Inflammatory Bowel Diseases Flashcards
(110 cards)
1
Q
two major disorders of IBD
A
Ulcerative colitis (UC) Chrones disease (CD)
2
Q
chronic inflammatory condition
A
CD and UC
3
Q
relapsing and remitting episodes of inflammation
A
UC
4
Q
inflammation limited to the mucosal layer of the colon
A
UC
5
Q
transmural inflammation and what does it lead to
A
CD > fibrosis and obstructive clinical picture
6
Q
involves rectum and colon preferably
A
UC
7
Q
favors illeum but can go anywhere in GI tract
A
CD
8
Q
may extend proximally and continuously to involve more of the colon
A
UC
9
Q
skip lesions or cobble stone apearance
A
CD
10
Q
age diagnosed for UC and CD
A
15-40 and 50-80
11
Q
male predominance
A
UC
12
Q
female predominance
A
CD
13
Q
racial predominance for both
A
jewish, caucasian
14
Q
percentage of CD and UC patients that have a 1st degree relative with IBD
A
10-25%
15
Q
smoking is not a risk factor
A
UC
16
Q
smoking is a risk factor
A
CD (cessation resulting in less flares)
17
Q
3 main factors of IBD
A
genetic predisposition
altered dysregulation of immune response (helper T cells)
altered response to gut bacteria
18
Q
clinical manifestations of UC
A
diarrhea +/- blood frequent and small BM colicky periumbilical > LLQ abd pain bowel urgency tenesmus incontinence mucus from rectum when rectum is involved, constipation
19
Q
onset of symptoms in UC
A
gradual and progressive over a few weeks
20
Q
severity of UC
A
10 stools daily with severe cramps and bleeding
21
Q
how does physical exam help diagnosis of UC
A
it really doesnt
22
Q
what causes UC?
A
inflammation of mucosa leading to ulceration, edema, bleeding, and fluid/electrolyte loss
23
Q
what immune reaction is prompted
A
cytokines are released by macrophages and target Type2 helper T cells causing them to be cytotoxic to surrounding tissues > inflammation
24
Q
microscopic level of UC
A
acute and chonic inflammatory changes to mucosa (lamina propria)
villous atrophy
discharge of mucus from goblet cells
25
signs of systemic toxicity
fever >99.5
tachy >90
anemia <10.5
elevated ESR
26
acute complications of UC
severe bleeding
fulminant colitis
toxic megacolon
perforation
27
fulminant colitis
>10 stools per day with continuous bleeding
abd pain and distension
toxic symptoms
28
toxic megacolon
colonic diameter >6cm or >9 with toxicity
potentially deadly
can perforate
29
how many patients develop extraintestinal manifestations?
only 10%
30
when do extraintestinal manifestations most commonly occur>
following an episode of colitis
31
extraintestinal manifestations of UC
arthritis of large joints
uveitis
cholangitis (fibrosis of gallbladder)
unprovoked PE or DVT
32
when do you start a workup for UC
chronic diarrhea >4 weeks
33
what labs to order for UC
ESR: inflammation
CBC: WBC and hemoglobin
PANCA and ASCA: pANCA+ > UC
34
stool studies for UC, what to look out for
```
salmonella
shigella
campylobacter
c.diff
ova/parasites
```
35
why is it important to take a good history for UC
rule out anal STDs
36
is imagine required to diagnose UC
no
37
imaging done to diagnose UC
endoscopy + biopsy
38
findings on endoscopy that indicate UC
bowel wall thickening
vascular markings due to engorgement of mucosa
edema, exudates, friability
pseudopolyps (more extensive UC)
erosions and ulcerations
continuous and circumfrential beginning at the anal verge
39
how likely is relapse in UC?
70% within the first 10 years
40
predictors of frequent relapse
disease flare within 2 years of diagnosis
presence of fever or weight loss upon diagnosis
active disease in preceding year
41
how likely is it for UC to extend up the colon?
