IBD - Crohn's Disease Flashcards
(173 cards)
1
Q
What is the aetiology of IBD and Crohns?
A
- Largely unknown
- An interaction between luminal microbial antigens, genetic susceptibility, immune response and environmental triggers
2
Q
What is Crohn’s disease characterized by?
A
- Dysfunctional regulatory T-cells which normally control pro-inflammatory cytokine releases.
- If activated antigen presenting cells and lymphocytes are allowed to secrete these pro-inflammatory cytokines, then tissue damage may result from prolonged inflammation
3
Q
What is a key player in crohn’s disease?
A
TNF alpha
4
Q
What is the prevalence of IBD? Is CD and UC more common?
A
- 0.67%
- CD slightly more common (129,000) compared to UC (104,000)
5
Q
Whats the difference between IBS and IBD?
A
IBD has presence of ulcerations
-May share similar symptoms
6
Q
What is the prevalence of crohn’s disease in Canada?
A
319 per 100,000
7
Q
In CD there are more females (T/F)
A
T
In UC, there are slightly more males, however we don’t know why
8
Q
What are the common characteristics of IBD? (3)
A
- Affects all levels of the GIT
- Often onset in youth
- 30-50% of people have the colon affected
9
Q
Which parts of the colon are often affected in IBD?
A
- Ileocolonic (50-60%)
- Crohn’s colitis (10-30%)
10
Q
(T/F) Crohn’s disease affects only the large intestine
A
F
Can be the small or large intestine, often “patches” throughout
11
Q
What is the difference between ileocolic and colon originates crohn’s disease?
A
- ileocolic will present with affected arears in the terminal ileum, and patches throughout the colon
- Colon means the patches are distributed throughout the colon only
12
Q
Where is the affected area in recto-sigmoid crohns?
A
- In the terminal sigmoid colon and rectum
- Continuous and not patchy
13
Q
When may UC be misdiagnosed for chron’s?
A
If it’s initial presentation is in the colon, and is patchy
14
Q
When may crohn’s be a misdiagnosis of UC?
A
When it is present in the colon and not yet pathcy
15
Q
What is the presentation of UC?
A
-Continuous, not patchy throughout the colon to anus
16
Q
What is the Montreal Disease Activity Score?
A
Allows us to define UC by the extent of affected area. Considers 3 subgroups.
17
Q
What does E1 represents in the MDAS?
A
- Ulcerative proctitis
- Involvement limited to the rectum (i.e, proximal extend of inflammation is distal to the rectosigmoid junction)
18
Q
What does E2 represent in the MDAS?
A
- Left sided UC, or distal UC
- Involvement limited to the portion of the colorectum distal to the splenic flexure
19
Q
What does E3 represent in the MDAS?
A
- Extensive US, or pan-colitis
- Involvement extents proximal to the splenic flexure
20
Q
What is the significance of tool required to diagnose IBD?
A
-There is often lengthly preparation to undergo these diagnoses, such as fasting, and often patients with IBD are malnourished at baseline
21
Q
Preparation for endoscopy?
A
- 8 hr NPO
- May exacerbate malnutrition
22
Q
Discuss the 2-3 day preparation in order to undergo a colonoscopy
A
1) Obtain bowel preparation solution at least 2 days before the test
2) 1 day before test; clear liquids all dat, Then, from 6-8pm drink 2L of any PEG-based solution
3) Dat of test, no solid food , and 4 hour before appointment, drink remaining 2L of PEG based solution
4) Stop drinking all liquids including water 2 h before the test
23
Q
What is the PEG solution?
A
- PIC-SALAX
- Contents are not absorbed, and will function to “clean the bowel” so that we can observe ulcerations upon colonoscopy
24
Q
Overall preparation guielines for colonoscopy on Pico-Salax?
A
- No fibre 3 days prior
- Day prior can have breakfast and then clear fluid only plus lavage
25
When assessing a patient with potential IBD, what do we need to investigate?
