Inflammatory Bowel Disease

Question 1

What is Crohn’s disease?

Answer 1

Chronic inflammatory disease affecting any area of the digestive tract

Question 2

What histiological signs are seen in crohn’s disease?

Answer 2

Mucus/increased goblet cells

Cobblestone appearance

Inflammation from mucosa-serosa/transmural

Non-caseating granulomas

Fissures

Fistulas

Question 3

What age is crohn’s most likely to occur?

Answer 3

Onset peaks in early adulthood and over 60s

Question 4

What sex is crohn’s more common in?

Answer 4

F = M

Question 5

What causes crohn’s?

Answer 5

Idiopathic

Genetic Predisposition/FH

• CARD15

Smoking

Question 6

How does crohn’s present?

Answer 6

Depends on side affected

Diarrhoea

Abdominal pain

• Right lower quadrant

Weight loss

Malaise

Blood in stool

Malabsorption

• Iron deficiency anaemia
• Vitamin deficiencies

Mouth ulcers

Angular stomatitis

Clubbing

Fever

Question 7

What investigations are used in crohn’s diagnosis?

Answer 7

>CRP and >ESR

• Severe attacks

Calprotectin

FBC

• >WCC
• >Platelets/Thrombocythemia
• Decreased Hb

Colonoscopy/Sigmoidoscopy with biopsy

Barium swallow

Malabsorption Tests

Question 8

What is calprotectin?

Answer 8

Protein biomarker, present in faeces, released by inflammed gut mucosa

Question 9

What barium signs are seen in crohns?

Answer 9

Cobble stone appearance

Rose thorn ulcers

Question 10

What malabsorption tests are used in crohns monitoring and diagnosis?

Answer 10

B12

Folate

Vitamin D

Ca

Question 11

What is used in the management of crohns?

Answer 11

Smoking cessation

Steroids/glucocorticoids

5ASA (Aminosalicylates)

Immunosuppression

Biologics

Enteral feeding/elemental diet

Surgery, although this does not cure disease

Question 12

Name an example of a 5ASA

Answer 12

Mesalazine

Sulphsalazine

Question 13

Name examples of immunosuppressants used in IBD

Answer 13

Azathioprine

Methotrexate

Question 14

Name examples of biologics used in IBD managament

Answer 14

Infliximab

Question 15

Name the classification that determines crohns severity

Answer 15

Montreal classification

Question 16

What does the Montreal classification take into consideration?

Answer 16

Age

Extent of disease

Severity

Disease behaviour, such as trictures and penetration

Question 17

Name some complications of chrons?

Answer 17

Anterior uveitis

Episcleritis

Arthritis

Sacroilitis

Erythema nodosum

Pyroderma gangrenosum

Gallstones and renal stones, more common than in UC

Small and large bowel malignancy

Fistulae and perinanal abscess

Question 18

What is erythema nodosum?

Answer 18

Swollen fat under the skin causing red bumps and patches

Question 19

What is Pyoderma Gangrenosum?

Answer 19

Rare inflammatory skin disease where painful pustules or nodules become ulcers that progressively grow

Single painful irregular deep ulcer on her right shin, with a pustular surface and a blue overhanging edge

Question 20

What is Ulcertative Colitis?

Answer 20

Chronic inflammatory condition affecting the large intestine and rectum, forming ulcers along lumen

Question 21

What histological signs are seen in UC?

Answer 21

Crypt abscesses

Pseudopolyps

Goblet cell mucus depletion

Vascular congestion

Inflammation confined to mucos

Question 22

What sex is UC most common in?

Answer 22

F>M

Question 23

What age is UC most likely to occur?

Answer 23

Peak at 15-25 and 55-65

Question 24

What is the most common inflammatory bowel disease?

Answer 24

UC

Question 25

What communities is UC most common in?

Answer 25

Caucasians and Jewish community

Question 26

What causes UC?

Answer 26

Idiopathic FH

Question 27

How does UC present?

Answer 27

Bloody diarrhoea Abdominal pain * Left lower quadrant Weight loss Frequent stools * \>6 a day, severe attack Anaemia/malbsorption Clubbing Tenesmus/feeling of incomplete evacuation

Question 28

What investigations are used in UC diagnosis?

