IBD

Question 1

Inflammatory bowel disease (IBD) includes ______ and ________

Answer 1

Crohn’s disease
Ulcerative colitis

Question 2

IBD is characterised by…

Answer 2

Inflammation of the gut mucosa with diarrhoea, rectal bleeding, abdominal pain, and weight loss.

Question 3

What two features distinguishes Crohn’s from UC

Answer 3

The location and type of inflammation distinguishes CD from UC

Question 4

UC - location and type of inflammation

Answer 4

Affects the colon only with continuous mucosal inflammation extending proximally from the anus

Question 5

Crohn’s - location and type of inflammation

Answer 5

Can affect anywhere in the GI tract, including the stomach, jejunum, the terminal ileum and/or colon with transmural inflammation and is often discontinuous

Question 6

Peak incidence of IBD is between ________ years but may occur at any age

Answer 6

15 and 35 years

Question 7

Diagnosis of IBD is made by _________

Answer 7

Colonoscopy and biopsy

Question 8

Consider either IBD or colorectal cancer if what symptoms?

Answer 8

Diarrhoea with urgency, PR bleeding, abdo pain, and weight loss.
Nocturnal symptoms, such as diarrhoea or abdominal pain, are waking the patient.
Functional diarrhoea, e.g. IBS, usually stops at night.

Question 9

Smoking relationship to Crohn’s

Answer 9

Smoking increases the risk of developing Crohn’s disease.

Question 10

Smoking relationship to UC

Answer 10

Smoking cessation can precipitate ulcerative colitis.

Question 11

Extra-intestinal manifestations of IBD

Answer 11

Skin, e.g. erythema nodosum, pyoderma gangrenosum
Arthritis (axial and peripheral)
Eye, e.g. uveitis, episcleritis, iritis
Mouth ulcers
Night sweats
Abnormal liver enzymes, e.g. primary sclerosing cholangitis

Question 12

Examination for suspected IBD

Answer 12

Check temperature, HR, BP
Abdomen, and rectum for PR bleeding and perianal disease, e.g. abscesses, fistula, fissures.

Question 13

If fever, tachycardia, hypotension, or significant abdominal pain in a patient with IBD then suspect…

Answer 13

Megacolon, perforation, bowel obstruction, or an abscess

Question 14

Initial investigations if suspected IBD

Answer 14

CBC, CRP, LFT, electrolytes
Coeliac markers
Faecal culture, including ova/parasites
Clostridium difficile (C. diff) toxin
Faecal calprotectin

Question 15

Blood test findings suggestive of IBD

Answer 15

Anaemia
Leucocytosis
Thrombocytosis
Increased CRP

Question 16

Does a normal faecal calprotectin rule out IBD?

Answer 16

A negative faecal calprotectin, i.e. less than 50 micrograms/L makes IBD extremely unlikely

Question 17

If blood tests suggestive of IBD and first presentation what should you do?

Answer 17

Ref gastro + request colonoscopy
If acutely unwell –> ref acutely

Question 18

Bloods that should be checked annually when patient is in remission

Answer 18

Iron stores
Vitamin B12
Folate
Zinc
CRP

Question 19

4 groups of medications that are used for either acute episodes or as maintenance treatment of inflammatory bowel disease (IBD)

Answer 19

Aminosalicylates (ASA)
Steroids (prednisone)
Immunomodulators
Biologics

Question 20

Consider the risk of immunosuppression in patients on _____________. Add an alert to patient notes. Recall patients for _________

Answer 20

Steroids, thiopurines, methotrexate and the biologics
Recall - annual influenza vaccinations and three yearly cervical screening

Question 21

Examples of aminosalicylates

Answer 21

Mesalazine (e.g., Pentasa, Asacol)
Olsalazine sodium
Sulfasalazine

Question 22

____________ are the core drugs for ulcerative colitis and are tried first-line for remission and maintenance

Answer 22

Aminosalicylates (ASA)

Question 23

All ASAs can cause __________. Advise patients to look out for ________

Answer 23

Blood disorders

Advise patients to report any unexplained bleeding, bruising, purpura, sore throat, fever or malaise that occurs during treatment.

Question 24

Which ASA is used more commonly

Answer 24

Mesalazine - effective and well tolerated

Question 25

Why is sulfasalazine used less commonly now?

