Inflammatory Bowel Disease

Question 1

Define Crohn’s disease

Answer 1

Chronic granulomatous transmural inflammation of any part of the GI tract, mainly the distal ileum and proximal colon

Question 2

What are the structural features of Crohn’s disease

Answer 2

Inflammation occurs anywhere from mouth to anus, Common in the terminal ileum (40%, R lower abdo pain) and peri-anal region
TRANSLUMINAL/full thickness inflammation
Skip lesions (inflamed and normal bowel interspersed)
Formation of strictures and fistulae, risk of obstruction
Goblet cell and granuloma involvement

Question 3

What are the suggested causes for and risk factors of Crohn’s disease

Answer 3

Genetic: CARD15, IL-23

RF:
White ethnicity
15-40 or 60-80
FHx IBD
Environmental: smoking, OCP, high refined sugar

Question 4

What are the symptoms of Crohn’s disease

Answer 4

Abdominal pain (cramping, constant, RLQ/peri-umbilical, relieved by defecation)
Prolonged diarrhoea (NON-bloody (or intermittent)
Obstruction → bloating, distension, vomiting, constipation
Fever
Malaise, fatigue, lethargy
Weight loss, growth failure, delayed puberty

Extra-intestinal: Ulcers, arthritis, erythema nodosum, pyoderma gangrenosum
- Anterior uveitis: painful red eye with loss of vision
- Scleritis : painful red eye with no loss of vision
- Episcleritis: uncomfortable red eye with no loss of vision
Crohn’s colitis → diffuse abdo pain, mucous blood and pus in stool

Question 5

What are the signs of Crohn’s disease on examination

Answer 5

General: pallor (anaemia)
ENT:
- Aphthous mouth ulceration
- Scleritis : painful red eye with no loss of vision
- Episcleritis: uncomfortable red eye with no loss of vision
Skin: erythema nodosum, pyoderma gangrenosum
Abdo: abdominal tenderness
PR: peri-anal lesions e.g. skin tags, fistulae, scarring, abscess

Question 6

What investigations should be done for Crohn’s disease

Answer 6

bedside: Faecal calprotectin (raised, but better for adults), stool culture
Blood:
- FBC: raised platelets, WCC, IDA
- ESR/CRP: raised
- Albumin: raised
- Iron studies: IDA
- Vit 12/folate: ?anaemia
- Plasma viscosity: raised

Other
- Upper intestinal endoscopy and biopsy
- AXR: narrowing, fissuring, bowel wall thickening, calcification
- CT abdomen: String sign of Kantor - fibrosis + strictures, ‘rose-thorn- fissures’
- Abdo US: ? osbtruction

Question 7

What is found on endoscopy and biopsy for Crohn’s disease

Answer 7

Mucosal oedema and ulceration with Cobblestone mucosa, fistulae, abscesses
Patchy inflammation
Ulceration appears yellow, horizontal or longitudinal

Biopsy
Transmural chronic inflammation with macrophage infiltration, lymphocytes and plasma cells
Superficial AND deep ulcerations
Histology: non-caseating epithelioid cell granulomata

Question 8

What is the management for Crohn’s disease

Answer 8

Induce and maintain remission
Monitor ferritin, B12, calcium and Vitamin D
Assess impact of symptoms on daily functioning (anxiety, depression)
Resources: Crohn’s and Colitis UK
Encourage stopping smoking
Assess risk of osteoporosis
Symptomatic treatment
Pre-immunological therapy vaccination

Question 9

Describe induction of remission therapy for Crohn’s disease

Answer 9

First line: Steroids (oral/IV) prednisolone
Second line: Immunomodulators (oral/IV) azathioprine, mercaptopurine, methotrexate
Third line: Biological (IV) adalimumab, inflixmab, vedolizumab
If corticosteroids CI → aminosalicylates (mesalazine, sulfasalazine)

Nutritional therapy:
- Whole protein modular feeds (polymeric) for 6-8 weeks, excessively liquid
- May required NG tube if struggling to drink

Question 10

Describe maintenance therapy for remission of Crohn’s disease

Answer 10

Immunomodulators e.g. azathioprine, Mercaptopurine, methotrexate
Amino salicylates e.g. mesalazine
Biological therapy (Anti-TNF antibodies) e.g. infliximab, adalimumab, vedolizumab

Question 11

When is surgery for Crohn’s disease indicated and what is the aim

Answer 11

Failure of medical treatment
Failure to thrive
Complications: obstruction, fistulae, abscess

Aim: resection of the affected bowel + stoma formation

Question 12

What are the complications of Crohn’s disease

Answer 12

Intestinal:
Obstruction
Haemorrhage
Toxic megacolon
Fistulae (bowel, bladder, vagina)
Abscess, sepsis
Perforation
Malignancy
Anaemia → IDA, B12 deficiency
Short-bowel syndrome

Extra-intestinal
Cholelithiasis
Primary sclerosis cholangitis
Hepatic steatosis, liver abscess, granulomatous hepatitis
Arthropathy
uveitis, episcleritis
Amyloidossis
Hypocalcaemia → osteoporosis

Question 13

What is the prognosis for Crohn’s disease

Answer 13

Relapsing-remitting, life-long disease
Long term prognosis for Crohn’s beginning in childhood is GOOD
Most people live normal lives, despite occasionally relapsing

