GI: IBS, IBD & Coeliac Disease Flashcards
(111 cards)
1
Q
What are the 2 main types of IBD?
A
1) Ulcerative colitis
2) Crohn’s disease
2
Q
When does IBD typically present?
A
20s
3
Q
General features of IBD?
A
Diarrhoea
Abdominal pain
Rectal bleeding
Fatigue
Weight loss
They are associated with periods of exacerbation and remission.
4
Q
Differentiating features of Crohn’s can be remembered with the “crows” NESTS mnemonic:
A
N - No blood or mucus
E - Entire length of GI tract (i.e. mouth to anus)
S - Skip lesions
T - Transmural (full thicknes) inflammation/terminal ileum most affected
S - Smoking is a risk factor (don’t set the nest on fire)
Crohn’s is also associated with strictures and fistulas.
5
Q
Differentiating features of ulcerative colitis can be remembered with the “you see (UC)” CLOSEUP mneumonic:
A
C - Continuous inflammation
L - Limited to colon and rectum
O - Only superficial mucosa affected
S - Smoking may be protective
E - Excrete blood and mucus
U - Use aminosalicylates
P - Primary sclerosing cholangitis
6
Q
Would mouth ulcers indicate Crohn’s or UC?
A
Crohn’s
7
Q
Give some other conditions that can occur in patients with IBD
A
1) Erythema nodosum
2) Pyoderma gangrenosum
3) Enteropathic arthritis
4) Primary sclerosing cholangitis (particularly UC)
5) Red eye conditions e.g., episcleritis, scleritis and anterior uveitis
8
Q
What is erythema nodosum?
A
Tender, red nodules on the shins caused by inflammation of the subcutaneous fat
9
Q
What is pyoderma gangrenosum?
A
rapidly enlarging, painful skin ulcers
10
Q
What is enteropathic arthritis?
A
a type of inflammatory arthritis
11
Q
Blood tests in IBD?
A
1) FBC (Hb low in anaemia), platelet count (raised in inflammation)
2) CRP
3) U&Es
4) LFTs (can show low albumin in severe disease –> protein is lost in the bowel)
5) TFTs for hyperthyroidism as a cause of diarrhoea
6) Anti-tissue transglutaminase antibodies (anti-TTG) for coeliac disease as a differential diagnosis
7) Vit D and B12 (often low)
12
Q
What is anti-TTG a marker for?
A
Coeliac disease
13
Q
Other investigations in IBD?
A
1) Stool microscopy and culture
2) Faecal calprotectin
3) Colonoscopy with multiple intestinal biopsies
4) Imaging investigations e.g. US, CT and MRI
14
Q
Purpose of LFTs in IBD?
A
can show low albumin in severe disease (protein is lost in the bowel)
15
Q
Purpose of TFTs in IBD?
A
hyperthyroidism as a cause of diarrhoea
16
Q
Purpose of anti-TTG antibodies in IBD?
A
for coeliac disease as a differential diagnosis
17
Q
Purpose of stool microscopy and culture in IBD?
A
to exclude infection as a differential diagnosis (e.g., Salmonella)
18
Q
Purpose of faecal calprotectin in IBD?
A
Is around 90% sensitive and specific for inflammatory bowel disease in adults.
It is used as an initial test before moving on to endoscopy.
19
Q
Investigation of choice in establishing diagnosis in IBD?
A
Coloscopy with multiple intestinal biopsies
20
Q
Purpose of imaging investigations in IBD?
A
to look for complications such as fistulas, abscesses and strictures.
21
Q
Management of mild to moderate acute UC?
A
1st line –> aminosalicylate (e.g., oral or rectal mesalazine)
2nd line –> corticosteroids e.g. oral or rectal prednisolone
22
Q
Management of severe acute UC?
A
1st line –> IV steroids (e.g. IV hydrocortisone)
Other options:
1) Intravenous ciclosporin
2) Infliximab
3) Surgery
23
Q
Curative treatment for UC?