Answer 25

Due to side-effects (headache, nausea, diarrhoea) and intolerance

Question 26

What route of administration do ASA's come in?

Answer 26

Rectal therapies (e.g., suppositories and enemas) are effective for distal disease and are given in addition to oral ASA

Question 27

When would you give ASA as an enema or suppository?

Answer 27

Suppositories - for rectal disease Enemas - for disease distal to the splenic flexure

Question 28

Are ASA's effective in Crohn's?

Answer 28

ASAs probably only have a very limited effect in active Crohn's disease

Question 29

For mesalazine and olsalazine when do adverse effects usually occur?

Answer 29

Within the first 3 months of therapy

Question 30

Blood test monitoring for mesalazine and olsalazine

Answer 30

CBC, AST, and ALT, creatinine Before initiation After 3 months Then annually if stable

Question 31

Indications for steroids (prednisone) in IBD

Answer 31

Can be used to obtain remission either initially for more severe disease or in flare-ups for both UC and Crohn’s

Question 32

Duration of course of steroids in IBD to achieve remission or flare ups

Answer 32

Usually 8 weeks and slowly reduce, otherwise an early relapse can occur.

Question 33

Can you use steroids for maintenance therapy?

Answer 33

Note that steroids have no role in maintenance therapy.

Question 34

Consider using what route of administration of steroids in patients with proctitis?

Answer 34

Topical treatment, such as enemas in those with proctitis (inflammation in the rectum)

Question 35

What should you offer at the same time as the steroid course?

Answer 35

Offer bone protection with calcitriol (0.5 micrograms daily) and calcium carbonate (depending on dietary calcium intake) at the same time as the steroid course.

Question 36

Examples of immunomodulators used in IBD

Answer 36

Azathioprine Methotrexate (second-line), oral or subcutaneous

Question 37

Examples of biologics used in IBD

Answer 37

Stelara Infliximab (Remicade) Adalimumab (Humira and Amgevita)

Question 38

Special considerations re COCP in IBD

Answer 38

Absorption may be reduced if there is small bowel involvement in Crohn's

Question 39

In IBD, the main factor in fertility relates to___________

Answer 39

Good disease control I.e. the better the disease control, the more likely to get pregnant

Question 40

Which IBD medication needs to be stopped when planning a pregnancy / during a pregnancy

Answer 40

Methotrexate

Question 41

ASA in pregnancy and breastfeeding

Answer 41

It is safe to continue aminosalicylates (ASA) in pregnancy and breastfeeding

Question 42

Steroids in pregnancy

Answer 42

Steroids may be associated with cleft palate in first trimester but should be used if required to control disease. Discuss with a gastroenterologist if unsure.

Question 43

In UC and Crohn's disease, long-term use or recurrent courses of________ is not appropriate. Request non-acute gastroenterology assessment for _______ treatments.

Answer 43

Prednisone Steroid-sparing treatments

Question 44

Criteria for an acutely unwell patient with ulcerative colitis

Answer 44

>6 bloody BM/day , plus ≥1 of the following: Temperature > 37.8°C Heart rate > 90 Hb < 105 CRP > 30

Question 45

Investigations in flare ups

Answer 45

Faecal culture and C. diff toxin. Relapses are often associated with pathogens or due to C. diff after antibiotics. Blood tests – CBC, CRP, LFT, electrolytes.

Question 46

Medication for acute flare up in UC

Answer 46

Optimise 5-Aminosalicylate (5-ASA) - Increase oral 5‑ASA - Start rectal 5‑ASA (e.g. suppositories/enemas)

Question 47

Flare up in UC - what to do if on max 5‑ASA or limited response after 1 week

Answer 47

Start prednisone and request non-acute gastroenterology assessment to consider starting an immunomodulator or changing the current medications.

Question 48

Medication for acute flare up in Crohn's

Answer 48

Start prednisone Refer gastro to consider starting an immunomodulators or biologic

Question 49

Can consider __________ as an alternative to steroids in the treatment of acute Crohn’s flare. This should be done with the support of a specialist dietitian.

Answer 49

Exclusive enteral nutrition

Question 50

In acute IBD flare - it may be more appropriate to arrange an urgent gastroenterology assessment, especially if a patient is already on __________

Answer 50

An immunomodulator or biologic.