Inflammatory Bowel Disease Flashcards by Izzie Setford

What is ulcerative colitis?

Diffuse mucosal inflammation limited to the colon

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What is ulcerative colitis defined by?

Distal colitis limited to rectum (proctitis) or rectum and sigmoid (proctosigmoiditis)
Left sided colitis to splenic flexure
Extensive colitis to hepatic flexure
Pancolitis

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What is Crohn’s disease?

Patchy, transmural inflammation affecting any part of the GI tract

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What is Crohn’s disease defined by?

Location - colonic, terminal ileum, perianal

Pattern of disease - inflammation, stricturing and fistulating

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Which gender is more likely to get which disease?

Slight female predominance - Crohn’s

Slight male predominance - ulcerative colitis

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Briefly describe the epidemiology of both diseases.

Diseases of young people

10-40 years, peak incidence
15% present over the age of 60

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What is the pathogenesis of both diseases?

Unknown 
Host response to environmental triggers in genetically susceptible individuals 
Genetic factors implicated
Smoking
- increases risk of Crohn's
- reduces risk of ulcerative colitis

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What would you ask for in the history when you suspect an IBD?

Stool frequency, consistency, urgency, blood
Abdominal pain, malaise, fever
Weight loss
Extraintestinal symptoms (joint, eyes and skin)
Travel
Family history
Smoking (passive)

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What skin conditions can be associated with IBD?

Erythema nodosum (shins commonly)
Pyoderma gangrenosum
- mostly UC

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What eye conditions can someone with IBD get?

Iritis
Uveitis
Dry eyes
Keratopathy

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What mouth problems can someone with IBD get?

Mouth ulcers
Cracked/fissuring lips
- particularly Crohn’s

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What do you expect to see on perineal examination in someone with Crohn’s disease?

Fistula’s
Stricturing
Skin tags
Peri-anal abscesses

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If you suspect someone has IBD, what initial investigations should you do?

FBC, ESR
U&amp;Es, LFTs
CRPs
Stool cultures for C.Diff toxin
Faecal calprotectin 
- non-specific, but if low, it exclude inflammation
Abdominal X-Ray

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If you suspect someone has IBD, what in depth investigations should you do?

Rigid sigmoidoscopy 
Colonoscopy - used most
Avoid endoscopic examination in severe disease (bad symptoms)
Small bowel radiology/MRI
Labelled WCC scanning

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Describe the colon appearance in ulcerative colitis.

Granular mucosa
Not much ulceration
Lack of definition of the blood vessels
Contact bleeding 
Luminal pus

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Describe the appearance of the intestines in Crohn’s disease.

Ulceration
- fissuring ulceration
Patchy involvement of the colon or ileum
- not the rectum
Cobblestone appearance 
- areas of ulceration separated by narrow areas of healthy tissue

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What are the treatments for ulcerative colitis?

Corticosteriods
Thiopurines
Biologics
5ASAs if needed

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What are the treatments for Crohn’s disease?

Corticosteriods
Thiopurines
Biologics
Methotexate
Immune modulating diet

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What corticosteriods are used for IBD treatment?

Glucocorticoids

IV hydrocortisone
IV methyloprednisolone
oral prednisolone
budesonide
beclometasone

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How are steriods given and why in IBD?

They are given high dose at first to rapidly induce remission, then they are put on a slowly reducing course, to allow mucosal healing

because steroids can’t maintain remission
prednisolone 40mg/day for 1 week
reduce by 5mg/week

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What are the possible side effects of steroid use?

Immunosuppression
Impaired glucose tolerance 
Osteoporosis
Weight gain
Cushingoid appearance

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What is 5ASAs?

Study These Flashcards

Mesalazine
- 5-aminosalicylate (5ASA)
Different methods of release
- pH dependent release/renin coated
- time controlled release
- delivery by carrier molecules 
Can be effective as a topical therapy for distal disease
- suppositories and enemas
- good for symptomatic proctitis

What are aminosalicylates?

Study These Flashcards

Anti-inflammatory product used to treat ulcerative colitis

What is the function of aminosalicylates?

Study These Flashcards

Induction of remission in mild/moderate ulcerative colitis
Maintenance of remission
Efficacy relies on compliance
Maintenance therapy reduces cancer risk

What are the benefits of high doses of aminosalicylates?

