Inflammatory Bowel Disease

Question 1

What is IBD?

Answer 1

A term used to describe two chronic GI inflammatory conditions

• Ulcerative colitis
• Chron’s disease

Question 2

What is the prevalence of Chron’s?

Answer 2

Prevalence 50/100,000 (M=F)

Incidence peaks at 15-30 AND in 60s

Question 3

What are the risk factors for Chron’s?

Answer 3

Poor diet
FH
Smoking
Altered immune states

Question 4

What is the underlying pathophysiology of Chron’s?

Answer 4

Inflammation can affect any part of GI tract
-most commonly terminal ileum/ascending colon
-skip lesions present
-narrowed bowel, thickened wall
-deep ulcers (Rose thorn, cobblestone appearance on CT)
Inflammation throughout all layers of bowel
-fistulae/stenosis common

Question 5

What are the clinical features of Chron’s?

Answer 5

Abdo pain
Diarrhoea (steatorrhoea in ileal disease, bloody in colonic)
Wt loss
Severe apthous ulceration of mouth (early sign)
Anal complications
Extra GI manifestations
Acute RIF pain/mass

Question 6

What are the anal complications of Chron’s?

Answer 6

Fissure
Fistula
Haemorrhoids
Skin tags
Abscesses

Question 7

What is the prevalence of UC?

Answer 7

100-200/100,000
Peaks at 15-30yrs AND at 60yrs
F>M

Question 8

What effect does smoking have on UC?

Answer 8

Protective

Question 9

What is the underlying pathophysiology of UC?

Answer 9

Inflammation starts in rectum, extends proximally along colon
-proctitis if affects rectum only
Inflammation of distal terminal ileum (backwash ileitis)
Inflammation only affects mucosa (excessively ulcerate)
-adjacent mucosa looks like inflam polyps

Question 10

What are the clinical features of UC?

Answer 10

Crampy lower abdo discomfort
Gradual onset diarrhoea (often bloody)
Urgency/tenesmus (if disease confined to rectum)
Extra-GI sx

Question 11

What is the histological difference b/w UC & Chron’s?

Answer 11

Chron’s - transmural inflammation, lymphoid hyperplasia, granulomas
UC - mucosal inflammation, crypt abscesses, goblet cell depletion

Question 12

What is indeterminate inflammatory colitis?

Answer 12

Diagnosis given when biopsy taken in acute phase, not always possible to distinguish UC/Chron’s

Question 13

What is fulminant IBD?

Answer 13

Most of mucosa lost, leaving only a few islands of normal tissue
Toxic dilatation can occur

Question 14

What investigations are appropriate in suspected IBD?

Answer 14

Bloods - FBC, U&Es, CRP/ESR, LFTs, Fe/B12
Stool studies - stool chart, MCS x3, calprotectin
AXR/CXR/CT
Endoscopy (+/- biopsy)

Question 15

What medical therapy is available for a mild acute Chron’s flare?

Answer 15

SYMPTOMATIC BUT SYSTEMICALLY WELL

• oral prednisolone
• tapered steroids

Question 16

What medical therapy is available for a severe acute Chron’s flare?

Answer 16

SYMPTOMATIC AND SYSTEMICALLY UNWELL

• admission (if raised temp, pulse, CPR/ESR, low albumin)
• IV hydrocortisone 100mg/6h
• make pt NBM w/ parenteral nutrition)
• high level monitoring
• thiopurines
• infliximab (if refractory)
• transfer to oral prednisolone

Question 17

What medical therapy is available for Chron’s maintenance?

Answer 17

1st Line = Thiopurines (azathiopurine/6-mercaptopurine)
2nd Line = Methotrexate
Oral metronidazole (if anal disease)

Question 18

What screening should always be done before prescribing Thiopurines?

Answer 18

TPMT deficiency

-unable to metabolise thiopurine

Question 19

What medical therapy is available for a mild/mod acute UC flare?

Answer 19

<6 MOTIONS/DAY, SYSTEMICALLY WELL

• topical aminosalicylate +/- oral mesalazine (proctitis/proctosigmoiditis)
• loading dose oral mesalazine +/- oral beclometasone/topical mesalazine (extensive disease)
• 2nd line = oral pred (if 4wks of sx)
• 3rd line = tacrolimus (after 2-4 more wks)
• 4th line = biological agents (specialist)

Question 20

What medical therapy is available for acute severe/fulminating UC?

Answer 20

MDT management (consider surgical intervention)
IV corticosteroids
SC heparin
Avoid anti-motility drugs (including opioids)
2nd line = IV ciclosporin (if sx worsen/no improvement w/i 72hrs steroids)
3rd line = biological agents (specialist)

Question 21

What are the indications for surgical treatment of acute severe/fulminating UC?

Answer 21

>8motions/day
Pyrexia
Tachycardia
Colonic dilatation
Low albumin
Low Hb
CRP >45

Question 22

What medical therapy is available for UC maintenance?

Answer 22

1st line = 5-ASA derivatives (topical for proctosigmoiditis, oral if left-sided
-sulfasaslazine, mesalazine
2nd line = oral thiopurines
-azathioprine/mercaptopurine

Question 23

What monitoring do UC pts require?

Answer 23

Monitoring appropriate to specific drug

Bone health monitoring

Question 24

What are the general complications of IBD?

Answer 24

Bowel perforation
Lower GI haemorrhage
Toxic dilatation (most common in UC)
Colonic carcinoma

Question 25

What are the features of toxic dilatation?

Answer 25

Persistent fever
Tachycardia
Loose-blood stained stool

Question 26

What investigations are appropriate in suspected toxic dilatation?

Answer 26

Falling albumin/K

AXR (dilated colon, >6cm, w/ mucosal islands)

Question 27

What is the management of toxic dilatation?

Answer 27

Perforation imminent

Surgical management

Question 28

What are the Chron’s specific complications?

Answer 28

Small bowel obstruction
Fistulae (10%)
Abscess formation
B12/Folate/Fe deficiencies

Question 29

What are the surgical options for Chron’s disease?

Answer 29

Never curative
Temporary ileostomies - ‘rest’ distal diseased bowel
Limited resection of worst areas

Question 30

What is short bowel syndrome?

Answer 30

Malabsorption if <1m small bowel remains

Question 31

What are the surgical options for UC?

Answer 31

Bowel resection curative
Emergency
-subtotal colectomy & end ileostomy
-proctolectomy & end ileostomy
Elective
-completion proctocolectomy & ileoanal pouch reconstruction
-colectomy & ileorectal anastomosis

Question 32

What are the extra colonic manifestations of IBD present during the active phase?

Answer 32

Eyes - conjunctivitis/episcleritis/iritis
Joints - arthralgia of large joints
Skin - erythema nodosum, pyoderma gangrenosum
VTE
Fatty liver

Question 33

What are the extra colonic manifestations of IBD unrelated to disease activity?

Answer 33

AI hepatitis
Gallstones
Renal calculi
1o sclerosing cholangitis (more common in UC)
Cholangiocarcinoma (UC)
Ankylosing spondylitis (HLA B27 +ve Chron’s)