Inflammatory Bowel Disease

Question 1

Two types of extra-intestinal manifestations of IBD?

Answer 1

Type 1: pauciarticular(4 or less joints involved)

Type 2: polyarticular

Question 2

Describe Type 1 of extra-intestinal manifestations of IBD?

Answer 2

Attacks are acute and self-limiting (<10 weeks), associated with other extra-intestinal manifestations of IBD activity

Question 3

Describe type 2 of extra-intestinal manifestations of IBD?

Answer 3

Arthropathy lasts longer (months to years), is independent of IBD activity and usually associated with uveitis

Question 4

Eye manifestations of IBD?

Answer 4

Uveitis

Episcleritis, conjunctivitis

Question 5

Joint manifestations of IBD?

Answer 5

Arthritis

Seronegative arthropathy

Question 6

Skin manifestations of IBD?

Answer 6

Erythema nodosum
Pyoderma gangrenosum
Clubbing

Question 7

Liver and biliary tree manifestations of IBD?

Answer 7

Primary sclerosing cholangitis 
Fatty liver 
Chronic hepatitis 
Cirrhosis 
Gallstones

Question 8

What is Crohn’s disease?

Answer 8

Chronic inflammatory condition which may affect the whole git but tends to affect the terminal ileum and ascending colon.
Can involve 1 small area of gut or have skip lesions or whole colon

Question 9

Histology of bowel involved in Crohn’s disease?

Answer 9

Bowel normally thickened and narrowed
Cobblestone appearance
Inflammation is transmural: extends all area of the bowel

Question 10

Who gets Crohn’s disease?

Answer 10

• Jewish people
• White people
• Young people
• 1/4 diagnosed are kids
• People with family history
• Smokers
• NSAIDs
• Appendectomy increases risk

Question 11

How does Crohn’s generally present?

Answer 11

Diarrhoea (containing blood if colonic disease)
Abdominal pain
Perianal disease

Question 12

How does Crohn’s of small intestine present?

Answer 12

• Abdominal cramps
• Diarrhoea
• Wt loss

Question 13

How does Crohn’s in the colon present?

Answer 13

Abdominal cramps
Diarrhoea with blood
Wt loss

Question 14

Mouth crohn’s presents as?

Answer 14

Painful ulcers
Swollen lips
Angular chellitis

Question 15

Anus Crohn’s presents as?

Answer 15

Peri-anal pain and abscesses

Question 16

When should Crohn’s be considered?

Answer 16

Should be considered in all individuals with evidence of vitamin malabsorption and children with reduced growth velocity and diarrhoea

Question 17

Clinical evidence for Crohns?

Answer 17

Evidence of weight loss
RIF mass
Peri-anal signs

Question 18

Blood tests for Crohn’s?

Answer 18

Anaemia 
Raised ESR and CRP 
Hypoalbuminaemia 
Liver biochem 
Blood cultures (suspected septicaemia)
Serological tests

Question 19

Stool tests for Crohn’s?

Answer 19

Diarrhoea- C. Difficile toxin assay should be done
Microscopy for parasites in patients with travel
Faecal calprotectin and lactoferrin

Question 20

Imaging tests for Crohn’s?

Answer 20

• Colonoscopy
• Upper GI endoscopy (to exclude oesophageal and gastroduodenal disease) define extent
• Small bowel imaging (mandatory)
• US scanning
• Perianal MRI
• Capsule endoscopy

Question 21

Severity of CD can be assessed with?

Answer 21

Haemoglobin
WCC
Inflammatory markers (ESR, CRP, platelets)
Serum albumin

Question 22

lifestyle Treatment of CD?

Answer 22

Lifestyle
STOP SMOKING it aggravates
Diet

Question 23

Medical treatment of CD?

Answer 23

Oral or IV glucocorticosteroids (pred, budesonide)
Enteral nutrition
Immunosuppressants
Anti tumour necrosis factor (TNF) antibodies: promote apoptosis of activated T lymphocytes
IV fluids

Question 24

Examples of anti tumour necrosis factor (TNF) antibodies?

Answer 24

Infliximab IV
Adalimumab SC
Certolizamub pegol

Question 25

Maintenance of remission of CD?

Answer 25

Azathioprine Mercaotopurine (all immunosuppressants) Methotrexate Anti- TNF antibodies

Question 26

Perianal disease management?

