Inflammatory Bowel Disease

Question 1

What is ulcerative colitis?

Answer 1

inflammation and ulceration of the colon and rectum - limited to the mucosal layer - pattern of inflammation is continuous

Question 2

What is Crohn’s disease?

Answer 2

transmural inflammation of segments of the GI tract - affects the entire GI tract from mouth to perianal area (80% of patients have small bowel involvement - distal ileum)

Question 3

What are distinctive features of Crohn’s (differentiate from UC)?

Answer 3

transmural (all layers of the bowel) inflammation with skip lesions (cobblestone appearance), fibrosis, strictures, fistulas, affects primarily the ileum and proximal colon (sparing of rectum), absence of gross bleeding, presence of perianal disease

Question 4

What is the mechanism of effect in IBD?

Answer 4

autoimmune disease - antigen initiates inflammation - tissue damage is from inappropriate sustained immune response

Question 5

Which blood studies should be ordered to diagnose IBD?

Answer 5

CBC - iron deficiency and blood loss, WBC - signs of toxic mega colon/perforation, erythrocyte sedimentation rate (ESR)/C-reactive protein (CRP) - chronic inflammation, serum electrolytes, protein levels - hypoalbumin due to poor nutrition and protein loss, serum iron/B12

Question 6

What diagnostic studies should be ordered to diagnose IBD?

Answer 6

stool cultures (pus, blood, mucus), colonoscopy (patients presenting primarily with diarrhea), imaging (patients presenting with abdominal pain)

Question 7

What nutritional therapy is recommended for IBD?

Answer 7

high calorie, high protein, low-residue, vitamin/iron supplements, decrease dairy (for those lactose intolerant), low-fat (fats may trigger diarrhea)

Question 8

What are pseudopolyps?

Answer 8

tongue-like projections into the bowel lumen

Question 9

What are potential complications of Crohn’s disease?

Answer 9

abscesses or fistula tracts between bowel and skin, bladder, rectum, or vagina; thromboembolism; arthritis; ankylosing spondylitis; osteoporosis; liver disease; skin lesions

Question 10

What are potential complications of UC?

Answer 10

severe bleeding/hemorrhage (anemia), perforation, fulminant colitis (> 10 stools/day, continous bleeding, abdominal pain, distension, fever, anorexia), toxic megacolon (colonic dilation greater than 5 cm)

Question 11

What are the endoscopic findings with Crohn’s disease?

Answer 11

aphthous ulcers (earliest lesions seen), large ulcers interspersed with normal mucosa, cobblestone appearance (nodular thickening and linear/serpigious ulcers), strictures due to fibrosis

Question 12

What are the common symptoms of UC?

Answer 12

bloody diarrhea, abdominal cramping, tenesmus (painful spasm of the anal sphincter with urgent desire to defecate but without significant production of feces), rectal bleeding, fever, weight loss, anemia/fatigue - due to iron deficiency, tachycardia, dehydration, discharge of blood and mucus, small/frequent bowel movements

Question 13

What are the common symptoms of Crohn’s disease?

Answer 13

depends on site of involvement - diarrhea (non-bloody), colicky abdominal pain, malabsorption, nutritional deficiencies, fatigue, weight loss, fever

Question 14

How is UC classified (Montreal classification)?

Answer 14

(1) mild (<4 semi-formed stools/day - with or without blood, normal ESR, crampy pain, tenesmus, constipation)
(2) moderate (4-5 stools/day, bleeding, fever, malaise, anorexia, abdominal pain)
(3) severe (bloody diarrhea >5 stools/day, severe cramps, systemic toxicity, fever, techycardia, anemia, elevated ESR > 30 mm/hr, rapid weight loss)

Question 15

What are the types of UC?

Answer 15

proctitis, proctosigmoiditis, distal colitis, extensive colitis, pancolitis

Question 16

Which pharmaceutical agents are used for UC?

Answer 16

aminosalicylates (sulfasalazine/Azulfidine - decreases GI inflammation) and corticosteroids (decrease inflammation)

Question 17

Which pharmaceutical agents are used for Crohn’s disease?

Answer 17

aminosalicylates (sulfasalazine/Azulfidine - decreases GI inflammation); antimicrobials (metronidazole [10 or 20 mg/kg/day] or the combination of metronidazole and ciprofloxacin [500 mg twice daily]); corticosteroids (decrease inflammation); immunosuppressants; biologic therapy (tumor necrosis factor inhibitors - infliximab); antidiarrheals

Question 18

What are the common extraintestinal symptoms associated with IBD?

Answer 18

arthritis, ankylosing spondylitis (inflammatory disease that can cause some of the vertebrae in your spine to fuse together), uveitis, episcleritis, iritis, erythema nodosum, pyoderma gangrenosum, primary sclerosing cholangitis (inflammation and scarring of the bile ducts - fatigue, pruritis, fevers, chills, night sweats, RUQ pain), fatty liver, autoimmune liver disease, venous/arterial thromboembolism, renal stones, osteoporosis, vitamin B12 deficiency

Question 19

What are common laboratory findings in UC?

Answer 19

anemia, elevated ESR (>30 mm/hr), low albumin, electrolyte abnormalities, elevated serum alkaline phosphatase concentration, elevated fecal calprotectin/lactoferrin

Question 20

What are common imaging (abdominal radiography) findings with UC?

Answer 20

constipation, mucosal thickening, “thumbprinting”

Question 21

What conditions should be ruled out with UC?

Answer 21

recent travel, recent antibiotic use, Hx of/risk factors for STIs, atherosclerotic disease, Hx of abdominal/pelvic radiation, Hx of NSAID/medication exposure, cytomegalovirus (immunocompromise)

Question 22

What are common endoscopic findings in UC?

Answer 22

loss of vascular markings, granularity of mucosa, petechiae, exudates, edema, erosions, touch friability, spontaneous bleeding, pseudopolyps

Question 23

What are some long-term complications of chronic UC?

Answer 23

strictures, dysplasia, colorectal cancer

Question 24

What are features diagnostic of Crohn’s?

Answer 24

perianal fistulae, abscess, or large (> 5 mm) skin tags; small bowel involvement; mucosal ulceration/cobblestoning/stricture/obstruction; ulceration/stenosis of the ileocecal valve; noncaseating (non-necrotizing) granulomas