Colon Cancer, Polyps, IBD Flashcards
(226 cards)
1
Q
If a patient has ≥10 ADENOMATOUS polyps on a SINGLE colonoscopy, what should be TESTED for?
A
GENETICS for POLYPOSIS syndromes
2
Q
If a patient has ≥20 ADENOMATOUS polyps on CUMMULATIVE colonoscopies, what should be TESTED for?
A
GENETICS for POLYPOSIS syndromes
3
Q
If a patient has ≥2 HAMARTOMATOUS polyps on CUMMULATIVE colonoscopies, what should be TESTED for?
A
GENETICS for POLYPOSIS syndromes
4
Q
AUTOSOMAL DOMINANT, APC gene (5q21), HUNDREDS of adenomatous polyps, COLON CANCER at YOUNG AGE (39)?
A
Familial Adenomatous Polyposis (FAP) - colon cancer at age 39)
5
Q
At what AGE do patients with APC gene (5q21) begin to make colon polyps?
A
15
6
Q
OSTEOMAS (skull, long bones, between teeth), SKIN tumors (fibromas, lipomas, epidemoid cysts), EYE (CHRPE lesions), THYROID cancer, HEPATOBLASTOMA, ANGIOFIBROMA are found with what POLYPOSIS syndrome?
A
FAP (AD APC gene 5q21)
7
Q
What can you see on BIOPSY of the NORMAL-APPEARING colon of an FAP patient BEFORE polyps occurr (APC 5q21)?
A
MICROADENOMAS
8
Q
Who should be SCREENED in FAP and how frequently?
A
Test AFFECTED person 1st (father, etc) if suspecting child has it
If father has it, check APC GENE TEST of child at age 10-12
YEARLY COLONOSCOPY
(pretest counseling, informed consent)
9
Q
Treatment for FAP?
A
COLECTOMY (age 15-25)
10
Q
What is the POST-COLECTOMY follow-up of an FAP patient?
A
IF POUCH - YEARLY FLEX SIG
EGD for UGI polyps YEARLY (duodenal cancer)
THYROID
DESMOIDS - imaging
11
Q
At what LOCATION on the APC gene are the FAP mutations?
A
CENTER
12
Q
At what LOCATION on the APC gene are the ATTENUATED FAP mutations?
A
5’ and 3’ (at both ENDS)
13
Q
A patient that seems to have FAP but instead of HUNDREDS to THUSANDS of ADENOMATOUS polyps, they have < 100 and usually in the ASCENDING RIGHT COLON?
A
ATTENUATED FAP (AD colon cancer at 51)
14
Q
What is the SCREENING and TREATMENT for ATTENUATED FAP?
A
GENETIC TESTING of ALL FAMILY MEMBERS (pedigrees)
COLONOSCOPY q1-2 years in LATE TEENS
COLECTOMY when too many adenomatous polyps are found
15
Q
A patient that PRESENTS with findings of FAP or ATTENUATED FAP, AUTOSOMAL RECESSIVE inheritance, can also have UGI (duodenal polyps, cancer) and ASSOCIATED with BREAST, OVARIAN, URINARY and SKIN CANCERS (no osteomas, desmoids, thyroid or CHRPE - eye)?
A
MAP (AR MUTYH Associated Polyposis)
16
Q
HUNDREDS of colon polyps, with associated BREAST, OVARIAN, URINARY and SKIN cancers?
A
MAP (AR MUTYH Associated Polyposis)
17
Q
HUNDREDS -THOUSANDS of colon polyps with associated OSTEOMAS, DESMOID tumors, THYROID cancer and CHRPE?
A
FAP (AD thousands) or ATTENUATED FAP (AD hundreds)
18
Q
FAP presentation with BRAIN (MEDULOBLASTOMA)?
A
CRAIL’s SYNDROME (APC gene)
19
Q
LYNCH presentation with BRAIN (GLIOBLASTOMA)?
A
TURCOT’s SYNDROME (MMR gene - mismatch repair)
20
Q
Can PEUTZ-JEGHER patients develop polyps in the ESOPHAGUS?
A
NO (arborization and muscle fibers in hamartomas)
21
Q
STK11 GENE mutation is associated with which POLYPOSIS SYNDROME?
A
PEUTZ-JEGHERS (AD 19p13)
22
Q
Which POLYPOSIS SYNDROME is associated with Small Bowel INTUSUSCEPTION?
A
PEUTZ-JEGHERS (AD 19p13)
23
Q
POLYPOSIS SYNDROME associated with CANCERS of the BREAST, OVARY (MAP), PANCREAS, LUNG, CERVICAL (adenoma malignum) TESTICLES?
A
PEUTZ-JEGHERS (AD 19p13)
24
Q
This POLYPOSIS SYNDROME is associated with PREMATURE ADOLESCENCE of MALES due to SERTOLI CELL TESTICULAR TUMORS?
A
PEUTZ-JEGHERS (AD 19p13)
25
Which **POLYPS** should be **REMOVED** in patients with **PEUTZ-JEGHERS**?
All **STOMACH** & **COLON** polyps **>5 mm**
All **SMALL BOWEL** polyps **>10 mm**
26
Which **POLYPOSYIS SYNDROME** requires **YEARLY** surveillance with **EGD**, **COLONOSCOPY**, **EUS/MRI**, **SB** imaging, **MAMMOGRAM**, **PELVIC/PAP**, **TESTICULAR** exam?
**PEUTZ-JEGHERS** (AD 19p13)
27
What is the **DIFFERENCE** in **NUMBER** of **POLYPS** between **JUVENILE POLYPS** and **JUVENILE POLYPOSIS**?
**1-2 POLYPS** found in **JUVENILE** polyps
**>5 POLYPS** in **JUVENILE POLYPOSIS**
28
Which of **ALL** the **POLYPOSIS SYNDROMES** is **AUTOSOMAL RECESSIVE** (both gene copies needed for expression from mom and dad)?