- Is it UC or Crohn's? Where is the inflammation? (Recall that Crohn's can go from anus to mouth
- Are there stricture, ulcers? How deep are the strictures?
- What is the patient currently able to eat?
- Has there been weight-loss?
- What medication is she on?
26
A1?
16 years or younger
27
A2?
17-40 years
28
A3?
Over 40 years
29
L1?
Terminal ileum
30
L2?
Colon
31
L3?
Ileocolon
32
L4?
Upper GI
33
B1?
Non-stricturing, non-penetrating
34
B2?
Stricturing
35
B3?
Penetrating
36
B1 or 2 or 3 with p?
+ perianal
37
In UC, what do the ulcerations on the colon lead to?
- Toxic megacolin
- A thin, ulcerated colon which has complete lack of the strong-muscular walls
- People can due for this as the thin walls can perforate and cause sepsis
38
What is the solution for toxic megacolon?
- Take out the large intestine
| - Likely have an ostomy
39
What does Crohn's disease primarily present with?
- Ulcers, fistulas, strictures and obstructions
| - Makes the lumen and peristalsis less functional and flexible
40
What is transmural?
- All the way through
- Through the mucosa, submucosa and musculature into the peritoneal cavity (high risk of sepsis)
- Can transverse both circular an longitudinal muscle
41
What is the mesentery?
A set of tissues that attaches the intestines to the posterior abdominal wall in humans and is formed by the double fold of peritoneum.
-Helps lead nutrients to the surrounding vascular system
42
What happens when the mesentery is thickened?
-Will have difficulties in supplying nutrients from the villi, and will also not transport nutrients to the liver (bidirectional) may not have enough oxygen
43
What is commonly observed in the affected area during IBD?
-Enlarged lymph nodes
44
What is an aphthoid ulcer?
-Ulcer over payer's path'
-Ulcer over immune spots
and similar to canker sores
45
What are skip lesions?
- Patchy distribution of inflammation
| - Recall the inflammation is normally continuous and contained to the colon in UC
46
What is a fissure?
-Deep cleft, slit or linear ulcers
47
What is a fistula?
An abnormal passage from a hollow organ to surface of another organ stricture; narrowing of hollow organ can ensure, causing scaring and fibrosis
48
What are abscesses?
a swollen area within body tissue, containing an accumulation of pus.
49
What are granuloma?
When tissue in an organ becomes inflamed — often in response to an infection — groups of cells called histiocytes cluster to form little nodules. May become calcified and hardened over time.
50
What type of IBD is at higher risk of fistula development?
Crohn's
51
What else is consistent with IBD pathology?
- Perianal disease (when complication occur in the anus/rectum)
- Inflamed mucosa with adjacent normal tissue (recall skip lesions)
- Perianal skin tags
52
What are common clinical presentations of crohns?
- "Cobble-stoning" of intestinal lumen
- Marked thickening of bowel wall
- fat wrapping around outside of GI tract (due to high inflammatory state)
- Deep fissures
- -> MAJOR impacts on absorption
53
What are common clinical presentations of ulcerative colitis?
-Extremely thin, ulcerated wall
-"surviving" mucosa is known as pseudopolyps
-Loss of haustra
(the sacs)
---> MAJOR impact on absorption
54
What are the general clinical features of IBD?
- Skip lesions
- Thickened bowel wall
- Stricture formation
- Decreased brush-border lactase
- Diminished serum folate
- Reduce dietary intake (to avoid symptoms)
55
Which clinical features are conducive to malabsorption?
- Skip lesions
| - Decreased brush border lactase
56
Which clinical features are conducive to obstruction?
- Thickening of bowel wall
| - Stricture formation
57
(T/F) Due to decreased brush-border lactase, IBD patients must eliminate milk intake
- Not necessarily
- If tolerated, include in diet
- Important source of energy and protein
- Recall that patient likely malnourished at baseline, and if on corticosteroids even more so
58
If we must eliminate lactose from diet, what could be a compromise?
