Inflammatory bowel disease

Question 1

Define inflammatory bowel disease

Answer 1

umbrella term for chronic, relapsing-remitting, non-infectious inflammatory diseases of the gastrointestinal system

involve inflammation of the walls of the GI tract and are associated with periods of remission and exacerbation

Question 2

Name the two conditions that make up inflammatory bowel disease

Answer 2

Ulcerative colitis (UC)

Crohn’s disease (CD)

Question 3

Describe which part of the GI tract is ulcerative colitis affect

Answer 3

Continuous inflammation of the mucosa starting in the rectum (in most cases) and limited to the colon.

Question 4

Describe which part of the GI tract is Crohn’s disease affect

Answer 4

Transmural patchy inflammation is seen throughout the gastrointestinal tract.

Question 5

Describe the inflammation associated with ulcerative colitis

Answer 5

Continous

Mucosal

Question 6

Describe the inflammation associated with Crohn’s disease

Answer 6

Patchy transmural granulomatous

Question 7

Describe the distribution of the inflammation in ulcerative colitis

Answer 7

Rectum and variable amount of colon

Question 8

Describe the distribution of the inflammation in Crohn’s disease

Answer 8

seen throughout the gastrointestinal tract i.e. mouth to anus

Question 9

Describe the characteristics of Crohn’s disease

Answer 9

inflammatory bowel disease characterised by patchy, transmural inflammation (full thickness) of intestinal mucosa.

Question 10

What does transmural mean

Answer 10

Full thickness i.e. in crohns disease it means it affects the full thickeness of the colon wall

Question 11

Crohn’s disease can affect any part of the gastrointestinal tract from mouth to anus. Where it is usually seen

Answer 11

The terminal ilium and perianal locations.

Question 12

What is fistula

Answer 12

an abnormal opening that connects two or more organs or spaces inside or outside the body

Question 13

The transmural inflammation often leads to fibrosis causing intestinal obstruction. The inflammation can also result in sinus tracts that burrow through and penetrate the serosa, thereafter giving rise to perforations and fistulae.

What is a sinus tract in Crohn’s disease

Answer 13

A sinus tract in CD is a narrow opening extending from a wound in the epithelium of the GI tract through the walls.

Question 14

At what age is incidences of Crohn’s disease seen in

Answer 14

bimodal incidence

peaks between the ages of 15-30 and 60-80 years old.

Question 15

Granulomas formation is the key feature of CD.

What is Granulomas

Answer 15

Granulomas are collections of macrophages and neutrophils

Question 16

A number of pathophysiological changes occur in Crohn’s disease due to chronic inflammatory processes.

Describe the macroscopic (seen during endoscopy) features of Crohn’s disaese

Answer 16

Cobblestone appearance

Bowel wall thickening

Lumen narrowing

Deep ulcers

Fistulae

Fissures

Question 17

“crows NESTS” is used to remember the key features of Crohn’s disease

What does it stand for

Answer 17

N – No blood or mucus (less common)

E – Entire GI tract

S – “Skip lesions” on endoscopy (where normal bowel mucosa is found between diseased areas)

T – Terminal ileum most affected and Transmural (full thickness) inflammation

S – Smoking is a risk factor (don’t set the nest on fire)

Crohn’s is also associated with weight loss, strictures and fistulas.

Question 18

Name some of the microscopic (seen on histology) features of Crohn’s disease

Answer 18

· Inflammatory infiltration is noted on the lamina propria.

· Lymphoid hyperplasia

· Non-caseating granulomas.

· Skip lesions

· Transmural ulceration

Question 19

Name some of the risk factors for Crohn’s disease

Answer 19

Smoking – causative in CD

Family history of inflammatory bowel disease (IBD)

More common in white than in black or Asian people

Ashkenazi Jews have a 2- to 4-fold increased risk

Previous infectious gastroenteritis

Drugs e.g. NSAIDs

Males and females are equally affected

Question 20

Name some of the symptoms associated with Crohn’s disease

Answer 20

Fatigue

Diarrhoea (more watery than bloody)

Abdominal pain

Weight loss

Fever

GI bleeding.

