Inflammatory Bowel Disease Flashcards
(46 cards)
1
Q
IBD is an umberella term for what two main diseases?
A
- Ulcerative colitis
- Crohn’s disease
2
Q
At what age do pts with IBD commonly present?
A
3
Q
Discuss whether smoking is associated with IBD
A
- Crohn’s: smoking increases risk x3/4
- UC: 3x more common in non-smokers
4
Q
Compare and contrast crohn’s and UC, include:
- Where it affects
- Whether inflammation is continous or has skip lesions
- Depth of inflammation
- Colonscopy findings
- Incidence in smokers
A
5
Q
Which part of bowel is most commonly affected in crohn’s disease?
A
Terminal ileum
6
Q
Does UC have perianal disease?
A
No, only crohn’s has perianal disease (inflammation at or near the anus including tags, fissures, fistulae, abscesses, or stenosis.)
7
Q
State some risk factors for developing IBD
A
- Age (15-40 or 60-80)
- Family history of IBD
- Family history of autoimmune diseases
- White ethnicity
- Smoking (ONLY IN CROHN’S)
8
Q
Describe the symptoms of crohn’s and UC; highlighting any potential differences in symtpoms
A
- Diarrhoea
- Abdominal pain
- Weight loss
- Maleana
- Steatorrhoea
- Fatigue
- Anorexia
Symptoms more likely in UC due to rectal involvement (but can occur in Crohn’s if there is rectal involvement):
- Blood & mucus in stool
- Tenesmus
9
Q
State some clinical signs of IBD
A
- Erythema nodosum
- Pyoderma gangrenosum
- Clubbing
- Abdominal tenderness
- Aphthous mouth ulcers
- Conjunctivitis
- Episcleritis
10
Q
What does this image show?
A
Erythema nodosum: inflammation of fat cells under skin resulting in tender, erythematous paches or bumps on skin- most commmonly on anterior shins
11
Q
What does this image show?
A
Pyoderma gangrenosum- painful inflammatory ulcers which most commonly develop on the legs
12
Q
Discuss what investigations you would do if you suspect IBD, include:
- Bedside
- Bloods
- Imaging
- Others
A
Bedside
- Faecal calportectin: marker of inflammation in intestines
- Stool culture & sensitivity: exclude infection
- DRE
Bloods
- FBC: aneamia, infection, raised platelets
- U&Es: renal func
- LFTs: liver func
- TFTs: thyroid func- hyperthyroidism can cause diarrhoea
- CRP: inflammation
- Ferritin, TIBC, transferrin saturation: Fe deficiency
- B12: deficiency
- Folate: deficiency
Imaging
- AXR: check for signs of UC or crohns. Including complications
- CT abdo: see above
- MRI abdo: see above
Others
- Colonoscopy, endoscopy, flexible sigmoidoscopy, capsule endoscopy, small bowel enema (crohns), barium enema (colitis) *Colonoscopy + biopsy often imaging of choice. I**n patients with severe colitis colonoscopy should be avoided due to the risk of perforation - a flexible sigmoidoscopy is preferred
13
Q
Why is it important to check renal funcion in pts with IBD?
A
May hae deranged electrolytes or AKI due to GI losses
14
Q
What is faecal calprotectin?
Is it specific to IBD?
A
- Protein that is released by intestines when they are inflammed. Usually raised in active disease and negative in remission or in IBS.
- Not specific to IBD
- Shouldn’t be used in presence of blood as this requires further investigation. *Remember faecal occult test is test for blood in stool
15
Q
Does a normal CRP exclude IBD?
A
NO
16
Q
Why do you check for:
- Fe studies
- B12
- Folate
- … in suspected IBD?
A
- Fe absorption occurs in duodenum & upper jejenum
- B12 absorption occurs in terminal ileum
- Folate absorption occurs in duodenum and jejenum
THEREFORE MORE LIKELY TO HAVE THESE DEFICIENCIES IN CROHN’S DISEASE
17
Q
What investigations are used to diagnose IBD?
