Case 12- SAP

Question 1

What is included in IBD (inflammatory bowel disease)

Answer 1

Ulcerative Colitis (UC) and Crohn’s disease

Question 2

Inflammatory bowel disease

Answer 2

A chronic inflammatory disorder of the intestinal tract with a remitting and relapsing course

Question 3

Summary of differences- Crohn’s

Answer 3

1) Involves any part of the GI
2) Disease is patchy- skip lesions
3) Strictures are common
4) Cobblestone appearance
5) Can lead to fistula
6) Unusual to get Toxic megacolon
7) Ulcers are fissuring
8) Transmural lymphocytes
9) Marked fibrosis which leads to strictures
10) Granulomas (round collection of Macrophages)
11) Malignancy potential is low

Question 4

Summary of differences- UC

Answer 4

1) Colon only
2) Diffuse and continuous
3) From the anus upwards
4) Strictures are rare
5) No fistula
6) More likely to get toxic megacolon
7) Pseudopolyps- normal mucosa that looks like mushrooms
8) The ulceration is undermining- not that deep
9) Mild fibrosis
10) No granulomas
11) High malignancy potential

Question 5

UC (Ulcerative colitis

Answer 5

A diffuse chronic condition which repeated episodes of inflammation in the rectum and colon cause ulcers and irritation

Question 6

Pancolitis

Answer 6

Entire colon affected

Question 7

Distal colitis

Answer 7

Only descending colon and rectum affected

Question 8

Proctitis

Answer 8

Only rectum affected

Question 9

Causes of IBD

Answer 9

Genetic factors- family history, more important in Crohn’s than UC
• Protective lifestyle factors- breastfeeding, smoking (in UC)
• Lifestyle risk factors- adverse life events, stress, deression
Smoking (in Crohns)
GI infection
Excessive sanitation

Question 10

Crohn’s disease

Answer 10

A discontinuous inflammatory condition that affects any part of the GI tract, but mainly affects the ileum, colon and perianal region. There will be skip lesions i.e. part of the bowel which is healthy in-between parts with inflammation

Question 11

Pathology of IBD

Answer 11

• Decreased gut bacterial diversity
• Inappropriate response of mucosal immune system to flora and luminal antigens
• Triggers an inflammatory response

Question 12

Examination findings of someone with IBD

Answer 12

End of bed = weight loss, pain, fever, anaemia
Finger clubbing
Vitamin deficiencies
Ulcers
Bloating
PR examination could see blood/soreness

Question 13

Lab diagnostics for IBD

Answer 13

FBC = Increased WCC
Hb = Low due to anaemia of chronic disease
CRP = high
Faecal calprotectin = high, neutrophil migration to intestinal mucosa

Question 14

Main regions which Crohn’s affects

Answer 14

The ileum, colon and perianal regions

Question 15

History of someone presenting with IBD

Answer 15

Diarrhoea, often bloody (>6 weeks)
Abdominal pain
Fever
Perianal lesions
Weight loss
Failure to thrive
Arthritis
Epsicleritis
Clubbing

Question 16

Microscopic pathology changes in Crohn’s disease

Answer 16

Lymphoid aggregates i.e. lymphocyte patches proceeding all the way through the tissues as it is transmural
Fibrosis
Transmural inflammation- inflammation extends through all layers of the bowel wall
Granulomas i.e. large groups of macrophages
Fissuring ulcers - resulting in the loss of the mucosa - resulting in granulation tissue instead - leading to blood due to haemorrhaging

Question 17

Microscopic pathology changes in UC

Answer 17

Pseudopolyps
Gland destruction - forming crypt abscesses i.e. collection of neutrophils on the gland
Crypts can get worse and become fibrous tissue
Vascular congestion
Loss of mucosal folds

Question 18

Macroscopic changes in Crohn’s disease

Answer 18

Cobblestoning i.e. ulcers separated by normal mucosa
Ulcers in the mouth
Skip lesions as the pathology is discontinuous
The affected areas - commonly the ileum, colon and anus - will be red and inflamed

