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Flashcards in Inflammatory Bowel Disease Deck (53)
1

What two conditions come under the umbrella term of inflammatory bowel disease?

Crohn's Disease and Ulcerative colitis

2

What is a good way to think about inflammatory bowel disease?

Think of IBD as a spectrum.
Overlap between Crohn's and Ulcerative colitis and can be hard to distinguish

3

What is the Montreal Classification?

Classifies people on age, location, behaviour, extent and severity so that you can best treat their disease.

4

What is the aetiology of IBD?

Basically it is unknown

Environmental trigger as IDB used to be unheard of in the east but incidence has shot up now as people adopt a western lifestyle.
-Role of bacteria, Diet, vaccination history, social factors

Possibly genetically susceptible people.
Candidate gene identified NOD2.

5

What is the epidemiology of Ulcerative colitis?

VERY common
Can affect any age but peak incidence is 20-40 (when your most active in society)

More common in females
Local incidence 11.3 per 100,000

6

How do people with ulcerative colitis present?

Bloody diarrhoea
Abdominal pain
Weight loss

7

What is the difference between Crohn's disease and UC in terms of location where they effect?

UC = Large intestine is the only affected site.
Disease starts at rectum and moves proximally.
Inflammation is continuous along the affected areas length

Crohn's = Inflammation may occur in any part of the GI tract.
Inflammation may occur in patches

8

What is the difference in pain location in UC and Crohn's?

UC common in lower left abdomen
Crohn's common in lower right

9

How does the appearance of Uc and Crohn's differ?

UC = Colon wall is thinner and shows continuous inflammation.
Mucosal layer may have ulcers but these do not extend beyond the inner lining.

Crohn's = Wall may be thickened and may have a rocky appearance.
Ulcers along the digestive tract are deep and may extend through all layers of the bowel wall.

10

How does bleeding differ in Crohn's and UC?

Crohn's bleeding from the bowel through the rectum is not common.

UC = Bleeding through the rectum during bowel movements

11

What percentage of UC patients go on to have surgery?

3% at first attack
8% at 5 years

12

What are the clinical markers of a severe UC attack?

Stool frequency > 6 a day with blood

PLUS 1 of:
Fever >37.5
Tachycardia >90
ESR raised
Anaemia Hb

13

What is leucocytosis?

Increase in the number of WBC's in the blood

14

What is thombocytosis?

The production of too many platelets

15

What is the epidemiology of Crohn's disease?

M = F
Two peaks:
-Early adulthood (20-40)
-Over 60s (F>M)

Incidence 8.5 per 100,000

16

Why do the clinical features of patients suffering from Crohn's disease differ?

Clinical features depend on the regions involved

Very difficult to predict how it will present

17

Why can fistula's occur in crown's disease?

Ulceration occurs all the way through the wall so Crohn's can lead to fistula.

18

What are the clinical features of Crohn's Disease?

Diarrhoea
Abdominal Pain
Weight loss
Malaise, lethargy, anorexia Nausea and Vomiting
Low grade fever
Malabsorption
-Anaemia, vitamin deficiency

19

What are the complications of crown's disease?

Inflammation
Stricture
Fistula

20

What can you use to detect inflammation in IBD?

High ESR and CRP
High Platelet count
High White Cell Count
Low Hb
Low Albumin

21

What are the histological differences between UC and CD?

Granulomas in Crohn's Disease (hard to find)

Goblet cells depleted in UC

Crypt accesses: UC > CD

22

Fistulae and peri-anal disease are present in which form of IBD?

Crohn's Disease

23

Give some examples of extra-intestinal manifestations of IBD

Eyes: conjunctivitis

Joints

Renal calculi (CD only)

Liver and biliary tree (fatty change, sclerosing cholangitis, gallstones)

Skin (Erythema nodosum, vasculitis)

24

What is the differential diagnosis of IBD?

Chronic diarrhoeas
-Malabsorption
-Malnutrition

Ileo-caecal TB

Colitis must be distinguished from
-Infective, amoebic and ischaemic colitis

25

What is Sclerosing Cholangitis?

Disease of the bile ducts
Multiple strictures
Slowly progressive, can lead to cirrhosis

Colon cancer bigger risk if IBD and Sclerosing cholangitis

26

What is the complication of long term colitis?

Colonic Carcinoma

Extent and Duration significantly increases risk

27

How do you monitor patients who are at risk of progressing from chronic colitis to cancer?

Surveillance colonoscopy
-Extensive colitis
---8-20 yrs (3 yearly)
---30-40 yrs (2 yearly)
---40+ years (annually)

28

What is the medical management of outpatient IBD?

5ASA
Steroids
Immunosuppression
-Azathioprine
-Mercaptopurine
-Methotrexate
-Infliximab

29

What is the hospital management of IBD patients?

