IBD

Question 1

What is the most common extra-intestinal manifestation of IBD?

Answer 1

Arthritis

Question 2

What extra-intestinal skin changes can be seen in IBD?

Answer 2

Erythema nodosum and pyoderma gangrenosum.

Question 3

What is a major complication of UC?

Answer 3

Toxic mega colon.

Question 4

Uveitis is strongly associated with CD or UC?

Answer 4

UC

Question 5

Which hepatobiliary pathology is associated with UC?

Answer 5

Primary sclerosing cholangitis (PSC).

Question 6

Which classification system can be used to assess the severity of UC?

Answer 6

Truelove & Witts’ (classifies into mild, moderate and severe).

Question 7

What is the MOA of thiopurines (azathioprine and mercaptopurine)?

Answer 7

Purine synthesis inhibition in lymphocytes leading to immunosuppression.
Must check TPMT enzyme activity before use.

Question 8

What is the MOA of methotrexate?

Answer 8

Inhibits dihydrofolate reductase, having both immunomodulatory and anti-inflammatory properties.

Question 9

What is the MOA of infliximab and adalimumab?

Answer 9

TNF alpha inhibitor.

Question 10

Patients with CD and UC have an increased risk of which cancer?

Answer 10

Colorectal cancer.

Question 11

What are the differences between CD and UC?

Answer 11

CD: affects entire GI tract, skip lesions, transmural inflammation, smoking is a risk factor.
UC: affects rectum and colon, continuous inflammation, superficial mucosa affected, smoking is protective.

Question 12

Which part of the GI tract is most commonly affected in CD?

Answer 12

Terminal ileum.

Question 13

What is the aetiology of IBD?

Answer 13

Abnormal immune response to normal intestinal microflora within a genetically susceptible individual. Th1 response —> proinflammatory cytokines e.g. INF alpha.

Question 14

What are the histological features of CD?

Answer 14

Cobblestone appearance, rose thorn ulcers, lymph node hyperplasia, narrowing of lumen, thickening of intestinal wall, skip lesions, non-caseating granulomas.

Question 15

What are the histological features of UC?

Answer 15

Inflammatory polyps, crypt abscesses, goblet cell depletion, superficial inflammation and ulcers.

Question 16

UC that affects only the rectum is known as…

Answer 16

Proctitis

Question 17

Name 2 other variations of UC

Answer 17

Left-sided colitis, pancolitis.

Question 18

What are the clinical features of CD?

Answer 18

Diarrhoea (+/- blood), abdominal pain, weight loss, fever, fatigue, perianal disease, aphthous stomatitis.

Question 19

What are the clinical features of UC?

Answer 19

Bloody diarrhoea, rectal bleeding, abdominal pain, increased frequency/urgency, fatigue, fever.

Question 20

What is perianal disease?

Answer 20

Skin tags, fissures, fistulae, abscesses —> rectal bleeding.

Question 21

Name the marker of intestinal inflammation

Answer 21

Faecal calprotectin.

Question 22

How can IBD definitively be diagnosed?

Answer 22

Endoscopy and biopsy.

Question 23

Describe the management plan for inducing remission in CD

Answer 23

First line: glucocorticoids e.g. oral prednisolone.
Aminosalicylates.
Add on therapy: steroid + other drugs e.g. azathioprine, mercaptopurine, methotrexate.
Biological agents: adalimumab, infliximab.

Question 24

Describe the management plan for maintaining remission in CD

Answer 24

First line: azathioprine, mercaptopurine.
Methotrexate.
Infliximab, adalimumab.

Question 25

What are the surgical treatment options for CD?

Answer 25

Surgical resection of distal ileum or ileocaecal resection. Hemicolectomy. Colectomy (with ileostomy or ileo-rectal anastomosis). Proctocolectomy.

Question 26

Describe the management plan for inducing remission in mild-moderate UC

Answer 26

First line: aminosalicylates e.g. mesalazine oral or rectal. Glucocorticoids e.g. prednisolone. Tofacitinib (JAK inhibitor).

Question 27

Describe the management plan for inducing remission in acute severe UC

Answer 27

First line: IV hydrocortisone. IV ciclosporin. Infliximab.

Question 28

What is the MOA of ciclosporin?

Answer 28

Inhibits T cell activation and differentiation.

Question 29

Describe the management plan for maintaining remission in UC

Answer 29

Aminosalicylates. Azathioprine or mercaptopurine.

Question 30

What is the name of the surgery to remove the colon and rectum in UC?

Answer 30

Proctocolectomy

Question 31

What happens after a proctocolectomy?

Answer 31

Patient left with either an ileostomy or ileo-anal anastomosis (J-pouch).

Question 32

What is a J-pouch?

Answer 32

It attaches to anus and collects stools prior to defecation.

Question 33

Why is an ileostomy spouted?

Answer 33

Prevents skin irritation from small bowel contents produced by stoma.

Question 34

Describe classification of UC severity

Answer 34

Mild: < 4 stools/day, small amount of blood. Moderate: 4-6 stools/day, varying amounts of blood, no systemic upset. Severe: > 6 stools/day + features of systemic upset (pyrexia, tachycardia, anaemia, raised inflammatory markers).

Question 35

If a mild-moderate flare of UC doesn’t respond to topical aminosalicylates, what is the next step?

Answer 35

Add oral aminosalicylates

Question 36

What is a key haematological adverse effect of aminosalicylates?

Answer 36

Agranulocytosis

Question 37

Pancreatitis is a side effect of which aminosalicylate?

Answer 37

Mesalazine

Question 38

Heinz body anaemia is associated with which drug?

Answer 38

Sulphasalazine

Question 39

Inflammation of bowel limited to mucosa and submucosa is characteristic of…

Answer 39

UC

Question 40

A 22 year old man is investigated for weight loss and diarrhoea. A rectal biopsy is taken and reported as follows: ‘Deep inflammatory infiltrate from mucosa to muscularis externa. Numerous granulomata noted.’ What is the most likely diagnosis?

Answer 40

CD.

Question 41

What is the treatment for complex perianal fistulas in patients with CD?

Answer 41

Draining seton

Question 42

What is the management of haemorrhoids and anal fissures?

Answer 42

Lidocaine gel (analgesia), increased dietary fibre, increased oral fluids and laxatives.

Question 43

Topical glyceryl trinitrate can be used to treat…

Answer 43

Anal fissures - relaxes sphincter muscles, improving blood flow to area, enabling healing. Also provided analgesia.

Question 44

Why is CD associated with gallstones?

Answer 44

Bile salts aren’t absorbed due to inflammation of terminal ileum.

Question 45

What is the management for a peri-anal abscess?

Answer 45

Incision and drainage.

Question 46

A severe flare in UC should be treated with…

Answer 46

IV steroids

Question 47

If a mild-moderate flare of UC does not respond to topical or oral aminosalicylates, what should be tried next?

Answer 47

Oral corticosteroids

Question 48

In patients with severe colitis what method of endoscopy is preferred?

Answer 48

Flexible sigmoidoscopy - colonoscopy should be avoided due to the risk of perforation.