Question 19

Complications of Crohn’s disease

Answer 19

Strictures- wall of the affected area thickens due to fibrosis
Fistulas- abnormal connections between 2 organs, because the bowel is inflamed it presses on and breaks down nearby structures i.e. rectum connects to skin. Increases infection risk
Malabsorption- fistulas can cause protein loss. B12 deficiencies. Problems with bile salts, less fat absorption
Perforation- infection is transmural so bowel contents can enter the sterile abdominal cavity

Question 20

Macroscopic changes in UC

Answer 20

General continuous inflammation of the affected areas - red and friable
No cobblestones as ulceration is everywhere
Pseudopolyps i.e. mucosa trying to regenerate
Undermining ulceration
Colon may be shortened with a wall of normal thickness

Question 21

Complications of UC

Answer 21

Toxic megacolon- dilation of large bowel, colon becomes paralysed and is unable to move air/faecal matter. High risk of perforation
Dysplasia- precursor to cancer, abnormal development of cells
Cancer- doubles the risk of colonic carcinoma

Question 22

Differential diagnosis for IBD

Answer 22

• Infectious gastroenteritis- history tends to be more acute, present with diarrhoea and abdominal pain
• IBS- diagnosed through exclusion. Presents with constipation and diarrhoea, Mucus PR is common. This history is chronic (>6 weeks). The abdominal pain is made better by defecation and worse with stress and other triggers.
• Appendicitis- acute onset abdominal pain. Anorexia, fever and tachycardia. Often adolescents and young age
• Coeliac disease- presents with diarrhea, weight loss, anorexia and failure to thrive.

Question 23

NICE first line treatment for IBS

Answer 23

Laxatives for constipation - not lactulose (worsens cramps)
Loperamide for diarrhoea
Antispasmodic agents
Treat alongside dietary and lifestyle changes not just pharmacological

Question 24

Antispasmodic drugs

Answer 24

E.g. atropine sulfare, hyoscine butylbromide or peppermint

Competitive blockers of muscarinic receptors
Therefore blocking the effect of acetlycholine on the enteric plexus
Directly causing relaxation of smooth muscle wall
Decreases the intensity of cramps and contractions

Side effects- dry mouth, blurred vision and cardiac arrhythmias

Question 25

NICE guidelines second line treatment for IBS

Answer 25

Increase laxative intensity. If severe constipation is lasting >1y give linaclotide but only after you have tried other laxatives ``` Can give TCAs / SSRIs These block brain-gut pain signals Can help regulate normal bowel movement Only very low dose Only if no response to other drugs ```

Question 26

NICE guidelines for third line IBS

Answer 26

Eluxadoline Only for specialist use It is a opioid agonist which normalises GI motility

Question 27

NICE guidelines for UC

Answer 27

Use aminosalicylate acids (5-ASA) i.e. Sulfasalazine Use topically or combine topical and oral Oral on its own is much less effective Use oral prednisolone or topical corticosteroids for contraindications Stage 2: Add oral prednisolone as well as the topical 5-ASA Can add a biological agent e.g. infliximab or adalimumab These are monoclonal antibodies which target TNF

Question 28

NICE guidelines for CD

Answer 28

Glucocorticosteroid e.g. prednisolone, methylprednisolone Or 5-ASA treatment if not severe If 2 or more flare ups occur in a year: Immunosuppressant drugs e.g. azathioprine or mercaptopurine, use Methotrexate if patients cant tolerate these drugs Could also try biological agents e.g. infliximab (TNF monoclonal antibodies)

Question 29

Aminosalicylate (5-ASA)

Answer 29

E.g. sulfasalazine, mesalazine Help maintain or induce remission in UC and CD More effective in UC Oral or topically rectal administration If oral we need a pH sensitive coating so they dont get digested before they reach the large intestine Side effects- cough, Megaloblastic anaemia and Proteinuria

