Inflammatory bowel disease

Question 1

what is ibd

Answer 1

inflammation of the GI tract and the umbrella term for crohns and Ulcerative collitis

Question 2

Distinguishing factors of Crohns disease

Answer 2

N – No blood or mucus (less common)

E – Entire GI tract

S – “Skip lesions” on endoscopy

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

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

Question 3

distinguishing factors of Ulcerative collitis

Answer 3

C – Continuous inflammation

L – Limited to colon and rectum

O – Only superficial mucosa affected

S – Smoking is protective

E – Excrete blood and mucus

U – Use aminosalicylates

P – Primary Sclerosing Cholangitis

Question 4

What is UC

Answer 4

IBD
Involves rectum and extends to affect colon - never spread beyond ileocaecal valve - confined to large bowel

Question 5

microscopic features of ulcerative collitis

Answer 5

-mucosa only inflamed
- crypt abscesses
-depleted goblet cells

Question 6

microscopic features of Crohn’s disease

Answer 6

• transmural inflammation
• granulomas
• increased chronic inflammatory cells and lymphoid hyperplasia

Question 7

cause of Ulcerative colitis

Answer 7

inappropriate immune response against colonic flora in genetically susceptible individuals
HLAB27 association

Question 8

risk factors for UC

Answer 8

Family history - HLA b27
NSAIDS
Onset
Flares/relapse
Chronic stress + depression - triggers flares
White

Question 9

epidemiology of UC

Answer 9

• 50/50 m and f
  -20-40 yr olds
• incidence is 3x higher in smokers
• Highest incidence and prevalence in Northern Europe, UK and North America
• Affects caucasians and eastern European Jews most

Question 10

Pathophysiology of UC

Answer 10

Form ulcers along the inner-surface or lumen of the large intestine, including both the colon and the rectum.

ulcers are spots in the mucosa and submucosa where the tissue has eroded away and left behind open sores or breaks in the membrane.

Cytotoxic T cells are often found in the epithelium lining the colon, and they may be responsible for destroying the cells lining the walls of the large intestine, leaving behind ulcers
P-ancas

Question 11

Signs of UC

Answer 11

• Abdominal tenderness
• Fever - in acute UC
• Tachycardia - in acute severe UC

Question 12

Symptoms of UC

Answer 12

• REMISSIONS and exacerbations
• abdo pain, lower left quadrant
• weight loss
• episodic or chronic diarrhoes with blood
• fever and malaise

Question 13

systemic effects in UC attacks

Answer 13

fever
anorexia
malaise
weight loss

Question 14

complications of UC with regards to the colon

Answer 14

Blood loss
Perforation
Toxic dilatation
Colorectal cancer

Question 15

complications of UC and Crohns with regards to skin

Answer 15

Erythema nodosum
Tender red bumps
Symmetrically on shins

Question 16

Complications of UC with regards to liver

Answer 16

Fatty change
chronic pericholangitis
sclerosing cholangitis

Question 17

complications of uc with regards to joints

Answer 17

ankylosing spondylitis
arthritis

Question 18

Primary investigations

Answer 18

Faecal calprotectin
FBC
LFTs
CRP/ESR
Colonoscopy + Biopsy GS

Question 19

what may blood tests show for UC

Answer 19

Raised WCC4
Raised platelets
Raised CRP and ESR
Anaemia
pANCA may be positive

Question 20

what other investigations would you ask for if you suspect Ulcerative Collitis

Answer 20

• stool samples, to exclde c diff
• faecal calprotein
• colonoscopy
• abdo xray

Question 21

GS investigation for ulcerative collitis

Answer 21

colonoscopy
sigmoid oscopy

Question 22

what would colonoscopy show for UC

Answer 22

• continous lead pipe inflammation
• Crypt abscessesdue to neutrophil migration through gland walls
• Goblet cell depletion, withinfrequentgranulomas