Answer 28

\>CRP and \>ESR in severe attacks Calprotectin FBC * \>WCC in severe attack * \>Platelets/Thrombocythemia in severe attack​ * Decreased Hb Sigmoidoscopy with biopsy Barium swallow pANCA Stool microscopy/culture Abdominal X-ray (AXR)

Question 29

In how many UC patients is pANCA +

Answer 29

\>70%

Question 30

Why is an AXR used in UC?

Answer 30

Rule out toxic dilation

Question 31

What is the management of UC?

Answer 31

Topical/rectal 5ASA Oral 5ASA Corticosteroids IV steroids IV Ciclosporin/immunosuppresant Oral Thiopurines Surgery

Question 32

Name some chronic complications of UC

Answer 32

Fistula Conjunctivitis and Uveitis Primary sclerosing cholangitis Sacroiliitis Erythema nodosum Venous thrombosis Pyoderma gangrenosum Colorectal carcinoma Fatty liver

Question 33

Name some acute complications of UC

Answer 33

Haemorrhage Perforation Toxic megacolon

Question 34

What are the side effecrts of Aminosalicylates (5ASA)?

Answer 34

Agranulocytosis Headache GI upset Pancreatitis

Question 35

Name the side effects of Azathioprine

Answer 35

Leucopenia Hepatoxicity Pancreatitis Lymphoma

Question 36

Where is the most common site for UC inflammation?

Answer 36

Rectum, as inflammation always starts here

Question 37

What is the most common extra-intestinal feature of UC and CD?

Answer 37

Arthritis

Question 38

What is used in acute management of CD if steroids fail?

Answer 38

Biologic treatment

Question 39

What is first line to induce remission of CD?

Answer 39

Glucocorticoids (prednisilone or IV hydrocortisone)

Question 40

What is second line to induce remission of CD?

Answer 40

5ASA

Question 41

What is used as an add on to induce remission of CD?

Answer 41

Azathioprine or methotrexate

Question 42

What is used for refractory and fistulating CD?

Answer 42

Infliximab/biologics

Question 43

What is first line for maintaining remission of CD?

Answer 43

Azathioprine Methotrexate considered in patients where azathioprine is contraindicated

Question 44

What is used for peri-anal CD (abscess)?

Answer 44

Metrondiazole + Ceftriaxone

Question 45

What is the management for perianal fistulae?

Answer 45

Drainage for high/trans-sphincteric Fistulotomy for low/sub-mucosal

Question 46

Describe mild UC

Answer 46

Less than 4 stools a day Little blood

Question 47

Describe moderate UC

Answer 47

4-6 stools a day Varying amount of blood No systemic upset

Question 48

Describe severe UC

Answer 48

More than 6 bloody stools a day Systemic upset * Tachycardia * Pyrexia * Anaemia * Raised inflammatory markers

Question 49

What is first line for maintaining remission in mild-moderate UC?

Answer 49

Topical/rectal 5ASA | (oral if extensive disease)

Question 50

What is used for maintaining remission in severe UC?

Answer 50

Oral thiopurines

Question 51

What are the stages in inducing remission for mild-moderate UC?

Answer 51

Topical/Rectal 5ASA Oral 5ASA * Add if remission is not achieved in 4 weeks Corticosteroid * Add if remission is not achieved after rectal and oral 5ASA

Question 52

What are the stages for inducing remission in severe UC?

Answer 52

IV Steroids IV Ciclosporin * Add if no improvement in 72 hours

Question 53

What UC sign is seen in bariums swallows?

Answer 53

Lead pipe colon

Question 54

What should be assessed in patients before initiating Azathioprine?

Answer 54

Thiopurine methyltransferase (TMPT) activity As this is the enzyme involved in the metabolism of this medication, and so deficiency means the treatment will not work

Question 55

What surgery is used in UC?

Answer 55

Proctocolectomy

Question 56

Give differential diagnoses of clubbing

Answer 56

CF Mesothelioma Bronchiectasis Lung fibrosis Lung carcinoma Lymphoma Inflammatory bowel disease Cirrhosis Coeliac disease Cyanotic heart disease Myxoma Bacterial endocarditis