**MAP** (**M**UTYH **A**ssociated **P**olyposis)
29
Mutations in the **SMAD4** and **BMPR1A** genes with **POLYPS** that are **EDEMATOUS** and **CYSTIC** histologically?
**JUVENILE POLYPOSIS**
30
In patients with **JUVENILE POLYPOSIS** (>5 polyps) with **EITHER SMAD4** or **BMPR1A** mutations, what **SURVEILLANCE** is **REQUIRED** and at what age?
**EGD/COLONOSCOPY** starting at **age 12**
31
Which of the **TWO JUVENILE POLYPOSIS MUTATIONS** require **AVM** **SCREENING in BRAIN/LUNGS** as well as **EGD/COLONOSCOPY**?
**SMAD4** (also causes HHT)
32
This **HAMARTOMAROUS** disease is caused by a mutation of the **PTEN** gene, causes **GANGLIONEUROMA POYLPS** in colon, **BREAST CANCER,** **THYROID CANCER**, **COLON CANCER**, **CEREBELLAR GANGLIOCYTOMA**, **SKIN HAMARTOMAS**, **MACROCEPHALY**?
**COWDEN**'s SYNDROME
33
What surgical procedure **INCREASES** one's risk for **COLON CANCER**?
**URETERO-SIGMOIDOSTOMY**
34
**FAMILY HISTORY**, **RED MEAT**, **PELVIC Radiation** therapy, **DERMATOMYOSITIS**, **STREP BOVIS**, **ACROMEGALY**, **METABOLIC SYNDROME**, **CHOLECYSTECTOMY**, **I1307K APC** mutation, **CHOLECYSTECTOMY** are all **ASSOCIATED** with?
HIGHER RISK of **COLON CANCER**
35
Accumulated somatic mutations in **APC**, **K-RAS**, **DCC18q**, **p53** cause what?
**COLORECTAL CANCER**
36
Which are the **TWO** types of **PRE-CANCEROUS** colon polyps?
**ADENOMAS**
**SERRATED**
37
What are the **THREE** types of **SERRATED** colon polyps?
**Hyperplastic** (benign)
**Sessile** serrated adenoma
**Traditional** serrated
38
Colonoscopy: **NO POLYPS**, surveillance?
**10 YEARS**
39
Colonoscopy: **ALL < 10 mm; 1-2, 3-4, 5-10 ADENOMATOUS POLYPS**, surveillance?
1-2: **7-10** YEARS
3-4: **3-5** YEARS
5-10: **3** YEARS
40
Colonoscopy: **≥ 10 mm ADENOMATOUS POLYP**, surveillance?
**3** YEARS
41
Colonoscopy: **ANY SIZE ADENOMATOUS POLYP with "VILLOUS" HISTOLOGY**, surveillance?
**3** YEARS
42
Colonoscopy: **ADENOMATOUS POLYP with HIGH-GRADE DYSPLASIA**, surveillance?
**3** YEARS
43
Colonoscopy: **>10 ADENOMATOUS POLYPS**, surveillance?
**1** YEAR
44
Colonoscopy: **≥ 20 mm ADENOMATOUS POLYP PIECEMEAL REMOVAL**, surveillance?
**6 MONTHS**
45
**TIER 1 AVERAGE RISK COLORECTAL CANCER SCREENING**?
**COLONOSCOPY** **q10** YEARS
or **ANNUAL FIT** testing
46
**TIER 2 AVERAGE RISK COLORECTAL CANCER SCREENING**?
**VIRTUAL** COLONOSCOPY **q5** YEARS
or **FLEX SIG q5-10** YEARS
or **FIT-DNA q3** YEARS
47
**TIER 3 AVERAGE RISK COLORECTAL CANCER SCREENING**?
VIDEO **CAPSULE** ENDOSCOPY **q5** YEARS
48
**AFTER** what **AGE** should you **STOP** colorectal cancer **SCREENING**?
**85**
49
**IMMUNOLOGICAL** test for human **HEMOGLOBIN** in stool?
**FIT** (**ANNUAL**, single-sample)
50
**TEST** for **MOLECULAR MARKERS** for **COLORECTAL CANCER** in **STOOL**
**FIT-DNA** (**q3 YEARS**, single-sample)
51
What is the **SERUM** test for **COLORECTAL CANCER**?
**SEPTIN9** (methylated septin9)
52
**EXCLUDING COLONOSCOPY**, which test has the **HIGHEST SENSITIVITY** (identify disease when its actually there - rule in) for **COLORECTAL CANCER**?
**FIT-DNA** (cancer, NOT polyps)
53
**FAMILY HISTORY** of **≥1 FIRST DEGREE RELATIVE** with **COLORECTAL CANCER** at **ANY AGE**, **SURVEILLANCE**?
**Start** at **AGE 40** or **10 YEARS BEFORE EARLIEST CR**C and **EVERY 5 YEARS** after
54
**FAMILY HISTORY** of **≥1 FIRST DEGREE RELATIVE** with **ADVANCED ADENOMA or SESSILE SERRATED POLY** at **ANY AGE**, **SURVEILLANCE**?
**Start** at **AGE 40** or **AGE of ONSET of ADENOMA** and **EVERY 5 YEARS** after
55
**FAMILY HISTORY** of **2nd or 3rd DEGREE RELATIVES** with **CRC** at **ANY AGE**, **SURVEILLANCE**?
AS **PER USUAL SURVEILLANCE**, NO DIFFERENCE
56
After diagnosis of **COLON CANCER**, s/p **SURGERY**, when do you do **SURVEILLANCE** if normal **SURVEILLANCE** previosly? If **NONE** previously?
**1 YEAR**
**3-6 MONTHS**
57
After diagnosis of **COLON CANCER**, s/p **SURGERY**, when do you do **SURVEILLANCE** if find **ADVANCED ADENOMA** on the **1 YEAR SURVEILLANCE** colonoscopy?