Question 30

Sulfasalazine

Answer 30

Active component is 5-ASA This is the only component not absorbed but utilised Reduces inflammation by removing free radicals Removes excess prostaglandins and leukocytes Decreases neutrophil chemotaxis Side effects include diarrhoea and interstitial nephritis

Question 31

Glucocorticoids

Answer 31

E.g. prednisolone Potent anti-inflammatory agents Help induce remission in CD / UC Administered orally or by enema/suppository Not used for long term treatment because of side effects Stimulate synthesis of anti-inflammatory proteins

Question 32

Purgative drugs

Answer 32

Increase GI tract motility Therefore accelerating food passage Examples are laxatives

Question 33

Antidiarrheal drugs

Answer 33

Decrease GI tract motility

Question 34

Loperamide mechanism of action

Answer 34

Antimotility agent, helping decrease diarrhoea It is an opioid-receptor agonist on u-opioid receptors Decreases activity of the myenteric plexus Decreasing smooth muscle tone on the intestinal wall Therefore decreasing motility Allows time for more water to be absorbed from the bowel contents

Question 35

Side effects of Loperamide

Answer 35

Dizziness, headache, nausea, flatulence and constipation

Question 36

Racedotril

Answer 36

Antidiarrhoeal drug acting as a enkephalinase inhibitor Prevents the breakdown of opioids Therefore opioid levels increase in the myenteric plexus Has an anti-secretory effect i.e. prevents secretion of fluid and electrolytes in to the intestine Doesn't modify GI transit time

Question 37

Methylcellulose mechanism of action

Answer 37

``` Laxative drug Cant be digested so remains in the GI tract Attracts lots of water in to the colon Producing a softer and bulkier stool This stimulates peristalsis Be careful of dehydration however ```

Question 38

Stimulant laxative drugs

Answer 38

E.g. bisacodyl, senna Stimulate enteric nerves to increase peristalsis Increases electrolyte and water secretion by intestinal mucosa Helping with constipation

Question 39

Linalclotide

Answer 39

It works as a monoclonal antibody against tumour necrosis factors. The drug at therapeutic levels should be limited to the GIT lumen and not be absorbed, so wont be detected in the systemic circulation.

Question 40

Why is consent important

Answer 40

Upholds autonomy (self-determination_

Question 41

Different forms of consent

Answer 41

* Implied consent- suggestive conduct i.e. holding out your arm for an injection. Problem different actions can be interpreted differently by different people * Verbal consent * Written consent- ensures patient has considered everything, important legally. Used in surgery

Question 42

3 legal requirements for consent

Answer 42

* Has capacity. * Has adequate understanding. * Gives consent without being coerced (voluntary).

Question 43

Bolam test

Answer 43

Where a body of responsible medical professionals decide whether they think you did the right thing. For example, did you provide enough information about risk factors

Question 44

The Montgmonery test

Answer 44

States that if a reasonable person would attach significance to the risk the doctor should make the patient aware of it.

Question 45

Gillick competence

Answer 45

Children under 16 are allowed to give consent if they are Gillick competent, meaning they have sufficient understanding and understand the risks involved

Question 46

Criteria for using children in research

Answer 46

* You cant gain the information through using adults. * It is approved by an ethics committee. * The participant has given consent or consent has been given from the parents, a doctor may consent in emergency situations. The child should not seem to object to the parents consent.

Question 47

Doctor autonomy

Answer 47

If a patient asks for a procedure that you do not think will be beneficial you can refuse the treatment. However, you must respect a patients decision to refuse treatment even if you disagree.

Question 48

When would you be able to bypass parent consent

Answer 48

You can still go ahead by referring to the Children act of 1989 which states that child welfare is paramount. But you would need to go to court and get permission. In an emergency situation you can provide the life saving treatment but you must be prepared to defend it in court.