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G.I. > Inflammatory Bowel Disease (IBD) & Large Bowel > Flashcards

Inflammatory Bowel Disease (IBD) & Large Bowel Flashcards

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1
Q

What is a polyp?

A

Protrusion above an epithelial surface

A tumour (swelling)

Pedunculated - has a stalk

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2
Q

Commonest polyp?

A

Adenoma

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3
Q

What must happen to all adenomas?

A

They must be removed.

Potentially pre-malignant

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4
Q

Different types of polyps

A
  1. Adenoma
  2. Serrated polyp
  3. Polypoid carcinoma
  4. Ohter
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5
Q

What is a serrated polyp?

A

Sessile (flat) polyp lesion of the colon

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6
Q

What kind of necrosis is seen in large bowel cancers?

A

Dirty necrosis (looks like it has been flecked with dirt)

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7
Q

Dukes Staging

A

A: Confined by muscularis propria

B: Through muscularis propria

C: Metastatic to lymph nodes

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8
Q

Colorectal carcinoma - right and left sided presenting complaint

A

75% Left sided (rectum, signed, descending)

  • blood PR, altered bowel habit
  • obstruction

25% Right sided

  • anaemia, weight loss
  • do not normally obstruct (except at ileocoecal valve)
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9
Q

Common metastatic sites in colorectal carcinoma

A

Local - mesorectum, peritoneum

Lymphatic spread - mesenteric nodes

Liver

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10
Q

Inherited Cancer Syndromes

HNPCC
FAP

how many polyps in each

A

HNPCC//

Hereditary Non Polyposis Coli

<100 polyps

  • late onset
  • autosomal dominant
  • inherited mutation
  • right sided tumours
  • Crohn’s-like inflammatory response

FAP//

Familial adenomatous Polyposis

> 100 polyps to 1000s
throughout the colon
adenocarcinomas

EARLY onset
autosomal dominant
defect in tumour suppression

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11
Q

Diverticular Disease

what is it
complications

A

True/false diverticula

Out-pouchings of the large intestine

Complications//

inflammation (diverticulitis)
rupture
abscess
fistula
massive bleeding
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12
Q

Ischaemic colitis

histopathologically
complications
common in

A

“withering of crypts”
pink smudgy lamina propria
fewer chronic inflammatory ells

Common in: elderly

Complications: massive bleeding, rupture, stricture

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13
Q

Antibiotic Induced PSEUDOMEMBRANOUS colitis

Common in?
Bacteria responsible?

A

Patchy yellow membranous exudate on mucosal surface (looks like a scabby steak)

Explosive lesions on mucosa

Patients on broad spectrum antibiotics

Clostridium difficile - toxin A and B attack lining

Bloody diarrhoea

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14
Q

Antibiotic induced pseudomembranous colitis - treat with?

A

Vancomycin

or colectomy

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15
Q

Collagenous Colitis

A

Increase in thickness of sub epithelial collagen

Patchy disease

Watery diarrhoea, normal endoscopy

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16
Q

Lymphocytic colitis

A

Normal mucosa
Watery diarrhoea

MASSIVE increase in intraepithelial lymphocytes

possible coeliac disease

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17
Q

RADIATION COLITIS

A

Small ulces
Areas of mucosal haemorrhage

ecstatic mucosa
HISTORY of cervical carcinoma
Telangectasia - spider veins

due to chemo/radiotherapy

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18
Q

Acute infective colitis

A

Infection
Cryptitis
Neutrophils

May be onset of IBD

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19
Q

IBD - the 2 (main) types

A

Ulcerative colitis
— diarrhoea and bleeding

Crohn’s disease
— abdominal pain and peri-anal disease

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20
Q

Smoking and IBD

A

Aggravates Crohn’s

Protects against UC

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21
Q

Ulcerative Colitis - clinical features

A

Inflammation of colon
Affects rectum, extending proximally

affects mucosal layer only

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22
Q

What is inflammation of the rectum called?

A

Proctitis

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23
Q

Pancolitis

A

UC that affects the whole large intestine

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24
Q

Backwash ileitis

A

Ileocoecal valve is swollen and there is some patchy inflamed tissue in the distal ileum.

