Inflammatory Bowel Disease

Question 1

Where is the location of ulcerative colitis?

Answer 1

Limited to rectum and large colon. Inflammation is limited to mucosa

Question 2

What are the symptoms of ulcerative colitis?

Answer 2

Bloody diarrhoea or mucus
Abdominal pain
Tenesmus and urgency

Question 3

What are some extra-intestinal features of UC and Crohns?

Answer 3

Other HLA-B27
Ankylosing spondylitis
Arthritis
Erythema nodosum
Episcleritis
Osteoporosis
Uveitis
Pyoderma gangrenosum
Clubbing

Question 4

What disease can occur in ulcerative colitis?

Answer 4

Primary sclerosing cholangitis and cancer

Question 5

What is the histopathology of ulcerative colitis?

Answer 5

• Pseudopolyps,
• No granulomas
• Crypt abscesses
• Depletion of goblet cells

Question 6

What are the investigations for ulcerative colitis?

Answer 6

• Stool culture to rule out infective cause
• Faecal calprotectin
• CRP/ESR
• FBC/LFTs
• Colonoscopy + biopsy

Question 7

What are the differentials for UC?

Answer 7

• Crohn’s,
• Intermediate colitis
• Infective colitis
• Radiation colitis
• Diverticulitis
• IBS
• Ischaemic colitis
• Vasculitis

Question 8

What is acute severe ulcerative colitis and the management?

Answer 8

Passing > 6 stools per day and at least one of: Temp > 37.8, HR > 90, Hb <105 or CRP > 30.
Manage with IV hydrocortisone. If not response in 3 days then start IV Infliximab in addition to steroids

Question 9

What are the indications for surgery in UC?

Answer 9

Toxic megacolon, perforation, multiorgan dysfunction

Question 10

What treatment is used to induce remission in UC

Answer 10

Proctitis and proctosigmoiditis - Mesalazine topical or oral (add oral if remission not acheieved in 4 weeks).
Left sided/extensive disease - Oral Mesalazine and topical

Question 11

What is the treatment escalation for ulcerative colitis?

Answer 11

When patient is having severe or frequent relapses (>2 per year). Start on azathioprine or mercaptopurine. However it increases risk of lymphoma.
Further escilation - add biologic eg, infliximab.

Question 12

What is toxic megacolon?

Answer 12

Dilated colon with signs of toxicity such as: fever (>38.6), Hr >120, weight cell > 10.5 or anaemia

Question 13

What are the signs and symptoms of toxic megacolon

Answer 13

Fever, tachycardia, mental status change, hypotension and abdominal distention + pain and diarrhoea

Question 14

What is the management of toxic megacolon?

Answer 14

1. Resuscitation with IV fluids
2. Antibiotics
3. Supportive care
4. NG decompression
5. Emergency colectomy

Question 15

What is a mild and moderate UC flare?

Answer 15

Mild - Less than 4 bowel movements per day and systemically well
Moderate - 4-6 stools per day and mild-severe blood but systemically well

Question 16

What is the surgical management of UC?

Answer 16

Panproctocolectomy with ileostomy or ileo-anal anastamosis (J pouch)

Question 17

Describe features of crohn’s disease

Answer 17

IBD which can affect anywhere from mouth to anus. Transmural inflammation meaning it can fistulate. Commonly affects terminal ileum

Question 18

What are the symptoms of crohns disease?

Answer 18

• Crampy abdominal pain,
• Diarrhoea,
• Weight loss and anorexia
• Aphthous ulcers
• Perianal lesions

Question 19

What are the extra intestinal manifestations of Crohn’s disease/

Answer 19

• Erythema nodosum,
• Pyoderma gangrenosum
• Anterior uveitis
• Episcleritis
• Arthritis
• Ankylosing spondylitis
  Eyes, bones and skin

Question 20

What are the investigations for Crohn’s disease?

Answer 20

• FBC, Iron studies, B12 and folate, CRP
• Faecal calprotectin
• Stool culture to rule out infective cause
• Endoscopy
• Imaging such as CT or MRI enterography to look for fistula, abscesses and strictures

Question 21

What is the histopathology of crohn’s disease?

Answer 21

Skip lesions,
Cobblestone appearence,
Rose thorn ulcers (due to transmural inflammation)
Granulomas

Question 22

What is the treatment to induce remission in Crohn’s disease?

Answer 22

• Glucocorticoids
• Can add ASA or biological agent if failing to respond

Question 23

What treatment is used to maintain remission in Crohn’s disease?

Answer 23

• Azathioprine or mercaptopurine
• Methotrexate can be considered
• Biologics eg, infliximab, adalimumab, ustekinumab

Question 24

What enzyme must be assessed before giving azathioprine or mercaptopurine?

Answer 24

TPMT

Question 25

What is the treatment of peri-anal fistula and what is it a complication of?

Answer 25

Complication of Crohn's. Treat with drainage seaton, antibiotics and infliximab

Question 26

What is the management of peri-anal abscesses?

Answer 26

- Incision, drainage and clean out. - IV antibiotics eg, ceftriaxone and metronidazole

Question 27

Explain the presentation, investigations and treatment for ischaemic collitis

Answer 27

Presents with abrupt onset of pain, bloody diarrhoea +/- SIRS. Usually pain is in left abdomen. CT may show segmental colitis in watershed areas. Treatment is usually conservative with IV fluids +/- abx