Unit 10; Crohns, coeliac, lactose intolerance and colitis Flashcards

Question

Why might an Irritable Bowel syndomre diagnosis be considered milder than an INflammatory Bowel disease?

Answer 1

IBS - does not increase risk of colon cancer, IBD does IBS - typically require less hospitalisation and surgery is very rare.

Answer 2

NOD2 gene - loss of function IL-23R gene - gain of function TNFSF15 - gain of function, regulates immune homeostatise, resulting in increased INFy and NK responses alpha4beta7 - increased function on inflammatory T cell phnoetypes

Answer 3

is an intracellular PPR found in epithelial cells in the gut , loss of function, unable to recognise bacteria, results in bacterial persitance and chronic inflammation

Answer 4

Gain of function mutation IL-23 released by macrophages, promotes development of Th17 - enhances neutrophil response. Cascade signalling it increased inflammatory response such as TNFalpha release, and NK cell activation.

Answer 5

1.Predisposition due to genetic and environmental factors 2.Onset thought to be triggered by dysbiosis of the gut microbiome IMMUNE RESPONSE: APC - presents antigen - activation of Th1 - cytokines release - activation of macrophages - increases platelet-activating factor, proteases and free radicals. Activation of IEL killing infected epithelial cells. 3.Impaired NOD2 ability leads to persistence of the pathogen, and reduced effectiveness of macrophages, paneth cells and dendritic cells. Leads to chronic inflammation Impaired autophagy leading to failure to kill bacteria 4. Reduced barrier integrity allows pathogens to invade into the lamina propia and encourages further dysbiosis. By this stage there is activation of the innate and adaptive immune response 5. Increase in pro-inflammatory cytokines in response to impaired bacterial clearance. Characteristics Th17 effector responses 6. Uncontrolled immune response damaging the bowel indicates IBD

Answer 6

An inflammatory bowel disease characterised by an immune-mediated cause.

Answer 7

Inflammation in the mucosa (lamina propria) and submucosa Ulceration of the mucosa Mild fibrosis

Answer 8

Transmural inflammation Granuloma Fistula Stricture Fissuring Ulceration - skip lesions Significant fibrosis

Answer 9

Contains majority of mucus glands Damaged mucus glands - significantly decrease mucus production Increased exposure of tissue that is less adapted to acidic environment to stomach acid resulting in ulceration

Answer 10

Lymphocytes

Answer 11

Crypt distoration Fissuring ulceration (skip lesion) Mural hyperplasia Lymphoid aggregates Granuloma Inflammatory infiltrate from mucosa to muscularis external (tranmucosal inflammation) Fat wrapping

Answer 12

Ulceration - mucosa maybe into submucosa Pseudopolyps _ due to ulceration Crypt abscess Inflammatory infiltrate into submucosa

Answer 13

Crohns - mouth to anus, 60% have anal involvement UC - Continuous inflammation, normally beginning in the rectum and spreading to the sigmoid colon. 20% have anal involvement

Answer 14

Crohns - fat and vitamin malabsoprtion, strictures and fistulas are more likely, more fibrosis and serositis, malignant change is less common than UC UC - malignant change is more common, no malabsorption, very mild fibrosis and serostitis if any

Answer 15

Not rasied in Crohns Raised in Ulcerative colitis ANCA is an antibody that may be produced in an autoimmune condition, typically target protein inside white blood cells mainly neutrophils Tested for immunoassay Anti-neutrophil cytoplasmic antibodies.