**1 YEAR**
58
**ADENOMATOUS POLYP >1 cm**; **ADENOMATOUS POLYP** with **>25% VILLOUS** component; **ADENOMATOUS POLYP** with **HIGH-GRADE DYSPLASIA**; **ADENOMATOUS POLYP** with **EARLY INVASIVE CANCER**?
**ADVANCED ADENOMA**
59
After diagnosis of **COLON CANCER**, s/p **SURGERY**, when do you do **SURVEILLANCE** if **NO ADVANCED ADENOMA**? **THEN** if **NEGATIVE**?
**3 YEARS**
**5 YEARS**
60
**WHEN** should you **SCREEN IBD** patients with **COLONOSCOPY**?
**8 YEARS** after **DIAGNOSIS**
61
**HOW** do you **SCREEN IBD** patients with colonoscopy?
**CHROMO** or **HD WHITE LIGHT**, **4 QUADRANTS** every **10 cm**
62
**HOW FREQUENTLY** do you **SCREEN HIGH-RISK IBD** patient (PSC, EXTENSIVE disease, ACTIVE disease, FAMILY HISTORY of CRC)?
**YEARLY**
63
**HOW FREQUENTLY** do you **SCREEN LOW-RISK IBD** (REMISSION, LEFT-SIDED) patient?
**q2-3** YEARS
64
**WHEN** do you start **SCREENING** for **CRC** in a patient with **IBD** found to have **PSC**?
**IMMEDIATELY**
65
**AD**, **MISMATCH** REPAIR PROTEIN mutation, **NO POLYPS**, **RIGHT-SIDED** (proximal) **COLON CANCER**?
**LYNCH** SYNDROME
66
(**1,2,3**) **1**: **FAMILY MEMBER** diagnosed with colon cancer **< 50** yo; **2**: **2 GENERATIONS**; **3**: **3 or more with CRC**
**HNPCC** (**H**ereditary **N**on-**P**olyposis **C**olon **C**ancer)
67
**SPORADIC** Colon Cancers usually occur in which **PART** of the **COLON**?
**LEFT** (mean age of diagnosis is **68**)
68
**HNPCC** and **LYNCH** colon cancers occur in which **PART** of the colon?
**RIGHT** (mean age of diagnosis is **44**)
69
**LYNCH SYNDROME** is **MAINLY** associated with what **EXTRA-COLONIC** cancer?
**ENDOMETRIAL**
70
**CRC SCREENING** in **LYNCH SYNDROME**?
**Starting** at age **20-25**, **q1-2 YEARS** or 2-5 YEARS prior to EARLIEST CRC in family **if occured < 25 yo**
71
**BESIDES CRC SCREENING**, what else do you **SCREEN** for in patients with **LYNCH SYNDROME**?
**STOMACH** - EGD
**UTERUS/OVARIES** - TV US, CA-125
**GU** - U/A
**PROSTATE** - digital exam, PSA
72
In **WOMEN** with **LYNCH SYNDROME**, once **OUT** of **CHILD BEARING** age, what should be considered?
**HYSTERECTOMY + OOPHERECTOMY**
73
What **MEDICATION** is used **PROPHYLACTICALLY** for patients with **LYNCH SYNDROME**?
**ASPIRIN**
74
**M**LH1; **M**SH2; **M**SH6; P**M**S2; EPCA**M** mutations, **MICROSATELLITE** instability (addition of nucleotide repeats), **IMMUNOHISTOCHEMISTRY** (stain tumor for **ABSENT** mismatch repair proteins), **BRAF** mutation?
**LYNCH SYNDROME**
75
If pt **HAS MICROSATELLITE INSTABILITY** or on **IMMUNOHISTOCHEMISTRY**, has **ABSENCE** of the **MISMATCH REPAIR PROTEINS**, **BUT** **BRAF** testing shows **POSITIVE MUTATION (SOMATIC MLH1)** or **MLH1 PROMOTER HYPERMETHYLATION is PRESENT** (also **SOMATIC MLH1** mutation)?
**NOT LYNCH**
76
**BRAF** mutation **POSITIVE** or **MLH1 PROMOTER HYPERMETHYLATION POSITIVE**, **REGARDLESS** of **IMMUNOHISTOCHEMISTRY** or **MICROSATELLITE INSTABILITY FINDINGS**?
**NOT LYNCH SYNDROME**
77
**BRAF** mutation **NEGATIVE** or **MLH1 PROMOTER HYPERMETHYLATION NEGATIVE**?
**LYNCH SYNDROME**
78
To **DIAGNOSE LYNCH SYNDROME**, once **MICROSATELLITE INSTABILITY** is **FOUND** or **IMMUNOHISTOCHEMISRTY** is positive for **ABSENT MISMATCH REPAIR PROTEINS**, what **MUST** be done **NEXT**?
**BRAF** and **MLH1** **PROMOTER HYPERMETHYLATION** testing (if POSITIVE, NOT LYNCH)
79
**ANY** patient found to have **CRC**, what **TEST** is done next to determine if **GENETIC COMPONENT** exists?
**IMMUNOHISTOCHEMICAL TESTING** (look for **ABSENT mismatch repair proteins**)
80
A patient with **CRC** undergoes **IMMUNOHISTOCHEMICAL** testing and is found to have **ALL** mismatch repair proteins **PRESENT**, none are absent?
**NOT LYNCH**
81
A patient with **CRC** undergoes **IMMUNOHISTOCHEMICAL** testing and is found to **ABSENT MLH1 or PMS2** mismatch repair proteins, what is done **NEXT**?
**PROMOTER HYPERMETHYLATION** testing
or
**BRAF** mutation testing
if these are **PRESENT** - **NOT LYMCH**
if **ABSENT** - refer to **GENETIC COUNSELOR** for **GERMLINE TESTING**
82
A patient with **CRC** undergoes **IMMUNOHISTOCHEMICAL** testing and is found to **ABSENT MSH2 or MSH6** mismatch repair proteins, what is done **NEXT**?
