Inflammatory Bowel Disease Flashcards Preview

Gen Med: GI > Inflammatory Bowel Disease > Flashcards

Flashcards in Inflammatory Bowel Disease Deck (26):
1

What is IBD?

1. Autoimmune disease of the gastrointestinal (GI) tract characterized by
-Mucosal inflammation
-Recurrent diarrhea & abdominal pain
2. Chronic & relapsing
3. Idiopathic

2

What is ulcerative colitis?

-Affects colon & rectum
-Diffuse mucosal inflammation
-Involves the rectum ≈ 95% of cases
-Extends proximally in continuous pattern
-Rarely involves anus

3

What is Crohn's Disease?

-Can involve any part of GI tract (mouth to anus)
-Transmural inflammation
-Most commonly affects ileum & proximal colon, extends distally
-Interrupted or “skip lesions”
-Perianal involvement  

4

IBD Associated Comorbidities

Gallstones
Malnutrition
UTI
Kidney stones
Amyloidosis
Arthritis
Uveitis
Episcleritis
Aphthous stomatitis
Erythema nodosum
Pyoderma gangrenosum
(red-blue pus containing sores)
Ankylosing spondylitis
Sacroiliitis

5

Differential Diagnosis: IBD

1. Irritable bowel syndrome (IBS)
A. GI syndrome characterized by chronic abdominal pain & altered bowel habits w/out organic cause
B. NOT associated w/ inflammation

2. Celiac disease (aka celiac sprue or gluten-sensitive enteropathy)
A. Small-bowel disorder characterized by mucosal inflammation, villous atrophy & crypt hyperplasia
B. Sx’s occur w/ingestion of dietary gluten

6

Crohn's Disease: Etiology/Pathogenesis

1. Idiopathic
2. Disruption of immune homeostasis of intestine
(→ overreacts to environmental, dietary, infectious agents)
3. Hereditary predisposition
4. Edema w/ linear ulcerations of mucosal surface
(“Cobblestoning”)
5. Noncaseating granulomas - pathognomonic
6. High risk for
a. Scarring
b. Obstruction
c. Penetrating ulcers
d. Abscesses
e. Fistulas
6. Hypercoagulable state
-Stroke, retinal thrombus, DVT, PE
7. Extra-intestinal manifestations

7

Signs & Symptoms: Crohn's Disease

1. Chronic diarrhea
2. (+) blood if Crohn’s colitis
3. Crampy abdominal pain
4. Fever
5. Anorexia
6. Wt loss
7. Fatigue
8. Anemia
9. Sx’s wax & wane
- “Flares” mild/brief → severe/prolonged
10. N/V w/ partial or complete bowel obstruction

8

Differential Diagnosis: Crohn's Disease

-Appendicitis
-Diverticulitis
-IBS
-UC
-Bacterial/viral gastroenteritis
-Food poisoning

9

Diagnostic Studies: Crohn's Disease

1. Stool guaiac
2. CBC w/ diff
a. Microcytic/hypochromic
3. B12, Fe, TIBC, folate
-↓ Iron
-↓ B12
3. Stool for WBC, O&P, C. diff, Cx
4. ↑ ESR
5. ↑ CRP
6. CMP
-↓ Albumin
7. (+) ANCA (Anti-Saccharomyces Cerevisiae Ab)
8. (-) pANCA (Perinuclear Anti-Neutrophil Cytoplasmic Ab)
9. KUB
a. Air-fluid levels (obstruction), pneumoperitoneum (perforation)
10. CT abdomen/pelvis (procedure of choice)
a. Dx Crohn’s (“string sign” in terminal ileum) & manage abscesses
b. Wall thickening, abscess
11. Barium enema
a. Fistula, inflammation, skip lesions
12. UGI w/SBFT
a. Inflammation, stricture
13. Colonoscopy
a. Evaluate severity, location, tissue Bx
14. Upper endoscopy
a. Upper GI evaluation
15. MRI
a. Routine assessment of pelvis fistulae & sinus tracks
16. Capsule enteroscopy
a. Swallow encapsulated video camera w/ specific indications
b. Avoid w/ known strictures, fistulas

10

Where does crohns disease start?

In the terminal ilieum

11

Ulcerative colitis starts?

in the rectum (progresses proximal through the rectum), never effects the small bowel, mucosal surface (more superficial)

12

String Sign

1. Seen on CT w/contrast or UGI w/SBFT
2. Narrowing & stricturing in terminal ileum

13

Medical Management: Crohn's Disease

1. Step I
a. Acute/maintenance
b. Aminosalicylates – Asacol/Lialda/Pentasa/Rowasa/Apriso (mesalamine), Azulfidine (sulfasalazine) PR
2. Step I-A
a. Antibiotics – Metronidazole (Flagyl) or Ciprofloxacin (Cipro) prn fistula/abscess
3. Step II
a. Corticosteroid – Solu-Medrol/Cortef IV, Prednisone PO, Cortenema (Hz) enema PR,
b. Entocort EC (budesonide) PO or PR prn exacerbation
4. Step III
a. Immune modifiers – Imuran (azathioprine), methotrexate, cyclosporine
b. Use if difficult to maintain remission w/ aminosalicylates alone
5. Step III-A
a. TNF inhibitors – Remicade (infliximab), Humira (adalimumab)

6. Hospital Admission
a. Failed OP Tx
b. Dehydration
c. Uncontrolled diarrhea/pain

7. Speciality consultation prn
a. Extra-intestinal manifestations
b. Surgical indications

14

Symptomatic treatments: Crohn's Disease

-Antidiarrheal agents – Lomotil
-Antispasmodic agents - Bentyl
-Bile sequestrants – Questran
-Antispasmodics – Bentyl, Levbid
-Acid suppressants – H2 blockers, PPI’s
-Parenteral nutrition if severe

