Inflammatory Bowel Disease IBD - Chapter 326 Flashcards by Dddddd Sssss

These 2 countries have the highest IBD incidences in Asia.

India and China had the highest IBD incidences in Asia.

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Differentiate UC vs CD in terms of age of onset

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Ethnicity in which UC / CD are is most common

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Effect of smoking on UC vs CD

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Effect of oral contraceptives on UC vs CD

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Effect of appendectomy on UC vs CD

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Peak incidence of UC and CD is in what decades

Peak incidence of UC and CD is in the second to fourth decade

A second modest rise in incidence occurs between the seventh and ninth

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A second modest rise in incidence of UC and CD occurs between the what decades of life.

A second modest rise in incidence occurs between the seventh and ninth decades of life.

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IBD is not gender-specific.

true or false

True

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differentiate the ff based on age
* early onset IBD
* very early onset IBD
* infantile IBD

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part of the gut mainly affected in VEOIBD and infantile IBD

colon

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VEOIBD and Infantile IBD are very sensitive to standard medications

True or false

False.

VEOIBD and Infantile IBD are resistant to standard medications

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Rural areas have a higher prevalence of IBD than urban areas

True or false

False…

Urban areas have a higher prevalence of IBD than rural areas

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high socioeconomic classes have a higher prevalence of IBD than lower socioeconomic classes.

true or false

True

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Breast-feeding may also protect against the development of IBD.

true or false

True

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Infectious gastroenteritis with pathogens (e.g., Salmonella, Shigella, Campylobacter spp., Clostridium difficile) increases IBD risk by two- to threefold.

true or false

True

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Vitamin D has protective effect from UC.

True or false

False…

Vitamin D has protective effect from CD

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the strongest risk factor for the development of IBD

the strongest risk factor for the development of IBD is a first-degree relative with the disease

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how many times at risk to have UC ang kids na may mother or father na may UC

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how many times at risk to have CD ang kids na may mother or father na may CD

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most common CD phenotype in East Asians vs Latinx vs Blacks

all ileocolonic CD

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predominant extraintestinal manifestation (EIM) of IBD among Blacks vs Latinx

Among blacks, joint involvement is the predominant extraintestinal manifestation (EIM)

Dermatologic manifestations are the most common EIMs reported in Latinxs (10–13%).

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mucosal disease that usually involves the rectum and extends proximally to involve all or part of the colon.

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in UC, how many % of patients have :
* disease limited to the rectum and rectosigmoid
* extends beyond the sigmoid but not involving the whole colon
* pancolitis

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UC spreads distally. | True or False

**Proximal spread** occurs in continuity without areas of uninvolved mucosa.

backwash ileitis occurs in CD. | True or False

False.. it occurs in UC

in UC, although variations in macroscopic activity may suggest skip areas, biopsies from normal-appearing mucosa are usually **abnormal** | True or False

True

macroscopic appearance of UC with mild inflammation

macroscopic appearance of more severe UC

macroscopic appeaance of long-standing UC

in patients with many years of UC, the colonic mucosa appears atrophic and featureless | True or False

in patients with many years of UC, **the colonic mucosa appears atrophic and featureless**, and the entire colon becomes narrowed and shortened.

in patients with many years of UC, the entire colon becomes narrowed and shortened. | True or False

in patients with many years of UC, the colonic mucosa appears atrophic and featureless, and t**he entire colon becomes narrowed and shortened**.

Patients with fulminant disease (UC) can develop ____ where the bowel wall becomes thin and the mucosa is severely ulcerated; this may lead to perforation

Patients with fulminant disease can develop a **toxic colitis or megacolon** where the bowel wall becomes thin and the mucosa is severely ulcerated; this may lead to perforation

In UC, the histologic findings **correlate** well with the endoscopic appearance and clinical course of UC. | True or False

True

in UC, the process is limited to WHAT LAYERS...., with deeper layers unaffected except in fulminant disease.

in UC, the process is limited to the **mucosa and superficial submucosa**, with deeper layers unaffected except in fulminant disease.

In UC, what are the two major histologic features that suggest chronicity

in UC, THESE CELLS invade the epithelium, usually in the crypts, giving rise to cryptitis and, ultimately, to crypt abscesses

in UC, the **neutrophils** invade the epithelium, usually in the crypts, giving rise to cryptitis and, ultimately, to crypt abscesses

CD can affect any part of the gastrointestinal (GI) tract from the **mouth to the anus** | True or False

True

How many CD patients...have * small-bowel disease alone * disease involving both the small and large intestines * colitis alone

In the 75% of patients with small-intestinal disease in CD, the ____ is involved in 90%.

In the 75% of patients with small-intestinal disease in CD, the **terminal ileum** is involved in 90%.

Unlike UC, which almost always involves the rectum, the rectum is often spared in CD. | True or False

True | **but rectum can still be affected in CD

**UC** is often segmental with skip areas throughout the diseased intestine | True or False

False... kasi dapat... **CD** is often segmental with skip areas throughout the diseased intestine

CD may also involve the liver and the pancreas | True or False

True

Unlike UC, CD is a transmural process | True or False

True

Difference between endoscopic appeaance of MILD CD vs MORE ACTIVE CD

“cobblestone” appearance is characteristic of CD | true or false

true

pseudopolyps can form in both UC and CD | true or false

true

in ACTIVE CD, projections of thickened mesentery known as “____” encase the bowel, and serosal and mesenteric inflammation promotes adhesions and fistula formation

Projections of thickened mesentery known as “**creeping fa**t” encase the bowel, and serosal and mesenteric inflammation promotes adhesions and fistula formation