Refer to **GENETIC COUNSELOR** for **GERMLINE TESTING**
83
**ALL LYNCH** patients with **CRC** or **POSITIVE GENOTYPES** should be **RECOMMENDED** what?
**HYSTERECTOMY + OOPHERECTOMY**
84
**ALL LYNCH** patients with **CRC** should be **RECOMMENDED** what?
**COLECTOMY** with **SURVEILLANCE** of **RECTUM**
85
A patient with **FAP** with **COLECTOMY** with **RECTUM** intact, needs surveillance of **RECTUM HOW OFTEN**?
**YEARLY**
86
**DO FAP** patients have an increased risk of **GU** tumors necessitating **TV US** or **U/A**?
**NO**
87
A patient with **FAP** HOW OFTEN do they need surveillance of **THYROID**?
**q2-5 YEARS**
88
**PRESENCE** of **MSH2** or **MSH6** mutations?
**LYNCH SYNDROME**
89
If on **ENDOSCOPY**, a patient is found to have features of **JUVENILE POLYPOSIS SYNDROME** (**>5 EDEMATOUS**, **CYSTIC** polyps, multiple **GASTRIC** polyps), what is **RECOMMENDED NEXT**?
**GENETIC** TESTING (**SMAD4**, **BMPR1A**, **PTEN**)
90
On **COLONOSCOPY**, you remove a **HYPERPLASTIC POLYP >1 cm**, when should you **REPEAT** colonoscopy?
**3-5 YEARS**
91
What **FEATURES** does **ACUTE COLITIS** have that **IBD** does not?
**EDEMA**, **CRYTPTITIS** (vs crypt abscess - a chronic process), **STRAIGHT CRYPTS** (vs short, branched) **SURFACE** damage (much less), **PRESERVED MUCIN** (vs decreased)
92
How **MANY** cases of **IBD** are **UNCLASSIFIED** where features of **BOTH UC** and **CROHN's** seem to be present?
**5-20%**
93
What are **HIGH-RISK** features of both **UC** and **CROHN's**?
**YOUNGER** ONSET (**< 30-40**), **EXTENSIVE** INVOLVEMENT, **DEEP** ULCERS, **INFECTIONS**, **STRICTURING**, **STEROID** REQUIREMENT, **LOW SERUM ALBUMIN**
94
**BEFORE** deciding if a patient has **IBD FLARE** or **IBS** or **BOTH**, what should be **EVALUATED** for?
**INFLMMATION** (**CRP**, CALPROTECTIN)
**STRUCTURAL** ABNORMALITIES (**histology**, imaging)
95
**QUITTING SMOKING** is a **RISK** for what **IBD**?
**UC**
96
The use of what **MEDICATIONS** in **CHILDHOOD** is associated with the risk of developing **IBD** (**UC** or **CROHN's**)?
**ANTIBIOTICS**
97
How does **BREASTFEEDING** affect the potential of **IBD** development?
**PROTECTS AGAINST IT**
98
How does **OCP USE** affect the potential of **IBD** development?
**RISK** of **CROHN's**
99
How does **APPENDECTOMY** affect the potential of **IBD** development?
**RISK** for **CROHN's** develolment
**PROTECTIVE** for **UC** development
100
How does **LOW VIT D** affect the potential of **IBD** development?
**RISK** of developing **BOTH** **UC** and **CROHN's**
101
How does **TEA or COFFEE** affect the potential of **IBD** development?
**PROTECTIVE** against develpment of **BOTH**
102
**ASCA** and **OmpC** are **BOTH** seen in which **IBD**?
**CROHN's**
103
DNAse Sensitive **pANCA** is seen in which **IBD**?
**PREDOMINANTLY UC** (can be seen in **CROHN's**)
104
Is the use of **ASCA**, **pANCA** or **OmpC** antibodies recommended for **ESTABLISHING IBD** diagnosis or **PROGNOSIS**?
**NO**
105
What **TARGETS** should be **CONSIDERED** when treating **IBD** besides **SYMPTOM IMPROVEMENT** and **ENDOSCOPIC HEALING**?
**DECREASE** of **CRP** and **CALPROTECTIN**, NORMAL GROWTH in CHILDREN and HISTOLOGIC healing
106
**HOW** are **5-ASA** drugs **EFFECTIVE** for **IBD**?
These are effective for **INDUCTION** and **MAINTENANCE** therapy for **MILD** to **MODERATE UC**
107
What is meant by **DELIVERY-RESPONSE** relationship of **5-ASA** drugs used for mild to moderate **UC** (both induction and maintenance)?
Getting the drug to the **LOCATION** of the **DISEASE**
108
What **ADVERSE EFFECT** is most commonly seen with **5-ASA** drugs (**UC**) which are otherwise **VERY SAFE**?
**Interstitial Nephritis**
109
In **3%** of patients started on **5-ASA** drugs (**UC**), they **GET WORSE**, why?
**ALLERGIC** or **INTOLERANT** - **STOP THE DRUG**
110
**HOW** should **5-ASA** drugs be given for **SUPERIOR EFFICACY** in **UC**?
**ORAL+RECTAL** therapy
111
When treating **UC**, **WHEN** is it **SAFE** to **REDUCE** the **DOSE** of the **ORAL 5-ASA** (not the rectal)?
When there is evidence of **DEEP REMISSION**
112
Can **STEROIDS** (prednisone or budesonide) be used for **MAINTENANCE** in **IBD**?
**NO** (**INDUCTION** of **REMISSION ONLY**)
113
Which **FORMULATION** of **BUDESONIDE** is used for **CROHN's** and why?
