
Q

Define Crohn’s disease

A

Chronic granulomatous transmural inflammation of any part of the GI tract, mainly the distal ileum and proximal colon

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3
Q

What are the structural features of Crohn’s disease

A

Inflammation occurs anywhere from mouth to anus, Common in the terminal ileum (40%, R lower abdo pain) and peri-anal region
TRANSLUMINAL/full thickness inflammation
Skip lesions (inflamed and normal bowel interspersed)
Formation of strictures and fistulae, risk of obstruction
Goblet cell and granuloma involvement

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4
Q

What are the suggested causes for and risk factors of Crohn’s disease

A

Genetic: CARD15, IL-23

RF:
White ethnicity
15-40 or 60-80
FHx IBD
Environmental: smoking, OCP, high refined sugar

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5
Q

What are the symptoms of Crohn’s disease

A

Abdominal pain (cramping, constant, RLQ/peri-umbilical, relieved by defecation)
Prolonged diarrhoea (NON-bloody (or intermittent)
Obstruction → bloating, distension, vomiting, constipation
Fever
Malaise, fatigue, lethargy
Weight loss, growth failure, delayed puberty

Extra-intestinal: Ulcers, arthritis, erythema nodosum, pyoderma gangrenosum
- Anterior uveitis: painful red eye with loss of vision
- Scleritis : painful red eye with no loss of vision
- Episcleritis: uncomfortable red eye with no loss of vision
Crohn’s colitis → diffuse abdo pain, mucous blood and pus in stool

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6
Q

What are the signs of Crohn’s disease on examination

A

General: pallor (anaemia)
ENT:
- Aphthous mouth ulceration
- Scleritis : painful red eye with no loss of vision
- Episcleritis: uncomfortable red eye with no loss of vision
Skin: erythema nodosum, pyoderma gangrenosum
Abdo: abdominal tenderness
PR: peri-anal lesions e.g. skin tags, fistulae, scarring, abscess

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7
Q

What investigations should be done for Crohn’s disease

A

bedside: Faecal calprotectin (raised, but better for adults), stool culture
Blood:
- FBC: raised platelets, WCC, IDA
- ESR/CRP: raised
- Albumin: raised
- Iron studies: IDA
- Vit 12/folate: ?anaemia
- Plasma viscosity: raised

Other
- Upper intestinal endoscopy and biopsy
- AXR: narrowing, fissuring, bowel wall thickening, calcification
- CT abdomen: String sign of Kantor - fibrosis + strictures, ‘rose-thorn- fissures’
- Abdo US: ? osbtruction

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8
Q

What is found on endoscopy and biopsy for Crohn’s disease

A

Mucosal oedema and ulceration with Cobblestone mucosa, fistulae, abscesses
Patchy inflammation
Ulceration appears yellow, horizontal or longitudinal

Biopsy
Transmural chronic inflammation with macrophage infiltration, lymphocytes and plasma cells
Superficial AND deep ulcerations
Histology: non-caseating epithelioid cell granulomata

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9
Q

What is the management for Crohn’s disease

A

Urgent referral to paediatric gastroenterologist ± specialties for extra-intestinal S/S

MDT approach: easy access, dietician, paediatrician, GI
Induce and maintain remission
Monitor ferritin, B12, calcium and Vitamin D
Assess impact of symptoms on daily functioning (anxiety, depression)
Resources: Crohn’s and Colitis UK
Encourage stopping smoking
Assess risk of osteoporosis
Symptomatic treatment
Pre-immunological therapy vaccination

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10
Q

Describe induction of remission therapy for Crohn’s disease

A

First line: Steroids (oral/IV) prednisolone
Second line: Immunomodulators (oral/IV) azathioprine, mercaptopurine, methotrexate
Third line: Biological (IV) adalimumab, inflixmab, vedolizumab
If corticosteroids CI → aminosalicylates (mesalazine, sulfasalazine)

Nutritional therapy:
- Whole protein modular feeds (polymeric) for 6-8 weeks, excessively liquid
- May required NG tube if struggling to drink

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11
Q

Describe maintenance therapy for remission of Crohn’s disease

A

Immunomodulators e.g. azathioprine, Mercaptopurine, methotrexate
Amino salicylates e.g. mesalazine
Biological therapy (Anti-TNF antibodies) e.g. infliximab, adalimumab, vedolizumab

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12
Q

When is surgery for Crohn’s disease indicated and what is the aim

A

Failure of medical treatment
Failure to thrive
Complications: obstruction, fistulae, abscess

Aim: resection of the affected bowel + stoma formation

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13
Q

What are the complications of Crohn’s disease

A

Intestinal:
Obstruction
Haemorrhage
Toxic megacolon
Fistulae (bowel, bladder, vagina)
Abscess, sepsis
Perforation
Malignancy
Anaemia → IDA, B12 deficiency
Short-bowel syndrome

Extra-intestinal
Cholelithiasis
Primary sclerosis cholangitis
Hepatic steatosis, liver abscess, granulomatous hepatitis
Arthropathy
uveitis, episcleritis
Amyloidossis
Hypocalcaemia → osteoporosis

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14
Q

What is the prognosis for Crohn’s disease

A

Relapsing-remitting, life-long disease
Long term prognosis for Crohn’s beginning in childhood is GOOD
Most people live normal lives, despite occasionally relapsing

