Inflammatory Bowel Disease

Question 1

What is IBD?

Answer 1

A spectrum of disease characterised by chronic relapsing inflammatory conditions of the bowel.
Made up of crohn’s and ulcerative colitis

Question 2

What criteria do we use to classify IBD?

Answer 2

THe montreal classification uses:

• Age
• Location
• Extent of disease
• Severity
• Disease behaviour (strictures, penetration etc)

Question 3

What is the source of IBD?

Answer 3

Its thought to be some sort of environmental trigger in the genetically susceptible.

Question 4

Define Ulcerative Colitis?

Answer 4

Continuous colonic inflammation of variable distribution & severity.

Question 5

How/when does UC present

Answer 5

Presentation peaks at 20-40yrs
= Bloody Diarrhoea
= Abdominal pain
= Weight Loss

Also causes pseudopolyps & Ulcers

Question 6

Define a pseudopolyp

Answer 6

A “polyp” caused by destruction of the surrounding mucosa & submucosa rather than a proper polyp growing out from the gut wall

Question 7

What genes are associated with IBD?

Answer 7

UC - HLA gene

Crohn’s - NOD2 gene

Question 8

What do we call inflammation of the rectum?

Answer 8

Proctitis

Question 9

How does UC affect the risk of CRC?

Answer 9

Long term UC (i.e. Over 10 yrs) can lead to CRC

Question 10

What are the markers of a severe UC flare up?

Answer 10

A severe attack is defined by 6 or more bloody stools a day + 1 of the following:

• Fever
• Tachycardia
• Raised ESR or CRP
• Anaemia
• Low Albumin
• Leucocytosis or thrombocytosis

Question 11

Define leuco- & thrombocytosis

Answer 11

Leucocytosis - Increase WCC

Thrombocytosis - Increase platelets

Question 12

How/when does crohn’s disease present?

Answer 12

has two peaks:

• Age 20-40s
• Women >60
• Diarrhoea
• Abdominal Pain
• Weight loss & anorexia
• Malaise/lethargy/low fever
• Nausea & Vomiting
• Malabsorption leading to anaemia & vitamin deficiencies

Think logically. inflammation in the gut will make you absorp poorly so weight loos, anaemia, deficiencies.
Its an immune response so it will triger pain & general unwellness.
It will mess with passage of food causing nausea/vomiting and diarrhoea

Question 13

What does crohn’s disease look like in the gut?

Answer 13

Histologically you can see non-caseating granulomas.
It turns the serosa a granular dark grey.
Also causes the mesentery to be thick, oedematous and fibrotic with fat wrapping it and the gut.
The wall of the gut becomes thickened and narrows hte lumen.

Its also distinctive because it affects multiple areas with healthy tissue gaps in between, this is called skip lesions

Question 14

How can crohn’s be complicated?

Answer 14

With strictures, fistulas, abscesses and perforation.

It also incrases risk of cancer by 5x

Question 15

How do we test for IBD?

Answer 15

With blood and stool tests:
Stool = Calprotectin level, its a biomarker of intestinal inflammation and so indicates IBD over IBS and can be used to monitor the degree of IBD and its healing.

Bloods:
High - ESR/CRP/platelet/WCC
Low - Albumin/Hb
pANCA

Colonoscopy or Capsule Enterography

CT/MRI & Barium swallow can also be sued

Question 16

What is pANCA and how useful is it?

Answer 16

Perinuclear antineutrophilic cystoplasmic antibody test.

Its +ve in 75% of UC cases but only 25% of Crohn’s so its useful but not definitive for diagnosing IBD and UC spefically

Question 17

What features distingiush crohn’s from UC?

Answer 17

Crohn’s has:

• Skip lesions
• Peri-anal manifestations
• Fistulae
• non-caseating granulomas

UC has:

• Goblet cell depletion
• More crypt abscesses

Question 18

How does IBD present extra-intestinally?

Answer 18

It can cause inflammation in many other places such as the eyes, joints, liver and biliary tree and skin.

Some of the more obvious are erythema nodosum, gallstones, fatty change in the liver and in CD renal calculi (kidney stones)

Question 19

Sclerosing cholangitis is a liver disease often associated with IBD, what is it?

Answer 19

A progressive disease of the bile ducts where inflamation causes scarring & multiple strictures, eventually leading to cirrhosis.

Question 20

How do we screen for Colonic cancer in people suffering from IBD?

Answer 20

If they have extensive chronic colitis we will do surveillance colonoscopies.
Can either do them every 1,2 or 3 years depending on how long the colitis has been present.
Each time we will take a number of biopsies to check for dysplasia

Question 21

In short how is IBD treated?

Answer 21

In progression from:

• 5ASAs (Aminosalicylates)
• Steroids
• Immunosuppresion
• Biologic Agents
• Surgery

With nutrional support when necessary

Question 22

How does our care of an IBD patient change when an acute flare up causes admission?

Answer 22

Short term steroids
Anticoagulation
Rest
Can also use Immunosuppresant cyclosporin as a rescue therapy, surgery and biologic agents where necessary.

Question 23

How are steroids used for IBD?

Answer 23

Temporarily.

Most common is prednisalone.

Question 24

What immunosuppresants are used for IBD?

Answer 24

Azathioprine spares steroid use but has a number of side effects including long term raised lymphoma risk.

Methotrexate is also used, particularly in crohn’s.

Question 25

What are biologic agents?

Answer 25

Newish drugs such as anti-TNFAlpha antibodies (monoclonal antibodies) aka infliximab

They are given by IV or SC injection.

Question 26

When would antibiotics be used for IBD?

Answer 26

If there is perianal crohn’s or a small bowel bacterial overgrowth you might use metronidazole

Question 27

When would we regard medical therapy to have failed and surgery be necessary?

Answer 27

• IF the patient needs recurrent courses of steroids or has unacceptable steroid complications such as diabetes, osteoporosis or psychosis
• If you cant control the symptoms
• If they relapse before or soon after you stop treatment

Question 28

How do we surgically treat IBD?

Answer 28

Proctocolectomy with ileostomy
Or Colectomy with an ileoanal pouch

This can be an elective procedure after meds fail to work or an emergency during a severe flare up

Question 29

Its possible to remove the ileostomy from a total colectomy so the patient doesnt require a stoma bag, how is this done? What are the cons of this?

Answer 29

With pouch surgery.
A loop of small bowel is opened and attached to the rectum.

The patient needs to go to the toiler about as often as they empty their stoma bag (6-8 times a day) so ~60% choose to stick with the bag.

Question 30

What other indications are there for surgery, particularly in crohn’s? (i.e. other than the failure of meds)

Answer 30

• To relieve obstruction of the small bowel
• To manage fistulae
• To manage intra-abdominal abscesses
• To manage anal fissures, abscesses, fistulas and skin tags.