Higher remission rates | Better mucosal healing

What are the side effects of

``` Renal impairment (interstitial nephritis, nephrotic syndrome) - rare and idiosynchratic Sulphasalazine (related to mesalazine) - commonly badly tolerated Intolerance ```

What are thiopurines and when are they used?

Immunosuppressant Steroid sparing agent - used when patients require 2 or more steroid course a year - have experienced relapse on less than 15mg prednisolone

What are thiopurines used for?

Maintenance therapy for ulcerative colitis and Crohn's disease Post-op prophylaxis in complicated Crohn's

Describe the pathophysiology of thiopurines.

Purine anti-metabolites Immune modulting drugs Prevent T-cell clonal expansion in response to an antigenic stimuli and allows T-cell apoptosis

Name some thiopruines.

Azathioprine | Mercaptopurine

What is TMPT?

It's an enzyme that metabolises mercaptopurine to one of it's metabolities Genetically determined - reduced levels, reduces effect of immunosuppession

What are the metabolites of mercaptopurine measured in therapeutic drug monitoring?

MeMP - methylmercaptopurine - levels predict risk of a drug induced hepatitis 6TS - thioguanine nucleotide - active metabolite, used for adjusting levels and checking compliance

What are the common side effects of Thiopurines?

``` Leucopenia Nausea, vomiting (1 in 5) Arthralgia Pancreatitis Hepatitis (reversible) Squamous skin cancers - be careful in the sun, use sun cream Haematological malignancy (slight) ```

What is methotrexate?

Anti-metabolite Folate scavenger - need folate supplements Used in Crohn's when they can't tolerate Thiopurines

What are the side effects of methorextare?

``` GI upset Hepatotoxicity Immunosuppression Sepsis Pulmonary fibrosis Teratogenic ```

When would Infliximab be used?

Severe or fistulating Crohn's disease Rescue acute severe ulcerative colitis Moderate severe ulcerative colitis that doesn't respond to other treatment

What is Infliximab?

A mouse anti-TNF monoclonal antiboidy - prevents macrophage activation - switches off inflammatory process in the mucosa

How is Infliximab administered?

Loading regime at 0/2/6 weeks 2 month IV infusions thereafter - maintenance therapy

What are the complications associated with Infliximab?

The body may recognise it as foreign (mouse Ab) and produce antibodies - loss of efficacy - allergic reactions

What is Adalumimab?

Humanised anti-TNF alpha monoclonal antibody

What is the benefit of Adalumimab?

People are less likely to have a reaction compared to Infliximab - humanised

What is Golimumab?

Humanised anti-TNF alpha

What is Golimumab used for?

Moderate to severe ulcerative colitis | - less so for Crohn's

With all anti-TNF drugs, what are the complications?

``` Infection risk - reactivation of TB - reactivation of Hep B Neurological - incidence of MS - progressive multifocal leucoencephalopathy Malignancy - possible increased lymphoma risk ```

What is Vedoluzimab?

A new biologic Anti-adhesion - binds integrin (a lymphocyte adhesion molecule)

What is acute severe colitis?

Patients who fail to respond to optimal treatment with 5ASA/prednisolone or with severe disease warrant hospital admission

How is acute severe colitis?

IV steroid therapy Liaison with colorectal surgeon - stool frequency >8 day - or CRP >45 on day 3 predicts colectomy in 85%

What obs/blood results suggest acute severe colitis?

``` >6 bowel movements per day Frequent PR blood Raised temperature pulse >90 < 10 Hb - anaemia ESR >30 ```

What investigations should you do if someone has suspected acute severe colitis?

``` Daily FBCs, ESR, U&Es and CRP Stool cultures - C.Diff - high incidence of infection Daily abdominal X-Ray Sigmoidoscopy - if it is a new presentation ```

How is acute severe colitis treated?

Prophylactic LMWH heparin - high risk of DVTs IV hydrocortisone 100mg or methylprednisolone 30mg Treat for 72 hours and if they improve, they can be given oral steroids - if they don't they need rescue therapy

What is rescue therapy in acute severe colitis?

Ciclosporin IV Infliximab single dose Surgery - if medical therapy doesn't work

What is the surgery done in ulcerative colitis?

Curative | Ileo-anal pouch (don't need a stoma) or ileostomy

When is surgery done in Crohn's disease?

Indicated for stricturing, perforation, fistulising disease | Sparing

Inflammatory Bowel Disease Flashcards

(53 cards)