- Consider lactase enzyme supplement or lactose-free products to avoid omission of high protein high energy foods
- People with IBD are often already at increased risk of osteoporosis
59
What are the general clinical manifestations of IBD?
- Abdominal pain, bloody diarrhea, tenesmus
- Febrile, tachycardia
- CRP and WBC elevated
- Weight loss
60
What is tenesmus? What may it be caused by?
- The feeling of needing to pass stools even if there are none
- May be caused by strictures
61
What happens when people are tachychardic?
They often don't sleep well
62
What is common in IBD?
- Anemia is very common
| - Must determine whether IDA or AOCD (as both are likely)
63
What may indicate IDA?
- High CRP
- Low/normal Serum Ferritin
- Low HmG, low HcT
- Normal hydration status
- Historical low PO intake
64
What may indicated AOCD?
- High CRP
- HIGH serum ferritin (+APP)
- Low HmG, low Hct
- Normal Hydration status
65
What may low or normal WBC and CRP indicate?
That "inflammation" is still occurring, but managed by corticosteroids
-Consider when interpreting AOCD and IDA
66
Why do we need to make sure we interpret AOCD and IDA appropriately
- As we don't want to unnecessarily provide an iron supplement as they can be irritating and cause constipation
- On the other hand, if they are really IDA this must be addressed as there is recurring blood loss and we want to avoid further decline in nutritional state
67
Common characteristics of small intestine crohn's in the adult?
- Obstructive in nature (require Sx)
- Pain when eating
- Palpitation causes pain in LRQ
- Anorexia/diarrhea
- Malabsorption, including lactose intolerance
68
Which type of IBS has a high incidence of fistula formation?
-Ileocolonic disease
69
What is located in the LRQ?
Ileocolonic area, likely ileocolonic disease
70
How do many people manage diarrhea?
Will often just not eat --> anorexia and weight-loss
71
Colonic Crohn's can be similar to UC, What are 5 clinical presentations which may differentiate CC from UC?
- Hematochezia
- Pain prior to defecation
- Perianal skin tags
- Deep anal fissures
- Perianal fistula
72
What is hematochezia?
Diarrhea which often contains blood
73
What are systematic and extra-intestinal manifestations of crohn's?
- Fever
- Weight loss
- Arthritis
- Oral ulcers, skin lesions
- UTI
- Enhanced oxalate absorption (kidney stones)
- Altered body composition
74
What are the 4 stages of Crohn's disease? **Important**
- Mild-moderate
- Moderate-severe
- Severe-fulminant
- Remission
75
Mild-moderate score?
CDAI 15-220
76
Moderate-Severe Disease?
CDAI 220-450
77
Severe-Fulminant Disease?
CDAI >450
78
Mild-moderate crohn's?
- Ambulatory
- Able to tolerate oral intake without dehydration
- Toxicity (fevers)
- Abdo tenderness
- Painful mass, obstruction
- -> OR 10% weight-loss
79
Moderate-severe crohn's?
- Failure to respond to treatment for mild-moderate disease OR
- Those with major fevers
- Significant weight-loss
- Abdo pain/tenderness
- Intermittent nausea/vomiting (w/o obstruction)
- Significant aneamia
80
What does fulminant mean?
When it cannot be under-control
81
Severe-fulminant Crohn's?
- Persisting symptoms in spite of steroid Rx OR
- Those with high fever, persistent vomiting
- Intestinal obstruction
- Rebound tenderness
- Cachexia OTR
- EvidenceIn of abscess
82
Remission crohns?
- Asymptomatic
- Without inflammatory sequela AND
- includes those who have responded to acute medical intervention or surgical resection w/o gross evidence or residual disease
83
(T/F) Remission includes those who have receive steroids and are asymptomatic F
F
84
What does the crohns activity index consider?