Granulomas are a characteristic feature of **UC**. | true or false

False... kasi dapat... Granulomas are a characteristic feature of **CD**

transmural inflammation that is accompanied by fissures that penetrate deeply into the bowel wall and sometimes form fistulous tracts or local abscesses | CD or UC

5 major symptoms of UC

The major symptoms of UC are * Diarrhea * Rectal bleeding * Tenesmus * Passage of mucus * Crampy abdominal pain

in UC, the severity of symptoms correlates with the extent of disease. | True or False

True

IN THIS VARIANT OF UC, patients usually pass fresh blood or blood-stained mucus, either mixed with stool or streaked onto the surface of a normal or hard stool

UC patients with proctitis

IN THIS VARIANT OF UC, patients have tenesmus, or urgency with a feeling of incomplete evacuation, but rarely have abdominal pain

UC patients with proctitis

in UC, when the disease extends beyond the THIS PART OF GUT, blood is usually mixed with stool or grossly bloody diarrhea may be noted

in UC, when the disease extends **beyond the rectum**, blood is usually mixed with stool or grossly bloody diarrhea may be noted

timinig of diarrhea in UC (2)

Diarrhea is often * nocturnal and/or * postprandial

3 physical signs of proctitis in UC

hepatic tympany is consistent with **toxic colitis OR megacolon**

severe pain and bleeding is consistent with **toxic colitis OR megacolon**

Both toxic colitis and megacolon may have signs of peritonitis | True or False

True | if perforation has occured

in UC, this is a highly sensitive and specific marker for detecting intestinal inflammation | fecal lactoferrin or fecal calprotectin

fecal lactoferrin

in active UC, these lab results are what... increased or decreased... * CRP * ESR * platelet * Hgb

in UC, levels of this marker correlate well with histologic inflammation, predict relapses, and detect pouchitis | fecal lactoferrin or fecal calprotectin

fecal calprotectin

in UC, fecal calprotectin detects what disease

pouchitis

in UC, Proctitis or proctosigmoiditis rarely causes a rise in CRP | True or False

True

This endscopic method is used to assess disease activity and is usually performed before treatment.

Sigmoidoscopy

In UC, if the patient is not having an acute flare, this endoscopy method is used to assess disease extent and activity

in UC, histologic features change FASTER than clinical features but can also be used to grade disease activity | True or False

False.... kasi dapat.... Histologic features change **more slowl**y than clinical features but can also be used to grade disease activity

This classification system is used to describe extend and severity of UC

Differentiate differents extents of UC based from Montreal Classification * E1 * E2 * E3

Differentiate differents severity of UC based from Montreal Classification * S0 * S1 * S2 * S3

This is defined as a transverse or right colon with a diameter of >6 cm, with loss of haustration in patients with severe attacks of UC.

Toxic megacolon

Diameter of transverse or right colon in patients with toxic megacolon

transverse or right colon with a diameter of >6 cm

2 triggers of toxic megacolon

can be triggered by * electrolyte abnormalities * and narcotics

Management of toxic megacolon is always surgical. True or False

False.... **About 50% of acute dilations will resolve with conservative management alone**, but urgent colectomy is required for those who do not improve.

If surgery is needed for toxic megacolon, this procedure is done....

About 50% of acute dilations will resolve with conservative management alone, but **urgent colectomy** is required for those who do not improve.

most dangerous local complication of toxic megacolon

perforation

Strictures occur in 5–10% of patients and are always a concern in UC because of the possibility of underlying ____. df

Neoplasia

Although benign strictures can form from the inflammation and fibrosis of UC, strictures that are ____should be presumed malignant until proven otherwise.

Although benign strictures can form from the inflammation and fibrosis of UC, strictures that are **impassable with the colonoscope** should be presumed malignant until proven otherwise.

A stricture that prevents passage of the colonoscope is an indication for surgery | True or False

True

UC patients occasionally develop anal fissures, perianal abscesses, or hemorrhoids, but the occurrence of extensive perianal lesions should suggest CD | True or False

True

two patterns of disease in CD

name of the classification system for CD

the Vienna and Montreal Classification Systems for CD are divided into what 3 parameters

most common site of inflammation in ileocolitis in CD

most common site of inflammation is the **terminal ileum**

usual presentation of ileocolitis in CD (2)

chronic history of recurrent episodes of right lower quadrant pain and diarrhea

Sometimes the initial presentation of this disease mimics acute appendicitis with pronounced right lower quadrant pain, a palpable mass, fever, and leukocytosis.

ileocolitis in CD

High-spiking fever in ileocolitis suggests what complication

High-spiking fever suggests **intraabdominal abscess formation**

The “string sign” on radiographic studies is seen in what disease

ileocolitis in CD

This finding in ileocolitis in CD is caused by incomplete filling of the lumen as the result of edema, irritability, and spasms associated with inflammation and ulcerations.

string sign

The string sign of ileocolitis in CD may be seen in **both nonstenotic and stenotic phases of the disease**. | True or False

True

Pellagra from ____ deficiency can occur in extensive small-bowel disease in jejunoileitis

Pellagra from **niacin deficiency (Vitamin B3)** can occur in extensive small-bowel disease

malabsorption of ____ in jejunoileitis can lead to megaloblastic anemia

Vitamin B 12

This symptom is characteristic of active disease in jejunoileitis in CD

Diarrhea

The third portion of the duodenum is more commonly involved than the bulb in CD | True or False

The **second portion** of the duodenum is more commonly involved than the bulb.

in CD, patients usually have a Helicobacter pylori–positive gastritis | True or False

False... Patients usually have a **Helicobacter pylori–negative gastritis**

**Fecal lactoferrin** is a more sensitive marker of ileocolonic or colonic inflammation rather than isolated ileal inflammation. | True or False

False... kasi dapat ... **Fecal calprotectin** is a more sensitive marker of ileocolonic or colonic inflammation rather than isolated ileal inflammation.

