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IBD Flashcards

1
Q

What are inflammatory bowel diseases (IBD)?

A

chronic
relapsing
immunologically mediated disorders

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2
Q

What 4 main processes are thought to contribute to IBD pathogenesis?

A
  • luminal microbial antigens and adjuvants
  • genetic susceptibility
  • immune response
  • environmental triggers
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3
Q

Of the 110 IBS loci that are common between UC and Crohn’s, what are the main pathways implicated?

A

leprosy
myobacterial susceptibility
other immune-mediated disease

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4
Q

Name 2 loci implicated in Crohn’s susceptibility

A

NOD2

PTPN22

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5
Q

Name a loci implicated in UC susceptibility

A

MHC

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6
Q

What are common triggers for IBD?

A

NSAIDs
antibiotics
infections (viral, bacterial, parasitic)

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7
Q

What causes the mucosal damage in IBD?

A

hyper activation of T cell adaptive immune responses to commensal enteric bacteria
in combo with genetic susceptibility and environmental factors

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8
Q

What does the mucosal damage in IBD result in?

A

translocation of luminal contents
abnormal immune responses
chronic inflammation

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9
Q

What is ulcerative colitis?

A 
chronic inflammatory disease 
unknown aetiology 
affects colon only 
diarrhoea with blood and mucus
systemic features if extensive/severe
flare ups and remission
15-20% attacks are severe
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10
Q

What proportion of the colon is affected in UC?

A

Proctitis and distal colitis (36%)
Left-sided colitis (37%)
Pancolitis (37%)

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11
Q

What treatments can be used for UC?

A

proctitis: 5-ASA suppository

distal colitis: 5-ASA foam enema

L-sided colitis: 5-ASA liquid enema

pancolitis: topical and oral treatment

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12
Q

What is Crohn’s disease?

A 
chronic 
granulomatous inflammatory disease
affects any part of GI tract
most common: ileo-colonic
Crohn's colitis behaved similarly to UC
small number of colitis cases are indeterminate
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13
Q

Which areas of GI tract are commonly affected in Crohn’s disease?

A 
gastroduodenual (5%)
small intestine alone (5%)
distal ileum (35%)
right colon (35%)
colon alone (20%)
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14
Q

What are the main features of UC?

A 
11:100,000
M=F incidence
risk: 15-30, 60-80 yr
smoking reduces risk of UC
pANCA +ve in 75% of cases
8% concordance in twins
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15
Q

What are the main features of Crohn’s?

A 
7:100,000
M>F
risk: 15-30 60-80 yr
smoking increased risk
pANCA -ve
ASCA +ve in 86% of cases
67% concordance in twins
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16
Q

What are the Sx of UC?

A 
bloody diarrhoea
mucus
mucosal and submucosal inflammation
continuous/confluent disease
association with PSC
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17
Q

What are the Sx of Crohn’s?

A 
systemic Sx (weight loss)
abdo mass
fistulae/strictures
perianal disease
rectal sparing
skip lesions
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18
Q

What is the histology of UC?

A 
granular, friable
pseudopolyps
acute + chronic inflammation
muscularis and serosa are normal 
crypt abscesses
diminished goblet cells
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19
Q

What is the histology of Crohn’s?

A 
transmural 
submucosal oedema
lymphoid aggregates
fibrosis 
aphthous ulcers
granulomas (e.g. sarcoid/TB)
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20
Q

What are the microscopic features of UC?

A

Architectural:
crypt distortion, decreased crypt density, villous surface

Inflammatory:
increased transmucosal laminal propria cells, diffuse basal plasmacytosis, mucin depletion, paneth cell metaplasia

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21
Q

What are the microscopic features of Crohn’s?

A

architecture: normal/irregular/villous, crypt atrophy, distorted/dilated crypts

inflammatory:
basal plasmacytosis, increased basal lamina propria cells (neutrophils, round cells)

specific: epithelioid granuloma, basal giant cells, histiocytes infiltration in lamina propria

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22
Q

What are basal giant cells?

A

basal cells are the lowest layer of the epidermis (outer layer of skin)
presence of basal giant cells can be indicative of a malignancy/neoplasm, named on their appearance not that have to be a primary basal cell tumour

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23
Q

What are some extra-intestinal symptoms of IBD?

A

many - can lead to deficiencies affect multiple systems

e. g. eye: episcleritis
skin: pyoderma gangrenosum
circulation: phlebitis

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24
Q

What musculoskeletal complications can develop with IBD?

