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Clinical Topic 1: Inflammatory Bowel Disease Flashcards

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1
Q

Genetic, Microbial and environment factors associated the development of Crohn’s Disease?

A

Genetic: Family history of First degree relative with Crohn’s

Microbial:
TB, Listeria, Pseudomonas

Environmental:
- Smoking
- Roaccutane
- Increased animal protein intake
- Reduced vegetable intake
- NSAIDs
- Appendectomy
- High sugar/fat diet
- Stress
- Breastfeeding
- Good hygeine

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2
Q

What are the Gastrointestinal and Systemic manifestations of Crohns disease?

A

Gastrointestinal: aphthous ulcers, diarrhoea, RLQ abdominal pain, anal/anorectal/enteral fistulas, strictures

Systemic: Failure to thrive, weight loss, loss of appetite

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3
Q

What might you see on ileocolonscopy of a Crohn’s Disease patient’s GI tract?

A

Patchy inflammation, skip lesions, cobblestone appearance, granulomas of immune cells, rectal sparing

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4
Q

What is the epidemiology of Crohn’s Disease?

A

Male = female
Most common in Europeans, Ashkenazi Jews
Bimodal age distribution - 20 and 50 years old

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5
Q

What steroid might be given orally to patients with Crohn’s Disease? What is it given with?

A

Topical budesonide
Calcium

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6
Q

What might you see on blood test results with a Crohn’s patient?

A

Raised WCC, CRP, ESR, Plts = inflammation

Reduced B12 = terminal ileum disease

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7
Q

What is the stool marker for IBD?

A

Faecal Calprotectin

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8
Q

What might you see on abdominal X-ray for a patient with Crohn’s Disease or Ulcerative Colitis?

A

“Thumb printing” - colon thickening

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9
Q

What AXR findings are seen in Ulcerative colitis only?

A

Mucosal islands (pseudopolyps in caecum)

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10
Q

What surgery can be offered to patients with Crohn’s?

A

Generally not a resection, due to <1 year recurrence of CD, however stricturoplasty may be offered to remove strictures

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11
Q

What are Gastrointestinal Symptoms of Ulcerative Colitis?

A

LLQ abdominal pain, mucoid and bloody diarrhoea, tenesmus

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12
Q

What are the general medication options for patients with IBD?

A

Steroids i.e. Prednisolone or Budenoside
5-ASA drugs i.e. Mesalazine
Thiopurines i.e. Azathiopurine or 6-Mercaptopurine
Antifolates i.e. Methotrexate
Ciclosporins
Biologics i.e. Infliximab, Adalimumab, Vedolizumab

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13
Q

What is the genetic mutation associated with Ulcerative Colitis?

A

HLA-DR103

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14
Q

An appendectomy is protective for which IBD?

A

Ulcerative Colitis

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15
Q

What is p-ANCA?

A

Antibodies associated with Ulcerative Colitis

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16
Q

What are the complications of Ulcerative Colitis?

A
  • Thromboembolism
  • Toxic megacolon (>6cm in diameter)
  • Bowel perforation
  • Colorectal bleeding
  • Colorectal carcinoma
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17
Q

Fistulas are common in which IBD?

A

Crohn’s

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18
Q

Pseudopolyps are common in which IBD?

A

Ulcerative Colitis

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19
Q

Why is colorectal carcinoma indicated in IBD? What are such patients then offered?

A

Increased risk of dysplasia in the colon, hence are offered 1-5 year colonoscopy surveillance

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20
Q

What endoscopic surveillance is offered to IBD patients with an increased risk of colorectal carcinoma?

A

Pancolonic Chromoendoscopy: Indigo Carmine dye is sprayed in the colon and dysplasia is highlighted. Better than biopsy

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21
Q

What are the two types of Microscopic Colitis?

A

Lymphocytic colitis

Collagenous colitis

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22
Q

What is Loperamide and what is the MoA?