Numerical score based on:
- # of diarrheal stools
- abdo pain
- general well-being
- systemic manifestations
- use of anti-diarrheal agents
- presence of abdo mass
- body weight
85
Index values of ___ and below are associated with quiescent disease. Values above ___ are seen with extremely sever disease
150
| 450
86
Lowering of ___ points id indicative of positive change in the crohn's activity index
70
87
Whats another use of the crohn's activity index?
These parameters could be turned into questions to ask patients or consider in the chart
88
In the CAI, which parameter has the largest weighting factor? Which factor is weighted more than # liquid stool, abdo pain, or hct level?
- Anti-diarrheal use
| - General well-being
89
In CDAI, how are # of stools calculated?
Total/week x 2
90
In CDAI, how is pain calculated?
- Scale of 0-3 (non to severe)
| - Sum score/wk x 5
91
In CDAI, how is well being calculated?
0-4 (well to terrible)
92
How is weight calculated in CDAI?
100 x [(std wt - actual wt/std wt]
93
What does the Truelove and Witts Criteria assess?
--Disease activity for US
94
TWC daily BM for mild and severe activity?
- =5
| - >5
95
TWC hematochezia for mild and severe activity?
- Small amounts
| - Large amounts
96
TWC temperature for mild and severe activity?
- <37.5
| - >/=37.5
97
TWC pulse for mild and severe activity?
- <90/minn
| - >/= 90/min
98
TWC erythrocyte sedimentation rate for mild and severe activity?
- <30 mm/h
| - >/= 30 mm/h
99
TWC hmg mild and severe activity?
- >10 g/dl
| - = 10 g/dl
100
At what score are those with UC suggested to have moderately active disease?
-When less than all 6 of the criteria for severe disease activity has been met
101
Prior to planning, what should we know about the patient Hx?
- Their appetite and activity
- Type and duration of IBD, relapse
- Severity and extent of current symptoms
- Meds
- 3 day food record to assess for insufficiencies
102
Prior to planning, what should we observe for in our physical exam?
- Height and weight
- loss of subcutaneous fat
- muscle wasting, edema, skin rash
- hepatomegaly
103
What is stool guaiac?
blood in stool
104
Prior to planning, which special tests may be ordered?
- Tests of absorption
- xylose
- 73 hr fecal fat
- lactose breath test (uncomfortable and must consume a lot of lot of lactose(
- Schillings test
105
What is the xylose absorption test?
-Dose of d-xylose provided, which is normally absorbed
-Urine is collected and if xylose low = malabsorption (not absorbed into the bloodstream,
lost in stool)
106
A 72 hr fecal fat tests requires prep for 2 days prior and during the test, what kind of diet needs to be adhered to? Which result indicates malabsorption? When may it indicate crohns's?
- Regular diet containing 100 g fat or max tolerated
- Constant amount of fat = best
- Daily fat intake calculates
- MCT oil NOT used
- Then stool fat measured and subtracted
- -> 6 indicates malabsorption, which is usually very high in Crohn's
107
What is the lactose breath test/hydrogen breath test?
- 50 g of lactose ( a LOT)
- If undigested, bacteria in colon will break down
- H2 absorbed and measured in breath
108
What is the schilling's test?
- Intravenous B12 is given first, then radioactive B12
- Look for normal excretion of radioactive B12 in urine
- -> Lower excretion indicates deficiency (3%(, normal is 8%
109
What does ADA suggest for active IBD nutrition prescription?
- If NS, caution for RF
| - If oral; progress to low-fat, low-fibre, high-protein high kcal, SFM and then progress to normal diet as tolerated
110
Which vitamin and minerals are recommended for active IBD?
- Vit , zinc, calcium and magnesium'
| - Folate, vit B12,iron
111
Which vit/mins are exceptions to the DRI?
-All previously mentioned plus vit E, K, C and copper
112
When should fibre be restricted?
- CI
- Active IBD
- Acute flare-ups with exacerbations o strictures
113
Nutrition prescription of IBD in remission?