Answer 16

Crohns - increased risk Ulcerative collitis - protective factor

Answer 17

CRP - activate complement ESR - increased in inflammation, due to increased pro-coagulatn factors Procalcitonin - indicates systemic inflammation

Answer 18

Calprotectin - calcium binding protein found in neutrophil cytoplasm Lactoferrin - iron binding glycoprotein secretes in neutrophil secondary granules

Answer 19

Weight loss, malnutrition Apthous ulceration of the mouth - inflammatory or nutritional deficiency Angular chelitisis - vitamin A deficiency. Occosional abdominal tenderness and right illiac fossa mass (sticture build up of faeces and fibrous and mural hyperplasia

Answer 20

Skip lesions And deep longitudinal ulcers

Answer 21

Barium meal follow through - appears white Bubble warp appearance - cobblestone mucosa Fistulas and strictures can also be idneitifed by considering the flow of barium and the width of the lumen

Answer 22

Combination of environmental and genetic factors. Autoimmune conditions - thought to be triggered by molecular mimicry, where immune response launched against a pathogen with a similar antigen structure to those found in neutrophils Is characterised by CD8+ cells Also triggered by bacteria producing large amounts of sulfides Produce p-ANCA and c-ANA targes proteins found in neutrophils

Answer 23

Pain - right lower quadrant Diarrhoea Blood in stool from ulceration Malabsoprtion - present as anemia or ulcers in the corners of the mouths weight loss Bloating and fever - due to presence of bacteria Anal involvement - pain or drainge

Answer 24

Pain - lower left quadrant Diarrhoea Blood in stool Unintended weight loss - diahorrea, drugs, or reduced appetite

Answer 25

Pernicious anemia - crohns damage to the terminal ileum, vitamin B12 and IF complex is unable to bind to IFR Iron deficiency anemia - malabsorption due to damage to the duodenum including DMT1 receptors Blood loss (hemolytic anemia) - reduced levels of rbcs and Hb in the blood stream

Answer 26

Is a glucocorticoid - has a cholsesterol base as a steroid Pass through cell membrane into the cytoplasm where it binds to glucocorticoid receptors, which are actived when they heterodimerise and dissocited from heat shock proteins Binds to glucocorticoid response element in the nucleus, acts as a transcription factor to alter gene expression Results in increased expression of anti-inflammatory cytokines such as TGF-beta and reduced expression of pro-inflammatory cytokines such as TNFalpha Can induce apoptosis in TNFalpha dependent immune cells such as lymphocytes. Reduces capillary permeability and migration of lymphocytes. increases Annexin A1 transcription - which inhibits COX-2 and and PLA2 - prevents prostaglandin production Overall leads to a chemical and cellular profile that favours anti-inflammatory conditions.

Answer 27

**Cushing syndrome - moon face (round and red), slow growth rate and weight gain with fat accumulation on the trunk but loss from the arms, legs and buttocks. Commonly causes: *Anxiety, behaviour abnormality and cognitive impairment Electrolyte imbalance and fluid retention *GIT discomfort Fatigue, nausea, osteoporosis, skin reactions and sleep disorders hypertension Lots of high risk side effects

Answer 28

Mercaptopurine Methotrexate Vedolizumab Adalimumab

Answer 29

Is taken up by t-lymphocytes, decreases NFKb causing apoptosis of leukocytes, is converted into TIMP, TIMP inhibits processed involving IMP meaning purine bases are not synthesised. Converted into TGTP which is inserted into RNA preventing elongation during transcription. Finally is converted into TdGTP which is inserted into DNA inhibiting semi-conservative replication. This inhibits the S phase of the cell cycle. Hence it can be used as an immunosuppresant or a cancer (ALL) maintenance therapy.

Answer 30

Prevents the proliferation of inflammatory cells by antagonising the production of folate. Is an antimetabolite, folic analogue. It does this by inhibiting the dihydrofolate reductase enzyme (thymine synthesis), inhibits AICART (purine synthesis), decreasing AICART also has anti-inflammatory effects. This prevents the formation of new DNA nucleotides, this stops the cell cycle during interphase. This stops the proliferation of immune cells.

Answer 31

Monoclonal antibody, binds specifically to alpha 4 beta 7 dextrin, prevents from binding to MaDCAM-1 found in endothelial cells in the GIT To prevent gut homing of memory T lymphocytes into GALT Causes a reduction in gastrointestinal inflammation.

Answer 32

Is a monoclonal antibody. Is anti-inflammatory, binds to TNF alpha, and prevents interaction with cell surface receptors p55 and p75 on immune cells (not Rbcs or immature T cells). This decreases pro-inflammatory cytokine secretion, leukocyte migration, decreases epidermal thickness, causes apoptosis in mononuclear cells with TNF alpha receptors, and inhibits the release of IL-6 and acute-phase proteins. Used in Crohn's disease and arthritis.

