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Flashcards in IBD Deck (50):
1

Patho of IBD

Exact mechanism unknown but thought the be a combination of factors including:
- damage to epithelial mucin proteins and tight junctions
- breakdown of homeostatic balance between host's mucosal immunity and enteric microflora
- genetic polymorphisms in toll-like receptors
- disrupted homeostatic balance between regulatory and effector T cells
- Host immune response to own gut flora
- imbalance and deregulation between regulatory and effector T cells

2

Where is IBD prevalent and why?

W. world due to diet and environment

3

Two types of IBD

ulcerative colitis and Crohn's disease

4

Which IBD disease has a higher incidence

ulcerative colitis

5

Age for Ulcerative colitis

15-30 and 50-70 (bimodal)

6

What is most important in ulcerative colitis

family history

7

Who has the highest risk factor of ulcerative colitis

Ashkenazi jews

8

What environmental factors affect ulcerative colitis?

- smoking decreases risk of flares
- history of prior GI infections (shigella, salmonella, campylobacter) changes gut flora--> chronic inflammatory process
- weak association btw NSAID/OCP and UC
- stress is not a trigger

9

Clinical UC

- symptoms wax and wane
- rectal bleeding
- bloody diarrhea
- fecal urgency
- tenesmus
- abdominal pain LLQ and suprapubic pain
- abdominal tenderness
- aphthous oral ulcers
- iritis- severe eye pain and photophobia
- seronegative arthritis with flares
- erythema nodosum on lower extrem. and extensors
- autoimmune hemolytic anemia
- primary sclerosing cholangitis

10

Clinical Mild UC

- gradual onset of diarrhea less than 4 days and intermittent bloody mucoid stool
- urgency and tenesmus
- LLQ cramping relieved by bowel movement
- mild fever, anemia, hypoalbunemia

11

Clinical Moderate UC

- gradual onset of diarrhea less than 6 days and intermittent bloody mucoid stool
- urgency and tenesmus
- LLQ cramping relieved by bowel movement
- mild fever, anemia, hypoalbunemia

12

Clinical Severe UC

- more than 6 bloody diarrhea stools/day
- severe anemia, hypovolemia, hypoalbunemia with nutritional deficit
- abdominal pain and tenderness
- fulminant colitis
- pulse over 90
- fever over 37.5C
- ESR over 30

13

What is fulminant colitis

- subset of severe dz which is rapidly worsening symptoms with toxicity
- distended abdomen, tender leukocytosis, severe diarrhea, fever

14

Primary sclerosing cholangitis

- life long chronic disease or scarring anti-inflammation of the bile ducts
- bile ducts scar and narrow

15

Which UC extraintestinal symptoms improve after colectomy

- arthritis
- ankylosin spondylitis
- erythema nodosum
- pyoderma gangrenosum

16

Which UC extraintestinal symptoms do not improve after colectomy

primary sclerosing cholangitis

17

Who is more likely to develop primary sclerosing cholangitis

HLA-B8 or HLA-DR3

18

What is increased risk with primary sclerosing cholangitis? What is cure for primary sclerosing cholangitis?

colon cancer
liver transplant

19

Classification of UC

E= extent/location
1- inflammation of rectum (proctitis)
2- inflammation of splenic flexure (left side; distal)
3- inflammation extendes to proximal splenic flexture (pancolitis)
S= severity
0- remision, no sx
1- mild
2- moderate
3- severe

20

UC and CD dx

- based on clinical symptoms and confirmed by sigmoidoscopic and colonoscopic and histologic examination

21

If severe pancolitis use what for dx?

flex sig

22

UC colonoscopy results

- diffuse confluent disease from dentate line proximal
- edema, friability of mucosa, mucous, erythema, erosions, ulcerations, and spontaneous bleed
- only found in the colon

23

Histology UC

distortion of crypt architecture
crypt abscee
infiltration of lamina propria with plasma cells
eosinophils
lymphocytes
lymphoid aggregates
mucin depletion