A
Panproctocolectomy –> removing the entire large bowel and rectum
24
Q
Following a panproctocolectomy, the patient has either a permanent ileostomy or an ileo-anal anastomosis (J-pouch).
What is an ileostomy?
A
An ileostomy is where the end portion of the small bowel (ileum) is brought onto the skin with a spout that drains stools directly into a tightly fitting stoma bag.
25
What is a J pouch?
A J-pouch is where the ileum (small bowel) is folded back on itself and fashioned into a larger pouch, which is attached to the anus and functions like a rectum, collecting stools before the person opens their bowels.
26
1st line management of an exacerbation of Crohn's?
Steroids (e.g., oral prednisolone or IV hydrocortisone) first-line
27
What is an alternative to steroids in Crohn's, particularly where there are concerns about steroids affecting growth?
Enteral nutrition --> a specially formulated liquid diet given orally or by NG feed that replaces the patient’s diet.
28
How can enteral nutrition induce Crohn's remission?
1) Treating nutritional deficiencies
2) Improving the gut microbiome
3) Removing inflammatory foods
29
When steroids alone are inadequate in Crohn's, what can be added?
Azathioprine
Mercaptopurine
Methotrexate
Infliximab
Adalimumab
30
1st line for maintaining remission in Crohn's?
1) Azathioprine
2) Mercaptopurine
Maintaining remission in Crohn’s disease is tailored to the individual, based on risks, side effects, nature of the disease and patient wishes. This might also involve no medications.
31
What is an alternative for maintaining remission in Crohn's where 1st line options are not suitable?
Methotrexate
32
Surgical options for Crohn's?
1) Resecting the distal ileum when the disease is isolated to this area
2) Treating strictures
3) Treating fistulas
33
Where does Crohn's disease most commonly affect?
Terminal ileum (but may be seen anywhere from the mouth to anus)
34
Features of Crohn's disease
- non-specific symptoms such as weight loss and lethargy
- diarrhoea: most prominent symptom in adults, may be bloody diarrhoea
- abdo pain
- perianal disease e.g. skin tags or ulcers
- extra-intestinal features
35
Is primary sclerosing cholangitis more common in Crohn's or UC?
UC
36
What is the most common extra-intestinal feature in both CD and UC?
Arthritis
37
Is episcleritis more common in Crohn's or UC?
Crohn's
38
Is uveitis more common in Crohn's or UC?
UC
39
Complications of Crohn's?
small bowel cancer (standard incidence ratio = 40)
colorectal cancer (standard incidence ratio = 2, i.e. less than the risk associated with ulcerative colitis)
osteoporosis
40
Features of UC?
- bloody diarrhoea
- urgency
- tenesmus
- abdominal pain, particularly in the left lower quadrant
- extra-intestinal features
41
Typical findings on coloscopy and biopsy in UC?
red, raw mucosa, bleeds easily
no inflammation beyond submucosa (unless fulminant disease)
widespread ulceration with preservation of adjacent mucosa which has the appearance of polyps ('pseudopolyps')
inflammatory cell infiltrate in lamina propria
neutrophils migrate through the walls of glands to form crypt abscesses
depletion of goblet cells and mucin from gland epithelium
granulomas are infrequent
42
What may be linked to an UC flare?
1) stress
2) medications e.g. NSAIDs, antibiotics
3) cessation of smoking
43
When can a diagnosis of IBS be considered?
If the patient has had the following for at least 6 months:
1) Abdominal pain, and/or
2) Bloating, and/or
3) Change in bowel habit e.g. watery, loose, hard
44
When can positive diagnosis of IBS be MADE?
If the patient has abdominal pain relieved by defecation or associated with altered bowel frequency stool form, in addition to 2 of the following 4 symptoms:
1) altered stool passage (straining, urgency, incomplete evacuation)
2) abdominal bloating (more common in women than men), distension, tension or hardness
3) symptoms made worse by eating
4) passage of mucus
45
Is abdo pain relieved by defecation in IBS?
Yes
46
Is IBS more common in men or women?
