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IBD Flashcards

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1
Q

What is the age distribution of Crohn’s disease?

A

Bimodal peak age presentation - 15-30 and 60-80 yrs old

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2
Q

What course does Crohn’s disease usually follow?

A

Remitting and relapsing course

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3
Q

What can happen as a result of severe exacerbations of Crohn’s disease?

A

Life-threatening causing:
Systemic upset
Bowel perforation
rarely death

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4
Q

What is the pathophysiology of Crohn’s disease?

A

Can affect any part of GI tract - commonly distal ileum or proximal colon - much of aetiology unknown

Smoking increase risk of developing unlike UC

Transmural inflammation producing deep ulcers and fissures (cobblestone appearance)
Skip lesions

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5
Q

What are the macroscopic changes seen in Crohn’s disease?

A

Discontinuous inflammation (skip lesions)

Fissures and deep ulcers (cobblestone appearance)

Fistula formation

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6
Q

What are the different types of fistula that can form in Crohn’s disease?

A

Perianal fistula (54% of pts)

Entero-enteric fistula (24%)

Recto-vaginal (9%)

Entero-cutaneous fistula

Entero-vesicalar fistula

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7
Q

What is the microscopic change seen on Crohn’s disease?

A

Non-caseating granulomatous inflammation

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8
Q

What are the risk factors for Crohn’s disease?

A

Strong FH

Smoking (developing and relapse)

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9
Q

What are the typical symptoms of Crohn’s disease?

A

Episodic abdominal pain - colicky in nature and site varies depends on region affected

Diarrhoea - often chronic and may contain blood or mucus

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10
Q

What are some systemic symptoms of Crohn’s disease?

A

Malaise

Anorexia

Low grade fever

Malabsorption and malnourishment if severe - late presenting feature (children may intially present as failure to grow or thrive)

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11
Q

What is the oral involvement in Crohn’s disease?

A

Oral aphthous ulcers (can be painful and recurring)

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12
Q

What is the perianal involvement of Crohn’s disease?

A

Perianal disease, including with peri anal abscess

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13
Q

What are the different types of extra-intestinal manifestations of IBD?

A

Musculoskeletal

Skin

Eyes

Hepatobiliary

Renal

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14
Q

What are the musculoskeletal manifestations of IBD ?

A

Enteropathic arthritis (sacroiliac and other large joints)

Nail clubbing

Metabolic bone disease (secondary malabsorption)

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15
Q

What are the skin manifestations for IBD?

A

Erthyema nodosum

Pyoderma gangrenosum (erthyemstous papules/pustules that develop into deep ulcers)

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16
Q

What are the eye manifestations of IBD?

A

Episcleritis
Anterior uveititis
Iritis

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17
Q

What are the hepatobilary manifestations of IBD?

A

Primary sclerosing cholangitis (more associated with UC)

Cholangiocarcinoma (associated with PSC)

Gallstones

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18
Q

What is the renal manifestation of IBD?

A

Renal stones

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19
Q

What investigations should be order for suspected Crohn’s disease?

A

Routine bloods - CRP/WCC - check for anaemia

Faecal calprotectin test

Stool sample for potential infective cause

Colonoscopy is GOLD standard - biopsies are taken

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20
Q

When can colonoscopy not be used to make diagnosis of Crohn’s disease?

A

When disease more proximal to terminal ilium - presumed diagnosis on clinical features and imaging alone

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21
Q

What other investigations may be warranted in Crohn’s disease and wha are they looking for?

A

CT scan abdomen pelvis - severe Crohn’s disease, look for bowel obstruction or perforation or any intra-abdominal collections - useful in acute phase when colonoscopy contraindicated

MRI imaging - asses disease severity for any eneteric fistula or peri-anal disease.
Examination under anaesthesia (EUA) with proctosigmoidoscopy - examine and treat perianal fistula.

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22
Q

Where should pts with IBD be managed?

A

Referred to gastroenterologist

Acute severe disease should be admitted on an emergency basis

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23
Q

What is done to induce remission in Crohn’s disease?

Study These Flashcards
A

Fluid resuscitation, nutritional support and prophylactic heparin and anti-embolic stocking (pro thrombotic state of IBD flares)

Corticosteroid therapy as first line.

Subsequent treatments including - immunosuppressive agents (mesalazine, azathioprine) or biological agents (infliximab or adalimumab)

24
Q

What is the severity classification of Crohn’s disease?

