Revision - IBD & Coeliac

Question 1

What can LFTs show in severe IBD?

Answer 1

Low albumin (protein lost in bowel)

Question 2

The severity of a UC flare is usually classified as being mild, moderate or severe.

Describe each

Answer 2

a) mild: <4 stools/day, only a small amount of blood

b) moderate: 4-6 stools/day, varying amounts of blood, no systemic upset

c) severe: >6 blood stools/day + systemic upset (fever, tachycardia, anaemia, raised inflammatory markers)

Question 3

Mx of mild-mod flare of UC?

Answer 3

5-ASAs (topical or oral depending on location)

Question 4

Mx of moderate/severe flare of UC?

Answer 4

IV steroids e.g. hydrocortisone

Question 5

Treating mild-to-moderate UC: proctitis?

Answer 5

1) Topical ASA

2) Add oral ASA if remission not achieved in 4 weeks

3) Add oral/topical steroids if remission not achieved in 4 weeks

Question 6

Treating mild-to-moderate UC: proctosigmoiditis and left-sided UC?

Answer 6

1) Topical ASA

2) Add high dose oral ASA or switch to high dose ASA + topical steroid if remission is not achieved within 4 weeks

3) Stop topical treatments and offer an oral ASA and an oral steroid if remission still not achieved

Question 7

Treating mild-to-moderate UC: extensive disease?

Answer 7

1) Topical ASA + high dose oral ASA

2) Stop topical treatments and offer a high-dose oral ASA and an oral steroid if remission is not achieved within 4 weeks

Question 8

Curative treatment for UC?

Answer 8

Panproctocolectomy –> removing the entire large bowel and rectum

Question 9

1st line management of an exacerbation of Crohn’s?

Answer 9

Steroids (e.g., oral prednisolone or IV hydrocortisone)

Question 10

What is an alternative to steroids in Crohn’s, particularly where there are concerns about steroids affecting growth?

Answer 10

Enteral nutrition –> a specially formulated liquid diet given orally or by NG feed that replaces the patient’s diet.

Question 11

When steroids alone are inadequate in Crohn’s, what can be added?

Answer 11

Azathioprine
Mercaptopurine
Methotrexate
Infliximab
Adalimumab

Question 12

1st line for maintaining remission in Crohn’s?

Answer 12

Azathiorpine / mercaptopurine

Question 13

What is an alternative for maintaining remission in Crohn’s where 1st line options are not suitable?

Answer 13

Methotrexate

Question 14

Where does Crohn’s disease most commonly affect?

Answer 14

Terminal ileum

Question 15

What is the most common extra-intestinal feature in both CD and UC?

Answer 15

Arthritis

Question 16

Is episcleritis more common in Crohn’s or UC?

Answer 16

Crohn’s

Question 17

Is uveitis more common in Crohn’s or UC?

Answer 17

UC

Question 18

Typical findings on coloscopy and biopsy in UC?

Answer 18

red, raw mucosa, bleeds easily

no inflammation beyond submucosa (unless fulminant disease)

widespread ulceration with preservation of adjacent mucosa which has the appearance of polyps (‘pseudopolyps’)

inflammatory cell infiltrate in lamina propria

neutrophils migrate through the walls of glands to form crypt abscesses

depletion of goblet cells and mucin from gland epithelium

granulomas are infrequent

Question 19

What is 1st line anti-diarrhoeal indicated in IBS?

Answer 19

Loperamide

Question 20

What is 1st line laxative indicated in IBS?

Answer 20

Bulk-forming (e.g. ispaghula husk)

Question 21

What laxative is avoided in IBS?

Answer 21

Lactulose –> can cause bloating

Question 22

Coeliac disease is associated with what 2 human leukocyte antigen (HLA) genotypes?

Answer 22

1) HLA-DQ2 (95%)
2) HLA-DQ8 (80%)

Question 23

Rarely coeliac disease can present with neurological symptoms.

What are some of these symptoms?

Answer 23

1) Peripheral neuropathy
2) Cerebellar ataxia
3) Epilepsy

Question 24

Gold standard for coeliac diagnosis?