Women (more common in younger adults)
47
Symptoms of IBS?
I – Intestinal discomfort (abdominal pain relating to the bowels)
B – Bowel habit abnormalities
S – Stool abnormalities (watery, loose, hard or associated with mucus)
48
Common symptoms in IBS?
Abdominal pain
Diarrhoea
Constipation
Fluctuating bowel habit
Bloating
Worse after eating
Improved by opening bowels
Passing mucus
49
What can IBS symptoms be triggered by?
Anxiety
Depression
Stress
Sleep disturbance
Illness
Medications
Certain foods
Caffeine
Alcohol
50
Top differentials in IBS?
1) Bowel cancer
2) Inflammatory bowel disease
3) Coeliac disease
4) Ovarian cancer (often presents with vague symptoms, particularly bloating in women over 50 years)
5) Pancreatic cancer
51
Investigations for IBS?
Note these will be normal:
1) Full blood count for anaemia
2) Inflammatory markers (e.g., ESR and CRP)
3) Coeliac serology (e.g., anti-TTG antibodies)
4) Faecal calprotectin for inflammatory bowel disease
5) CA125 for ovarian cancer
52
Diagnosis for IBS explained:
NICE suggest before a diagnosis, differentials need to be excluded, and the patient should have at least 6 months of abdominal pain or discomfort with at least one of:
1) Pain or discomfort relieved by opening the bowels
2) Bowel habit abnormalities (more or less frequent)
3) Stool abnormalities (e.g., watery, loose or hard)
For a diagnosis, patients also require at least two of:
1) Straining, an urgent need to open bowels or incomplete emptying
2) Bloating
3) Worse after eating
4) Passing mucus
53
Is IBS better or worse after eating?
Worse
54
Lifestyle advice in IBS?
- Drinking enough fluids
- Regular small meals
- Adjusting fibre intake according to symptoms (more fibre if predominantly constipated, less with diarrhoea/bloating)
- Limit caffeine, alcohol and fatty foods
- Low FODMAP diet, guided by a dietician
- Probiotic supplements may be considered over-the-counter (discontinuing after 12 weeks if there is no benefit)
- Reduce stress where possible
- Regular exercise
55
1st line medications in IBS?
1) Loperamide --> for diarrhoea
2) Bulk-forming laxatives (e.g., ispaghula husk) --> for constipation
3) Antispasmodics for cramps e.g. mebeverine, alverine, hyoscine butylbromide
56
What laxative is AVOIDED in IBS?
Laculose --> can cause bloating
57
Example of antispasmodics used in IBS?
1) mebeverine
2) alverine
3) hyoscine butylbromide
58
Other treatment options in IBS where symptoms remain uncontrolled?
Low-dose tricyclic antidepressants (e.g., amitriptyline)
SSRI antidepressants
Cognitive behavioural therapy (CBT)
Specialist referral for further management
59
What is coeliac disease?
Coeliac disease is an autoimmune condition triggered by eating gluten.
60
Coeliac disease often has a link with other autoimmune conditions.
Which 2 in particular?
1) T1D
2) Thyroid disease
TIP - we test all new cases of type 1 diabetes and autoimmune thyroid disease for coeliac disease, even if they do not have symptoms.
61
What condition should you test for in all new cases of type 1 diabetes and autoimmune thyroid disease? (1)
Coeliac disease --> even if no symptoms
62
Pathophysiology in Coeliac disease?
1) autoantibodies are created in response to exposure to gluten
2) these target the epithelial cells of the small intestine, leading to inflammation
3) coeliac disease causes atrophy of the intestinal villi, resulting in malabsorption.
63
What are the 3 antibodies related to coeliac?
1) Anti-tissue transglutaminase antibodies (anti-TTG)
2) Anti-endomysial antibodies (anti-EMA)
3) Anti-deamidated gliadin peptide antibodies (anti-DGP)
64
Where does inflammation in coeliac affect?
Inflammation affects the small bowel, particularly the jejunum.