Question 23

mild to moderate management of Ulcerative Collitis

Answer 23

1st line- aminosalicylate
2nd line - corticosteroids

Question 24

how do aminosalicylate work

Answer 24

limiting the inflammation in the lining of the GI tract

Question 25

management for severe disease of UC

Answer 25

1st line- corticosteroids 2nd line- IV ciclosporin

Question 26

SEVERE cases with no response to treatmemt :

Answer 26

colectomy - whole colon removed -ileoanal anastomosis

Question 27

Complications of UC

Answer 27

- **Toxic megacolon**: - **Perforation**: associated with high mortality - **Colonic adenocarcinoma** - **Strictures and obstruction:**

Question 28

What is Crohn's disease

Answer 28

inflammatory bowel disease characterised by transmural inflammation of the gastrointestinal tract (anywhere from mouth to anus), with the terminal ileum and colon most commonly affected

Question 29

Epidemiology of Crohns

Answer 29

- Highest incidence and prevalence in Northern Europe, UK and North America - The disease has its peak onset in early life (20-40 years) with a second peak among the elderly (50-80) - F>M

Question 30

cause of chrons disease

Answer 30

IM system triggered by foreign pathogen (TB or psudomona) in GI tract IM system targets pathogen but large and uncontrolled > destruction of cells in GI tract Th cells > cytokines > macrophages Macrophages: proteases, Platelet activating factor and free radicals

Question 31

How does transmural inflammation occur?

Answer 31

The immune cells invade deep into the mucosa and organise themselves into granulomas. Eventually ulcers form, which can go through all the layers. This is known as transmural.

Question 32

risk factors for crohns disease

Answer 32

Family history Stronger genetic association than UC Smoking – 2-4x risk NSAIDs – exacerbate it Chronic stress + depression

Question 33

symptoms if crohns is in the small bowel

Answer 33

- abdo pain - malabsorption - weight loss - terminal ileum--- right iliac fossa pain

Question 34

What will malabsorption cause?

Answer 34

- b12/folate deficiency - gall stones/ kidney stones - diarrhoea - failure to thrive

Question 35

clinical signs of crohns

Answer 35

Bowel ulceration Abdo tenderness Abdo mass Perianal disease

Question 36

What investigations would you do for crohns

Answer 36

pANCA -ve fecal calprotectin elevated FBC CRP/ESR UE LFT Colonoscopy - GS

Question 37

DDs for Crohns

Answer 37

- Ulcerative colitis - Alternative causes of diarrhoea should be excluded e.g. Salmonella spp, Giardia intestinalis and rotavirus - Chronic diarrhoea

Question 38

What would biopsy show for crohns

Answer 38

transmural inflammation with non caseating granulomas

Question 39

what would blood tests show with crohns

Answer 39

Raised WCC Raised platelets Raised CRP & ESR pANCA negativw Anaemia

Question 40

management for crohns disease to induce remission

Answer 40

1st line- Glucocorticoids ORAL PREDNISOLONE for flare ups or IV steroids Immunosuppresants Antibiotics

Question 41

To maintain remission

Answer 41

**1st line:** Azathioprine or Mercaptopurine **2nd line:** Methotrexate, Infliximab, Adalimumab **Post-surgery**: consider azathioprine, with or without methotrexate

Question 42

Non medical management of crohns

Answer 42

smoking cessation iron/ folate/b12 supplements Stop NSAIDs

Question 43

if a patient is non responsive to steroids in crohns disease what are the options...

Answer 43

Anti - TNF antibodies

Question 44

Histological features that will be seen in ulcerative collitis

Answer 44

Increase in plasma cells in lamina propria Ulceration Crypt distortion

Question 45

What does tnf-a cause

Answer 45

- An increased immune response - Angiogenesis - formation of new blood vessels - Paneth cells necrosis - Intestinal epithelium cell death

Question 46

What would you give for remission in crohns

Answer 46

azathropine