- Maximize E and P intake for maintenance of weight
- Avoid foods high in oxalate (FFA)
- Increase antioxidant intake
- Consider omega-3 FA and glutamine supplementation
- Use of pro and prebiotics
114
What is oxalate normally bound to?
FFA, but in Crohn's there is an increase in FFA in lumen due to malabsorption which will bind calcium instead. Oxalate is consequently absorbed, and can form oxalate kidney stones
115
What is a major reason for sub-optimal calcium and vitamin D status?
Long term steroid use
116
What is a major reason for sub-optimal folate status? (And subsequent anemia)
-Medications, such as methotrexate
117
Province of PEM in CD? UC?
- 50-70%
| - 18-62%
118
% of CD underweight at presentation?
65-75%
119
Is hypoalbuminemia more common in CD or UC hospitalized patients?
CD
120
How does hypoalbuminemia develop in CD compared to UC?
- Develop chronically in CD and more acutely in UC, depending on severity of disease
- Basis is multi-factorial, pro-inflammatory cytokines, malabsorption, maldigestion, GI losses and reduced intakes
121
What is the general high nutrient density diet in IBD?-
- Fluid of 1ml/kcal
- E of 25-30 kcal/kg
- Protein of 1-1.5 g/kg/day
- High minerals and vitamins
122
Is there as SF consistent for IBD?
No, based on symptoms
123
Which key vitamin/minerals to consider in UC?
- Iron
- Ca (1500 mg)
- Vitamin D (800-1000 IU)
- Increase fibre as long as not an acute exacerbated state
124
Other macronutrient considerations of nutritional management with IBD?
- Fibre should be normal (high fibre may prevent relapse)
- Complex CHO
- Lactose OK
- Fat as tolerated, but sometimes low in the event of steatorrhea
125
Why should complex CHO be used?
-Keep osmolality low if malabsorption and diarrhea (larger, less quick breakdown)
126
Why should lactose still be included?
-Even if we suspect intolerance, we should not entirely exclude milk products --> w e should gradually adapt
127
What are the beneficial effects of dietary fibre intake?
- Decrease gut transit time
- Increase stool bulking
- Decreased diarrhea
- Decreased constipation
128
Which type of fibre will decrease diarrhea?
-Soluble
129
Which type of fibre will decease constipation?
Insoluble
130
What are the effects of fibre in the gut microbiota?
-Changes in microbe composition, facilitating SCFA production, regulating gut motility and maintaining functional imunne homeostasis
131
What else does fibre effect on the gut?
- Decrease inflammation
- Increase permeability
- Increase tissue healing
- --> We want to prioritize keeping the gut mucosa healthy
132
You are following two patients. One patient c/o of frequent oily stools and another one has frequent watery stools , which one would benefit from a low oxalate diet?
- Oily stool sis indicative of fat malabsorption
| - Therefore, would benefit from low oxalate diet
133
What is the problem with low oxalate intake?
We are not 100% sure of the oxalate content in foods
134
What could be an alternative to the low oxalate diet?
-Combine with water intake and low fat diet
135
What would be the low-oxalate diet prescription?
- 3-4 L/day water and low fat if steatorrhea
- Avoid Vitamin C supplements (DRI OK)
- Urinary oxalate measurements (should be low0
- One choice/day of high oxalate foods (125 ml)
136
Examples of high oxalate foods?
- Chocolate
- Tea
- rhubarb
- Beets
137
In the high oxalate diet, how should be limit our fruits and vegetables? Whole grains?
- No more than 4-5 servings AND avoid high-oxalate
| - Whole grains, breads and cereals nor more the 3/day
138
Examples of appropriate choices for low oxalate diet?
- Apples
- Pears
- Bananas
- Yellow corn
- Red pepper
- Onions
- Mushrooms
- Peas
139
What are FODMAPs?
-Fermentable oligo-di-monosaccharies
| and polyols
140
What are examples of disaccharides that are excluded in the low FODMAP diet?