**ENTOCORT** (Controlled Ileal Release)
Because it is **RELEASED** and **ABSORBED** in the **TI** and **CECUM**
114
Which **FORMULATION** of **BUDESONIDE** is used for **UC** and why?
**UCERIS** (Extended Release)
Because it is **RELEASED** **THROUGHOUT** the **COLON**
115
What is meant by that the **USE** of **STEROIDS** is **PROGRNOSTIC in IBD**?
**DICTATES SUBSEQUENT OUTCOMES**
116
**WHICH STEROIDS** should be used **FIRST** in attempting **INDUCTION** of **REMISSION** in **IBD**?
**NON-SYSTEMIC** (budesonide)
117
When **TREATING IBD** patients and **ESPECIALLY** when using **STEROIDS**, what **MUST** be **MONITORED**?
**BONE DENSITY** and **VIT D** levels
118
How **LONG** does **STEROID USE** for **IBD** **REQUIRE** a **TAPER**?
**≥2 WEEKS**
119
**GENETICALLY-DETERMINED METABOLISM** applies to which **IBD** drug which therefore **REQUIRES CHECKING** of **INDIVIDUAL LEVELS**?
**THIOPURINES** (6-MP/AZATHIOPRINE)
120
Explain **6-MP METABOLISM**?
6-MP is BROKEN into **6-TGN** (therapeutic, toxic) by **HPRT**
6-MP is BROKEN into **6-MMPN** (inactive) by **TPMT**
121
What happens in patients taking **6-MP** who **GENETICALLY** make **NORMAL**/**INTERMEDIATE**/**LOW TPMT**?
**NORMAL**: adequate drug is made, **NO TOXICITY**
**INTERMEDIATE**: **GIVE LESS DRUG** to **AVOID TOXICITY**
**LOW**: **TOXICITY** can develop **BONE MARROW SUPPRESSION**
122
If an **ASIAN** or **LATINO** patient experiences **EARLY LEUKOPENIA** on **AZATHIOPRINE** or **6-MP**, what is the **ISSUE**?
Presence of **NUDT15** enzyme
123
What **MUST** be done **BEFORE** starting a patient on **THIOPURINES** (azathioprine or 6-MP)?
Check **TPMT** levels (because if LOW or ABSENT, this will dictate TOXICITY due to OVERPRODUCED 6-TGN - bone marrow suppression) - can use ALLOPURINOL to block shunting to a predimonant 6-MMP metabolite (inactive)
124
A patient is started on **AZATHIOPRINE** or **6-MP** (1-2 doses) and develops **SEVERE JOINT-PAIN** and **FEVER**, what happened?
**ALLERGIC REACTION** to **THIOPURINES**, **STOP** the drug (this is NOT an infection)****
125
What **IBD DRUG CLASS** is associated with **LYMPHOMA** and **N**on-**M**elanoma **S**kin **C**ancers?
**THIOPURINES** (azathioprine, 6-MP) - risk returns to normal after discontinuation
126
What occurs if **TOO MUCH 6-MMPN** (inactive metabolitie) is made by **TPMT** and not enough **6-TGN**
**LIVER TOXICITY** (shunt with ALLOPURINOL)
127
If **TOO MUCH** of **6-TGN** is made (TPMT is intermediate or LOW), what is the **TOXICITY**?
**BONE-MARROW SUPPRESSION** (reduce dose of thiopurine)
128
Is **EARLY** use of **THIOPURINES** more effective than **PLACEBO** or **CONVENTIONAL** therapy for **CROHN's** disease?
**NO**
129
**METHOTREXATE** is a drug used for what **IBD ONLY**?
**CROHN's** disease
130
Why is **METHOTREXATE** useful when used in **COMBINATION** with other drugs when trating **CROHN's** disease?
Prevents formation of **ANTI-DRUG ANTIBODIES**
131
What is the **MAJOR ADVERSE EFFECT** of **METHOTREXATE**?
**TERATOGEN** (women only) - others are cirrhosis, pneumonitis, bone marrow suppression and rash
132
If a patient on **THIOPURINES** developes **PANCREATITIS**?
**STOP** the **DRUG** (genetically predisposed)
133
**NAUSEA** with **METHOTREXATE** is **TREATED** how?
**ONDANSETRON**
134
What **MUST** be given **WITH METHOTREXATE** and what **MUST** be **MONITORED** with this drug?
**GIVE**: **FOLIC ACID**
**MONITOR**: **LFTs** every 6 MONTHS
135
# , INFLIXI
Antibiologics used in **TREATMENT** of **CROHN's**?
**CERTO**lizumab, **ADA**limumab, **INFLIXI**mab, **NATA**lizumab, **VEDO**lizumab, **USTE**kinumab, **RISAN**kinumab
136
Antibiologics used in **TREATMENT** of **UC**?
**ADA**limumab, **GO**limumab, **INFLIXI**mab, **VEDO**lizumab, **USTE**kinumab (ada go in, vedo use)
137
What **IBD** severity are **anti-TNF** drugs used in?
**MODERATE - SEVERE**
138
Which is the **ONLY** medication **LABELED** for treatment of **PERIANAL CROHN's**?
**INFLIXIMAB**
139
**50% LOSS** of **RESPONSE** or **DOSE ESCALATIONS** are seen with these **IBD** drugs at **ONE YEAR**?
**anti-TNF** (Certo, Ada, GO, IN)
140
Risk of **INFECTION**, **REACTIVATION** of latent **TB** and **Hep B** are seen with these **IBD DRUGS**?
**anti-TNF** (Certo, Ada, GO, IN)
141
**BEFORE** starting **anti-TNF** (Certo, Ada, GO, IN) in a patient with **IBD**, what should you **ALWAYS** check for?
Latent **TB**, **Hep B**
142
Antibody formation to **anti-TNF** (Certo, Ada, GO, IN) drugs is associated with what?