Endoscopic features of CD (4)

Endoscopic features of CD include * rectal sparing, * aphthous ulcerations, * fistulas, * skip lesions.

Characteristics of strictures in CD that respond better to endoscopic dilation (2)

**Strictures ≤4 cm in length**and those **at anastomotic sites** respond better to endoscopic dilation.

This endoscopy method allows direct visualization of the entire small-bowel mucosa

**Wireless capsule endoscopy (WCE)** allows direct visualization of the entire small-bowel mucosa

In CD, early radiographic findings in the small bowel include (2)

* thickened folds * aphthous ulcerations

The diagnostic yield of detecting lesions suggestive of active CD is higher with wireless capsule endoscopy (WCE) than CT or magnetic resonance (MR) enterography | True or False

True

in CD, “Cobblestoning” from longitudinal and transverse ulcerations most frequently involves the WHAT PART OF THE BOWEL

small bowel

The earliest macroscopic findings of colonic CD

The earliest macroscopic findings of colonic CD are **aphthous ulcers.**

This underutilized imaging study is at least as sensitive as MR enterography and CT enterography for detecting small-bowel CD

Small bowel ultrasound or **SBUS** is at least as sensitive as MR enterography and CT enterography for detecting small-bowel CD

SBUS is best suited for PROXIMAL small-bowel assessment | True or False

SBUS is best suited for distal small-bowel assessment, as the sensitivity of detecting lesions within the duodenum and proximal jejunum may be lower due to anatomic position.

Perforation occurs in 1–2% of CD patients, usually in the WHAT PART OF GUT

Ileum

anti–Saccharomyces cerevisiae antibody (ASCA) is more common in CD OR UC

perinuclear antineutrophil cytoplasmic antibody (pANCA) is more common in CD OR UC

.____measures a panel of serologic (S), genetic (G), and inflammatory (I) biomarkers, but the test is costly, and reliable results are based on the pretest probability of the patient having IBD

Prometheus IBD SGI Diagnostic blood test

.____is a validated web-based tool to display individual CD outcomes and considers multiple variables including disease location (large or small bowel, perianal), serologies (ASCA, CBir1, ANCA), and genetics (NOD2 frameshift mutation)

PROSPECT

Clinical factors described at diagnosis are more helpful than serologies at predicting the natural history of IBD. | True or FAlse

True

Once a diagnosis of IBD is made, distinguishing between UC and CD is impossible initially in up to 15% of cases. These are termed WHAT

indeterminate colitis

This infectious disease can mimic the endoscopic appearance of severe UC and can cause a relapse of established UC.

This bacteria can cause watery or bloody diarrhea, nausea, and vomiting.

This infectious disease causes watery diarrhea, abdominal pain, and fever followed by rectal tenesmus and by the passage of blood and mucus per rectum.

This infection occurs mainly in the terminal ileum and causes mucosal ulceration, neutrophil invasion, and thickening of the ileal wall.

**Yersinia enterocolitica infection**

three categories of E. coli which can cause colitis

* enterohemorrhagic, * enteroinvasive, * enteroadherent E. coli

Gonorrhea, Chlamydia, and syphilis can also cause proctitis. | True or false

True

sites commonly affected in GI disease caused by mycobacterial infection

Distal ileal and cecal involvement

These viral diseases (2) cause proctitis and may occur in immunocompetent px

Although most of the patients with viral colitis are immunosuppressed, **cytomegalovirus (CMV) and herpes simplex proctitis** may occur in immunocompetent individuals.

How to diagnose CMV infection of GI tract vs Herpes simplex infection of the GI tract

* CMV: identification of characteristic **intranuclear inclusions** in mucosal cells on biopsy * HSV: rectal biopsy with identification of characteristic **cellular inclusions**and viral culture

Colonoscopy findings in entamoeba histolytica infection

focal punctate ulcers with normal intervening mucosa;

3 factors that favor CD over diverticulitis

Diverticular-associated colitis is similar to CD, but mucosal abnormalities are limited to the WHAT PARTS OF THE GUT (2)

Diverticular-associated colitis is similar to CD, but mucosal abnormalities are limited to the **sigmoid and descending colon**.

This DDx IBD...Patients usually present with sudden onset of left lower quadrant pain, urgency to defecate, and the passage of bright red blood per rectum.

ischemic colitis

This DDx of IBD....Endoscopic examination often demonstrates a normal-appearing rectum and a sharp transition to an area of inflammation in the descending colon and splenic flexure.

ischemic colitis

Endoscopy findings in GIT after undergoing radiotherapy

Solitary rectal ulcer syndrome is uncommon and can be confused with IBD. Ulceration, which may be as large as 5 cm in diameter, is usually observed AT WHAT PART OF THE GI TRACT

anteriorly or anterolaterally 3–15 cm from the anal verge

Examples of immune checkpoint proteins (2)

The most common clinical presentation of ICI-related colitis is...

