Give five types of inflammatory bowel disease
• Ulcerative colitis • Crohn's disease • Diversion colitis • Diverticular colitis Radiation, drugs, infectious diseases, ischaemic colitis
What is ulcerative colitis?
• An inflammatory disorder that affects the rectum and extends proximally, in continuity (no breaks in inflammation!)
Where is the incidence of ulcerative colitis the highest?
• US, UK and northen Europe • Presents in young adults, more commonly young women
What inflammatory cells are found in the mucosa of patients with ulcerative colitis?
• T helper cells, which produce transforming growth factor (TGF and IL-5)
What are the three main symptoms of ulcerative colitis?
• Rectal bleeding • Diarrhoea • Abdominal pain
What is Chrohn's disease?
• A condition of chronic inflammation involving any location of the GI tract from mouth to anus
When are the two peaks of incidence of Chron's disease?
• 1st at 15-30 • 2nd at 60 years
What inflammatory cells are found in the mucosa of Chron's disease patients?
• Th1 helper cells, which produce interferon gamma and IL-2
What does the presentation of Chrohn's disease depend on?
What is the presentation of Chron's disease in someone with upper GI tract involvement?
• Nausea and vomiting • Dyspepsia • Small bowel obstruction • Anorexia, weight loss • Loose stools
What is the presentation of chron's disease in someone with colonic diseasE?
• Diarrhoea • Passage of blood
What happens if terminal ileum is involved in Chron's disease?
• May be pernicous anaemia due to poor absorption of B12
What is hypothesised to cause IBD (of which Chrohn's and UC are two types)
• Genetic presdispostion • Environmental factors
What genetic factors cause IBD?
• IBD1 • NOD2/CARD15 • Having one copy of a risk allele confers 2-4 fold risk for Crohn’s • Two couples of risk allele confers 20-40 fold risk for Crohn’s
What environmental factors cause IBD?
• NSAIDs ○ Altered intestinal barrier due to decreased mucous production • Early Appendectomy ○ Increased UC incidence • Smoking ○ Protects against UC ○ Increases risk of CD
Give 6 triggers of IBD
• Antibiotics ○ Gets rid of normal flora • Diet • Acute infections • NSAIDs • Smoking ○ Increase’s risk of Crohn’s • Stress
Give six methods of investigating inflmamtory bowel disease
• Colonoscopy ○ Biopsies of involved mucosa ○ Ulceration • Stool analysis ○ Parasites ○ Clostridium difficile toxin ○ Culture • Barium radiographs • CT scan • Capsule endoscopy Plain X-Ray if bowel obstruction or perforation suspected
Outline the macroscopic changes found in Chrohn's
• Involved bowel is usually thickened and is often narrowed • Deep ulcers and fissures in the mucosa may produce a cobblestone appearance Fistulae and abcesses may be seen
Outline the macroscopic changes found in Ulcerative Colitis
• Mucosa looks reddened, inflamed and bleeds easily • In severe disease there is extensive ulceration with the adjacent mucosa appearing as inflammatory polyps
Outline the microscopic changes found in chrohn's
• Inflammation through all layers of the bowel (Transmural) • Increase in chronic inflammatory cells • Lymphoid hyperplasia • Granulomas (TH1 Response)
Outline the microscopic changes found in Ulcerative Colitis
• Superficial inflammation • Chronic inflammatory cell infiltrate in the lamina propria • Crypt abscesses • Goblet cell depletion
Outline three ways in which CD and UC can be separated
• Clinical • Radiological data • Histological differences seen in rectal mucosa
When is it difficult to tell difference between CD and UC?
Acute phase, tissues look very much the same
What is CD/UC in acute phase called when it is difficult to tell the difference?
• Colitis of undetermined type and aEitology CUTE
What serological tests can be used to distinguish UC from CD?
• Anti-neutrophil cytoplasmic antibodies in UC • Anti saccaromyces cervisiae antibodies in CD
Give 5 ways in which abnormalities can be seen in Chrohn's disease
• Colonoscopy • Upper GI endoscopy • Small bowel imaging • Perianal MRI or endoanal Ultrasound • Capsule endocscopy
What can a colonoscopy be used to see in Chrohn's disease?
• Performed if colonic involvement is suspected • Mild, patchy surface ulceration à Cobblestoning
How does Upper GI Endoscopy do in a Chrohn's diagnosis?
• Required to exclude oesophageal and gastroduodenal disease in patients with relevant symptoms
Outline the process of small bowel imaging in Crohn's
• Barium follow through • CT scan with oral contrast • Small bowel ultrasound • MRI • Asymmetrical alteration in the mucosal pattern with deep ulceration, and areas of narrowing or structuringr • String sign of Kantor
What does perianal MRI or endoanal ultrasound do?
• Used to evaluate perianal disease
What is capsule endoscopy used for in Chrohn's?
• Used in Chrohn's disease patients who have a normal radiological examination
Give two tests used to define Ulcerative Colitis?
• Colonoscopy • Imaging
What does colonoscopy do in UC?
• Allows biopsy, which is gold standard for UC diagnosis • Allows us to assess disease activity and extent
What does imaging allow to see in UC?
• Plain Abdominal X-Ray to exclude colonic dilation • Other imaging techniques rarely used as endoscopy is preferred • Collar Button Ulcers ○ Ulcer through the bowel mucosa to the muscle, then up and down in a ‘T’ shape
Give three overarching aims of Chrohn's disease treatment?
• Induction of remission • Maintenance of remission • Perianal disease
How is induction of remission initiated in Chrohn's?
• Oral or IV Glucocorticosteroids • Enteral Nutrition • Anti-TNF antibodies (Infliximab)
How is maintenance of remission achieved in Crohn's disease?
• Methotrexate, Azathioprine • Anti-TNF antibodies (Infliximab)
How is perianal disease treated in Crohn's?
• Ciprofloxacin and Metrronidazole • Azathioprine • Anti-TNF antibodies (Infliximab)
What do anti-TNF antibodies do?
• Bind to membrane bown TNF-a and induce immune cell apoptosis
Outline the surgical management of crohn's
• Failure of therapy with acute or chronic symptoms • Complications, e.g. dilation, obstruction, perforation, abscesses • Failure to grow in children despite treatment • Colectomy and ileorectal anastomosis may be performed.
Give three types of UC and their treatment
• Distal Disease (Proctitis) ○ Topical or suppository corticosteroids • Left Sided Colitis ○ Topical corticosteroid enema • Extensive Colitis ○ Oral corticosteroids ○ Infliximab
Outline the surgical management of UC
• Patients with complications / Corticosteroids dependence • In acute disease, subtotal colectomy with end ileostomy and preservation of the rectum is the operation of choice.