A
- OGD (also known as endoscopy)
- Colonscopy
18
Q
What would you find on OGD and colonscopy in Crohn’s disease?
A
- Cobblestone apearance
- Skip lesions
- Strictures
- Fistulaes
- Ulcers
- Hyperaemia (red & inflammed bowel)
19
Q
What would you find on colonscopy in UC (macroscopically)?
A
- Continuous inflammation confined to colon
- Lack of haustra (most likely seen on imaging)
- Pseudopolyps (areas that are healing after inflammation)
20
Q
Describe the microscopic pathological appearance of crohn’s
A
- Granulomas
- Increased number of goblet cells
21
Q
Describe the microscopic pathological appearance of UC
A
- Crypt abcesses
- Irregular shaped glands
- Dysplasia of glands
- Darker crowded nuclei
- Reduced number of goblet cells
- Increased number of paneth cells
22
Q
Describe the appearance of UC on AXR
A
- Thumbprinting
- Pseudopolyps
23
Q
Pts admitted to hospital with acute IBD are at high risk of what…?
A
VTE therefore need prophylactic heparin
24
Q
State some potential triggers for UC flare
A
- Smoking cessation
- Stress
- NSAIDs
25
Discuss the management of Crohn's disease, include:
* Inducing remission
* Maintaining remission
* Surgery
Treatment of IBD is about inducing and then maintaining remission. ALL SHOULD BE ADVISED TO STOP SMOKING.
_Inducing remission:_
* First line= steroids e.g. oral prednisolone, oral budenoside (small bowel disease), IV hydrocortisone, rectal suppositories
* Enteral feeding is alternative to steroids when there are concerns about ADRs of steroids (e.g. children)
* Second line= 5ASA drugs are second line to steroids but not as effective
* Add on therapy (e.g. in addition to steroids): immunosupressant medication e.g. azathioprine, mercaptopurine
* Metronidazole for isolated perianal disease
_Maintaining remission:_
* First line: azathioprine, mercaptopurine
* Second line: methotrexate, infliximab, adalimumab
_Surgery:_
* Used to remove strictures, fistulas or severely diseased parts of bowel
* Not curative
* ~50-80% of pts with crohn's will need surgery at some point in their life
26
Discuss the management of UC, include:
* Inducing remission
* Maintaining remission
* Surgery
_Inducing remission_
* Mild-mod disease:
* First line: aminosalicylate
* Proctitis: rectal (if in 4 weeks remission not achieved add PO ASA.)
* Proctosigmoiditis: rectal (if in 4 weeks remission not achieved add HIGH dose PO ASA)
* Extensive disease: rectal and high dose PO ASA
* Second line: corticosteroids
* Severe disease:
* First line: IV steroids
* Second line: IV ciclosporin
* Third line: surgery
_Maintaining remission_
* First line: aminosalicylates (rectal only, rectal and PO, PO only)
* Second line following severe relapse or \>2 exacerbations past year: azathioprine or mercaptopurine
* Third line: biologics
* *NOTE METHOTREXATE NOT RECOMMENDED*
_Surgery_
* May be used to treat severe disease
* Can be curative (if remove the colon and rectum)
27
What medications are useful in crohns patients with perianal disease?
* Isolated perianal disease can use metronidazole (most pts with perianal disease given metronidazole)
* Biologics/anti-TNF e.g. infliximab
* May also have draining seton
* Perianal abscesses need incision & drainage
28
What dose of IV steroids would you give in acute IBD flare?
~100mg hydrocortisone QDS
29
Why do pts on azathioprine, mercaptopurine and biologics to maintain remission require frequent monitoring?
All immunosupressants hence require frequent monitoring of FBC, U&Es, LFTs
30
Describe the mechanism of action of azathioprine?
Drug class: antiproliferative
* Broken down by liver into 6-Mercaptopurine
* 6-Mercaptopurine broken down into TIMP
* TIMP then converted into either:
* 6-MeMPN (by TPMT): inhibits de novo synthesis of purines
* 6-TGN: incorporated into DNA
* Limits DNA & RNA synthesis hence prevents immune cell production
31
What must you check before starting a pt on azathioprine?