A

arthritis - seronegative spondylo-arthropathies

type 1: pauciarticular (< 5 joints), associated with disease activity

type 2: polyarticular

Rx: NSAIDs/sulphasalazine

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25
How often do IBD patients have musculoskeletal complications?
9-53% of patients
26
In which forms of IBD are musculoskeletal complications more common?
more common in: - Crohn's colitis than UC - pancolitis UC than left-sided UC - colonic than small bowel disease
27
Why is there osteoporosis risk for patients with IBD?
``` corticosteroid use - to reduce IBD inflammation reduced physical activity inflammatory-mediated bone resorption Ca/Vitamin D malabsorption poor intake (lactose intolerance) ``` Fracture risk is 40% higher than general population
28
What dermatological manifestations can present in IBD?
affects 2-34% of IBD patients 1-10.5% UC patients 0.5-20% of Crohn's patients erythma nodusom (EN) and pyodema gangrenosum (PG) are most common others: psoriasis, angular stomatitis, aphthous stomatitis, Sweet syndrome
29
What is ertythema nodosum?
painful palpable nodes F>M Crohn's > UC mirror disease activity
30
What is pyoderma gangrenosum?
affects shins usually adjacent to stoma pathergy (exaggerated skin injury)
31
What is Sweet syndrome?
very rare inflammatory skin condition causes sudden onset of fever and painful rash on skin of limbs also called acute febrile dermatosis
32
What hepatopancreatobiliary complications are associated with IBD?
``` PSC cholelithiasis portal vein thrombosis drug-induced hepatotoxicity drug-induced pancreatitis ```
33
What is PSC?
primary sclerosing cholangitis (PSC) inflammation, stricturing and fibrosis of intra- and extra-hepatic bile ducts 5% of UC patients have PSC 2% of Crohn's patients have PSC pancolitis > left-sided UC 30-59 years M > F (2:1) ``` raised ALP raised ANA (33%) raised pANCA (80%) ``` 12-15% of patients with PSC undergoing liver transplantation increased risk of colorectal Ca
34
What malignancies is PSC a risk factor for?
cholangiocarcinoma also increases risk of colorectal cancer
35
What is cholelithiasis in IBD?
gall stones affects mostly Crohn's patients with ileal disease causes interruption of enterohepatic circulation of bile acids -> bile acid malabsorption
36
Why does pancreatitis present in IBD patients?
common side effect of azathioprine and 6-mercaptopurine | immunosuppressive medications used in IBD
37
What ocular manifestations are common in IBD?
affects 0.3-5% of IBD patients less common is isolated small bowel disease episcleritis - can mimic intestinal inflammation, treat bowel disease to correct. Can also use topical steroids Scleritis: can impair vision. More severe cases may require systemic steroids/immunosuppression uvetis: associated with musculoskeletal and/or dermatological presentations f > M (4:1)
38
What renal compilations present with IBD?
affects 6-23% of IBD patients nephrolithiasis (kidney stones) obstructive uropathy (hindrance to normal urine flow, normally structural or functional) renal fistulae treated with NSAIDs/sulphasalazine
39
What is the main pulmonary complication of IBD?
Pulmonary embolus (PE)
40
What is acute colitis?
bloody diarrhoea Sx of colonic inflammation irrespective of cause
41
How is colitis assessed?
history toxicity extent: pulse, temperature, abdo tenderness and distension, wellness of patient bloods: ESR/CRP, Hb, WCC, Platelets, albumin Abdo X-ray
42
What is the Ddx for (acute) colitis?
Infective: campylobacter, shigella, salmonella, E coli, C. diff, CMV colitis IBD Ischaemic colitis Behcet's Drug-related (in UC): NSAIDs, cocaine, amphetamines Drugs: nicorandil
43
What is nicroandil used for?
used to treat angina | causes vasodilation
44
What is Behcet's disease?
inflammatory disorder affect multiple systems most common; painful mouth sores, genital sores, eye inflammation, arthritis sores last a few days cause is unknown, likely partly genetic
45
What pharmacological treatment can be used for UC?
``` 5-ASA: amino salicyclates azathioprine: immunosuppressive oral steroids IV hydrocortisone ciclosporin: immunosuppressive infliximab (monoclonal Ab targeting TNFa) ```
46
What are the Truelove and Witts criteria for severe colitis?
``` - 6+ bloody stools daily one or more of: - temp > 37.8 - pulse > 90 - Hb < 10.5 g/dL - ESR > 30mm/h ```
47
What is the mortality for acute ulcerative colitis?
untreated 24% steroids 7% timely surgery <1%
48
What are the reasons why mortality of acute ulcerative colitis is thought to be <24% in DGHs?
- delays in surgery - delays in Dx - undue persistence with unsuccessful medical treatment
49
What are the factors predicting colectomy in severe UC?
Day 1 stool frequency > 9/day albumin <30 HR >90 Day 3 Stool frequency >8/day CRP > 45 (colectomy 85%) Any colonic dilatation (>5.5cm) mucosal islands on AXR (abdo x ray) (colectomy 75%)
50
What are the Travis criteria (in UC)?
CRP > 45 Stool frequency >= 8 after 3 days of IV hydrocortisone 85% colectomy rate unless treatment is escalated
51
By day 3 of treatment (in severe UC), what management must be implemented?
- stool culture results - corrected electrolytes (esp. Mg) - colonic biopsy results - decision on treatment escalation (gastroenterologists)
52
What is the role of Mg in the intestine?
intestinal inflammation can be caused by Mg deficiency
53
What is toxic megacolon?
acute form of colonic distension with abdo distension, fever, abdo pain and shock very dilated colon observed on AXR bad sign - call surgeons
54
What investigations are done to screen for toxic megacolon?
daily abdo X-ray (AXR)
55
What does treatment escalation depend on | in (severe) colitis?
- age - severity - "colitis history" - pre-flare up therapy - patients wishes Rx options - cyclosporin - infliximab - surgery
56
How is the treatment option decided for colitis?
cyclosporin/infliximab vs surgery - ongoing azathioprine/6-mercaptopurine therapy - co-morbidies - patient wishes
57
What are the types of staged surgery available for UC?
colectomy + ileostomy ileoanal pouch
58
What is cyclosporin?
calcineurin inhibitor blocks activation of pro-inflammatory mediators rapid onset of action (IV route) high oral bioavailability
59
How effective is cyclosporin?
response rate 80-90% colectomy rate reduced to 30-47% in patients who respond to cyclosporin (6-9 months after Rx) colectomy avoided at 5 years for 55-70%
60
What is infliximab?
monoclonal antibody targeting TNFa mainly used in Crohn's increasing evidence for use in UC
61
How can C. difficile infection complicate IBD?
C. diff + IBD = colectomy rate 20% C. diff can mimic/precipitate IBD flares C.diff enteritis is more problematic in IBD patients

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