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15
Q

Define ulcerative colitis

A

Chronic relapsing and remitting inflammatory and ulcerating bowel disease that characteristically affects the rectum and colon mucosa

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16
Q

What is the pathophysiology of ulcerative colitis

A

Most cases arise in the rectum (proctitis)
Incompetent ileocaecal valve or backwash ileitis → may extend ~30cm proximally → terminal ileitis
90% of children have pancolitis
Bowel wall is thin/normal but may appear thick due to oedema, muscle hypertrophy and fat accumulation
Only involves the mucosa → crypt abscesses and depletion of goblet cell mucin
Inflammation of the crypts of Liebekuhn + abscesses
Ulcerated areas are covered by granulation tissue

17
Q

What are the risk factors for ulcerative colitis

A

Family history of IBD
HLA-B27 (Also associated with Ankylosing spondylitis)
Infection
NSAIDs
Non-smoker, former smoker

18
Q

What are the symptoms of ulcerative colitis

A

Rectal bleeding/mucous passage (intermittent, gross or occult)
Diarrhoea (Bloody, <4 a day)
Abdominal pain and tenderness (cramps, associated with tenesmus)
Arthritis and spondylitis
Failure to thrive, weight loss and growth retardation (<Crohn’s)
Fever
Constipation

19
Q

What are the signs of ulcerative colitis on examination

A

General: clubbing, pallor, dehydration
Obs: tachycardia
ENT: uveitis, episcleritis
Skin: erythema nodosum, pyoderma gangrenosum
Abdo: tenderness
PR: blood, mucous, tenderness

20
Q

What investigations should be done for ulcerative colitis

A

bedside: Faecal calprotectin (raised, but better for adults), stool culture (-ve culture, raised WCC)
Blood:
- FBC: raised platelets, WCC, IDA
- ESR/CRP: raised
- U&Es: hypokalaemic metabolic acidosis
- LFTs: ?PSC
- Albumin: raised
- Iron studies: IDA
- Vit 12/folate: ?anaemia

Other
- Ileocolonoscopy and upper endoscopy + biopsy
- AXR: ? toxic megacolon
- Double-contrast barium enema: lead pipe appearance

21
Q

What would be seen on ileocolonoscopy and biopsy for ulcerative colitis

A

Rectal involvement
Continuous uniform involvement
Loss of vascular marking
Diffuse erythema
Fistulas

Biopsy: Mucosal ulcers, crypt abscesses/loss/distortion, continuous distal disease, mucin depletion, basal plasmacytosis, diffuse mucosal atrophy of ONLY the mucosa and submucosa, absence of granulomata

22
Q

What are the severity classifications of ulcerative colitis

A

Mild: <4 stools daily ± blood, NO systemic disturbance, normal ESR/CRP
Moderate: 4-6 stools a day, minimal systemic disturbance
Severe: >6 stools a day, containing blood + systemic disturbance (fever, tachy, abdo tenderness, distension, anaemia, hypoalbuminaemia)

23
Q

How do you assess severity of ulcerative colitis

A

Paediatric Ulcerative Colitis Activity Index (PUCAI)
Markers of activity:
↓Hb
↓albumin
↑ESR/CRP
Diarrhoea frequency (<4 a day = mild,
>6 days = severe)
Bleeding
Fever

Flares: Truelove and Witts’ severity index

24
Q

What is the management for ulcerative colitis

A

Induction and maintenance therapy

Induction:
1. Mesalazine (5-ASA) rectal 1000mg once daily at night for 3-6 weeks AND mesalazine oral
- remission not achieved by 4 weeks → oral aminosalicylate
2. Beclometasone diproprionate PO

Maintain:
1. azathioprine OR mercaptopurine
2. Infliximab IV at 0, 2, 6 weeks (TNF-alpha inhibitor)
3. Vedolizumab or tofacitinib (integrin receptor antagonists) IV
4. Ciclosporin
5. Colectomy

25
Q

What is the management for non-fulminant acute ulcerative colitis

A

Non-fulminant
1. Rectal aminosalicylate (mesalazine)
2. Oral prednisolone
3. fulminant management

26
Q

What is the management for fulminant acute ulcerative colitis

A
  1. admit
  2. IV corticosteroids e.g. hydrocortisone
  3. IV fluids, no bowel rest
  4. ciclosporin or infliximab
  5. Colectomy if not responsing to corticosteoirds
27
Q

What are the complications of ulcerative colitis

A

Toxic megacolon
Colonic adenocarcinoma (3-5%)
Primary sclerosing cholangitis
Perforation
Infection
Massive LGI bleed
Benign stricture
Inflammatory pseudopolyps
Dysplasia-associated lesion or mass (DALM)
Extra-GI: Uveitis, renal calculi, arthropathy, sacroiliitis, ankylosing spondylitis, erythema nodosum, pyoderma gangrenosum, osteoporosis, amyloidosis

28
Q

What is the prognosis for ulcerative colitis

A

Ulcerative colitis is a lifelong condition, characterized by periods of relapse and remission with recurrent cycles of inflammation
Overall mortality does not appear to be increased, but may be in older patients and those who develop complications
Surgery appears to increase mortality
Most common cause of death is toxic megacolon

29
Q

What are the differentials for IBD

A

Irritable bowel syndrome
Gastroenteritis
Giardiasis
Meckel’s diverticulum
Abdominal migraine
Lactose intolerance
Coeliac’s disease
Malignancy
Anal fissure