Answer 33

1. Glucorticoids - prednisolone most often 2. If not avaiable consider budesonide or amniosalicylates 3. If severe and active may consider biological therapies such as adalimuman and vedolizumab

Answer 34

Member of the drug class includes sulfasalazine Split into acitve components by bacteria in the gut: 5-ASA and sulfapyridine 5-ASA remains in lumen, is absorbed, acts on nuclear receptor Signalling pathway alters gene expression to decrease expression of NFKB and COX-2 this reduced pro-inflammatory cytokines

Answer 35

1. Conventional glucocorticoids if first flare up in 12 months 2. Otherwise suggest addition of mercapopurine, azathioprine or methotrexate

Answer 36

Encourage regular surveilence of the colon Mercaptopurine and methotrexate No glucocorticoid treatments

Answer 37

Induce and maintain remission Achieve mucosal healing to prevent disease progression and complications

Answer 38

Mild - 5-ASA, may add antibiotics if uneffective Moderate - Oral corticosteroids potentially with antibiotics ,gradually tapered off, addition of infliximab if needed Severe - IV corticosteroids with antibiotics, with infliximab and surgery is required

Answer 39

Key symptoms to consider include: Upper GIT: jaundice, apthous ulceration, vomiting, haematemesis, acid reflux, dyshagia, odynophagia Lower GIT symptoms: pain, abdomeinal distention, contisptaion, diarrhoea (with blood), malaena, bleeding rectum fresh blood Symstemic: anorexia, weight fluctuation, nausea, fatigue, fever, confusion Important risk factors: pre-existing GIT disease, family history of GIT disease, alcohol, smoking, recreational drugs, diet

Answer 40

Patient lying flat on the beg, arms to their side and legs uncrossed. Exposed from waist up (may keep bra on) Inspect for scars, distention, ceput medisae, stretch marks, hernias, bruising in the flanks Not the presence and features of any stomas Ask if the patient is any pain Light palpate all nine quadrants of the abdomen Deep palpate all nine quadrants of the abdomen Notice any (rebound) tenderness, guarding, masses Palpate the liver from the right illiac fossa upwards, use a sweeping motion pushing inwards and upwards whilst the patient takes a deep breath in and removing when they take a deep breath out If liver edge is identified, palpate the degree of extension below the costal margin, smoothness of the edge My try to palpitate the gall bladder at midclavicular right costal margin moves with respiration _not normally felt Palpate the spleen starting the the right illiac fossa and heading towards the spleen Ballot the kidneys using force from above and below May also palpate the bladder and the abdominal aorta Percuss the liver, spleen and bladder Assess shifting dullness (ascites) Listen for bowel sounds

Answer 41

Repeated symptomatic episode of diarrhoea and othe rsymptosm after previously experiencing remission Can be caused by: missing a dose of medication, NSAIDs, antibiotics, smoking, infections. Worsened by: stress, certain foods .

Answer 42

Clinical diagnosis - syndrome of symptoms Unable to diagnose with something else Is no positive test for IBS Typically bowel shows no structural damage or signs of inflammation on endoscopy.

Answer 43

4 weeks before: stop taking NSAIDs and antibiotics, avoid collecting water and urine into the test container. Detected by immunoassay

Answer 44

Online system Allows GPs and other health care professionals to request that their patients receive an appointment from a different speciality Uase by patients to choose their first hospital or clinic appointment with a specialist, bookings can be made online, using a telephone or directly in the GP surgery at the time or referral (urgent referall). Creates online centralise patient records Maximum waiting times are: 18 weeks for non-urgent appointments 2 weeks for suspected cancer 48 hours for an urgent referall

Answer 45

GP Urgent Referall to gastronenterologist and later referal to dietitian Online system allows good communication between different members of the team, providing synchronous and continuous care for the patient