Steroids
Anticoagulation
Rest
Other
-Cyclosporin
-Infliximab
-Surgery

30

Give some examples of Aminosalicylates.

What must you be careful of when prescribing these?

Mesalazine
-Acrylic Resin
-Ethylcellulose Microgranules

Pro-drugs
-Balsalazide
-Olzalazine
-Sulfasalazine

Prescribe by the BRAND.
Brands are slightly different

31

What is the first line treatment in Mild-Moderate UC for achieving an induction in remission?

5ASA (5-aminosalicylic acid)
>3g per day

Rectally for distal and more extensive disease

32

How do Steroids compare to 5ASA in induction of remission in Mild Moderate UC?

Steroids have similar effects but work faster with more side effects

Rectal 5ASA better than steroids

33

What is the first line therapy for the maintenance of remission in Mild-Moderate UC?

5ASA

34

What is the maintenance of remission of UC with 5ASA associated with?

Reduced number and severity of relapses
Reduced CRC risk
-Lifeling therapy with >2g per day

35

How is 5ASA used in Crohn's?

Widely used but limited evidence.

Induction of remission in mildly active ileocolonic disease

Maintenance of remission if induction is by 5ASA
Post small bowel resection

Help prevent progression to cancer

36

What steroids do you prescribe in IBD?

Prednisolone
-Optimal dose is 40mg daily
-Tapering reduction over 4 weeks

Budenoside
-Slightly less effective than Prednisolone
-Better side effect profile
-Ileal and ascending colon disease only.

37

What is the next step up in treatment of IBD after steroids?

Immunosuppression

Thiopurines = azathioprine (6-Mercaptopurine)
Methotrexate

Others:
Ciclosporin
Mycophenolate
Tacrolimus

38

Describe the use of Azathioprine to treat IBD

Induction (Number needed to treat NNT = 5)
Maintenance (NNT = 7)

Most patients feel rotten for the first few weeks then get better. Some don't.

39

What is leucopenia?

Decrease of WBC's found in the blood

40

What do you need to do with hepatotoxicity from azathioprine?

Blood Monitoring
-Weekly for 8 weeks then every 8 weeks
-Patients must see GP if sore throat/infection

41

What are the significant side effects of azathioprine?

Significant side effects (NNT = 14):
-Leucopenia
-Hepatoxicity
-Pancreatitis
-Possible long term lymphoma risk
-Up to 28% intolerence

42

Describe the use of methotrexate to treat IBD

Unlicensed use

Works better for Crohn's but still sometimes used for UC
Induction and maintenance of remission

Require specialist follow up

43

What side effect do you have to keep in mind when prescribing methotrexate?

Cannot become pregnant on this

Long term treatment so have to look 10 years ahead

44

Describe the use of other immunosuppressants other than azathioprine and methotrexate

Ciclosporin
-Salvage therapy for refractory UC
-3-6 months as bridge to azathioprine

Mycophenolate
-Rarely used (no evidence)
-If you see someone on this they are clutching at straws

Tacrolimus
-Increasing anecdotal evidence

45

What is the next step up in treatment of IBD after you have tried immunosuppressants?
Give some examples

Biologics
Anti TNF-a antibodies

Infliximab (Remicade)
-8 weekly IV infusions
Adulimumab (Humera)
-2 weekly SC injections (patient can administer)

46

What are the risks of biologics?

1 in 100 will get cancer from these drugs
Symptoms are so shit patients are willing to risk it

47

Why do anti TNF-a antibody drugs sometimes just stop working?

Body may start to produce anti anti TNF-a antibodies

48

What drug is used to treat peri anal disease in Crohn's?

Metronidazole

Also used to treat small bowel overgrowth

49

What is elemental feeding?

Exclusive elemental feeding
Can be as effective as steroids
Works better in children because parents can force them and they have no other choice.
Adults really struggle to comply because it tastes shit

50

Give an overview of some of the failures of medical therapy in IBD

Recurrent courses of steroid
Relapse prior to or shortly after stopping therapy
Failure to control symptoms
Unacceptable complications of steroids:
-Diabetes
-Severe osteoporosis
-Psychosis

51

What are the surgical options in UC?

Emergency or Elective

PROCTOCOLECTOMY
Total colectomy with ileostomy and rectal preservation
This gives a rectal stump that may have symptoms
Wall in rectum is thick so shouldn't perforate

May also do a pouch procedure which doesn't give an ileostomy

52

What are the surgical options in Crohn's?

Never going to cure
take away the smallest area possible
Chances of needing another operation 60%

53

What are the surgical indications for Crohn's?

Failure of medical management
Relief of obstructive symptoms (small bowel)
Management of fistulae (e.g. bowel to bladder)
Management of intra-abdominal accesses
Management of anal conditions
Failure to thrive