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Flashcards in Gastrointestinal Deck (59):
1

What is crohn's disease?

Immune related disorder that causes inflammation in the bowel (thought to be an uncontrolled inflammatory reaction to a pathogen which leads to the destruction of healthy tissue - this is different to an autoimmune disease)

2

What is the most common place for crohns disease to affect?

Ileum and colon

3

What are symptoms of crohns disease in the mouth?

Ulcer
Swollen lips
Angular chelitis

4

What are symptoms of crohns disease in the small intestine?

Right lower quadrant pain (associated with the ileum)
B12 deficiency
Diarrhoea
Weight loss

5

What are symptoms of crohns disease in the colon?

Lower abdominal pain
Bloody diarrhoea
Weight loss

6

What are symptoms of crohns disease in the anus?

Abscess
Fistula
Sphincter damage

7

Is there a genetic link to IBD? if so what is it?

Yes, a positive family history is the major risk factor for disease development
Early onset disease appears to have the strongest genetic links.
The risk in first degree relatives in between 2 - 16%.
In twins the concordance for crohns disease is 36% and 16% for UC

8

Where does ulcerative colitis affect?

The rectum and ascends proximally

9

What are the three main types of UC?

Proctitis (36%)
Left sides colitis (27%)
Pancolitis (37%)

10

What are the main symptoms of ulcerative colitis?

Determined by disease extent and severity
- Diarrhoea and bleeding
- Increased bowel frequency
- Urgency
- Tenesmus
- Incontinece
- Night rising
- Lower abdominal pain (LIF especially)

11

How is the severity of ulcerative colitis assessed?

Truelove and Witt criteria assesses for severe UC (Severe UC has a 30% risk of colectomy)
More than 6 bloody stools in 24 hours +
1 or more of..
- Fever over 37.8 degress
- Tachycardia of over 90
- Haemoglobin less than 10.5g/dl
- Elevated ESR over 30mm/hr

12

What might you see in a plain abdominal X Ray of ulcerative colitis?

- No stool in an inflammed colon
- Mucosal oedema ('thumb printing')
- Toxic megacolon (transverse more than 5.5cm and caecum over 9cm)

13

What is toxic megacolon?

The inflammation becomes so sever that the tone of the bowel is affected.

14

What do you see on a colonoscopy of UC?

Confluent inflammation extending from the anal margn to a transition zone
- Loss of vessel pattern
- Granular mucosa
- Contact bleeding
- Pseudopolyps (occur as a result of past inflammation)
- Loss of haustra
- Crypt distortion

15

What does the histology of crohns disease show?

Only affects mucosal layer
Absence of goblet cells
Crypt distortion and abscess

16

What are the long term complications of ulcerative colitis?

Increased risk of colorectal cancer (severity of inflammation, duration of disease and the extent of disease)
Extensive colitis (beyond the splenic flexure) requires cancer surveillance after 10 years of disease

17

What are some of the extra intestinal manifestations of ulcerative colitis?

Eyes
- Episcleritis
- Uveitis
Mouth
- Stomatitis
Skin
- Pyoderma gangrenosum
- Erythema nodosum
Joints
- Spondylitis
- Sacroilitis
- Peripheral arthritis
Kidneys
- Stones (oxalate renal stones)
- Hydronephrosis
- Fistulae
- UTI
Derangned LFTs

18

What is primary sclerosing cholangitis?

Chronic inflammatory disease of the biliary tree
Most people are asymptomatic but may have an itch or rigors.
Cholestatic LFTS
80% have associated IBD (usually UC)

19

What are the long term complications of PSC?

Median time to death/lover transplant in 10 years
15% of patients get cholangiocarcinoma

20

Describe the pattern of disease in crohn's disease?

- It can affect any region of the GI tract from the mouth to the anus
- Skip lesions (ie disease free areas)
- Transmural inflammation)
- Per anal disease (recurrent abscesses, pain, fistula leading to leakage, sphincter damage)

25% of people have continuous disease
50% of people have intermittent flares
75% require surgery within 8 - 10 years

Much more aggressive disease than UC

21

What blood tests would you need if you suspected someone had IBD?

CRP (this correlates well with disease activity)
Albumin (low)
Platelets (increases with inflammation)
B12 (low as absorbed in terminal ileum)
Ferritin

22

What investigations do you do to stage the disease activity in crohn's disease?

Colonoscopy
Endoscopy

23

What would you seen on endoscopy of the bowel affected with crohns diseae?

Cobblestoning mucosa
Fissures
Wall thickening

24

What is the histology associated with crohn's disease?

Granulomas
Patches of disease then patches of normal mucosa
Inflammation in all layers from mucosa to serosa

25

What investigations are used to assess the severity of crohns disease?

