IBD Flashcards
(28 cards)
What is ulcerative colitis?
A relapsing and remitting inflammatory disorder of the colonic mucosa
What does ulcerative colitis affect?
May affect just rectum (proctitis, 30%)
Or extend to part of colon (L-sided colitis, 40%)
Or entire colon (pancolitis, 30%)
Never spreads to ileocaecal valve
What causes ulcerative colitis?
Inappropriate immune response against (? abnormal) colonic flora in genetically susceptible individuals
What are the risk factors for ulcerative colitis?
- Family history
- Infection trigger
- <30yo
- Caucasian
- Ashkenazi Jewish heritage
- Acne meds (accutane)
What are the epidemiological features of ulcerative colitis?
Prevalence = 100-200/100,000
Incidence = 10-20/100,000/yr
Typically 20-40yo
3-fold as common in non-smokers
What are the presenting symptoms of ulcerative colitis?
- Episodic or chronic diarrhoea
- Crampy abdo discomfort
- Urgency/tenesmus = proctitis
- Systemic symptoms in attacks: fever, malaise, anorexia, weight loss
What are the signs O/E of ulcerative colitis?
- May be NONE
- Acute/severe UC: fever, tachycardia, tender + distended abdomen
Extra-intestinal:
- Clubbing
- Aphthous oral ulcers
- Erythema nodosum
- Pyoderma gangrenosum
- Conjuctivitis
- Episcleritis
- Iritis
- Large joint arthritis
- Sacroilitis
- Ankylosing spondylitis
- Nutritional deficitis
What are the investigations for ulcerative colitis?
BLOODS: FBC, ESR, CRP, U+E, LFT, culture
STOOL MC&S/CDT: to exclude Campylobacter, Shigella, C diff, Salmonella, E Coli, Amoebae infection
FAECAL CALPROTECTIN: GI inflammation w/high sensitivity
AXR: No faecal shadows; mucosal thickening/islands; colonic dilatation
LOWER GI ENDOSCOPY: Flexi sig if acute to assess + biopsy; full colonoscopy once controlled to define disease extent
What are the complications of ulcerative colitis?
ACUTE:
- Toxic dilatation of colon (mucosal islands, colonic diameter > 6cm) with risk of perforation
- Venous thromboembolism
CHRONIC: Colon cancer
How are the possible acute complications of ulcerative colitis managed?
VTE: prophylaxis for all regardless of rectal bleeding
What is the goal of IBD management?
To INDUCE then MANTAIN remission
How is remission induced in mild to moderate ulcerative colitis?
Step 1:
Proctitis or proctosigmoiditis:
- Topical 5-ASA (suppository/enema) +/- oral 5-ASA
- Consider oral 5-ASA alone
- If CI: topical corticosteroid (hydrocortisone as Colifoam) OR oral prednisolone
- If subacute: oral prednisolone
L-sided or extensive UC:
- Oral 5-ASA
- Can add topical 5-ASA or PO beclometasone dipropionate
- CI or subacute: oral prednisolone
Step 2:
- No improvement in 4 weeks/symptoms worsen: add oral prednisolone
- Inadequate response after 2-4 weeks oral prednisolone: refer to secondary care for consideration of tacrolimus
- Consider referall for possible infliximab treatment
How is remission induced in acute severe ulcerative colitis?
- Admit to hospital for treatment from gastroenterologist and colorectal surgeon
- IV corticosteroid
- IV ciclosporin or infliximab
How is remission maintained in UC:
Procitis or proctosigmoiditis:
- Daily/intermittent topical 5-ASA +/- oral 5-ASA
OR
- oral 5-ASA alone
L-sided or extensive UC:
- Oral 5-ASA
If 2 or more inflammatory exacerbations in 12 months needing systemic corticosteroids or if remission is not maintained this way:
- Refer to secondary care - azathioprine or mercaptopurine
Acute severe UC:
- 1st episode: refer to secondary care - azathioprine or mercaptopurine
- If pt declines, can’t tolerate/CI: oral 5-ASA
What is Crohn’s disease?
A chronic inflammatory disease characterised by transmural granulomatous inflammation affecting any part of the gut from mouth to anus (especially terminal ileum - 70%)
What causes Crohn’s disease?
An inappropriate immune response against (? abnormal) gut flora in a genetically susceptible individual
What are the risk factors for Crohn’s disease?
F 15-35 yo White SMOKER (increases risk 3-4x) NA + Europe NSAIDs may exacerbate
What are the epidemiological features of Crohn’s disease?
Prevalence: 100-200/100,000
Incidence: 10-20/100,000/yr
Typically presents 20-40yo
What are the presenting symptoms of Crohn’s disease?
- Diarrhoea
- Abdo pain
- Weight loss/failure to thrive
- Systemic: fatigue, fever, malaise, anorexia
What are the signs O/E of Crohn’s disease?
- Bowel ulceration
- Abdo tenderness/mass
- Perianal abscess/fistulae/skin tags
- Anal strictures
- Clubbing
- Skin, joint, eye problems
What are the investigations for Crohn’s disease?
BLOODS: FBC, ESR, CRP, U+E, LFT, INR, ferritin, TIBC, B12, folate
STOOL MC&S + CDT: to exclude C diff, Campylobacter, E Coli infection
FAECAL CALPROTECTIN: GI inflammation
COLONOSCOPY + BIOPSY: even if mucosa looks normal
SMALL BOWEL: to detect insolated proximal disease by e.g. capsule endoscopy
What are the complications of Crohn’s disease?
- Small bowel obstruction
- Toxic dilatation (colonic diameter >6cm)
- Abscess formation (abdo, pelvic, perianal)
- Fistulae - 10%: entero-enteric, colovesical, colovaginal, perianal
- Primary sclerosing cholangitis
- Malnutrition
- Perforation
How is remission induced in Crohn’s disease?
1st presentation or single inflammatory exacerbation in 1 year period:
- Monotherapy with GC (prednisolone, methylprednisolone or iv hydrocortisone
For pts who decline, can’t tolerate or CI:
- BUDESONIDE if there is distal ileal, ileocaecal or R-sided colonic disease
- MESALAZINE (less effective)
2 or more inflammatory exacerbations in 1 year or GC dose cannot be tapered:
- Refer to secondary care for AZATHIOPRINE, MERCAPTOPURINE or METHOTREXATE
Pts with severe active CD:
- Consider referral for INFLIXIMAB or ADALIMUMAB
What are the indications for surgery in adults with Crohn’s disease?
- Early in disease course as an alternative to medical Tx in pts whose disease is limited to DISTAL ILEUM
- For pts with strictures, refer to secondary care for ballon dilation