Answer 24

Intestinal biopsy

Question 25

Biopsy findings that support coeliac disease?

Answer 25

1) villous atrophy 2) crypt hyperplasia 3) increase in intraepithelial lymphocytes 4) lamina propria infiltration with lymphocytes

Question 26

What infections are those with coeliac disease most at risk of?

Answer 26

Encapsulated bacteria such as Streptococcus pneumoniae --> due to hyposplenism

Question 27

Complications of coeliac?

Answer 27

a 1) anaemia e.g. iron, folate and vitamin B12 deficiency 2) hyposplenism (with immunodeficiency, particularly to encapsulated bacteria such as Streptococcus pneumoniae) 3) osteoporosis, osteomalacia 3) lactose intolerance 4) enteropathy-associated T-cell lymphoma (EATL) of small intestine 5) subfertility, unfavourable pregnancy outcomes 6) rare: oesophageal cancer, small bowel adenocarcinoma 7) Non-Hodgkin lymphoma 8) Ulcerative jejunitis

Question 28

Is folate deficiency or vitamin B12 deficiency more common in coeliac?

Answer 28

Folate

Question 29

Patients with coeliac disease often have a degree of functional hyposplenism. For this reason, all patients with coeliac disease are offered which vaccine?

Answer 29

Pneumococcal vaccine every 5 years

Question 30

Give some general side effects of aminosalicylates

Answer 30

1) GI upset 2) Headache 3) Agranulocytosis 4) Pancreatitis 5) Interstitial nephritis

Question 31

What is a key investigation in unwell patients taking aminosalicylates?

Answer 31

FBC --> risk of agranulocytosis

Question 32

Is pancreatitis more common in patients taking mesalazine or sulfalazine?

Answer 32

7x more common with mesalazine

Question 33

What are some associations with sigmoid volvulus?

Answer 33

- older patients - chronic constipation - Chagas disease - neurological conditions e.g. Parkinson’s disease, Duchenne muscular dystrophy - psychiatric conditions e.g. schizophrenia

Question 34

What is a perianal fistula?

Answer 34

Inflammatory tract or connection between the anal canal and perianal skin.

Question 35

What is the investigation of choice in a perianal fistula/

Answer 35

MRI

Question 36

1st line management of patients with symptomatic perianal fistulae?

Answer 36

Oral metronidazole

Question 37

Management of a perianal abscess?

Answer 37

Incision & drainage and abx

Question 38

Best surgical management of severe rectal Crohns that has developed complications such as haemorrhage and multiple fistulae?

Answer 38

Proctectomy

Question 39

What is maintenance treatment for patients with UC if they have had a severe relapse or ≥2 exacerbations in the past year?

Answer 39

Oral azathioprine or mercaptopurine to maintain remission

Question 40

Mx of giardiasis?

Answer 40

Metronidazole

Question 41

What medications are generally used to induce remission in Crohn's?

Answer 41

Steroids

Question 42

What can be used for complex perianal fistulae in patients with Crohn's disease?

Answer 42

A draining seton

Question 43

AXR features of UC?

Answer 43

Leadpipe colon

Question 44

What type of IBD do crypt abscesses indicate?

Answer 44

UC

Question 45

If a mild-moderate flare of ulcerative colitis does not respond to topical or oral ASAs, what should be added?

Answer 45

Oral steroids

Question 46

Most common site affected in UC?

Answer 46

Rectum

Question 47

What is fulminant UC?

Answer 47

The most severe type of UC, characterised by severe inflammation and sores in the colon lining that causes the colon walls to expand (toxic megacolon).

Question 48

Mx of fulminant UC?

Answer 48

Subtotal colectomy --> rectum will be left in situ as resection of the rectum in these acutely unwell patients carries an extremely high risk of complications.

Question 49

What may patients with UC wishing to avoid a permanent stoma be considered for?

Answer 49

Ileoanal pouch

Question 50

What type of IBD is associated with gallstones?

Answer 50

Crohn's --> can result in terminal ileitis. This is the section of the bowel where bile salts are reabsorbed. Loss of bile salts is a risk factor for gallstones.