**LOSS** of **RESPONSE** & **HYPERSENSITIVITY** reaction (**RASH**, tachycardia, anaphylaxis)
143
The **ADDITION** of what **DRUG** to **INFLIXIMAB** (anti-tnf) causes **LESS** antibody formation, **BETTER** drug exposure and response, making the combination **MORE EFFECTIVE** in treating **BOTH CROHN's** and **UC**?
**AZATHIOPRINE**
144
Do **USTE**kinumab or **VEDO**lizumab benefit from **COMBINATION** therapies?
**NO**
145
Are **5-ASA** drugs helpful when **ESCALATING** to **ADVANCED THERAPIES**?
**NO** (stop these when escalating)
146
Does the use of **anti-TNF** (Certo, Ada, GO, IN) drugs risk formation of **SOLID TUMORS**?
**NO**
147
**IMMUNOGENICITY** (immune system deactivates drug), **AUTOIMMUNITY**, **INFECTION** (fungal pneumonia, histoplasmosis, listeria, TB, viral), **LYMPHOMA**, **MELANOMA**, **PSORIASIS**, **CHF**, **DEMYELINATION** (optic neuritis, MS, transverse myelitis) can all be seen with these **IBD** drugs?
**anti-TNF** (Certo, Ada, GO, IN)
148
What should be used to guide **TREATMENT CHANGES** when using **anti-TNF** (Certo, Ada, GO, IN) drugs in patients with **IBD**, **ONLY** if treatment **DOESN'T** seem to work or **STOPS** working?
**REACTIVE** **T**herapeutic **D**rug **M**onitoring (TDM)
149
When **DOSING** and **CHNAGING THIOPURINE** theray, what is **RECOMMENDED**?
**TPMT** testing and **6-TGN/6-MMPN** (metabolite) monitoring - **NOT ROUTINELY** when just on therapy
150
An **IBD** patient is **LOSING RESPONSE** to an **anti-TNF** (Certo, Ada, GO, IN) drug, what do you do **NEXT**?
**MEASURE** **anti-TNF** drug **LEVES** and formation of **ANTIBODIES**
151
An **IBD** patient is **LOSING RESPONSE** to an **anti-TNF** (Certo, Ada, GO, IN) drug, they have **LOW** **anti-TNF** drug **levles** and **NO** drug **antibodies**?
**INCREASE** anti-TNF **DOSE** or **DECREASE** administration **INTERVAL**
152
An **IBD** patient is **LOSING RESPONSE** to an **anti-TNF** (Certo, Ada, GO, IN) drug, they have **HIGH** **anti-TNF** drug **levles** and **POSITIVE or NEGATIVE** drug **antibodies**?
**SWAP** to another drug **CLASS** (no anti-TNF drugs)
153
An **IBD** patient is **LOSING RESPONSE** to an **anti-TNF** (Certo, Ada, GO, IN) drug, they have **LOW** **anti-TNF** drug **levles** and **HIGHLY-POSITIVE** drug **antibodies**?
**CYCLE** to another anti-TNF drug (**NOT biosilimar**)
or
**SWAP** drug CLASS
154
An **IBD** patient is **LOSING RESPONSE** to an **anti-TNF** (Certo, Ada, GO, IN) drug, they have **LOW** **anti-TNF** drug **levles** and **LOW-POSITIVE** drug **antibodies**?
**TRANSIENT**, so **INCREASE DOSE**
If **NO RESPONSE**, **CYCLE** or **SWAP**
155
What **CROHN's DRUGS** should be used to **PREVENT RECURRENCE** after **SURGERY**?
**anti-TNF**
156
What is the **RUTGEERT SCORE**?
Assessment of the **CROHN's POST-SURGICAL** anastomosis for presence of **ulcers** and **stricturing** (**0-4**)
157
If a patient is on an **anti-TNF** drug for **CROHN's** **POST-SURGICAL** anastomosis and on colonoscopy they scored at a **RUTGEERT** score of **≥2** (0-4), what is **RECOMMENDED**?
**CHANGE TREATMENT STRATEGY**
158
Should a **5-ASA** drug or **STEROID** be used to treat a **CROHN's** patient **POST-SURGERY**?
**NO** (use anti-TNF)
159
After a patient with **CROHN's** has surgery for **CROHN's** whetehr or not they have been **STARTED** on **anti-TNF** prophylactic therapy, **WHEN** should colonoscopy **SURVEILLANCE** resume?
**6 MONTHS**
160
Which are the **anti-IL12/23** and **anti-IL23** **IBD** drugs **BOTH** of which are used in **moderate to severe UC** and **CROHN's**?
anti-IL**12/23**: **USTE**kinumab
anti-**IL23**: **RISAN**kizumab
**BOTH** are **EQUALLY EFFICACIOUS**
161
How **MANY** patients on the anti-IL12/23 and anti-IL23 drugs used to treat moderate to severe **UC** and **CROHN's** (ustekinumab/risankizumab) require **DOSE ESCALATION**?
**20%**
162
Is **USTE**kinumab more effective than **AD**Alimumab?
**NO** (no difference)
163
In what **UC/CD** patients would you use the **anti-IL12/23** and **anti-IL23** (ustekinumab/risankizumab) drugs?
Those with **SKIN DISEASE** (psoriasis) as well as those who have had **ANTIBODIES** against **anti-TNF** drugs (certo, ada, go, in)
164
Which are the **TWO** **anti-INTEGRIN** drugs used to treat **IBD**?
**NATA**lizumab and **VEDO**lizumab
165
This **anti-INTEGRIN DRUG** is limited to the **GUT** (selects for alpha-4, beta-7 integrins) and is used for **INDUCTION** and **MAINTENANCE** of moderate-severe **UC** and **CROHN's**?
**VEDO**lizumab
166
Whis was foud to be **SUPERIOR** for treatment of **UC**, **ADA**limumab (anti-TNF) or **VEDO**lizumab (anti-INTEGRIN)?