TPMT levels
32
Describe the mechanism of action of ciclosporin
Drug class: calcineurin inhibitor
* Enter helper T cell
* Bind to certain protein in cell
* Ciclosporin bind to cyclophilin
* Tarcolismus bind to tacrolismus binding protein
* Drug-protein complexes bind to calcineurin and inhibit its phosphatase activity
* Calcineurin would usually dephosphorylate cytoplasmic component of nuclear factors that in activated T cells would migrate to nucleus and induce transcription of genes such as IL2
* If calcineurin phosphate activity inhibited then it can't make cytoplasmic nuclear factor into a form that can cross nuclear membrane hence IL2 production inhibited
33
Describe the mechanism of action of methotrexate
Mechanism of action in non-malignant disase unclear but we know it is not via usual folate mechanism. Possible mechanism include:
* Inhibition of accumulation of adenosine
* Inhibition of T cell activation
* Supression of intracellular adhesion molecule expresin by T cells
34
What must you give to pts who are prescribed methotrexate for non-malignant reasons?
Folate supplement
35
What antibiotic can you NOT prescribe for someone on methotrexate?
Trimethoprim (both inhibit folate)
36
Describe the mechanism of action of aminosalicyclates e.g. mesalazine
NOTE: mesalazine is also called 5ASA
* Poorly absorbed
* Anti-inflammatory effect in lumen
*\*IN IMAGE, ignore sulfapyridine part. Only have that part if you give sulfasalazine (which has both parts)*
37
Describe the mechanisms of biologics such as infliximab & adalimumab
* Anti-TNF
* Block actions of TNF-alpha (which is a proinflammatory cytokine)
38
What must you test for before prescribing anti-TNF treatment?
**TB** (TST and IGRA) as TNF is required to maintain granulomas
39
If a pt is having flare of UC and they are receiving rescue therapy (with ciclosporin or steroids) why is it important to involve surgical team and discuss surgery?
Around 50% pts receiving rescue therapy for acute UC won't respond and will need surgery
40
Discuss the surgery options for someone with UC if they wish to cure their disease
* Panproctocolectomy: *remove entire colon & rectum. Pt left with either ileostomy or an ileo-anal anastomosis (J-pouch)- ileum is folded back in on itself to form a larger pouch that fashions like a rectum. The pouch is then attached to anus and collects stools prior to passing a motion*
41
What is meant by IBD-U?
* IBD unclassified
* Inflammation only in colon but not sure if it is crohn's or UC
* Commoner in children. Usually becomes apparent later in life which it is: crohn's or UC
42
State some potential complications of IBD- think about which are more common in crohn's and which are more common in UC
_Crohn's_
* Bowel obstruction (strictures)
* Abscess formation
* Fistulae
* Malnutrition
* Toxic megacolon
* Anaemia
_UC_
* Toxic megacolon- perforation- sepsis
_Both_
* Gastro cancer
* Other cancer (immunosupressants)
* Infection (immunosupressants)
* VTE
* CVD
43
IBD requires MDT management; state some members of MDT invovled
* Gastro team: consultant, IBD nurse
* Dietician
* Dermatologist
* Gynaecologist
* Mental health team
44
State two scoring systems used in Crohn's disease
* CDAI: crohn's disease activity index
* ECCO: European crohn's & colitis organisation
45
Why would you use the CDAI score?
What is included in scoring system?
* Help assess disease severity and quality of life
* Includes:
* Weight
* Ideal weight
* Number of stools per day
* Abdo pain
* General wellbeing
* Extra-GI manifestations
* Score between 0-600+
46
What scoring system is used for UC?
When would you use it?
What are some components of the scoring system?
* Truelove & Witts
* Help classify severity of UC
* Patients with severe disease should be admitted to hospital
*\*Can think of severe as having features of systemic upset*