Many patients have non-specific symptoms and remain undiagnosed for many years.

Question 21

Which type of inflammatory bowel disease is most associated with watery diarrhoea (instead of bloody)

Answer 21

Crohn’s disease

Question 22

Which type of inflammatory bowel disease is most associated with bloody diarrhoea

Answer 22

Ulcerative colitis

Question 23

Name some of the extra-intestinal manifestations of Crohn’s disease

Answer 23

Clinical features that occur outside the gastrointestinal tract within CD.

Skin: Erythema nodosum, a panniculitis, is characterised by reddened, raised, tender nodules.

Skin: Pyoderma gangrenosum presents with ulcerating nodules characterised by black (gangrenosum) edges and central pus (pyoderma).

Eye: Episcleritis (inflammation of your episclera)

Question 24

What is the key investigation used to distinguish between IBD and irritate bowel syndrome (IBS).

Answer 24

Faecal calprotectin

High in IBD; Normal in IBS

Question 25

Faecal calprotectin is sensitive for inflammatory bowel disaese but not specific. What does this mean

Answer 25

good at picking up inflammation but is not specific for IBD

Question 26

Name some of the investigations of Crohn's disease

Answer 26

Faecal calprotectin Ileocolonoscopy MR enterography Intestinal biopsy Routine bloods - for anaemia, infection, thyroid, kidney and liver function CRP - detecting inflammation

Question 27

MR enterography have high diagnostic accuracy for disease in which part of the GI tract

Answer 27

Small bowel disease

Question 28

mesalazine is used in which type of inflammatory bowel disaese

Answer 28

Ulcerative colitis only DO NOT USE IN CROHNs

Question 29

The general principle in the management of Crohn's disease is to induce and then maintain remission. What pharmacological options induce remission

Answer 29

In patients presenting with CD for the first time, or those who develop a flare of CD, the principle aim is to induce remission. Methotrexate and thiopurines are potential induction therapies however it is unclear the benefit of thiopurines as an induction therapy.

Question 30

The general principle in the management of Crohn's disease is to induce and then maintain remission. What pharmacological options are for maintenance therapy

Answer 30

predominantly thiopurines, methotrexate and biologics.

Question 31

Give an example of a Thiopurines

Answer 31

azathioprine mercaptopurine

Question 32

What is the mechanism of action of Thiopurines in the maintence of Crohn's disease

Answer 32

Work through purine synthesis inhibition in lymphocytes leading to immunosuppressive properties.

Question 33

WHat must be checked before using Thiopurines and why?

Answer 33

Must check TPMT enzyme activity before use. Homozygous mutations in TPMT can lead to dangerous bone marrow suppression.

Question 34

Name a side effect of Thiopurines

Answer 34

pancreatitis hepatotoxicity

Question 35

Methotrexate can be used in the maintence of crohns disease How does it work

Answer 35

Inhibits dihydrofolate reductase. Has both immunomodulatory and anti-inflammatory properties.

Question 36

WHat must be checked before using methotrexate

Answer 36

Liver and renal function

Question 37

Name some of the side effects of methotrexate

Answer 37

bone marrow suppression, hepatotoxicity and pulmonary toxicity.

Question 38

Biologics are monoclonal antibodies. Can be used in the maintence of crohn's disease. Give an example of a tumour necrosis factor (TNF) alpha inhibitors

Answer 38

infliximab/adalimumab

Question 39

Biologics are monoclonal antibodies. Can be used in the maintence of crohn's disease. Give an example of an alpha-4/beta-7 integrin inhibitor

Answer 39

vedolizumab

Question 40

Name some of the side effects of biologics use

Answer 40

Shortness of breath, lead to immunosuppression so patients are prone to serious infections. They can also lead to reactivation of dormant infections such as TB and hepatitis B.

Question 41

What score is used as the standard evaluation of post-surgical recurrences at ileocolic anastomosis level (Crohn's disease)

Answer 41

Rutgeerts score

Question 42

Surgery still forms a key part of management in CD. Often patients require a combination of pharmacological and surgical management. When would surgery be used as a treatment

Answer 42

treatment for localised CD (e.g. localised ileocaecal Crohn’s) for patients wanting to avoid medical therapy or among patients that fail to respond to medical therapy to manage complications (e.g. perforation, abscess formation).