20% of pts in the first 5 years
42
what does repeated inflammation prompt in UC
benign strictures only in 10% of patients
rectosigmoid colon
evaluate on endoscopy and biopsy to rule out cancer
43
is there increased risk for cancer with UC?
yes, colorectal cancer.
44
greatest risk factors for colorectal cancer and UC?
extent of colitis (how much of the GI tract)
| duration of the disease (how long they've been diagnosed)
45
highest risk for colorectal cancer of UC patients
pancolitis
46
when does the risk start for colorectal cancer?
8-10 years after pancolitis diagnosis
47
step 1 therapy for proctitis or proctosigmoiditis
5-ASA
Mesalanine (Canasa) BID topical for rectal (suppository)
Mesalanine (Rowasa) BID topical for >colon (enema)
48
with topical therapy how soon will relief and bleeding subside in UC?
a few days
49
how long must UC pts stay on topical mesalanine for complete healing
6-8weeks --> gradual taper
50
step 2 therapy for UC
5-ASA topical + oral if they don't respond
| or if they refuse topical
51
5-ASA PO drugs
Sulfalazine (azulfidine)
| mesalanine (asacol, lialda,pentasa, apriso)
52
sulfalazine mechanism
prodrug splits into sulfapyridine and mesalanine by bacteria in the colon
53
MOA of sulfasalazine
blocks prostaglandin production in the colon and inhibits inflammations
54
S.E. of sulfasalazine
due to sulfapyridine component
nausea, headache, rash, fever
leukopenia in first 3 months + fever and rash
inhibits folic acid transport across cell membrane
watery diarrhea, abd pain, pancreatitis
55
monitoring while on 5-ASA therapy for UC
baseline CBC and LFTS
continue q2w x3m
qmonth x3m
q3m after
56
what do you need to prescribe with sulfasalazine
1mg Folic acid qd
57
when don't we recommend maintenance 5-ASA therapy
patient with first episode of mild ulcerative proctatitis that responds to treatment
58
when do we recommend maintence therapy for UC
pts with >1 relapse per year
| ALL patients with proctosigmoiditis
59
when can we consider taking a pt off maintenance therapy for UC
when they've been on meds for 2+ years and get clearance from GI specialist
60
pts on topical therapy for induction of remission
1 5-ASA suppository QHS with proctiits
1 5-ASA enema QHS with proctosigmoiditis
possible they need sulfasalazine to remain in remission
61
first line therapy for left sided colitis or pancolitis
combo of oral and topical 5-ASA (enema)
62
second line therapy for left sided colitis or pancolitis
no remission in 2-4 weeks or systemic symptoms
GLUCOCORTICOIDS (prednisone)
only for pts with systemic symptoms, toxicosis, tachycardic
63
which patients with left colitis or pancolitis need maintenance therapy?
all of them
can taper down from BID enemas to QHS
no glucocorticoids, taper after pt stable for 2-4 weeks
64
when can we use supportive treatment for UC?
in those with MILD disease and without SYSTEMIC TOXICITY
65
diarrhea support in UC
loperamide (immodium)
66
abdominal cramping support in UC
anticholinergic medicines like
| hyoscamine (Levsin)
67
avoid what med while treating UC
NSAIDs
| opiates
68
surgical treatment for UC
total colectomy
69
when are total colectomies most commonly done in UC
intractable disease
dependence upon steroids to maintain remission
progression of dx with worsening symptoms
major complications with medications
70
when to conduct colorectal screenings in UC
after 8 years in pancolitis
after 15 years in left colitis
repeat every 1-2 years regardless of reults
71
when to perform osteoporosis screening in UC pts
```
all UC patients who are
postmenopausal
>60 y.o
ongoing corticosteroid use >3m
history of low-trauma fractures
```
72
where does chrones occur?