A

Anti-diarrhoeal agent
u-Opiod receptor agonist, acting on the myenteric plexus of the large intestine, decreasing its activity. This increases transit time for water re-absorption

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23
Q

What abnormalities might you find on LFTs in patients with IBD?

A

Raised GGT and ALP, suggestive of Primary Schlerosing Cholangitis

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24
Q

What might you see on colonoscopy of an Ulcerative Colitis patient’s GI tract?

A

Continous mucosal inflammation Pseudopolyps

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25
Rose thorn ulcers are common in which IBD?
Crohn's Disease
26
Crypt abscesses are common in which IBD?
Ulcerative Colitis
27
What is defined as mild, moderate and severe Ulcerative Colitis?
Mild: < 4 stools/day, little blood Moderate: 4-6 stools/day, varied blood, no systemic upset Severe: >6 bloody stools, systemic upset
28
What is the treatment to induce remission in Ulcerative Colitis patients?
Rectal/oral aminosalicyclates Topical steroids
29
What is the first and second-line treatment to induce remission in Crohn's Disease patients?
First line: Oral, topical, IV steroids | Second line: Aminosalicyclates
30
What is the first line treatment to maintain remission in Ulcerative Colitis patients?
Oral aminosalicyclates
31
What is the first and second-line treatment to maintain remission in Crohn's Disease patients?
First line: Azathioprine / 6-Mercaptopurine | Second line: MTX
32
Which has a higher prevalence, Crohn's or Ulcerative Colitis?
Ulcerative Colitis
33
Can the diagnoses of UC and Crohn's overlap?
Yes - Colitis of Undetermined Type and Aetiology (CUTE)
34
What is IBD?
Chronic relapsing inflammatory diseases of the GI tract
35
What's the peak onset of IBD?
20-40 years 1/4 diagnosed before 18.
36
Which part of the GI tract does Crohn's disease commonly affect?
Terminal ileum + ascending colon - 40% Small intestine/colon only - 20%
37
Which part of the colon does UC most commonly affect?
Rectum/rectum + sigmoid colon - 40-50%
38
Difference between inflammation of Crohn's disease and UC?
Crohn's - patchy inflammation throughout small and large bowel UC - continuous, uniform inflammation of the large bowel Crohn's - Transmural disease potentially leading to fistula formation UC - disease of mucosa only
39
How can you determine the severity of a UC flare?
Truelove and Witts severity index
40
What are the layers of the intestinal wall?
Mucosa Submucosa Muscularis Serosa
41
Histological findings with Crohn's and UC?
Crohn's - granulomas and goblet cells UC - crypt abscesses
42
Signs and symptoms of Crohn's disease?
Signs: Children have poor growth, delayed puberty, malnutrition RIF tenderness RIF mass PR exam - anal tags, fistulas, fissures, perianal abscess Symptoms: Non bloody Diarrhoea Abdominal pain Rectal bleeding Fatigue Weight loss
43
Investigations for Crohns disease?
Low Hb, low albumin high ESR, high CRP, high WCC, high PLT Abnormal LFTs Blood cultures if septic Serology pANCA (will be negative) Stool cultures including for C. diff Stool microscopy for parasites Faecal calprotectin and lactoferrin will be high in active disease Colonoscopy, OGD, X ray, CTAP/CT enterography, MRI enterography, perianal MRI, endoanal USS Small bowel visualisation: VCE, US, radionuclide scans
44
Management of Crohns disease?
Symptom management: - Diarrhoea - avoid loperamide/codeine unless allowed by doctor as risk of obstruction - Diarrhoea due to bile acid malabsorption - bile salt sequestrants - Anaemia - B12, folate, iron supplements - STOP SMOKING Inducing remission: - Oral prednisolone 30-60mg OD / IV hydrocortisone 100mg QDS - Oral budesonide 9mg OD if mild or moderate ileocaecal disease - Enteral nutrition Maintenance of remission: - Azathioprine, 6MP, methotrexate, mycophenolate mofetil For perianal disease: - Ciprofloxacin and metronidazole - Azathioprine Biologics Surgery