15

Surgical Management: Crohn's Disease

1. Therapeutic
a. Not curative - high recurrence
b. Mostly for complications (strictures, fistulas, bleeding, abscess, dysplasia/CA)
- CT percutaneous abscess drainage has shown great success w/↓ rate of recurrence, as compared to surgery
c. Segmental resection w/ re-anastomosis 
d. Stricturoplasty
e. Diverting ileostomy/colostomy (severe perianal disease allowing healing for 6-12 mo)
f. Fistula resection
g. Perirectal abscess drainage

16

Emergency Management: Crohn's Disease

1. Steroids
2. Bowel rest
3. NG suction
4. IV hydration
a. Electrolytes prn
5. Surgical consult & admission
a. Toxic
b. Obstruction
c. Hemorrhage
d. Peritonitis

17

Maintenance/Prevention: Crohn's Disease

1. Diet
-Low residue
-Lactose avoidance if intolerant

2. Sitz baths/soap & water after stooling if perianal sx

3. Dietary supplements
-Probiotics, Ca/Vit D if steroid use
-Vit A, D, E, K, Fe, folic acid if taking sulfasalazine

4. Psych support

18

Morbidity & Mortality: Crohn's Disease

1. Prognosis
-10% w/prolonged remission
-75% w/chronic intermittent Dz
-12% w/unremitting Dz

2. Obstruction occurs in 20-30% of cases

3. Intestinal perforation in 1-2% of cases

4. Fistulas w/ abscess in 50% of cases

5. GI cancer (Adenocarcinoma)
-Leading cause of mortality in Crohn’s Dz
-Occurs in small & large intestine in areas of chronic Dz

19

What is ulcerative colitis?

Chronic inflammation & ulcerative disease of colonic mucosa & submucosa

Main sx of active disease is usually diarrhea mixed w/ blood

Gradual onset

Systemic disease affecting many parts of the body

20

Epidemiology: UC

1. Affect as many as 700,000 Americans
2. M = W
3. Most people Dx’d in mid-30’s
4. Older men > older women
5. Tends to run in families, but no clear pattern of inheritance
6. ↑ Risk
a. European caucasians
b. Jewish heritage

21

Cause of UC

- Undetermined etiology
- Autoimmune inflammatory colitis
- Usually begins in rectum, may remain there or spread proximally
- Severe disease causes large ulcers & purulent exudate
- Pseudopolyps or hyperplastic tissue growth at sites of previous ulceration
- Stricture formation
- 10-20% develop adenoCA after 10 yr

22

Signs & Symptoms: UC

1. Exacerbations alt. w/remissions
2. Bloody diarrhea
3. Absent or minimal pain
4. Fatigue
5. Urgency to defecate
6. Mild lower abdominal cramping
7. Mucus &/or blood in stool
8. May follow intestinal infection
9. Loose/frequent (≥ 10) stools/day
10. Tenesmus
11. Systemic sx’s w/ severe disease
a. Malaise, fever, anemia, anorexia, wt loss

23

Diagnostic Studies: UC

1. (+) pANCA (Perinuclear Anti-Neutrophil Cytoplasmic Ab) > 45% of cases
2. (-) ANCA (Anti-Saccharomyces Cerevisiae Ab)
3. Stool guaiac
4. CBC w/ diff
a. Microcytic/hypochromic anemia
5. Stool for WBC, O&P, C. diff, Cx
6. ↑ ESR
7. CMP
a. ↓ Albumin , ↓ K, ↓ Mg, ↓ Ca

8. Imaging generally not indicated
a. Barium enema w/ rectal involvement, “stove-pipe” appearance due to loss of haustrae
b. UGI w/SBFT if unable to perform complete BE due to stricture
c. CT w/o abscesses or fistulas

Colonoscopy w/ Bx when not acute

24

Medical Management: UC

1. Tx  acute symptoms w/ goal to induce remission, then maintain 
2. Anemia often requires the use of parenteral iron
3. Low residue diet
4. Correct nutritional deficiencies
a. Folic acid
b. TPN w/ bowel rest if severe

1. Step I- Aminosalicylates
a. Acute/maintenance
b.Asacol/Lialda/Pentasa/Rowasa/Apriso (mesalamine) PO or PR, Azulfidine (sulfasalazine) PR, Dipentum (olsalazine) PO, Giazo/Colazal( balsalazide) PO
2. Step II-Corticosteroid
a. Solu-Medrol/Cortef IV, Prednisone PO, Cortenema (Hz) enema PR, Entocort EC (budesonide) PO or PR prn exacerbation
3. Step III-Immunosuppressive drugs
a. Mercaptopurine ( Purinethiol), Azathioprine (Imuran) ,Methotrexate (inhibits folic acid)
4. Step IV-TNF inhibitors
a. Infliximab (Remicade)

Those with less severe disease but do not respond to IV steroids w/in 7–10 days should be considered for colectomy or IV cyclosporine

25

Hygiene Hypothesis

1. Low incidence of autoimmune Dz in less developed countries
2. ↑ autoimmune Dz in industrialized countries
3. Suggests helminthic infections protect individuals from developing autoimmune Dz

4. Helminthic therapy
a. Inoculation of pt w/ specific parasitic intestinal helminths
b. Experimental Tx to reduce the severity of autoimmune response in IBD

26

Dietary Recommendations: UC

1. Lactose intolerance common in UC
 a. Lactose breath hydrogen test
b. Ca supplement to avoid bone loss
2. If (+) cramping or diarrhea
a. Avoid fresh fruit, caffeine, carbonated drinks, high fructose corn syrup & sorbitol
3. ”Specific Carbohydrate Diet”
a. Avoid disaccharides & polysaccharides
b. Monosaccharides  allowed