65
Coeliac disease is associated with what 2 human leukocyte antigen (HLA) genotypes?
1) HLA-DQ2 (95%)
2) HLA-DQ8 (80%)
66
Presentation of Coeliac?
Asymptomatic and is under-diagnosed - have a low threshold.
Presenting symptoms can include:
- Failure to thrive in young children
- Diarrhoea
- Bloating
- Fatigue
- Weight loss
- Mouth ulcers
- Dermatitis herpetiformis
- Anaemia
IBD is often a differential.
67
Rarely coeliac disease can present with neurological symptoms.
What are some of these symptoms?
1) Peripheral neuropathy
2) Cerebellar ataxia
3) Epilepsy
68
How can coeliac lead to anaemia?
Anaemia occurs secondary to malabsorption and deficiency of iron, B12 or folate.
69
What is dermatitis herpetiformis?
Dermatitis herpetiformis is an itchy, blistering skin rash, typically on the abdomen, caused by coeliac disease.
70
How is coeliac diagnosed?
The patient must continue eating gluten while being investigated. Antibodies and histology may be normal if the patient is gluten-free.
71
1st line blood tests in coeliac?
1) Total immunoglobulin A levels (to exclude IgA deficiency)
2) Anti-tissue transglutaminase antibodies (anti-TTG)
2nd line --> anti-endomysial antibodies (anti-EMA) where there is doubt (e.g., a borderline result).
72
In what conditions should you also screen for coeliac disease?
1) T1D
2) Autoimmune thyroid disease
3) Dermatitis herpetiformis
4) IBS/IBD
5) First-degree relatives (parents, siblings or children) with coeliac disease
73
For what symptoms should you screen for coeliac?
1) Chronic or intermittent diarrhoea
2) Failure to thrive or faltering growth (in children)
3) Persistent or unexplained GI symptoms including N&V
4) Prolonged fatigue ('tired all the time')
5) Recurrent abdominal pain, cramping or distension
6) Sudden or unexpected weight loss
7) Unexplained iron-deficiency anaemia, or other unspecified anaemia
74
Why is it important to look for selective IgA deficiency in coeliac?
IgA deficiency which would give a false negative coeliac result:
1) Initial anti-TTG and anti-EMA antibody tests are IgA.
2) Some patients have an IgA deficiency.
3) When you test for these antibodies, it is important to test for total IgA levels because if the total IgA level is low, the antibody test will be negative, even in a patient with coeliac disease.
4) In this circumstance, you can test for the IgG version of anti-TTG or anti-EMA antibodies.
75
2nd line blood test in coeliac?
Anti-endomysial antibodies (anti-EMA)
76
How to test for coeliac in patients with IgA deficiency?
In this circumstance, you can test for the IgG version of anti-TTG or anti-EMA antibodies.
77
Next investigations in patients with a positive Ab test in coeliac?
Patients with a positive antibody test are referred to a gastroenterologist to confirm the diagnosis by endoscopy and jejunal biopsy.
78
Gold standard for coeliac diagnosis?
Endoscopic intestinal biopsy
79
Biopsy findings that support coeliac disease?
1) villous atrophy
2) crypt hyperplasia
3) increase in intraepithelial lymphocytes
4) lamina propria infiltration with lymphocytes
80
Management of coeliac?
A lifelong gluten-free diet should completely resolve the symptoms.
81
What can help monitor coeliac disease?
Coeliac antibodies
82
Complications of coeliac?
1) anaemia e.g. iron, folate and vitamin B12 deficiency
2) hyposplenism (with immunodeficiency, particularly to encapsulated bacteria such as Streptococcus pneumoniae)
3) osteoporosis, osteomalacia
3) lactose intolerance
4) enteropathy-associated T-cell lymphoma (EATL) of small intestine
5) subfertility, unfavourable pregnancy outcomes
6) rare: oesophageal cancer, small bowel adenocarcinoma
7) Non-Hodgkin lymphoma
8) Ulcerative jejunitis
83
Is folate deficiency or vitamin B12 deficiency more common in coeliac?