```
anywhere in the the GI tract
80% most commonly in the distal ileum
50% in the ileum and colon
20% in colon
5-10% in mouth, esophagus, or duodenum
```
73
what do the cytokines target in CD?
type 1 helper T cells
| just like UC, cytotoxic effect on surrounding tissues > villous atrophy
74
why does diarrhea occur in CD?
excessive fluid secretion bc of inflammed bowel, but atrophy doesn't allow the bowel to reabsorb
bile salts aren't absorbed by terminal ileum
75
describe abd pain in CD
crampy
periumbilical > RLQ
transmural involvement
relieved with BM
76
diarrhea in CD
common at presentation
NOT usually bloody
may include mucus or pus
77
how does CD in only the colon present?
just like UC
78
evidence of malabsorption in CD
weight loss, anorexia, NV
79
complication of deepening transmural involvement in CD
fistula formation in bladder, skin, bowel, and vagina
| increasing chances longer diagnosed
80
if a sinus tract does not extend all the way to another organ in CD it forms an...
abscess
81
extraintestinal manifestations of CD
same as UC (more frequent if colonic involvement of a flare)
82
labs for diagnosis
ESR: inflammation
Iron: deficiency due to bleeding or poor absorption of Fe
B12: ileum absorption
CBC: hemoglobin, white count
pANCA and ASCA: + ASCA > CD
(if colon involed, pANCA might be positive
83
stool studies look out
same as UC
84
endoscopic findings
aphthous ulcers
cobblestoning
linear ulcers
discontinuous lesions
85
CD disease course
remission followed by exacerbation
| active disease in past year > 70% chance having disease active 1 year later
86
patients who go in remission for 1 year
80% chance of remaining in remission another year
| only 13% of CD pts
87
pts who have annual relapses
20%
88
pts who go in and out of remission?
70%
89
predictors of more severe disease cours
```
>40y.o @ diagnosis
perianal or rectal disease
smoking
low education level
initial requirements of glucocorticoids
```
90
choice of treatment for CD depends on
anatomic location of disease
severity
goal of therapy
91
treatment for oral lesion
triamcinolone oral gel
92
first line therapy for Ileitis and colitis with CD
glucocorticoids (prednisone) + immunomodulators or biological agents
93
glucocorticoids in CD
60-80% respondance in 10-14 days
taper drug after condition improves
not long term
94
support in CD for diarrhea
immodium (loperamide)
95
immunomodulators
Azathioprine (imuran)
| Methotrexate (CHEAPER!!!)
96
azathioprine (imuran) MOA
inhibits an enzyme needed for DNA synthesis
| affects proliferating cells especially T and B cells
97
how long does it take for Azathioprine to be effective
3-6 months
98
role of azathioprine
to get people into remission who have symptoms even on chronic steroid therapy
99
risks of azathioprine
secondary infection
malignancy
leukopenia (long term)
thrombocytopenia (long term)
100
methotrexate mOA
interferes with DNA synthesis, repair, cellular replication
rapidly dividing cells are more sensitive to this effect (malignant cells, bone marrow, fetal cells, intestinal mucosa, bladder cells)
101
role of methotrexate
induction and maintenance of CD remission
102
risk of methotrexate
teratogenic
males should not try to get pregnant until 3 months after stopping medication
females should not try to get pregnant until they have one full ovulatory cycle after stopping medication
103
unexpected severe symptoms of methotrexate
bone marrow suppression, aplastic anemia (WITH NSAIDs)
104
biological agents, when do we use them?
Inflizimab (remicade)
when you fail prednisone + methotrexate
105
how is inflizimab given?
IV
106
MOA of infliximab
antibody against TNF > blocks it in the serum and cell surface causing lysis of macrophages and T cells
107
role of infliximab
induction of remission (if it works stay on it for maintenace)
108
risks of infliximab
increased risk of opportunisitc infections
test for TB prior to prescribing
higher rates of Hodgkin's and non-Hodgkin's lymphoma in those who started therapy <18 y.o occuring 1-84 months post start of therapy (most prescribed concomitant immunosuppressants)
Heart Failure: do not use with pts with moderate to severe heart failure
109
who needs surgery for CD?
intracable symptoms
obstruction
perforation
110
colorectal screening for CD?
same as UC
