Inflammatory bowel disease

Question 1

Crohn’s

Answer 1

No blood or mucus (less common)

Entire GI tract

Skip lesions

Terminal ilium most affected and transmural inflammation

Smoking is a risk factor

Diarrhoea is most prominent feature in adults

Abdominal pain most prominent feature in children

Question 2

Ulcerative colitis

Answer 2

Continuous inflammation

Limited to colon and rectum

Only superficial mucosa affected

Smoking is protective

Excrete blood and mucus

Use aminosalicylates

Primary sclerosing cholangitis

Question 3

Other features of both

Answer 3

Arthritis

Erythema nodosum

Episcleritis

Osteoporosis

Uveitis

Pyoderma gangrenosum

Clubbing

Question 4

Testing

Answer 4

Bloods for anaemia, infection, thyroid, kidney and liver function

CRP

Faecal calprotectin

Endoscopy with biopsy is diagnostic

US/CT/MRI to look for complications

Question 5

Inducing remission in Crohn’s

Answer 5

Glucocorticoids (oral, topical or IV) first line

5-ASA (mesalazine) second line

Azathioprine or mercaptopurine as an add on therapy

Metronidazole for isolated peri-anal disease

Question 6

Maintaining remission in Crohn’s

Answer 6

Same as inducing remission

Stop smoking

Azathioprine or mercaptopurine used first line

TPMT activity assessed before starting

Methotrexate used second line

Question 7

Surgery in Crohn’s

Answer 7

Stricturing terminal ileal disease- ileocaecal resection

Segmental small bowel resections

Stricturoplasty

Question 8

Perianal fistulae

Answer 8

Inflammatory tract between anal canal and perianal skin

MRI to diagnose simple or complex

If symptomatic given metronidazole

Anti-TNF (infliximab) effective in closing and maintaining closure

Draining seton used for complex fistulae

Question 9

Perianal abscess

Answer 9

Requires incision and drainage

Antibiotic therapy

Draining seton may be placed if tract identified

Question 10

Complications of Crohn’s

Answer 10

Small bowel cancer

Colorectal cancer

Osteoporosis

Question 11

Severity of UC

Answer 11

Mild: <4 stools/day and small amount blood

Moderate: 4-6 stools/day, varying amount blood, no systemic upset

Severe: >6 bloody stools/day and features systemic upset

Question 12

Inducing remission in mild-moderate UC

Answer 12

Proctitis: topical aminosalicylate, if remission not achieved 4 weeks add oral, if remission still not achieved add topical/oral corticosteroid

Proctosigmoiditis and lef-sided UC: topical aminosalicylate, if remission not achieved 4 weeks add high-dose oral aminosalicylate +/- topical corticosteroid, if remission still not achieved offer oral aminosalicylate and oral corticosteroid

Extensive disease: topical aminosalycilate and high-dose oral aminosalicylate, if remission not achieved 4 weeks stop topical and offer high-dose oral aminosalicylate and oral corticosteroid

Question 13

Inducing remission in severe UC

Answer 13

Should be treated in hospital

IV steroids first line

If no improvement after 72 hours consider adding IV ciclosporin or consider surgery

Question 14

Maintaining remission for mild-moderate UC

Answer 14

Proctitis/ proctosigmoiditis: topical aminosalicylate alone or oral aminosalicylate plus topical or oral aminosalicylate alone

Left-sided and extensive UC: low maintenance dose oral aminosalicylate

Question 15

Maintaining remission following severe relapse or >2 exacerbations in past year

Answer 15

Oral azathioprine or oral mercaptopurine

Question 16

Surgery in UC

Answer 16

Typically only affects colon and rectum so panproctocolectomy will remove the disease

Left with ileostomy or J pouch