24

Tx Mild UC

- 5-ASA drugs (aminosalicylates)- release only in colon
(Mesalazine PR suppository or budesonide rectal foam if rectal proctitis)
- Distal colon inflammation- rectal/oral 5-ASA (PO sulfasalazine and PR mesalazine)
- long term maintenance with 5-ASA

25

Tx Mild/Moderate UC

-Fail of 5-ASA
- PO Budesonide
- Prednisone
- Taper over 60 days

26

Tx Severe UC

-hospitalization and IV steroids with IVF (methylprednisone 60mg/d)
- Anti-biologics if fail steroid tx (TNF alpha- infliximab, adalimumab, golimumab) or (VGEF blocker if fail TNF- vedolizumab)
- cyclosporine is last resort

27

Maintenence TX UC

- once in remission
- 5-ASA
- Budesonide
- Immunosuppressant- golimumab or 6-MP
- Induct with infliximab, then continue use
- probiotics

28

Only curative tx for UC

colectomy

29

Surgery TX UC

Emergency- toxic megacolon
Urgent- severe dz and not responding to tx in hospital
Elective
- refractory: intolerant to long term maintenance tx
- colorectal dysplasia or adenocarcinoma found
- dz more than 7-10yrs

30

UC patients at increased risk of?

colorectal cancer

31

Screening UC

- colonoscopy begins 8yrs after dz onset
- if L. sided colitis/pancolitis: every 1-2 yrs
- UC with PSC: every yr from PSC dx

32

Def Crohn Dz

insidious variable presentation of lifelong idiopathic inflammatory dz that affects anywhere in GI system

33

What type of inflammation in crohn dz and what does it cause?

transmural inflammation in skip distribution that causes strictures, fistulas, ulcerations, abscess

34

MC area affected in Crohn dz

small bowel and colon (terminal ileum and ascending colon)

35

Strongest risk factor for CD

family hx

36

Environmental factors for CD

tobacco
sedentary lifestyle
exposure to air pollution
consumption of western diet

37

When does CD commonly begin?

after infectious gastroenteritis

38

Clinical CD

- RLQ, periumbilical pain
- watery diarrhea
- incontinence
- low grade fever
- weight loss/anorexia/ malnutrition
- weak, fatigue, malaise
- bone loss
- SBO presentation
- rectal abscess or anal fistula
- arthralgia
-iritis
- erythema nodosum

39

6 complication of CD

abscess
obstruction
fistula
perianal dz
colon cancer
dysplasia/malignancy--> malabsorption

40

Treat fistulas in patient with CD

TPN/ oral elemental diet
Antibiologics for 10 weeks
Surgery is medication fails

41

Treat perianal dz in patient with CD

ABX (flagyl or cipro)
Mesalamine suppository or tacrolimus ointment if refractory fissure
Antibiologics

42

Classification of CD

L= extent
1- terminal ileum
2- colon
3- ileum and colon
4- upper GI
L3+L4= upper GI and distal
B= phenotype
1- no stricture and non-penetrating
2- stricture
3- penetrating
3p- perianal penetrating

43

Colonoscopy results for CD

aphthoid, stellate, linear ulcers
strictures
segmental involvement with skip lesions

44

General TX CD

- stop smoking
- diarrhea: loperamide, BAS (terminal ileal disease), low fat diet if short gut

45

Tx mild CD

Mesalamine (colon and small bowel)

46

Tx moderate to severe

- Steroid short term to control sx, use until remission and then a slow 60day taper
- immunosuppressants (azathioprine or methotrexate)

47

When to use TNF alpha in CD

- steroid dependent and no taper
- fistula tx no responding to ABX
refractory cases
- can do an induction and maintenance
- infliximab, adalimumab, certolizumab pegol

48

When to use anti-integrins in CD

- no response to TNF
- vedolizumab (gut leukocyte trafficking)

49

Screen CD

- Regular screen TB, hepatitis, CMV, HIV, and C. diff
- more than 1/3 colon affected (L3) colonoscopy 8 yrs after onset and repeat every 1-2yrs and 1-3 once normal
- PSC= annual screening

50

PSC and CD have a risk of? Screen with?

cholangiocarcinoma (cancer of bile ducts)
screen with MRCP