The most common clinical presentation of ICI-related colitis is **self-limited diarrhea** that can be associated with frank colitis and can lead to significant morbidity and mortality if not managed appropriatel

Moderate to severe symptoms of ICI-related colitis usually require this DRUG CLASS

glucocorticoids

THESE DRUGS (2) are used in steroid- refractory cases of ICI-related colitis

biologics such as **anti-TNF agents** and **integrin inhibitors** are used in steroid- refractory cases of ICI-related colitis

Two atypical colitides—collagenous colitis and lymphocytic colitis have **completely normal endoscopic appearance**s | True or False

True

what are the two atypical colitides

Two atypical colitides * collagenous colitis and * lymphocytic colitis

two main histologic components of collagenous colitis

two main histologic components of collagenous colitis * increased subepithelial collagen deposition * colitis with increased intraepithelial lymphocytes.

female-to-male ratio of collagenous colitis

female-to-male ratio is 9:1

Collagenous colitis present in what decade of life

present in the sixth or seventh decade of life

main symptom collagenous colitis

main symptom is chronic watery diarrhea.

Risk factors of collagenous colitis (3)

Risk factors of collagenous colitis : * smoking; * use of NSAIDs, proton pump inhibitors, or beta blockers; * and a history of autoimmune disease.

Lymphocytic colitis has features similar to collagenous colitis, including age at onset and clinical presentation but it is different in 2 clinical aspects

Both collagenous colitis and lymphocytic colitis have increased intraepithelial lymphocytes | True or False

True

Use of of THIS DRUG is an additional risk factor for lymphocytic colitis

Use of **sertraline** (but not beta blockers) is an additional risk factor for lymphocytic colitis

The frequency of ____disease is increased in lymphocytic colitis and ranges from 9 to 27%

The frequency of **celiac disease** is increased in lymphocytic colitis and ranges from 9 to 27%

This is an inflammatory process that arises in segments of the large intestine that are not continuous with the fecal stream.

Diversion colitis

Diversion colitis usually occurs in patients with...

It usually occurs in patients with ileostomy or colostomy when a mucus fistula or a Hartmann’s pouch has been created.

Crypt architecture in diversion colitis is normal, which differentiates it from UC but not necessarily CD. | True or False

True

____ may help in diversion colitis but the definitive therapy is surgical reanastomosis

Short-chain fatty acid enemas

Short-chain fatty acid enemas may help in diversion colitis but the definitive therapy is____

surgical reanastomosis

Mycobacterial diseases that can mimic IBD. Give 2

Viral diseases that can mimic IBD. Give 3

Fungal diseases that can mimic IBD. Give 3

Parasitic diseases that can mimic IBD. Give 3

Drugs/chemicals that can mimic IBD. Give 3

Mild UC based from Montreal Classification is defined as...

Moderate UC based from Montreal Classification is defined as...

Severe UC based from Montreal Classificatio is defined as...

This extraintestinal dermatologic manifesation of IBD has the ff characteristics: * Lesions are hot, red, tender nodules measuring 1–5 cm in diameter * Lesions are found on the anterior surface of the lower legs, ankles, calves, thighs, and arms.

Erythema nodosum (EN)

in Erythema nodusoum, skin lesions develop after the onset of bowel symptoms, and patients frequently have concomitant ____ (disease)

active peripheral arthritis

EN parralels bowel activity. True or False

True

only 2 dermatologic manifestation of IBD that does not parallel bowel activity

## Footnote Pyoderma gangrenosum and Psoriasis

Treatment of pyoderma gangrenosum

They are sometimes very difficult to treat and often require IV antibiotics, IV glucocorticoids, dapsone, azathioprine, thalidomide, IV cyclosporine (CSA), infliximab, or adalimumab.

Pyoderma gangrenosum may occur years before the onset of bowel symptoms, | True or False

True

Pyoderma gangrenosum is usually associated with mild disease. | True or False

False.... kasi dapat... It is usually associated with **severe** disease.

Difference of Pyoderma vegetan vs Pyostomatitis vegetans in terms of location

This dermatologic EIM of IBD is a neutrophilic dermatosis

This dermatologic EIM of IBD is a rare disorder defined by cutaneous granuloma formation.

only rhematologic EIM of IBD that parralels bowel activity

Rheumatologic EIM of IBD with the ff characteristics: * Asymmetric, migratory * Parallels bowel activity

Rheumatologic EIM of IBD with the ff characteristics:

Rheumatologic EIM of IBD with the ff characteristics: * Symmetric: spine and hip joints * Independent of bowel activity

Rheumatologic EIM of IBD with the ff characteristics: * Gradual fusion of spine * Independent of bowel activity * Two-thirds have HLA-B27 antigen

Treatment of periphral is directed at ____

reducing bowel inflammation

About one-thirds of IBD patients with AS express the HLA-B27 antigen. | True or false

False... kasi dapat... About **two-thirds** of IBD patients with AS express the HLA-B27 antigen.

In severe UC, colectomy frequently cures the arthritis. | True or False

True

About two-thirds of IBD patients with AS express THIS ANTIGEN

About two-thirds of IBD patients with AS express the **HLA-B27 antigen**.

Ankylosing spondylitis does not remit with glucocorticoids or colectomy. | True or false

True

THIS therapy in AS * reduces spinal inflammation * and improves functional status and quality of life.

