Inflammatory bowel disease

Question 1

What is the pathology of ulcerative colitis?

Answer 1

It is inappropriate immune response against colonic flora. This leads to continuous inflammation that does not spread proximal to the ileocaecal valve.

Question 2

What is the nature of the inflammation in ulcerative colitis?

Answer 2

It causes formation of pseudopolyps and punctate ulcers that is not transmural

Question 3

What are some of the common UC symptoms?

Answer 3

Episodic or chronic diarrhoea (may have blood and mucus), crampy abdominal discomfort, urgency, tenesmus
Also fever, malaise and weight loss

Question 4

What are some of the extraintestinal signs of UC?

Answer 4

Clubbing
Large joint arthritis
Erythema nodosum
Conjunctivitis

Question 5

What tests can be done to diagnose UC and rule out other conditions?

Answer 5

Blood tests: FBC, CRP, U and E, LFT, culture
Stool: microscopy and culture and c diff test to rule out salmonella, campylobacter etc.
Faecal calprotectin: sensitive test for GI Inflammation
AXR
Lower GI endoscopy - sigmoidoscopy to assess and biopsy and full colonoscopy to assess disease extent

Question 6

What abdominal x ray signs will be seen for UC?

Answer 6

No faecal shadows
Mucosal thickenings/Islands
Colonic dilation

Question 7

What are some acute complications of UC?

Answer 7

Colonic dilation
Perforation
venous thromboembolism - give all patients prophylaxis

Question 8

What are some of the chronic complications of UC?

Answer 8

Colonic cancer
Colonoscopy every 1-5 yrs depending on risk
multiple random biopsies

Question 9

How do you treat mild, moderate and severe UC?

Answer 9

Mild give mesalazine which is a 5 aminosalasinic acid (5ASA) plus topical steroid foams or prednisolone retention enemas if needed
Moderate is treated with oral prednisolone 40mg/d for one week then taper. Used with 5asa
Severe - admit for IV hydration/electrolytes, IV steroids e.g. hydrocortisone, thromboembolism prophylaxis
Azathioprine can work but methotrexate only for crohns

Question 10

When are biologics required in UC?

Answer 10

When patients get flares during steroid tapering or require more than 2 steroid courses in a year

Question 11

What are the characteristics of lesions in crohns disease?

Answer 11

These are skip lesions

Transmural and granulomatous

Question 12

What is the cause of crohns disease?

Answer 12

Abnormal immune response against gut flora in genetically susceptible individuals

Question 13

What are the symptoms of crohns?

Answer 13

Diarhoea, abdo pain, weight loss/failure to thrive

Systemically - fatigue, malaise, anorexia

Question 14

What are the signs of crohns disease?

Answer 14

Bowel ulceration, abdo tenderness, strictures

Systemically - clubbing, skin, joint and eye problems

Question 15

What are some of the complications of crohns disease?

Answer 15

Bowel obstruction, toxic dilation, abscess formation, colon cancer

Question 16

What tests can be done for crohns?

Answer 16

Bloods - fbc, esr, crp, u and e, lft, inr, ferritin
Stool - culture and sensitivity, faecal calprotectin (sensitive to gi inflammation)
Colonoscopy and biopsy
MRI to look at small bowel

Question 17

What is the treatment for mild-moderate crohns

Answer 17

For flares prednisolone 40mg/d for one week then taper for 7 weeks
If refactory to steroids then start on azathioprine
5-asa only used for uc and has no role in crohns

Question 18

What is a contra indication to methotrexate?

Answer 18

Female of reproductive age

Question 19

What is the treatment for severe crohns

Answer 19

Admit for iv fluids and steroids
Hydrocortisone 100mg/6hr IV
Thromboembolism prophylaxis
Monitor and consider need for blood transfusionand nutritional support
Tnf alpha inhibitors such as infliximab and adalimumab are used

Question 20

How can you differentiate UC from crohns in terms of presentations?

Answer 20

UC usually presents with bloody diarrhoea

Crohns is the only one that causes strictures, these cause pain and are relieved by not eating