Inflammatory bowel disease

Question 1

When does people typically develop IBD ?

Answer 1

before the age of 30.

Question 2

What is the pathophysiology of Crohn’s Disease?

Answer 2

Inappropriate immune response against the
gut flora causes Transmural chronic inflammation anywhere in GI tract with rectal sparing. The worse affection is seen at the terminal ilium. The lesion distribution is called skipped lesions as there are unaffected segments between affected. The disease has genetic etiology, but is not fully elucidated.

Question 3

What is the epidemiology of Crohn’s Disease?

Answer 3

6 / 100,000 cases in Ireland with biomodal distribution one 15 – 35yoa and another 50 – 70yoa.

Question 4

What are the GI manifestations of Crohn’s disease ?

Answer 4

• Crampy abdominal pain and Watery diarrhoea.
• Bloody diarrhoea may or may not be present.
• Evidence of malabsorption such as B12 deficiency and Steathorroea.
  *Aphthous ulcers, Odynophagia and Dysphagia.

Question 5

What are the Extraintestinal Manifestations of Crohn’s disease ?

Answer 5

– Arthritis
– Uveitis and Episcleritis
– Pyoderma gangrenous
– Erythema nodosum
– Kidney stones
– Gallstones

Question 6

What are the complications of Crohn’s disease ?

Answer 6

• Intestinal Strictures and fistulas
• Phlegmon which is the acute spreading soft tissue inflammation.
• Perianal abscesses
• Fissures
• Increased risk for colorectal cancer

Question 7

What is the utility of Calprotectin testing ?

Answer 7

It is a faecal protein marker of intestinal inflammation with low sensitivity and high specificity. It is Generally used to eliminate the likelihood of IBD in a patient presenting with chronic abdominal pain and diarrhoea. A positive test requires endoscopic follow-up

Question 8

What should be the approach to negative Calprotectin testing ?

Answer 8

If faecal calprotectin is “negative” in a patient
with low risk for IBD, Consider workup and treatment for IBS.

Question 9

What are the colonoscopy or endoscopic features of Crohn’s disease ?

Answer 9

– Skip lesions
– “Cobblestoning”

Question 10

What is the CT findings in Crohn’s disease ?

Answer 10

“Fat wrapping” or “Creeping fat sign” .

Question 11

What are the biopsy findings in Crohn’s disease ?

Answer 11

– Transmural involvement
– Non-caseating granuloma

Question 12

What is the Crohn’s disease sign in on barium enema?

Answer 12

String sign

Question 13

What is the algorithm for Crohn’s disease dx ?

Answer 13

https://www.aafp.org/content/dam/brand/aafp/pubs/afp/issues/2018/1201/p661-f1.jpg

Question 14

What are the four major classes of drugs used in Crohn’s disease ?

Answer 14

1.Oral 5-aminosalicylates (eg, sulfasalazine, mesalamine)
2.Glucocorticoids (eg, prednisone, budesonide)
3.Immunomodulators (eg, azathioprine, 6-mercaptopurine, methotrexate)
4.Biologic therapies (eg, infliximab, adalimumab, certolizumab pegol, natalizumab, vedolizumab,
ustekinumab)

Question 15

What is the Step-up medical therapy approach in Crohn’s disease ?

Answer 15

• Typically starts with less potent medications associated with fewer side effects
• More potent & potentially more toxic meds are used only if initial therapies ineffective.

Question 16

What is the top-down medical therapy approach in Crohn’s disease ?

Answer 16

• Starts with more potent therapies, such as biologic therapy and/or immunomodulators
• Done early in the course of the disease before patients become glucocorticoid dependent, and
  possibly even before they receive glucocorticoids

Question 17

What are the indications for surgery in Crohn’s disease ?

Answer 17

– Bowel perforation and abscess
– Gastrointestinal bleeding
– Symptomatic fibrotic stricture causing intestinal
obstruction or Enteric fistula
– Small bowel or colorectal cancer
– Refractory to medical therapy.
– Growth retardation in children with Crohn’s disease

Question 18

What is the pathophysiology of UC ?

Answer 18

Inappropriate immune response against the gut flor causing mucosal inflammation. The disease typically starts in rectum and spreads proximally through colon but NOT proximal to ileocecal valve. Smoking has a protective effect in UC as it is more common in non-smoker’s.

Question 19

What is the epidemiology of UC in Ireland ?

Answer 19

15/100,000 cases with bimodal distribution 15 to 35 years and 50 to 70 years.

Question 20

What are the intestinal manifestation of UC ?

Answer 20

– Abdominal pain
– Diarrhoea Episodic or chronic and can be Bloody non-bloody.
– Tenesmus

Question 21

What are the systemic symptoms during acute flare of UC ?

Answer 21

– Fever
– Malaise
– Anorexia

Question 22

What are the extra colonic manifestations of UC ?

Answer 22

– Iron deficiency anaemia
– Arthritis
– Uveitis or Episcleritis
– Primary Sclerosing Cholangitis
– Pyoderma gangrenosum
– Erythema nodosum

Question 23

What is the presentation of severe UC ?

Answer 23

• Severe GI bleeding
• Colitis
  – Continuous bleeding and > 10 stools per day
• Toxic megacolon
• Increased risk for colorectal cancer

Question 24

What is the diagnostic criteria for UC ?

Answer 24

1. Chronic diarrhoea x 4 weeks
2. Colonoscopy
   – Circumferential inflammation and Ulceration
   – Friable mucosa that bleeds during biopsy
3. Biopsy
   – Mucosa AND submucosa involvement
   – Crypt abscesses

Question 25

What is the remission induction therapy for Proctitis or proctosigmoiditis?

Answer 25

*Topical mesalamine (suppository or enema); if needed, one of the following may be added:
– Topical or oral glucocorticoid
– Oral 5-ASA

Question 26

What is the remission induction therapy for extensive UC ?

Answer 26

Topical mesalamine + oral 5-ASA; if unsuccessful,
Oral 5-ASA + topical glucocorticoid

Question 27

When is maintenance therapy required in UC ?

Answer 27

• Provided to every patient with UC unless disease limited to ulcerative proctitis with ≤ 1 flare per year.
• Choice of maintenance therapy depends on which drug induced remission.
  *General recommendation is to continue that drug at lowest possible dose.

Question 28

What is the pathophysiology of toxic megalocolon in UC ?

Answer 28

Inflammation increases NO synthesis by macrophages and smooth muscle cells leading to dilation of the colon and colonic muscular paralysis.

Question 29

What is the clinical presentation of toxic megalocolon ?

Answer 29

It occurs early after diagnosis with repeated episodes in the first few years. Patients presents with severe bloody diarrhoea, abdominal pain and distention. They may often have malase, tachicardia, alterd mental status, fever and hypotension.

Question 30

What is the diagnostic criteria for toxic megalocolon ?

Answer 30

• Radiographic evidence of colonic
  dilation (diameter > 6 cm) .
• PLUS at least three of the following: Fever >38ºC, Heart rate >120 beats/min, Neutrophilic leucocytosis > 10,500/microL, and Anaemia.
• PLUS at least one of the following: Dehydration, Altered sensorium, Electrolyte disturbance and Hypotension

Question 31

What is the treatment of toxic megalocolon ?

Answer 31

– ICU admission
– Bowel rest followed by enteral
feeding and Antibiotics
– Stop all meds that can impede
colonic motility (e.g., opiates)
– Intermittent rolling or knee-elbow position to expel gas