Answer 46

Normal barrier function is impaired by genetic and environmental risk factors - noticeable disruption of tight junction Leads to increased permeability of the epithelium to commensals and pathogens including microbial products Macrophages and dendtiric cell recognition of pathogen resulting in T cell activation Leads to production of interleukins, pro-inflammatory cytokines such as TNF-alpha. Activation of intra-epithelial lymphocytes to kill epithelial cells If acute inflammation is not resolves, progresses to chronic inflammation resulting in tissue destruction, stenosis and even cancer

Answer 47

May be prescribed ferrous sulphate tablets everyday and for three months after deficiency has been corrected : synthetic iron supplements Iron is absorbed by FMT1 across the duodenal brush border into epithelial cells. Is then oxidised to iron Fe3+ and sequester by transferrin for transport in the blood. Oral use is only suitable if the patient deficiency is due to dietary factors rather than malbasoprtion, if needed should be given as IV

Answer 48

Vulnerable to opportunisitic infections, which are then harder to treat Hair loss Mouth sores Osteoporosis Acne Fatigue High blood pressure

Answer 49

Provide expert support and advice for people living with Crohn's and Colitis under the care of specialist IBD services. Encourage self-management where possible Involved in support at diagnosis and ongoing, patient education, counselling and monitoring medication, co-ordinating and referal to other health professionals as required. Provide a link between hospital and community services.

Answer 50

A doctor who treats digestive disorders including the alimentary canal and the billary organs, including pancrease, liver and bowel Typically work in hospitals and outpatient clinics. Role in diagnostic tests and treatment management Are not surgeons – work alongside gastrointestinal surgeons

Answer 51

The only qualified health care professional who can assess, diagnose and treat nutritional related health problems at the individual and public health level. Typically identify nutritional needs and work alongside the patient to find plausible ways of meeting their nutritional goals. Translate guidance into practical advice Normally become involved with patients who have complex health needs or have a concerning BMI with health complications

Answer 52

Cultural foods - may be less understood by dietitian and harder to incorporate into diet plan, many spciy foods that may be preferred are thought to trigger inflammation Stimga - less likely to go the GP with a personal issue such as diarrhoea, may be embarrassed, view as a dirty problems that shouldn't be shared outside of the household Assumptions based on race - diagnosed with lactose intolerance incorrectly - problems continue to worsen as effective treatment is not given LIC - lack of diagnostic tools, often thought to be a result of an infection such as cholera, poor sanitation means more social stigma and embarrassment for the indivdual

Answer 53

1. Females less likley to seek help, embarrased to share an intimate diagnosis with a male doctor. Flatulence and discussions around bowel movements are not very lady like 2. Males may find it harder to manage symptoms when out of home, male toilers often only one to two cubiles can be more obvious when suffering from bowel movements 3. Socially comical for a man to have diahorrea or to go to the bathroom when he needs to, females more secretive about this behaviour

Answer 54

A significant, sudden change that alters an individuals life that changes its plans and directions Crohns diagnosis - ability to work, go to education, ability to travel, ability to complete activities

Answer 55

Disavowl - lack of control and noramlity False normality - partial control but not long standing The new normal - acceptance is achieved, less vulnerable to stress Disruption - exposure to stressful situation illness or not

Answer 56

Smoking - 1.76x, is immunosuppressive, decreased neutrophil activity and reducing chemotaxic and cytokine signalling Family history - children and siblings 17-35x more likely Drugs - NSAIDs, oral contraceptive Diet - effects gut microbiome, high fat and low plant fibre diet has the greatest risk Age - before 30yrs Ethnicity - white, dietary and genetic links NOD2 and IL23R mutations

Answer 57

H2 CO2 and CH4 Alongside short chain fatty acid production including Propionate, acetate and butyrate

Answer 58

rectum distendts Inhibitory signlas in teh anus - causing to relxa and distend to accommodate the movement of faeces

Answer 59

IgA tTG antibodies are tested for Gliadin is a part of gluten broken down into peptides, these are modified by transglutaminase (TG) TG associated with peptides triggers an immune response

Unit 10; Crohns, coeliac, lactose intolerance and colitis Flashcards

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