Question 14

Define ulcerative colitis

Answer 14

Chronic relapsing and remitting inflammatory and ulcerating bowel disease that characteristically affects the rectum and colon mucosa

Question 15

What is the pathophysiology of ulcerative colitis

Answer 15

Most cases arise in the rectum (proctitis)
Incompetent ileocaecal valve or backwash ileitis → may extend ~30cm proximally → terminal ileitis
90% of children have pancolitis
Bowel wall is thin/normal but may appear thick due to oedema, muscle hypertrophy and fat accumulation
Only involves the mucosa → crypt abscesses and depletion of goblet cell mucin
Inflammation of the crypts of Liebekuhn + abscesses
Ulcerated areas are covered by granulation tissue

Question 16

What are the risk factors for ulcerative colitis

Answer 16

Family history of IBD
HLA-B27 (Also associated with Ankylosing spondylitis)
Infection
NSAIDs
Non-smoker, former smoker

Question 17

What are the symptoms of ulcerative colitis

Answer 17

Rectal bleeding/mucous passage (intermittent, gross or occult)
Diarrhoea (Bloody, <4 a day)
Abdominal pain and tenderness (cramps, associated with tenesmus)
Arthritis and spondylitis
Failure to thrive, weight loss and growth retardation (<Crohn’s)
Fever
Constipation

Question 18

What are the signs of ulcerative colitis on examination

Answer 18

General: clubbing, pallor, dehydration
Obs: tachycardia
ENT: uveitis, episcleritis
Skin: erythema nodosum, pyoderma gangrenosum
Abdo: tenderness
PR: blood, mucous, tenderness

Question 19

What investigations should be done for ulcerative colitis

Answer 19

bedside: Faecal calprotectin (raised, but better for adults), stool culture (-ve culture, raised WCC)
Blood:
- FBC: raised platelets, WCC, IDA
- ESR/CRP: raised
- U&Es: hypokalaemic metabolic acidosis
- LFTs: ?PSC
- Albumin: raised
- Iron studies: IDA
- Vit 12/folate: ?anaemia

Other
- Ileocolonoscopy and upper endoscopy + biopsy
- AXR: ? toxic megacolon
- Double-contrast barium enema: lead pipe appearance

Question 20

What would be seen on ileocolonoscopy and biopsy for ulcerative colitis

Answer 20

Rectal involvement
Continuous uniform involvement
Loss of vascular marking
Diffuse erythema
Fistulas

Biopsy: Mucosal ulcers, crypt abscesses/loss/distortion, continuous distal disease, mucin depletion, basal plasmacytosis, diffuse mucosal atrophy of ONLY the mucosa and submucosa, absence of granulomata

Question 21

What are the severity classifications of ulcerative colitis

Answer 21

Mild: <4 stools daily ± blood, NO systemic disturbance, normal ESR/CRP
Moderate: 4-6 stools a day, minimal systemic disturbance
Severe: >6 stools a day, containing blood + systemic disturbance (fever, tachy, abdo tenderness, distension, anaemia, hypoalbuminaemia)

Question 22

How do you assess severity of ulcerative colitis

Answer 22

Paediatric Ulcerative Colitis Activity Index (PUCAI)
Markers of activity:
↓Hb
↓albumin
↑ESR/CRP
Diarrhoea frequency (<4 a day = mild,
>6 days = severe)
Bleeding
Fever

Flares: Truelove and Witts’ severity index

Question 23

What is the management for ulcerative colitis

Answer 23

Induction and maintenance therapy

Induction:
1. Mesalazine (5-ASA) rectal 1000mg once daily at night for 3-6 weeks AND mesalazine oral
- remission not achieved by 4 weeks → oral aminosalicylate
2. Beclometasone diproprionate PO

Maintain:
1. azathioprine OR mercaptopurine
2. Infliximab IV at 0, 2, 6 weeks (TNF-alpha inhibitor)
3. Vedolizumab or tofacitinib (integrin receptor antagonists) IV
4. Ciclosporin
5. Colectomy

Question 24

What is the management for non-fulminant acute ulcerative colitis

Answer 24

Non-fulminant
1. Rectal aminosalicylate (mesalazine)
2. Oral prednisolone
3. fulminant management

Question 25

What is the management for fulminant acute ulcerative colitis

Answer 25

1. admit
2. IV corticosteroids e.g. hydrocortisone
3. IV fluids, no bowel rest
4. ciclosporin or infliximab
5. Colectomy if not responsing to corticosteoirds

Question 26

What are the complications of ulcerative colitis

Answer 26

Toxic megacolon
Colonic adenocarcinoma (3-5%)
Primary sclerosing cholangitis
Perforation
Infection
Massive LGI bleed
Benign stricture
Inflammatory pseudopolyps
Dysplasia-associated lesion or mass (DALM)
Extra-GI: Uveitis, renal calculi, arthropathy, sacroiliitis, ankylosing spondylitis, erythema nodosum, pyoderma gangrenosum, osteoporosis, amyloidosis

Question 27

What is the prognosis for ulcerative colitis

Answer 27

Ulcerative colitis is a lifelong condition, characterized by periods of relapse and remission with recurrent cycles of inflammation
Overall mortality does not appear to be increased, but may be in older patients and those who develop complications
Surgery appears to increase mortality
Most common cause of death is toxic megacolon