Question 43

What is the cumulative rate of symptomatic recurrence of crohn's disease after curative resection

Answer 43

50%

Question 44

What is the most common inflammatory bowel disease

Answer 44

Ulcerative colitis

Question 45

Inflammation of the rectal mucosa initially (proctitis) and may progress proximally to proximal parts of the colon. What perctange of patients suffer from proctitis only

Answer 45

50%

Question 46

Inflammation of the rectal mucosa initially (proctitis) and may progress proximally to proximal parts of the colon. What perctange of patients suffer from pancolitis (inflammation of the entire colon).

Answer 46

20%

Question 47

What are Patients with pancolitis in ulcerative colitis at risk of

Answer 47

At risk of developing backwash ileitis

Question 48

What is backwash ileitis.

Answer 48

backwash ileitis is the reflux of colonic contents into the distal few centimetres of the ileum through the ileocaecal valve. Backwash ileitis can make distinction between UC and CD more difficult.

Question 49

At what age is incidences of Ulcerative colitis seen in

Answer 49

15-25 and 55-65 years of age.

Question 50

Is ulcerative colitis most common in: males or females

Answer 50

Females

Question 51

Which type of inflammatory bowel disease is skip lesions seen in

Answer 51

Crohn's disease

Question 52

Describe the histology of Ulcerative colitis

Answer 52

Tends to be superficial only affecting the mucosa so perforations and fistulae are not associated with UC.

Question 53

Complications such as perforations and fistulae are seen in which type of inflammatory bowel disease

Answer 53

Crohn's disedase No ulcerative colitis as the inflammation tends to be superficical only affects the mucosa

Question 54

Smoking is protective in \_\_\_\_, whereas it is a risk factor in \_\_\_\_ Crohn's or Ulcerative colitis

Answer 54

Smoking is protective in **ulcerative colitis**, whereas it is a risk factor in **crohns**

Question 55

Mneominic "U – C – CLOSEUP" is used to remember the classic characteristics of ulcerative colitis. What does it stand for

Answer 55

C – Continuous inflammation L – Limited to colon and rectum (usually) O – Only superficial mucosa affected S – Smoking is protective E – Excrete blood and mucus U – Use aminosalicylates P – Primary Sclerosing Cholangitis

Question 56

Describe the macroscopic changes seen in ulcerative colitis

Answer 56

Macroscopic changes can be seen in endoscopy Red inflammed mucosa Continous inflammation Mucosa is easily friable to touch Inflammatoy polyps

Question 57

Describe the microscopic changes seen in ulcerative colitis

Answer 57

Microscopic changes can be seen in histology Goblet cell depletion Crypt absecesses Inflammatory infiltrate in lamina propria

Question 58

In which inflammatory bowel disease is there goblet cell depletion

Answer 58

Ulcerative colitis

Question 59

There is increased inflammatory infiltration into the lamina propria in ulcerative colitis. What type of cells make up the majority of the inflammatory infiltrates

Answer 59

Neutrophils

Question 60

What is the hallmark feature of ulcerative colitis

Answer 60

Blood diarrhoea/ rectal bleeding

Question 61

Name some of the clinical features of ulcerative colitis

Answer 61

Diarrhoea Abdominal pain Passing blood Weight loss

Question 62

What is the first line medication used to induce remission in mild to moderate ulcerative colitis

Answer 62

aminosalicylate e.g. mesalazine oral or rectal – topical i.e. rectal is better)

Question 63

What is the **second** line medication used to induce remission in mild to moderate ulcerative colitis

Answer 63

corticosteroids e.g. prednisolone

Question 64

What is the **First** line medication used to induce remission in **severe** ulcerative colitis

Answer 64

IV corticosteroids e.g. hydrocortisone

Question 65

What is the **second** line medication used to induce remission in **severe** ulcerative colitis

Answer 65

IV ciclosporin

Question 66

Does aminosalicylate e.g. mesalazine induce or maintain remission of ulcerative colitis