**Anti-TNF** therapy in AS * reduces spinal inflammation * and improves functional status and quality of life.

This rhuematologic EIM of IBD * is symmetric, * occurs equally in UC and CD | True or False

Sacroiliitis

Sacroiliitis * is often asymptomatic, * and does not always progress to AS | True or false

True

This ocular EIM of IBD has the ff characteristics * Ocular pain, photophobia, blurred vision, headache * Independent of bowel activity

Uveitis

This ocular EIM of IBD has the ff characteristics * Mild ocular burning * Parallels bowel activity

This ocular EIM of IBD parallels bowel activity

Common treatment for the 2 ocular EIM of IBD

____is detectable in about one-half of the abnormal liver biopsies from patients with CD and UC; patients usually present with hepatomegaly

**Hepatic steatosi**s is detectable in about one-half of the abnormal liver biopsies from patients with CD and UC; patients usually present with hepatomegaly

____is a disorder characterized by both intrahepatic and extrahepatic bile duct inflammation and fibrosis, frequently leading to biliary cirrhosis and hepatic failure

Primary sclerosing cholangitis (PSC)

Although it can be recognized after the diagnosis of IBD, PSC can be detected earlier or even years after proctocolectomy | True or False

True

both IBD and PSC are commonly pANCA negative | True or false

false.... kasi dapat... both IBD and PSC are commonly **pANCA positiv**e

traditional gold standard diagnostic test for PSC

traditional gold standard diagnostic test is **endoscopic retrograde cholangiopancreatography (ERCP)**

In patients with PSC, both ERCP and MRCP demonstrate multiple bile duct strictures alternating with relatively normal segments. | True or False

True

Gallbladder polyps in patients with PSC have a high incidence of malignancy, and cholecystectomy is recommende | True or False

True

How often should GB ultrasound be done in px with GB polyp and IBD

Gallbladder surveillance with ultrasound should be performed annually

Patients with IBD and PSC are at increased risk of colon cancer and should be surveyed ( HOW OFTEN ) by colonoscopy and biopsy.

yearly

cholangiography is normal in a small percentage of patients who have a variant of PSC known as ____.

cholangiography is normal in a small percentage of patients who have a variant of PSC known as **small duct primary sclerosing cholangitis (AKA pericholangitis)**

hepatobiliary EIM of IBD with the ff characteristics * Secondary to chronic illness, malnutrition, steroid therapy

hepatobiliary EIM of IBD with the ff characteristics * Intrahepatic and extrahepatic * Inflammation and fibrosis leading to biliary cirrhosis and hepatic failure * 7–10% cholangiocarcinoma * Small-duct PSC involves small-caliber bile ducts and has a better prognosis

hepatobiliary EIM of IBD with the ff characteristics * Patients with ileitis or ileal resection * Malabsorption of bile acids, depletion of bile salt pool, secretion of lithogenic bile

The highest frequency of nephrolithiasis (10–20%) occurs in this subset of CD patients

The highest frequency of nephrolithiasis (10–20%) occurs in **patients with CD following small-bowel resection.**

Calcium oxalate stones develop secondary to ____

Calcium oxalate stones develop secondary to **hyperoxaluria**, which results from increased absorption of dietary oxalate

Patients with IBD have an increased risk of both venous and arterial thrombosis **even if the disease is not active.** | True or False

True

The renal disease in secondary or reactive amyloidosis can be successfully treated with WHAT DRUG

Colchicine

5-ASA are effective at inducing and maintaining remission in UC. | True or False

True

____ is effective treatment for mild to moderate UC, but its high rate of side effects limits its use.

Sulfasalazine

Sulfasalazine is effective treatment for mild to moderate UC, but its high rate of side effects limits its use. Although sulfasalazine is more effective at higher doses, at ____g/d, up to 30% of patients experience allergic reactions or intolerable side effects

6 or 8 g/day

This vitamin should be given when admnistering sulfasalazine

Sulfasalazine can also impair folate absorption, and patients should be given folic acid supplements.

This contains an azo bond binding mesalamine to the carrier molecule 4-aminobenzoyl-β-alanine; it is effective in the colon.

Balsalazide

Balsalazide is effective at what part of the gut

colon

These are enteric-coated forms of mesalamine (2) with the 5-ASA being released at pH >7.

Delzicol and Asacol HD (high dose)

This is a once-a-day formulation of mesalamine (Multi-Matrix System [MMX]) designed to release mesalamine in the colon.

Lialda

The ____incorporates mesalamine into a lipophilic matrix within a hydrophilic matrix encapsulated in a polymer resistant to degradation at a low pH (<7) to delay release throughout the colon.

MMX technology

is a formulation containing encapsulated mesalamine granules that delivers mesalamine to the terminal ileum and colon via a proprietary extended-release mechanism (Intellicor).

Apriso

This is another mesalamine formulation that uses an ethyl cellulose coating to allow water absorption into small beads containing the mesalamine.

Pentasa

This an unencapsulated version of mesalamine, It has been in use in Europe for induction and maintenance of remission for several years.

Salofalk Granu-Stix

Dosing per day of Sulfasalazine (Acute vs Maintenance)

Examples of different kinds of Mesalazine * Delayed-release * Controlled-release * Delayed- and Extended-release

5-ASa agents that are delivered to the colon only (2)

5-ASa agents that is delivered to the distal ileum-colon only (2)

5-ASA agents that are delivered to the ileum-colon (2) | iba pa yung dital ileum-colon

5-ASA agents that is delivered to the stomach-colon (1)

Renal function tests and urinalysis in px taking 5-ASA should be checked HOW OFTEN

yearly

These enema enemas are composed of mesalamine and are effective in mild-to-moderate distal UC.

Topical Rowasa enemas

____ suppositories composed of mesalamine are effective in treating proctitis.

Canasa

Canasa suppositories composed of mesalamine are effective in treating ____.

proctitis

for active UC that is unresponsive to 5-ASA therapy * Prednisone is usually started at what dose...

Prednisone 40–60 mg/d

A newer glucocorticoid for UC, ____, is released entirely in the colon and has minimal to no glucocorticoid side effects.