due to pancolitis

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25
UC - symptoms
Diarrhoea + BLEEDING Mucous and blood PR Increased bowel frequency Urgency Tenesmus - feeling of unfinishedness Incontinence Night rising Lower abdo pain - LIF Proctitis - constipation
26
Who is UC most common in/peak incidence?
20s and 30s
27
Severe UC How many stools/day Other symptoms
>6 bloody stools + one of > Fever > Tachycardia > Anaemia > Elevated ESR
28
Mucosal oedema in UC is known as? 👍
Thumb printing
29
What is TOXIC MEGACOLON
Dilatation of colon Transverse >5.5cm Caecum >9cm
30
UC - Ix
Bloods AXR Endoscopy Biopsy
31
UC - endoscopy
Endoscopy - define extent of disease - loss of vessel pattern - granular mucosa - contact bleeding - pseudopolyps (surviving mucosa) - Loss of haustra - Crypt distortion
32
UC - histology
- Absence of goblet cells - Crypt distortion - Abscess - Affects mucosal layer only
33
UC - complications Extra-intestinal manifestations
↑ Risk of colorectal cancer determined by - severity of inflammation, duration and disease extent. Toxic megacolon - acute or acute on chronic fulminant colitis, colon swells up to massive size will RUPTURE unless removed --> emergency colectomy Colorectal carcinoma - chronic inflammation leads to epithelial dysplasia and then carcinoma Blood loss Electrolyte disturbance Anal fissures Intractable disease - continuous diarrhoea, total colectomy, flare ups Extra-intestinal// deranged LFTs Oxalate renal stones PSC - stricture within bile duct -->Chronic inflammatory disease of biliary tree --> cholangiocarcinoma ``` Uveitis Stomatitis Steatosis Erythema nodosum arthritis ankylosing spondylitis Pyoderma gangrenous, erythema nodosum ```
34
Crohn's affects everywhere from...
Bum to gum
35
What kind of lesions are present in Crohn's
Skip lesions Discontinuous inflammation (unlike UC) Granulomatous
36
Crohns has mucosal/transmural inflammation?
Transmural
37
Does Crohn's have exacerbations?
Yes (as does UC)
38
Perianal crohn's disease
Recurrent abscess formation Pain Fistulae - persistent leakage Damaged sphincters
39
Crohn's disease phenotypes
Stenosis of oleo-coecal valve Inflammation Fistuale within the intestine (from ileum to sigmoid) Strictures causing distension of the proximal bowel
40
Crohn's symptoms are determined by...?
The site of the disease
41
Crohn's - symptoms
S.I.// Abdo cramps (peri-umbilical) Diarrhoea Weight loss Colon// Abdo cramps (lower abdo) Diarrhoea (sometimes w/blood) Weight loss Mouth// Painful ulcers Swollen lips Angular cheilitis Anus// Peri-anal pain abscess fistulae
42
Crohn's - on examination Clinical Bloods Colonoscopy Histology
Clinical// Evidence of weight loss RIF mass (inflamed bowel/abscess) Peri-anal signs Bloods// ``` CRP Albumin Platelets B12 Ferritin ``` Colonoscopy// Crohn's has "fat wrapping" and cobblestoned appearance of mucosa "Fat creeping" Thickened wall Histology// ``` Patchy Granuloma (non caseating) ```
43
Most common site of Crohn's?
Ileocoecal region
44
Small bowel assessment
Barium follow through Small bowel MRI Technetium-labelled white cell scan
45
Typical Patient ``` 22 years old Male Abdo pain Bloody diarrhoea for 3/12 Tender abdomen ``` Patchy, segmental disease with "skip" areas, anywhere in GI tract
Crohn's disease
46
What kind of granuloma is crohn's associated with?
Non-caseating granuloma
47
Typical endoscopic signs in Crohn's
Fissuring (ulceration destroys the mucosa) Stricturing of terminal ileum Thickening of bowel wall Cobblestoning Pseuodpolyps TRANSMURAL inflammation Cryptitis Crypt abscesses
48
Complications of Crohn's
Malabsorption - -- short bowel syndrome - -- Hypoproteinaemia - -- vitamin deficiency - -- anaemia - -- gallstones Fistulae Anal disease - - sinuses - - fissures - - skin tags - - abscesses - - skin tags ``` Intractable disease Bowel obstruction Perforation Malignancy Amyloidosis Toxic megacolon extra-GI conditions are rare ```
49
What can repeated resections lead to?
Short bowel syndrome
50
Pathogenesis of Crohn's
Genetics Environmental triggers/ - smoking - infectious agents - vasculitis - sterile environment theory - NSAIDs Abberant immune response - persistent activation of T cells and macrophages - excess pro-inflammatory cytokines
51
Is Toxic megacolon more likely in Crohn's or UC?
UC
52
32 yo Female Bloody diarrhoea and mucous Goes to toilet 25 times a day diffuse, continuous disease involving rectum
Ulcerative colitis
53
Histology - UC
Irregular-shaped branching crypts --- acute cryptitis Crypt abscesses Ulceration - -- fibrinopurulent exudate - -- broad base
54
What are aphthous ulcers most commonly associated with
Coeliac disease and Crohn's disease
55
Ulcers in Crohn's and UC
Crohn's - fissure like ulcers UC -horizontal, box like, undermining ulcers
56
Lifestyle advice for IBD
Avoid smoking Diet (can influence symptoms)
57
Drug therapy for Crohn's
Steroids Immunosuppressants Anti-TNF therapy
58
Drug therapy for UC
5ASA (mesalazine) Steroids Immunosuppressants Anti-TNF therapy
59
5ASA mechanism & side effects
Topical effect Anti-inflammatory Reduces risk of colon cancer side effects: diarrhoea, idiosyncratic nephritis can be taken as: Prodrug pH dependent release Delayed release Suppositories Enema
60
Corticosteroids in IBD
Anti-inflammatory Prednisolone/Budenoside Induce remission Short course
61
Immunosuppression IBD
When most potent suppression of inflammation required (if steroids are not working) Azathioprine Methotrexate Mercatopurine
62
Azathioprine what drug should be avoided when prescribing this one?
Immunosuppressant TPMT activity --> toxicity Avoid ALLOPURINOL Side effects// pancreatitis leukopoenia hepatitis lymphoma (small risk)
63
Anti TNF-alpha therapy
Proinflammatory cytokine Anti TNF promotes the apoptosis of activated/effector T lymphocytes rapid mucosal healing in responders
64
TNF antibodies
Infliximab | Adalimumab
65
Infliximab
TNF antibody
66
Adalimumab
TNF antibody
67
When to use anti TNF
Part of long term strategy - including immune suppression; surgery (Crohn's) supportive Refractory/fistulising disease Exclude current infection (like TB)
68
What disease is 5ASA used for?
Ulcerative colitis
69
Surgery in IBD
Emergency// - failure to respond to medical therapy - small bowel obstruction - abscess, fistula Elective// - failure to respond to medical therapy - dysplasia of colonic mucosa - best scenario (patient prepped for outcome)
70
Crohn's - surgery
Minimise amount of bowel resected NOT curative Repeated resection can lead to small bowel syndrome and lifelong parenteral nutrition
71
Surgery for UC
CURATIVE Option of permanent ileostomy Restorative proctocoloectomy and pouch

G.I. (20 decks)

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