Barium follow through
Small bowel enema - highly sensitive and specific for disease of the terminal ileum
Small bowel MRI
Technetium labelled white cell scan

26

What is the main lifestyle advice to give to people with crohn's?

Stop smoking
Diet may help symptoms

27

What is the treatment to induce remission in ulcerative colitis?

Topical 5ASA (mesalazine)
An oral 5ASA can also be added
If there is no improvement within 4 weeks then an oral steroid can be added
If there is still no improvement then oral tacrolimus can be added.

28

What is the treatment to induce remission in ulcerative colitis if the patient cannot have a 5ASA?

Topical corticosteroid or oral prednisolone

29

What are the treatments used to maintain remission in people with ulcerative colitis?

1. Topical ASA
2. Oral ASA
3. Azathioprine or mercapturine

30

What drug do you need to avoid giving with azathiprine?

Allopurinol

31

Give examples of some of the 5 ASA (Aminosalicylates) drugs that are currently used?

Sulphasalazine
Mesalazine
Pentasa

32

How does mesalazine work?

Acts locally on colonic mucosa (full mechanism not entirely understood)

33

How long and at what dose are steroids usually given to induce remission in UC?

Short course initially a high dose but slowly reducing over 6 - 8 weeks.

34

What is mechanism of azathioprine?

- A pro drug for mercaptopurine
- Inhibits purine synthesis and therefore less DNA and RNA are formed
- This means that less white blood cells are made which causes immunosuppression

35

How quickly does azathioprine work?

It has a slow onset of action (16 weeks)

36

What are the main potential side effects of azathioprine?

Pancreatitis
Leucopenia
Hepatitis
Lymphoma
Skin cancer (makes you more sensitive to the sun)

37

Give examples of the anti TNF therapies used in IBD?

Infliximab - IV infusion s
Adalimumab - SC injection

38

Describe how anti TNF therapy works in IBD?

- TNF is an important part of the body's defence against infection. It is the first cytokine to appear in the blood and it triggers the release of other cytokines such as IL 1 and IL 6.
- Anti TNF therapy is a monoclonal antibody that attaches to TNF and disables causes apoptosis of activated T lymphocytes
- Rapid onset of action
- 30 - 40 % of people will go into remission after a single infusion of anti TNF

39

What are the risks of anti TNF therapy?

Infusion reactions
Infection (have to make sure patients don't have current infection/ latent TB)
Increases risk of lymphoma and sold tumours

40

What is the first line drug for inducing treatment in crohn's disease?

Steroids (required as it is more aggressive than UC)

41

What is peutz jeghers syndrome?

An autosomal dominant condition characterised by numerous hamartomatous polyps in the GI tract. It is also associated with pigmented freckles on the lips, face, palms and soles.
Around 50% of patients will have died from a GI tract cancer by age 60.
Management is conservative unless complications develop

42

If you are getting an endoscopy when should you stop your PPI?

2 weeks before

43

What is the mechanism of action for terlipressin?

An analogue of vasopressin (ADH) used in the management of low blood pressure (upper GI bleeds)

44

What investigations do you do if someone has had an upper GI bleed?

FBC
U & E
LFTs
Cross match 4 - 6 units
Endoscopy

45

What investigations do you do if you suspect acute pancreatitis?

FBC, LFTs, U & E
Amylase
Glucose
USS
CT abdo if in doubt

46

What bacteria comes from dairy/ meat and causes profuse vomiting within 6 hours?

Staph aureus

47

Rapid onset vomiting after rice

Bacillus cereus

48

Which bacteria is mainly found in meat and prevents with diarrhoea and cramps

Clostridium perfringens

49

List 6 bacterial causes of gastroenenteritis that present with 12 - 72 hours of digestion?

1. Campylobactor Jejuni
2. Salmonella enterititis
3. Cholera
4. E Coli
5. Shigella
6. C Difficile

50

What neurological disease can be precipitated by campylobacter gastroenteritis?

guillan barre

51

Which bacterial gastroenenteritis presents with blood stools, colicky pain and is caused by meat or dairy?

Campylobacter

52

Which bacteria causes rice water stools?

Cholera

53

Which bacteria is spread by faceal oral route and mainly affects the elderly and children?

Salmonella enterititid

54

How does shigella act and present?

Invades enterocytes and produces bloody stools

55

How does E Coli act and present?

Travellers diarrhoea
Invades enterocytes and can produce bloody stools.
Can cause HUS in children

56

How do you treat C Difficile?

1. Metronidazole
2. Vancomycin

57

Which bacteria causes a psuedomembranous colitis?

C Difficile

58

What is giardiasis?

Parasitis disease caused by flagellated protozoa giardia lamblia

Causes diarrhea, pain, weight loss.

Usually begins 1 - 3 weeks after exposure and without treatment may last up to 6 weeks.

59

How do you treat giardiasis?

Metronidazole