**VEDO**lizumab (does NOT work on ANY outside of the GUT manifestations of IBD)
167
Was **VEDO**lizumab found to be a **SAFE** drug?
**YES!!**
No **INFECTIONS**, No **CANCERS**, No **PML**, No **IMMUNOGENICITY**
168
What is the **RECOMMENDED** **1st LINE AGENT** after using **5-ASA** in **UC**?
**VEDO**lizumab
169
Which **NEW IBD** drugs **TARGET INFLAMMED TISSUES**?
**S1P** (1-5) **DRUGS**
the **ONLY** one available is **OZANIMOD** (for **UC**) S1P**1,5**
170
How does the **ORAL** S1P**1,5** drug for **UC**, **OZANIMOD** compare to **anti-TNF**?
**LESS EFFECTIVE**
only causes elevated **LFTs** which resolve spontaneously
171
Which are the **TWO JAK-inhibitors** used in **IBD**?
**TOFA**citinib (**UC**) JAK 1-3
and
**UPADA**citinib (**UC & CD**) JAK-1
172
When are the **JAK-inhibitors** (**TOFA**citinib - **UC** and **UPADA**citinib - **UC & CD**) **RECOMMENDED** for use for **IBD**?
**ONLY** after **anti-TNF** treatment **FAILURE**
173
Patients with **IBD** who have **LOW ALBUMIN**, **ARTHROPATHY** and **SPONDYLOARTHROPATHY** and have **FAILED anti-TNF** drugs, would do well on which drugs?
**TOFA**citinib (**UC**) JAK 1-3
and
**UPADA**citinib (**UC & CD**) JAK-1
174
What **IBD** drugs can be used **WITHOUT STEROIDS** as they work **VERY FAST** (8-12 week induction) but have to be used **ONLY** after **anti-TNF failure** (can sometimes have a delayed repsonse of 16-24 weeks)?
**TOFA**citinib (**UC**) JAK 1-3
and
**UPADA**citinib (**UC & CD**) JAK-1
175
What **VACCINE MUST** be given prior to using **TOFA**citinib or **UPADA**citinib?
**HERPES ZOSTER** (shingles) vaccine
176
**WHEN** should **ANTI-BIOLOGICS** be used in **IBD**?
**THE SOONER THE BETTER** (higher likelihood of response and lower likelihood of losing response)
177
**WHICH** of the **anti-biologics** are preferred in patients with **ECZEMA** or **PSORIASIS**?
**IL-23** (**USTE**kinumab, **RISAN**kizumab) - because its a clue to an IL-23 dominant pathway
178
**WHICH** of the **anti-biologics** are preferred in patients with **ATOPIC DERMATITIS** or **JOINT** problems (arthropathies/spondyloarthropathies, ankylosing spondylitis, sacroiliitis)?
**TOFA**citinib (**UC**) JAK 1-3
and
**UPADA**citinib (**UC & CD**) JAK-1
179
If a patient with **IBD** has **DIABETES**, which treatmet should you **AVOID**?
**STEROIDS** (use the JAK-inhibitors instead if FAILED anti-TNF)
180
In a patient who has **IBD** and **ATOPIC DERMATITIS** and would benefit from a **JAK-inhibitor** (**TOFA**citinib or **UPADA**citinib) what **REQUIREMENT** are they **EXEMPT** from?
Failing anti-TNF therapy first (**can use right away**)
181
What are the **TWO** drugs to consider as **FIRST-LINE** for **UC** (after 5-ASA + STEROIDS)?
**VEDO**lizumab (anti-integrin alpha-4, beta-7) or **OZANIMOD** (S1P1,5)
182
What are the **TWO** drugs to consider as **FIRST-LINE** for **CROHN's WITHOUT peri-ANAL** involvement?
**VEDO**lizumab (anti-integrin alpha-4, beta-7) or **USTE**kinumab (IL-23)
183
What are the **TWO** drugs to consider as **FIRST-LINE** for **CROHN's WITH peri-ANAL** involvement?
**INFLIXIMAB** (anti-TNF) **+ AZATHIOPRINE**
184
In a patient with **CROHN's** who **FAILED anti-TNF**, what do you use **NEXT**?
**USTE**kinumab or **RISAN**kizumab (IL-23)
185
In a patient with **UC** who **FAILED anti-TNF**, what do you use **NEXT**?
**TOFA**citinib or **VEDO**lizumab or **USTE**kinumab
186
What **DIET** is **RECOMMENDED** in patients with **CROHN's** disease which **IMPROVES SYMPTOMS** but does **NOT CHANGE INFLAMMATORY** markers?
**Mediterranean** Diet (olive oil, fruits and vegetables, nuts and cereals, nor red meat, processed foods or sweets)
187
Which **COLONIC INFECTION** is **COMMON** in **IBD** (**CROHN's** and **UC**) even **WITHOUT** antibiotic exposure?
**C.diff**
188
All patients who **PRESENT** with **IBD FLARE** should be tested for what?
**C.diff**
189
What is the **RECOMMENDED** treatment of **C.diff** in **IBD** patients?
**VANCOMYCIN**
190
If patient with **C.diff** and **IBD** has **PERSISTENT** or **RECURRENT DIARRHEA** what **MUST** be done?
**TEST** for recurrence of C.diff
191
**WHERE** should patients with **IBD** and **C.diff** be treated?
**HOSPITAL**
192
How do you treat an **IBD** patient with **RECURRENT C.diff** infection?
**F**ecal **M**icrobiota **T**ransplant (**FMT**)
193
How many people with **UC** get **POUCHITIS** after an **ILEOANAL** anastomosis?
**50%**
194
Having **PSC**, **SMOKER**, **EXTENSIVE UC**, **BACKWASH ILEITIS**, **pANCA**, **NSAID** use are all **RISK** factors for what **POST-COLECTOMY** issue in **UC** patients?