A newer glucocorticoid for UC**, budesonide (Uceris**), is released entirely in the colon and has minimal to no glucocorticoid side effects.

dose and duration of Budesonide in UC

Hydrocortisone enemas are significantly absorbed from the rectum and can lead to ____ with prolonged administration

adrenal suppression

Topical steroid therapy is more effective than topical 5-ASA therapy in the treatment of distal UC. | True or false

False... kasi dapat... **Topical 5-ASA therapy** is more effective than topical steroid therapy in the treatment of distal UC.

Glucocorticoids play no role in maintenance therapy in either UC or CD. | True or False

True

Glucocorticoids have many side effects. Which adverse effect is not related to the dose and duration of therapy

Osteonecrosis

Antibiotics have no role in the treatment of active or quiescent UC. | True or False

True

Antibiotics have no role in the treatment of active or quiescent UC. However, pouchitis, which occurs in ~30–50% of UC patients after colectomy and IPAA, usually responds to treatment with a variety of antibiotics including ____ and ____

metronidazole and ciprofloxacin.

Antibiotics have no role in the treatment of active or quiescent UC. However,____, which occurs in ~30–50% of UC patients after colectomy and IPAA, usually responds to treatment with a variety of antibiotics including metronidazole and ciprofloxacin.

pouchitis

These are purine analogues used concomitantly with biologic therapy or, much less often, as the sole immunosuppressants for IBD

Azathioprine and mercaptopurine (MP

____ is rapidly absorbed and converted to MP, which is then metabolized to the active end product, thioinosinic acid, an inhibitor of purine ribonucleotide synthesis and cell proliferation.

Azathioprine

Azathioprine is rapidly absorbed and converted to MP, which is then metabolized to the active end product, ____, an inhibitor of purine ribonucleotide synthesis and cell proliferation.

Azathioprine is rapidly absorbed and converted to MP, which is then metabolized to the active end product, **thioinosinic acid**, an inhibitor of purine ribonucleotide synthesis and cell proliferation.

Adherence to azathioprine and mercaptopuirine can be monitored by measuring the levels of ____ and ____, the end products of MP metabolism.

Adherence can be monitored by measuring the levels of **6-thioguanine** and **6-methylmercaptopurine**, end products of MP metabolism.

Dose of azathioprine vs mercaptopurine

Although azathioprine and MP are usually safe, THIS ADVERSE EFFECT occurs in 3–4% of patients, typically presents within the first few weeks of therapy, and is completely reversible when the drug is stopped.

Although azathioprine and MP are usually safe, **pancreatitis** occurs in 3–4% of patients, typically presents within the first few weeks of therapy, and is completely reversible when the drug is stopped.

in Azathioprine and MP, Bone marrow suppression (particularly **thrombocytopenia**) is dose-related and often delayed | True or False

False... kasi dapat... Leukopenia

enzyme responsible for drug metabolism to inactive end products 6-methylmercaptopurine

thiopurine methyltransferase

Age with highest risk for thiopurine-associated lymphoma vs moderate risk

* highest risk --patients >65 years old actively using thiopurines * moderate risk -- ages of 50 and 65

IBD patients on azathioprine and MP have fourfold risk of THIS CANCER

lymphoma

____inhibits dihydrofolate reductase, resulting in impaired DNA synthesis.

Methotrexate

Intramuscular (IM) or subcutaneous (SC) doses of MTX range from ___ to ___mg/week.

Intramuscular (IM) or subcutaneous (SC) doses range from **15 to 25 mg/week**

Potential toxicities of methotrexate include ____and ____ necessitating periodic evaluation of CBCs and liver enzymes.

Potential toxicities include **leukopenia and hepatic fibrosis**, necessitating periodic evaluation of CBCs and liver enzymes.

Hypersensitivity pneumonitis is a rare but serious complication of therapy of what IBD drug

Methotrexate

CSA is a lipophilic peptide with inhibitory effects on both the cellular and humoral immune systems. | True or False

True

CSA has a more rapid onset of action than MP and azathioprine. | True or False

True

This drug most effective when given at 2–4 mg/kg per day IV in severe UC that is refractory to IV glucocorticoids, with 82% of patients responding.

Cyclosporine

This drug can be an alternative to colectomy.

Cyclosporine

Cyclosporine levels as measured by monoclonal radioimmunoassay or by the high-performance liquid chromatography assay should be maintained between ____ and ____ ng/mL.

Levels as measured by monoclonal radioimmunoassay or by the high-performance liquid chromatography assay should be maintained **between 150 and 350 ng/mL.**

gingival hyperplasia and hypertrichosis are common side effects of this IBD drug

Cyclosporine

Seizures may also complicate therapy using cyclosporine , especially if the patient has these 2 low lab values (2)

Seizures may also complicate therapy, especially if the patient is * hypomagnesemic or * if serum cholesterol levels are <3.1 mmol/L (<120 mg/dL)

antibiotic prophylaxis with ____ should be given in patients taking Cyclosporine

trimethoprim-sulfamethoxazole

____ is a macrolide antibiotic with immunomodulatory properties similar to CSA but 100 times as potent

Tacrolimus

Tacrolimus is a macrolide antibiotic with immunomodulatory properties similar to CSA but **10 times as potent** | True or False

False... 100 times as potent

tacrolimus has poor oral absorption because of proximal small-bowel Crohn’s involvement | True or False

False... kasi dapat... tacrolimus has **good oral absorption** despite proximal small-bowel Crohn’s involvement

Tacrolimus is effective in these 4 subset of populations

Tacrolimus is effective * in children with refractory IBD * in adults with extensive involvement of the small bowel * in adults with glucocorticoid-dependent or refractory UC and CD * in adults with refractory fistulizing CD

High-risk patients with UC who are more likely to require biologics (3)

High-risk patients with CD who are more likely to require biologics

Four TNF inhibitors are currently approved for the treatment of IBD

* infliximab * adalimumab * certolizumab pegol * golimumab

first biologic therapy approved for moderately to severely active inflammatory and fistulizing CD and UC

Infliximab

a chimeric IgG1 antibody against TNF-α

Infliximab

This trial compared infliximab plus azathioprine, infliximab alone, and azathioprine alone in immunomodulator- and biologic therapy–naive patients with moderate to severe CD.

