Inflammatory Bowel Disease Flashcards
What are the pathological features of Crohn’s disease?
Bimodal peaks at 15-30 & 60-80 YO
Th1 Medicated (Lymphocyte, Plasma Cells, Macrophages)
Non-continuous inflamm w/ skip lesions
- Ileocecal only – 40%
- Terminal Ileum only – 35%
- Colon only – 20%
Spares Rectum
Perianal Disease (Fistula, Fissure) possible
Transmural a/w Granuloma, Strictures, Fistulas
Cobblestone appearance
Histo: Non-Caseating Granuloma
A/w ASCA: anti saccharomyces cerevisiae Ab
What are the risk factors of Crohn’s disease?
- HLAB27
- ↑ a/w FHx: 10x ↑ risk in 1st deg relatives
- Smoking
- Infections
- Drugs: NSAIDs, OCP, Abx
- Diet: refined sugars, low-fibre
What are the complications of Crohn’s disease?
↑ risk of Small Bowel Lymphoma
Smaller ↑ risk of CRC
Impaired absorption of Vitamin B12: Macrocytic Anaemia, Pernicious Anaemia
Impaired reabsorption of bile acids:
- Bile acid diarrhoea
- Steatorrhoea
- KADE Vitamin deficiency
Abscess: palpable masses (often ileal, causing RIF mass), swinging fevers
Fistula
- Colo-vesical fistula: fecaluria, pneumaturia, recurrent UTI
- Colo-uterine fistula: Fecal incontinence, PID
Strictures can lead to IO – abdo pain, distension, N&V, constipation/ obstipation
What is the presentation of Crohn’s disease?
If Colon Dz (Colitis): Bloody Diarrhoea, Urgency, Abdominal Pain (Constant)
If Perianal
- Fissure & Abscess: Anal Pain
- Fistula: Leakage between bowel movements
- Perianal skin tags
If SB disease (more silent): Abdominal Pain (Constant), Watery Diarrhoea, Chronic Malnutrition, LOW
What are the Extra-GI Manifestations (Joints, Eyes, Liver, Skin) due to Crohn’s disease?
- Seronegative Spondyloarthropathy
- Anterior Uveitis; Episcleritis
- Acute Arthritis
- Erythema Nodosum
- Autoimmune Hepatitis
- Perianal skin tags, oral mucosal lesions
What are the associations of Ulcerative Colitis?
- ↑ risk of CRC
- ↑ Risk of perforation
- ↑ Risk of toxic megacolon**
What is the presentation of Ulcerative Colitis?
- Bloody Diarrhoea (from colitis)
- ↓ Abdominal Pain (less severe than CD)
- ↓ Growth Failure
What are the Extra-GI Manifestations (Joints, Eyes, Liver, Skin) due to Ulcerative Colitis?
- Seronegative Spondyloarthropathy
- Anterior Uveitis; Episcleritis
- Acute Arthritis
- Erythema Nodosum
- Autoimmune Hepatitis
- Pyoderma Gangrenosum (Ulcerative)
- Primary Sclerosing Cholangitis
What is the presentation of Ulcerative Colitis?
- Bloody Diarrhoea (from colitis)
- Abdominal pain in UC is less than CD (b/c transmural CD inflammation causes peritoneal irritation 🡪 more painful)
What is the management of Crohn’s disease?
Inducing remission: Steroids (Mainstay)
- Budesonide Enema (Mild-Moderate)
- Prednisolone Enema (Mild-Moderate)
- IV Hydrocortisone (Severe Dz)
Maintain Remission
- IV Azathioprine (Mainstay)
- IV Methotrexate (Possible, but ↑ S/E)
- Salicylates
What is the management of Ulcerative Colitis?
Inducing Remission:
- Salicylates (5-ASA, Mainstay) –> Sulfasalazine, Mesalazine
- Steroids (2nd line)
Maintaining remission
- Salicylates
- Cyclosporine (if severe UC)
- Azathioprine (useful in SOME pt, for severe UC only)
What is the non pharmacological management of Crohn disease?
Trigger Avoidance
- NSAIDs and antibiotics
- Smoking Cessation: improves maintenance of remission
Nutrition
- Vitamin Supplementation (esp B12 if terminal ileum Dz)
- Iron Supplementation (for anaemia)
What is the pharmacological management of Crohn disease?
Pre-Treatment
- TRO chronic latent infections before initiating therapy
- Exclude: TB, Hepatitis, HIV
Induce Remission
• Steroids (Mainstay), not for long-term use
- Budesonide Enema (Mild-Moderate)
- Prednisolone Enema (Mild-Moderate)
- IV Hydrocortisone (Severe Dz)
• If non responsive – TNF-α inhibitors* (eg: Infliximab, Adalimumab)
Maintain Remission
- IV Azathioprine (Mainstay)
- IV Methotrexate (Possible, but ↑ S/E)
- Salicylates
- If non responsive: TNF-α inhibitors* (eg: Infliximab, Adalimumab)
*CD is the ONLY IBD Dz that is POTENTIALLY CURABLE by MEDICAL therapy via TNF-α inhibitors since CD is TH1 Mediated
Adjuncts
- Metronidazole: Sepsis or bacterial overgrowth
- Ciprofloxacin: Fistulating disease (peri-anal)
- Anti-Diarrhoeal: Loperamide
- Supportive Therapy: Analgesia, Hydration, Antipyretics
How does fulminant colitis present?
Fulminant Colitis refers to
- Presence of >10 bloody stools a day
- Continuous bleeding
- Abdominal pain, Distension
- Acute severe toxic symptoms including fever and anorexia
- Possible aetiologies: Severe UC (less commonly CD), C Diff infection
TRO complications of Toxic megacolon (colon > 5.5cm, systemic toxicity)
What are the investigations required for ulcerative colitis?
Bloods
- FBC: anemia, leucocytosis & thrombocytosis indicate more severe disease
- U/E/Cr: hypokalaemia & dehydration in prolonged diarrhoea
- LFT: hypoalbuminemia due to poor nutritional intake; ↑ALP & GGT if PSC
- CRP, ESR: markers of severity
- Autoantibody assay: p-ANCA ↑ in UC
Imaging: Flexible Sigmoidoscopy
- Pseudo-Polyps Appearance
- Continuous involvement, no skip lesions
- Presence of Crypt Abscesses
- Absence of Fistula, Abscess, Strictures
- Tissue biopsy – be careful! - Risk of perforation is high in active dz
Colonoscopy is contraindicated in patients with acute flare because of the high risk of perforation but should be performed once symptoms improve. Sigmoidoscopy may be considered as an alternative.
Supporting Ix to evaluate extent of Dz, loss of haustra & pseudopolyps:
- Barium Enema
Others
- Erect CXR: TRO Pneumoperitoneum
- AXR: Loss of colonic haustra (“lead pipe” appearance) in severe cases