**POUCHITIS**
195
If you **SUSPECT POUCHITIS** in a post-colectomy **UC** patient, what is the **FIRST STEP**?
**ENDOSCOPIC CONFIRMATION**
196
What is the **PREFERRED INITIAL TREATMENT** for **POUCHITIS**?
**ANTIBIOTICS** (**CIPRO** or **METRONIDAZOLE** x 2 WEEKS)
197
How does **PERIPHERAL ARTHROPATHY** present in **IBD**?
**SYMMETRICAL**, related to **DISEASE ACTIVITY**
198
Which **ARTHROPATHIES** in patients with **IBD MUST** be treated **SEPARATELY** and may **NOT** respond to treatment of the underlying **IBD** that sparked them?
**Ankylosing Spondylitis** and **Sacroileitis**
199
What **IBD** is this manifestation associated with?
**CROHN's** - **Erythema Nodosum** (tibia)
200
What **IBD** is this manifestation associated with?
**UC** - **Pyoderma Gangrenosum** (caused by **TRAUMA** to the skin - around **STOMAS** as well)
201
This manifestation is seen in **IBD** patients treated with what?
**Palmar Plantar Pustulosis** (**anti-TNF**)
202
On a colonoscopy of an **IBD** patient, histology looks like this, what is it?
**DYSPLASIA** (elongated nuclei)
203
What is the **PRIMARY RISK** factor of development of **NEOPLASIA** in **IBD** patients?
HISTOLOGIC **INFLAMMATION**
204
**Smoking** Cigarettes (reduces inflammation), **STATINS**, **5-ASA** drugs and **THIOPURINES** are **ALL PROTECTIVE** factors against formation of **NEOPLASIA** in what?
**IBD**
205
What **ENDOSCOPIC** feature is **PREFERRED** when examining an **IBD** patient?
**High-Definition** White Light (HD) +/- **NBI**
or **DYE-SPRAY CHROMOENDOSCOPY** if standard definition light
206
When a **SUSPICIOUS** lesion is noted in an **IBD** patient, what **INTERVENTION** is **PREFERRED**?
**ENDOSCOPIC RESECTION**
207
What **IBD** serologic marker is **NOT** repliable in **PREGNANCY**? Which one is?
**CRP** (unreliable in pregnancy)
Fecal **CALPROTECTIN** is!!
208
When is it **SAFE** to do an **MRI** for an **IBD** patient that is **PREGNANT**? **COLONOSCOPY**?
**2nd TRIMESTER**
209
Which **IBD** medications are **NOT PREGNANCY SAFE**?
**METHOTREXATE**, **THALIDOMIDE**, **TOFA**citinin (JAK), **UPADA**citinib (JAK), **OZANIMOD** (S1P1,5)
210
Is it **OK** to **VACCINATE IBD** patients?
**YES**
211
Colitis caused by these **ONCOLOGY** drugs looks like IBD?
**CHECKPOINT INHIBITORS** (CTLA-4, PD-1)
212
**WHEN** does **COLITIS** and **DIARRHEA** caused by a checkpoint inhibitor require treatment?
When the **DIARRHEA** is **MODERATE**(4-6 BM/day) to **SEVERE** (>6 BM/day)
213
In a patient taking a checkpoint inhibitor having **4-6 BMs/day**, what is the **TREATMENT**?
**ORAL STEROID** (budesonide) and **STOP** checkpoint inhibitor (moderate diarrhea)
214
In a patient taking a checkpoint inhibitor having **>6 BMs/day**, what is the **TREATMENT**?
**HOSPITALIZATION**, **IV STEROIDS** and if doest stop in **3-5 days**, **INFLIXI**mab or **VEDO**lizumab
215
In a **UC** patient who is **NOT RESPONDING** to **STEROIDS**, what should you check for prior to **MODIFYING** treatment?
**CMV** or **C.diff** Infection (even without takign antibiotics or seeing pseudomembranes)
216
On **SURVEILLANCE COLONOSCOPY**, a patient with **IBD** is noted to have **HIGH-GRADE** dysplasia or **FLAT**, **LOW-GRADE** dysplasia around an adenoma, what do you **RECOMMEND**?
**COLECTOMY**
217
How **OFTEN** do you repeat a **COLONOSCOPY** in an **IBD** patient with **PSC**?
**YEARLY**
218
If a patient presents with **POUCHITIS SYMPTOMS** but **NO POUCHITIS** is noted on **ENDOSCOPY**?
**Irritable POUCH Syndrome**
219
In a patient with **POUCHITIS** that is **LIMITED** to the **ANAL TRANSITION** zone?
**CUFFITIS**
220
In a patient with **POUCHITIS** that is **TRACKING up into the AFFERENT LIMB**?
**CROHN's** DISEASE
221
What **TWO** diseases can **MIMIC IBD**?
**TB** and **LYMPHOMA**
222
What differentiates **HISTOLOGICALLY** diagnosis of **IBD** vs **COLITIS**?
**CHRONICITY** (**CRYPT ABSCESSES**, etc.)
223
If an **IBD** patient presents with **BACK PAIN**, what should you do **NEXT**?
**X-RAY**, then **MRI** (**spondyloarthropathy** - bamboo spine)
224
What **MEDICATIONS** are **PREFERRED** in treating **IBD** in a patient with **JOINT PAINS**?
**SULFASALAZINE** (5-ASA), **METHOTREXARE**, **anti-TNF** and **JAK**tinibs
225
If on a colonoscopy, one finds **< 20 HYPERPLASTIC < 10 mm POLYPS**, when should the next **SCREENING COLONOSCOPY** be?
**10-YEARS**
226
If on a colonoscopy, one finds **>20 HYPERPLASTIC POLYPS or ANY HYPERPLASTIC POLYPS >10 mm or RIGHT COLON HYPERPLASTIC POLYPS**, when should the next **SCREENING COLONOSCOPY** be?
**3-5 YEARS**