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A

Montreal score:

Age at diagnosis

Location

Behaviour - e.g. stricture or no stricture add a “p” if concurrent perianal disease

25
What is the managing remission treatment for Crohn’s disease?
Azathioprine - first line mono therapy Smoking cessation Colonoscopic surveillance is offered offered to those who have had the disease for >10years with>1 segment of bowel affected
26
What other support should be offered for IBD?
IBD-nurse specialist and pt support groups Enteral nutritional support - young pts with growth concerns
27
What percentage of Crohn’s disease pts require surgical management in their lifetime?
70-80%
28
When is surgical management indicated in Crohn’s disease?
Failed medical management Severe complications (strictures or perforation) All operations bowel-sparing approach should be taken to avoid short gut syndrome in later years.
29
Which types of surgery are usually requires in Crohn’s disease?
- Ileocaecal resection (removal of terminal ileum and caecum with primary anastomosis) - Small bowel resection or large bowel resection - Surgery for peri-anal disease (e.g. abscess drainage, seton insertion, or laying open of fistulae) - Stricturoplasty (division of a stricture that is causing bowel obstruction) CD patients are typically high risk patients to operate on, therefore pre-operative optimisation (including treating any acute attack and managing nutrition) should be attempted where possible.
30
When should primary bowel anastomosis not be performed in Crohn’s disease?
Active severe flare up Or not at least without defunctioning stoma
31
What are the complications of Crohn’s disease?
Fistula Stricture formation Recurrent perianal fistulae - difficult to treat GI malignancy
32
What are the extraintestinal complications of Crohn’s disease?
Malabsorption - growth delay in children Osteoporosis - due to malabsorption or long term steroid use Increased risk of gallstones - reduced reabsorption of bile at terminal ilium Increased risk of renal stones - malabsorption of fats in small bowel which causes calcium to remain in lumen but oxalate is absorbed. Results in hyperoxaluria and formation of oxalte stones in renal tract.
33
Which drugs should be avoided in IBD and why?
Anti-motility such as loperamide. Avoid in acute attacks as these can precipitate toxic mega colon.
34
What is the prevalence and incidence of UC?
More common in Caucasian population Bimodal distribution - 15-25, 55-65 yrs old
35
What may occur in a severe fulminant exacerbation of UC?
Life threatening: Severe systemic upset Toxic megacolon Colonic perforation Death
36
What is a protective factor in UC?
Smoking
37
What is the pathophysiology of UC?
Diffuse continual mucosal inflammation of the large bowel. Beginning in the rectum and spreading proximally Portion of terminal may be affected if ileocaecal valve is not competent - backwash ileitis Hyperaemic/haemorrahigic colonic mucosa
38
What are the macroscopic changes seen in UC?
Continuous inflammation Pseudo-polyps (raised areas du to repeated cycles of ulcerations and healing) and ulcers may form
39
What are the microscopic changes that may occur in UC?
Crypt abscess formation Reduced (hypoplasia) goblet cells Non-granulomatous inflammation
40
What are the symptoms of UC?
Insidious onset. Cardinal feature is bloody diarrhoea, with visible blood in stool in more then 90% of cases. More likely if widespread colonic involvement + features of dehydration and electrolyte imbalance. Proctitis PR bleeding and mucus discharge Increased frequency and urgency of defecation and tenesmus
41
What are some systemic signs of UC?
Malaise Anorexia Low-grade pyrexia
42
What may be found on clinical examination of UC?
Unless severe exacerbation, generally unremarkable. Fulminant colitis, toxic megacolon or colonic perforation should be suspected if pt complains of severe abdominal pain and if signs of peritonism are present.
43
Which criteria can be used to grade the severity of UC exacerbations?
True love and Witt criteria
44
What are the diffential diagnosis of UC?
Crohn’s disease Chronic infections Mesenteric ischemia Radiation colitis Malignancy, IBS or coeliac disease
45
What investigations should be order for UC?
Routine bloods - CRP/WCC Faecal calprotectin - raised in IBD but normal in IBS. Stool sample Colonoscopy with biopsy
46
Which scores are used in UC?
Montreal score - quantify disease extent Mayo score - disease severity
47
What imaging may be order in acute exacerbations of UC?
AXR | CT imaging
48
What may be seen on AXR of UC?
Mural thickening and thumb printing Chronic cases - lead-pipe colon
49
What is the inducing remission management of UC?
Fluid resuscitation, nutritional support and prophylactic heparin Corticosteroid therapy and immunosuppressive agents such as cyclosporin or 5-ASA suppositories. Biological agents such as infliximab can be trialled as rescue therapy. Stepwise approach depending on clinical severity and location of exacerbation.
50
What is the maintaining remission management of UC?
Immunomodulators - typically 5-ASAa such as mesalazine or sulfaslazine or azathioprine Colonoscopic surveillance
51
How much percentage of pts with UC will require surgery?
30%
52
What are the indications for surgery in UC?
Refractory to medical treatment Toxic megacolon Bowel perforation
53
What are the surgical options for UC?
Depends on patient and disease factors Segmental bowel resection (subtotal colectomy) and defunctioning, as primary anastomosis during acute IBD flare is advised Elective cases - total proctocolectomy is curative (requires end ileostomy) or Can undergo subtotal colectomy with ileo-rectal anastomosis (IRA) or Panprotoctocolectomy with Leo-pouch anal anastomosis (IPAA)
54
What are the complications of UC?
Toxic megacolon Colorectal carcinoma Osteoporosis Pouchitis - inflammation of ideal pouch - IPAA
55
What are the symptoms of toxic megacolon and treatment?
Severe abdominal pain, abdominal distension, pyrexia and systemic toxicity Decompression of the bowel asap due to increased risk of perforation
56
What are the symptoms of pouchitis and what is the treatment?
Abdominal pain Bloody diarrhoea Treated with metronidazole and ciprofloxacin

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