Folate
84
Hyposplenism in coeliac can lead to immunodeficiency, particularly to what bacteria?
encapsulated bacteria such as Streptococcus pneumoniae
85
Patients with coeliac disease often have a degree of functional hyposplenism.
For this reason, all patients with coeliac disease are offered which vaccine?
Pneumococcal vaccine:
Coeliac UK recommends that everyone with coeliac disease is vaccinated against pneumococcal infection and has a booster every 5 years
86
Presentation of coeliac in children?
1) Failure to thrive
2) Diarrhoea
3) Abdo distension
4) Older children may present with anaemia
N.B. many cases are not diagnosed to adulthood
87
Give 3 examples of aminosalicylates
Mesalazine, sulphalazine, olsalazine
88
Give some general side effects of aminosalicylates
1) GI upset
2) Headache
3) Agranulocytosis
4) Pancreatitis
5) Interstitial nephritis
89
What is a key investigation in unwell patients taking aminosalicylates?
FBC - risk of agranulocytosis
90
Is pancreatitis more common in patients taking mesalazine or sulfalazine?
7x more common with mesalazine
91
Give some side effects specific to sulphalazine
rashes, oligospermia, headache, Heinz body anaemia, megaloblastic anaemia, lung fibrosis
92
Flares of ulcerative colitis are usually classified as either mild, moderate or severe.
What defines a mild flare?
1) Fewer than four stools daily, with or without blood
2) No systemic disturbance
3) Normal ESR and CRP
93
What defines a moderate flare of UC?
Four to six stools a day, with minimal systemic disturbance
94
What defines a severe flare of UC?
More than six stools a day, containing blood
Evidence of systemic disturbance, e.g.
- fever
- tachycardia
- abdominal tenderness, distension or reduced bowel sounds
- anaemia
- hypoalbuminaemia
95
What is intestinal angina (or chronic mesenteric ischaemia)?
Symptoms?
Most common cause?
Cause --> atherosclerotic disease in arteries supplying the GI tract
Symptoms (triad):
- severe, colicky post-prandial abdominal pain
- weight loss
- abdominal bruit
96
During the first stages of treatment, goserelin may cause a transient increase in symptoms of prostatic cancer.
What can be given alongisde?
Anti-androgen e.g. flutamide
97
What is volvulus?
Volvulus may be defined as torsion of the colon around it's mesenteric axis resulting in compromised blood flow and closed loop obstruction.
98
What is sigmoid volvulus?
Sigmoid volvulus (around 80% of cases) describes large bowel obstruction caused by the sigmoid colon twisting on the sigmoid mesocolon.
99
Features of sigmoid volvulus?
constipation
abdominal bloating
abdominal pain
nausea/vomiting
100
Associations of sigmoid volvulus?
- older patients
- chronic constipation
- Chagas disease
- neurological conditions e.g. Parkinson's disease, Duchenne muscular dystrophy
- psychiatric conditions e.g. schizophrenia
101
Presentation of uveitis vs episcleritis?
Episcleritis:
- most common ophthalmopathy
- presents with discomfort but no eye pain
- redness (scleral injection)
- normal visual acuity
Uveitis:
- redness & pain
- blurred vision
- light sensitivity
- decreased vision
- floaters
102
What is a perianal fistulae?
an inflammatory tract or connection between the anal canal and the perianal skin
103
What is the investigation of choice in a perianal fistula/
MRI
104
1st line management of patients with symptomatic perianal fistulae?
Oral metronidazole
105
Management of a perianal abscess?
incision and drainage combined with antibiotic therapy
106
What is longstanding UC a risk for?
Malignant transformation
107
Surgical option for emergency presentations of poorly controlled UC that fail to respond to medical therapy?
Sub total colectomy
108
Restorative surgery option in UC?
Involve an ileoanal pouch.
109
Best surgical management of severe rectal Crohns that has developed complications such as haemorrhage and multiple fistulae?
Proctectomy
110
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