SONIC trial... Study of Biologic and Immunomodulator-Naive Patients with Crohn’s Disease

Hospitalized patients with acute severe glucocorticoid refractory UC have a high inflammatory burden and may develop a ____, leading to an accelerated consumption, excessive fecal wasting, and low serum concentrations of infliximab.

Hospitalized patients with acute severe glucocorticoid refractory UC have a high inflammatory burden and may develop a **protein-losing enteropath**y, leading to an accelerated consumption, excessive fecal wasting, and low serum concentrations of infliximab.

This is a recombinant human monoclonal IgG1 antibody containing only human peptide sequences and is injected subcutaneously.

Adalimumab

ADA is approved for treatment of both moderate to severe CD and UC. | True or False

True

____ is an ADA maintenance study in patients who responded to ADA induction therapy.

CHARM (Crohn’s Trial of the Fully Human Adalimumab for Remission Maintenance)

the remission rate in both CD and UC patients taking ADA increases with a dose increase to 40 mg weekly instead of every other week. | True or False

True

This is a pegylated form of an anti-TNF Fab portion of an antibody administered SC once monthly.

Certolizumab Pegol

SC certolizumab pegol was effective for induction of clinical response in patients with active inflammatory **UC and CD**. | True or False

Fasle... CD lang dapat

another fully human IgG1 antibody against TNF-α and is currently approved for the treatment of moderately to severely active UC.

Golimumab

Golimumab is used for CD | True or False

False... it is used for UC only

anti TNF agents given via SC route (3)

* ADA * certolizumab * golimumab

If a patient has high anti-infliximab antibodies and a low trough level of infliximab, it is best to switch to another anti-TNF therapy. | True or Flase

True

If a patient has a therapeutic anti-TNF level and active inflammatory symptoms, the drug should be switched to a different class of biologic.

True

Most acute infusion reactions and serum sickness secondsry to biologics can be managed with THESE 2 DRUGS

Most acute infusion reactions and serum sickness can be managed with **glucocorticoids and antihistamines**.

It is now common practice to add ____ to anti-TNF therapy to help prevent antibody formation

It is now common practice to add an **immunomodulator such as azathioprine, MP, or MTX** to anti-TNF therapy to help prevent antibody formation

The baseline risk of THIS MALIGNANCY in CD patients is 2 in 10,000, slightly higher than in the general population. Azathioprine and/or MP therapy increases the risk to ~4 in 10,000.

Non Hodgkin's lymphoma

____ is a nearly universally fatal lymphoma in patients with or without CD.

Hepatosplenic T-Cell Lymphoma (HSTCL)

Patients with IBD may have a slight, unexplained, intrinsic higher risk of developing THIS SKIN CANCER

Patients with IBD may have a slight, unexplained, intrinsic higher risk of developing **melanoma.**

The risk of melanoma is increased almost twofold with anti-TNF and not thiopurine use. | True or False

True The risk of **nonmelanoma** skin cancer is increased with **thiopurines** and biologics, especially with ≥1 year of follow-up.

Patients on Biologics should have a skin check at least how many times a yeae

once a year

All of the anti-TNF drugs are associated with an increased risk of infections | True or False

True

Patients should have a purified protein derivative (PPD) or a QuantiFERON-TB Gold test before initiation of anti-TNF therapy. | True or False

True

Patients ____ years old have a higher rate of infections and death on infliximab or ADA than those ____ years old.

Patients >65 years old have a higher rate of infections and death on infliximab or ADA than those <65 years old.

Anti integrin that is a recombinant humanized IgG4 antibody against α4-integrin

Monoclonal antibody directed against a4B7-integrin specifically

Vedolizumab

Anti integrin thatg is a fully human IgG1 monoclonal antibody, blocks the biologic activity of IL-12 and IL-23 through their common p40 subunit

Natalizumab is no longer widely used for CD due to the risk of ____

Natalizumab is no longer widely used for CD due to the risk of **progressive multifocal leukoencephalopathy (PML).**

This anti integrin has the ability to convey gut-selective immunosuppression.

Vedolizumab

This anti integrin may be prescribed as a first-line biologic or after failure of a TNF antagonist in patients with CD or UC.

Vedolizumab

This trial suggests that among patients with UC, VDZ should be considered as first-line therapy and before treatment with ADA

VARSITY trial

This trial evaluated ustekinumab as 8-week induction and 44-week maintenance therapy in moderate to severe UC.

UNIFI trial

This trial showed that the remission rate for the highest 6 mg/kg IV induction dose of Ustekinumab followed by a dose of 90 mg every 8 weeks was 41.7%, compared with 27.4% for placebo, at 22 weeks in patients with CD no longer responding to anti-TNF therapy

UNITI trial

This drug is another option for the treatment of moderate to severe CD and UC and is particularly appealing for use in patients with **concomitant psoriatic arthritis.**

Ustekinumab

new class of orally administered medications developed for IBD that lack the immunogenicity associated with monoclonal antibodies

small molecules

____ is a reversible and competitive JAK inhibitor used for the treatment of moderate to severe UC refractory to conventional therapy. It competes with ATP to bind to the ATP-docking site of the kinase domain of JAK.