45
Indications of surgery for Crohns disease?
Failure of medical treatment Complications Failure to thrive in children Perianal sepsis
46
How many people in Crohns will require surgery during their lifetime?
80%
47
Symptoms and signs of Ulcerative colitis?
Symptoms: Bloody, mucoid diarrhoea Loose stools > 6 weeks Lower abdominal pain Aphthous ulcers Fatigue Signs: No specific signs Tender abdomen Distended abdomen Tachycardia and pyrexia PR exam - blood Rigid sigmoidoscopy shows inflamed, bleeding , friable mucosa
48
Which feature of UC is strongly associated with poor quality of life?
Fatigue
49
What is toxic megacolon?
Emergency where colon diameter >6cm Potentially leading to perforation and 25% mortality rate
50
Symptoms of proctitis?
Tenesmus Urgency Frequent passage of blood/mucus
51
Symptoms of pancolitis/left sided colitis?
10-20 liquid stool per day Nocturnal urgency Incontinence
52
Montreal classification E1 - procitis E2 - left sided colitis E3 - pancolitis
53
Investigations for Ulcerative Colitis?
Bloods: High ESR, CRP, WCC, PLT Low Hb (iron deficiency), albumin LFT abnormalities Serology - pANCA POSITIVE Stool cultures incl. C diff toxin assay Stool microscopy for parasites, e.g. amoebiasis Faecal calprotectin will be high in active disease Colonoscopy with mucosal biopsy - GOLD STANDARD Flexible sigmoidoscopy Abdominal x ray if severe attacks
54
When do you measure faecal calprotectin?
Differentiating IBD from IBS Monitoring disease activity and treatment guidance Prediction of relapse and post-op recurrence
55
What criteria is used to determine severity of inflammation in UC on endoscopy?
Mayo Endoscopy Score 0 (normal/inactive) = no findings 1 = MILD. Erythema, decreased vascular pattern, mild friability 2 = MODERATE. Marked erythema, absent vascular pattern, friability, erosions 3 = SEVERE. Spontaneous bleeding, ulceration
56
What is the management of ulcerative colitis?
IBD clinics and multidisciplinary team Inducing remission... For proctitis: RECTAL 5-ASA suppositories, topical steroids, oral 5-ASA. For left sided colitis: Topical 5-ASA enemas, oral 5-ASA For extensive colitis: oral 5-ASA, 5-ASA enemas. Curative - surgery
57
What drug is ulcerative colitis resistant to?
PO prednisolone
58
ACUTE SEVERE COLITIS What is acute severe colitis? What % of UC patients will have it? Management of acute severe colitis? What to monitor in acute severe colitis? What is the main therapy for acute severe colitis?
Flare up of Ulcerative colitis 25% Admit to hospital, monitor electrolytes (hypomagnesaemia and hypokalaemia), IV fluids, VTE prophylaxis with LMWH, avoid anticholinergics/antidiarrhoeal/NSAIDs, nutritional support with enteral 1st line or TPN, abx if infective, AXR to exclude toxic megacolon, flexible sigmoidoscopy, c.diff toxin assay Monitor: vital signs 4x day, stool chart, FBC, U&E, Mg, K+, albumin, LFTs, glucose, daily AXR if severe flare according to Truelove and Witts criteria, or abdominal distension IV methylprednisolone 60mg OD, or IV hydrocortisone 100mg QDS for 7-10 DAYS. If no response then 5mg/kg IV infusion of infliximab, OR 2mg/kg IV infusion of cyclosporin with rapid steroid wean
59
What is the indication for surgery in ulcerative colitis? What surgical options are there for ulcerative colitis?
Toxic dilatation, haemorrhage, imminent perforation, incomplete response to medical treatment, steroid dependence, dysplasia on colonoscopy
60

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