Answer 66

Both - used to induce and maintain remission

Question 67

Which inflammatory bowel disaese has a strong link with colorectal cancer

Answer 67

Ulcerative colitis

Question 68

Name some of the medications used to maintain remission of ulcerative colitis

Answer 68

Aminosalicylate e.g. mesalazine oral or rectal Azathioprine Mercaptopurine

Question 69

Name some of the local complications associated with ulcerative colitis

Answer 69

Haemorrhage Toxic dilation (aka toxic megacolon)

Question 70

Name some of the systemic complications associated with ulcerative colitis

Answer 70

Skin; erythema nodosum, pyoderma gangrenosum Liver; sclerosing cholangitis, cholangioCa Eyes; iritis, uveitis, episcleritis Ankylosing spondylitis

Question 71

Bloody diarrhoea is more common in which inflammatory bowel disease

Answer 71

Ulcerative colitis

Question 72

Watery, non-bloody diarrhoea is more common in which inflammatory bowel disease

Answer 72

Crohn's disease

Question 73

Weight loss is more prominent in which inflammatory bowel disease

Answer 73

Crohn's disease

Question 74

Which inflammatory bowel disease is there upper GI symptoms

Answer 74

Crohn's disease

Question 75

Which inflammatory bowel disease is associated with tenesmus i.e. not feeling quite finished after a bowel motion

Answer 75

Ulcerative colitis

Question 76

Abdominal pain in the left lower quadrant is more associated with which inflammatory bowel disease

Answer 76

Ulcerative colitis

Question 77

Abdominal mass palpable in the right iliac fossa is more associated with which inflammatory bowel disease

Answer 77

Crohn's disaese

Question 78

Gallstones are more common in which inflammatory bowel disease

Answer 78

Crohn's disaese Due to reduced bile acid reabsorption

Question 79

Primary sclerosing cholangitis are more common in which inflammatory bowel disease

Answer 79

Ulcerative colitis

Question 80

Name some of the complications associated with Crohn's disease

Answer 80

Obstruction Fistula Colorectal cancer

Question 81

In which inflammatory bowel disease is the lesions seen anywhere in the GI tract (from mouth to anus)

Answer 81

Crohn's disease

Question 82

In which inflammatory bowel disease is the inflammation starting at rectum and never spread beyond the ileocaecal valve

Answer 82

Ulcerative colitis

Question 83

In which inflammatory bowel disease does the inflammation affect all layers of the bowel wall (from mucosa to serosa)

Answer 83

Crohn's disease

Question 84

In which inflammatory bowel disease does the inflammation affect only the mucosa and does not extend beyond submucosa

Answer 84

Ulcerative colitis

Question 85

In which inflammatory bowel disease is there an increase of goblet cells seen in histology

Answer 85

Crohn's disease

Question 86

In which inflammatory bowel disease is there granuloma formation seen in histology

Answer 86

Crohn's disease

Question 87

In which inflammatory bowel disease is there crypt abscess formation seen in histology

Answer 87

Ulcerative colitis

Question 88

In which inflammatory bowel disease is there a depletion of goblet cells seen in histology

Answer 88

Ulcerative colitis

Question 89

What are the endoscopic features of crohn's disease

Answer 89

Deep ulcers Skip lesions Cobble-stone appearance

Question 90

What are the endoscopic features of ulcerative colitis

Answer 90

Widespread ulceration with preservation of adjacent mucosa May have polyps ('pseudopolyps')

Question 91

What kind of enema is used, in association with radiology, in Crohn's disaese

Answer 91

Small bowel enema as it is high sensitivity and specificity for examination of the terminal ileum

Question 92

What kind of enema is used, in association with radiology, in ulcerative colitis

Answer 92

Barium enema

Question 93

What are the radiological features of crohn's disease

Answer 93

strictures: 'Kantor's string sign' proximal bowel dilation 'rose thorn' ulcers fistulae

Question 94

'rose thorn' ulcers are seen in radiology. What inflammatory bowel disease are they suggestive of

Answer 94

Crohn's disease