- Fructose, including honey and fruit
| - Lactose, including milk, yogurt, cottage cheese and ice-cream
141
What are oligosaccharides excluded in the low FODMAP diet?
-Wheat, rye, onions, garlic,legumess
142
What polyols are excluded in the low FODMAP diet?
-Plums, avocado, mushrooms, sugar-free gum,tomatoes
143
(T/F) The low FODMAP diet has been should to help manage symptoms in IBD
T
But does NOT improve IBD disease activity
144
Is there a validated protocol to reintroduce FODMAPs?
No
145
What may be a disadvantage of the low FODMAP diet?
-Elimination can be a disadvantage to energy intakes, as fermentable SCFA contribute energy
146
Which CAM is on the rise for IBD treatment?
Probiotics
147
What was CAM use associated with?
- Less favourable adherence to conventional therapy
- Those who only used CAM specifically for IBD has this lower adherence
- Inquiring why a patient uses CAM is important
148
What have trials of probiotics show in Crohn's disease?
-No effects
149
What did trials of probiotics show in UC?
-Significant effects with the combination of pre and probiotics
150
Reasons of use of medicinal cannabis?
- Stimulate appetite
| - Cannabinoid receptors in GIT and immune system; promise for immune modulating effects
151
What can cannabis be used to alleviate?
- Diarrhea
- Abdo pain
- Loss of appetite
152
What is the current evidence to date about cannabis?
- May be helpful for certain symptom of IBD, but lack clear guidelines
- Cannot recommend as standard tx as of today
153
-RINE and Methotrexate?
Immunosuppressive drugs
154
-AZIDE, -AMINE, -AINE?
- Aminosalicylate
| - Enteric coated or bacterial cleavage of 5-ADA
155
-IDE/ONE?
- Glucocorticoid
| - Oral or IV
156
Ciprofloxacin?
-Flouroquinolone antibiotic
157
Infliximab?
Anti-TNF monoclonal antibody
158
Metronidazole?
Antibiotic
159
Cylocsporine?
Immunosuppressive
160
What can cyclosporine elevate?
-Elevate serum cholesterol, and grapefruit will increase absorption and increase elimination of the oral form of the drug
161
What are the top nutrient deficiencies in IBD?
- Folate
- Calcium
- Vitamin D
162
Which drugs can cause folate deficiency?
- Sulfasalazine (Aminsalicylates)
- Competes with folate in the intestinal lumen, causes reduced availability of folate
- Methotrexate --> antagonist to folic acid
163
% deficiency of folate in IBD patients?
20-60%
164
What happens if there is a folate deficiency? how can we avoid?
- Megoblastic anemia
- Reduce medications or ad supplemental folate if feasible
- Consider that DFE is higher for supplements (more bioavailable)
165
Which drugs will impair absorption and retention of calcium
Glucocorticoids
166
Why do glucocorticoids impair absorption and retention of calcium?
-They alter the action of 1-alpha hydroxylase, an therefore the conversion of 12-OH-D to 1,25 OH-D is altered, implication of bone deminieralization
167
What may glucorticoids increase?
Protein needs, cause Na retention
168
____ improved the health-related quality of life in Crohn's disease patients with long-term disease duration
EN
169
What should be recommended for one of the options for maintenance therapy for Crohns?
EN
170
What needs to be considered about TPN with EN?
HIGH risk of infections because of corticosteroids, and the GI tract is an important modulation of the immune symptoms
--> Last resort
171
Contraindications to EN in IBD?
- Oral intake adequate, or can use supplements
- Fistula
- SBS (Start with PN)
172
When do fistulas occur? When is PN required?
- Most after Sx, where may take 4-6 weeks to close
| - PN needed if high output >500 ml/day
173
When is EN possible with fistula?
- if low output <500 mol/day
- possible if proximal duodenal or jejunal or lower distal ileal or colonic
- use low or no fibre
- feed as distal or proximal to the fistula as possible