Tofacitinib

Although tofacitinib is a pan-JAK inhibitor, it has higher specificity for JAK2 and TYK2 | True or False

False... kasi dapat..... Tofacitinib is a pan-JAK inhibitor, it has higher specificity for **JAK1 and JAK3** than for JAK2 and TYK2.

This drug is potent sphingosine-1-phosphate (S1P1) receptor modulator that binds selectively with high affinity to the S1P receptor subtypes S1P1 and S1P5, both of which are involved in immune regulation. By preventing trafficking of disease-exacerbating lymphocytes to the gut, this drug may provide immunomodulatory effects and moderate disease processes.

Ozanimod

Because UC is a mucosal disease, the rectal mucosa can be dissected and removed down to WHAT LEVEL (2)

Because UC is a mucosal disease, the rectal mucosa can be dissected and removed down to : * dentate line of the anus * or ~2 cm proximal to this landmark

The part of the gut is fashioned into a pouch that serves as a neorectum.

The **ileum** is fashioned into a pouch that serves as a neorectum.

The most frequent complication of IPAA is ____

pouchitis

Patients with IPAA usually have____ bowel movements a day.

Patients with IPAA usually have **~6–10** bowel movements a day.

____is the most frequently performed operation, and in most cases, primary anastomosis can be done to restore continuity

Surgical resection of the diseased segment

An end-to-end anastomosis may provide the best opportunity for an optimal functional outcome, compared to an anti-peristaltic side-to-side anastomosis | True or False

True

Most surgeons believe that an IPAA is contraindicated in **UC** due to the high incidence of pouch failure. | True or False

False... kasi dapat CD

Patients with quiescent UC and CD have normal fertility rates; | True or False

True

Infertility in men can be caused by this IBD DRUG but reverses when treatment is stopped.

Infertility in men can be caused by **sulfasalazine** but reverses when treatment is stopped.

LEft side of fallopian tube is usually scarred in IBD. True or False

the fallopian tubes can be scarred by the inflammatory process of CD, especially on the **right side** because of the proximity of the terminal ileum.

why are women with IPAA have decreased fertility

Women with an IPAA have decreased fertility due to scarring or occlusion of the fallopian tubes secondary to pelvic inflammation and adhesions

Mild or quiescent UC or CD has no effect on birth outcomes. | True or False

True

Patients should be in remission for UC or CD for HOW MANY months before conceiving.

6 months remission dapat

all mesalamines are safe for use in pregnancy and nursing | True or False

True

This vitamin must be given for pregnant patients receiving sulfasalazine

Folic acid (vitamin B9)

Topical 5-ASA agents are safe during pregnancy and nursing. | true or false

True

Glucocorticoids are generally safe for use during pregnancy | True or False

True

The safest antibiotics to use for CD in pregnancy for short periods of time (weeks, not months) are.... (2)

ampicillin and cephalosporins

Metronidazole can be used in what trimester of pregnancy

Metronidazole can be used in the **second or third trimester.**

____ causes cartilage lesions in immature animals and should be avoided because of the absence of data on its effects on growth and development in humans

**Ciprofloxacin** causes cartilage lesions in immature animals and should be avoided because of the absence of data on its effects on growth and development in humans

MP and azathioprine pose minimal or no risk during pregnancy. | True or False

True

MTX is teratogenic and should be discontinued at least HOW MANY months before conception

MTX is teratogenic and should be discontinued **at least 3 months before conception**

Infants can have serum levels of infliximab and ADA up to 12 months of age, and live vaccines should be avoided during this time. | True or False

true

no increased risk of stillbirths, miscarriages, or spontaneous abortions was seen with infliximab, ADA, or certolizumab | true or false

true

this anti TNF drug crosses the placenta by passive diffusion, and infant serum and cord blood levels are minimal.

**Certolizumab** crosses the placenta by passive diffusion, and infant serum and cord blood levels are minimal.

VDZ and ustekinumab appear safe during pregnancy | True or False

True

Tofacitinib can be safely used during pregnancy. | True or False

Tofacitinib **should not be used** during pregnancy.

For Tocatinib, A washout period of at least HOW LONG is recommended before conception.

A washout period of **at least 1 week** is recommended before conception.

The best time to perform surgery in UC is in WHAT trimester if necessary.

The best time to perform surgery is in the **second trimester** if necessary.

Patients with IPAAs have increased nighttime stool frequency during pregnancy that resolves postpartum | True or False

True

Patients with long-standing UC are at increased risk for developing colonic epithelial dysplasia and carcinoma | True or False

True

Annual or biennial colonoscopy with multiple biopsies is recommended in UC | True or False

True

International guideline societies have recommended ____ for dysplasia surveillance in IBD

International guideline societies have recommended **chromoendoscopy** for dysplasia surveillance in IBD

In real-life settings, the practice has been to use standard-definition ____endoscopy with surveillance biopsies in patients with chronic colitis at average risk and ____endoscopy in higher-risk patients including those with a history of dysplasia, PSC, or family history of colorectal cancer.

In real-life settings, the practice has been to use standard-definition **white light endoscopy** with surveillance biopsies in patients with chronic colitis at average risk and **chromoendoscop**y in higher-risk patients including those with a history of dysplasia, PSC, or family history of colorectal cancer.

the same endoscopic surveillance strategy used for UC is recommended for patients with chronic Crohn’s colitis. | True or False T

True

Usual treatment if If flat high-grade dysplasia is encountered on colonoscopic surveillance in * CD vs * UC

usual treatment if flat lowgrade dysplasia is found

Inflammatory Bowel Disease IBD - Chapter 326 Flashcards

(344 cards)