Inflammatory Bowel Disease Flashcards
Define Crohn’s disease
Chronic granulomatous transmural inflammation of any part of the GI tract, mainly the distal ileum and proximal colon
What are the structural features of Crohn’s disease
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
What are the suggested causes for and risk factors of Crohn’s disease
Genetic: CARD15, IL-23
RF:
White ethnicity
15-40 or 60-80
FHx IBD
Environmental: smoking, OCP, high refined sugar
What are the symptoms of Crohn’s disease
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
What are the signs of Crohn’s disease on examination
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
What investigations should be done for Crohn’s disease
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
What is found on endoscopy and biopsy for Crohn’s disease
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
What is the management for Crohn’s disease
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
Describe induction of remission therapy for Crohn’s disease
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
Describe maintenance therapy for remission of Crohn’s disease
Immunomodulators e.g. azathioprine, Mercaptopurine, methotrexate
Amino salicylates e.g. mesalazine
Biological therapy (Anti-TNF antibodies) e.g. infliximab, adalimumab, vedolizumab
When is surgery for Crohn’s disease indicated and what is the aim
Failure of medical treatment
Failure to thrive
Complications: obstruction, fistulae, abscess
Aim: resection of the affected bowel + stoma formation
What are the complications of Crohn’s disease
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
What is the prognosis for Crohn’s disease
Relapsing-remitting, life-long disease
Long term prognosis for Crohn’s beginning in childhood is GOOD
Most people live normal lives, despite occasionally relapsing
Define ulcerative colitis
Chronic relapsing and remitting inflammatory and ulcerating bowel disease that characteristically affects the rectum and colon mucosa
What is the pathophysiology of ulcerative colitis
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