Answer 26

Surgical drainage of sepsis Ciprofloxacin & metronidazole Azathioprine

Question 27

Surgical treatment of Crohn's?

Answer 27

``` Should be avoided as not curative Indications for surgery: -Failure of medical therapy -Failure to grow in children -peri-anal sepsis ```

Question 28

Type of surgeries for CD?

Answer 28

Stricturoplasty- widening of strictures Resection Anastamosis Ileocolonoscopy to prevent disease recurrence

Question 29

Problems with ileostomy?

Answer 29

``` Mechanical problems Dehydration Psychosexual problems Erectile dysfunction Recurrence of CD ```

Question 30

Risk of CD?

Answer 30

Gallstones Malabsorption Bowel obstruction Increased risk of colorectal cancer & oestoporosis

Question 31

Anal and peri-anal complications of CD?

Answer 31

``` Fissure in ano Haemorrhoids Skin tags Perianal abscess Ischiorectal abscess Fistula in ano Anorectal fistulae ```

Question 32

What is Ulcerative Collitis?

Answer 32

IBD which affects the colon, can affect the rectum alone or can extend proximally to involve the different parts of the colon up to the whole colon + possible terminal ileum

Question 33

Histology of UC?

Answer 33

Inflammation is superficial, limited to the mucosa, including chronic inflammatory cell infiltrate in the lamina propria NO SKIP LESIONS Granulomas are very rare in UC

Question 34

What is UC inflammation mediated by?

Answer 34

TH1/TH2 natural killer cells

Question 35

Who gets UC?

Answer 35

``` People with Fam history NSAIDs Appendectomy decreases risk Young people NON SMOKERS ```

Question 36

How does UC present?

Answer 36

``` DIARRHOEA WITH BLOOD + MUCOUS Lower abdo pain Malaise/fatigue Lethargy Anorexia Wt loss Aphthous ulceration Less severe symptoms than CD Slightly distended abdomen Tachycardia & pyrexia (if severe) Rectal exam shows blood ```

Question 37

How is UC diagnosed?

Answer 37

Severe: 6 stools with a lot of blood, fever>37.5, >90bpm, erythrocyte sedimentation rate >30mm/h, <100g/L haemoglobin and <30g/L albumin

Question 38

Blood tests for UC?

Answer 38

WCC & platelet counts ESR and CRP- raised, liver biochemistry abnormal, hypoalbuniaemia pANCA- positive contrary to CD Albumin

Question 39

Gold standard for UC?

Answer 39

Endoscopy with mucosal biopsy

Question 40

How is severe UC treated?

Answer 40

``` Exclude enteric infection Admit to hospital Confirm diagnosis sigmoidoscopy Assess fluid status Prophylactic anticoagulation (LMWH) IV hydrocortisone Monitor daily ```

Question 41

Treating general UC?

Answer 41

``` Corticosteroids for acute attacks Aminosalicylates IV Fluids Immunosuppressants Anti-TNF therapy ```

Question 42

Treating proctitis?

Answer 42

Rectal 5-ASA suppositories = first line Topical steroids Oral 5-ASA prednisalone Oral pred for those who don't respond

Question 43

Surgical management of UC?

Answer 43

Can be curative Laproscopic surgery Permanent ileostomy & ileo-anal pouch

Question 44

Risk factor of severe colitis?

Answer 44

Toxic Megacolon - abdominal x ray will show dilated thin-walled colon with a diameter >6m, which is gas filled and has mucosal islands HIGH RISK OF PERFORATION AND DEATH

Question 45

Other risks of UC?

Answer 45

Primary sclerosing cholangitis

Question 46

Prognosis?

Answer 46

1/3 patients will undergo colectomy within 20 years of diagnosis

Question 47

Mouth manifestations of IBD?

Answer 47

Ulcers | Stomatitis

Question 48

Where can Crohn's affect?

Answer 48

Anywhere from mouth to anus

Question 49

What is different about treatment of UC and CD?

Answer 49

CD you do not use 5 ASA in

Question 50

IV steroids are used to?

Answer 50

Reduce severe flares

Question 51

General medications for IBD?

Answer 51

Corticosteroids Immunosuppression Anti-TNF Surgery