IBD

Question 1

which diseases make up IBD

Answer 1

Crohn’s and ulcerative colitis

Question 2

IBD epidemiology

Answer 2

• 10-40 y/o- 1/250 in UK - 40% CD smoke, 10% UC

Question 3

IBD aetiology

Answer 3

• mostly unknown - diet - smoking - infection - drugs - enteric microflora- appendectomy - stress - genetics

Question 4

how does smoking affect IBD aetiology

Answer 4

may worsen clinical course but may have prevented onset - nicotine affecting smooth muscle

Question 5

how does infection affect IBD aetiology

Answer 5

• bacteria causing TB - UC can occur after infective diarrhoea - associated with measles and mumps

Question 6

how do medications affect IBD aetiology

Answer 6

• NSAIDs can exacerbate - contraceptive pill can increase CD risk - isotretinoin

Question 7

how do genetics affect IBD aetiology

Answer 7

• Mutations of CARD15/NOD2 on chromosome 16 - inappropriate response to immune system- Genes OCTNI on chromosome 5 and DLG5 on chromosome 10 have also been linked to Crohn’s - 70% of ulcerative colitis patients have anti-neutrophil cytoplasmic antibodies

Question 8

pathophysiology of CD

Answer 8

• discontinuous- deep ulcer, fissures and strictures can appear - TH1 associated - transmural inflammation - through all layers of bowels

Question 9

pathophysiology of UC

Answer 9

• continuous - starts at rectum and moves upwards - crypt abcesses and mucosal ulceration - TH2 associated - only mucosa and submucosa affected - inflammatory cells infiltrate lamina propria

Question 10

which disease skips areas

Answer 10

CD

Question 11

which disease has a cobblestone mucosa

Answer 11

CD

Question 12

which disease has transmural movement

Answer 12

CD

Question 13

which disease is rectal sparing

Answer 13

CD

Question 14

which disease has perianal involvement

Answer 14

CD

Question 15

which disease has fistulas, strictures and granulomas

Answer 15

CD

Question 16

what are the 3 components that work together in the gut to maintain health

Answer 16

microbes epithelium immune cells

Question 17

which immune cells are involved in maintaining gut health

Answer 17

• payers patches - lymphatic - dendritic cells - sample antigens to lymphocytes - tolerogenic activation - Treg cells - once activated by dendritic cells move to laminar propria (IL10 to suppress immune response)

Question 18

how is inflammation caused by chemical, mechanical or pathogen invasion

Answer 18

• epithelium activated - immune cell influx - tregs stop il10 secretion- dendritic cells secrete il6/12/23- recruitment of neutrophils

Question 19

symptoms present in all IBD

Answer 19

diarrhoea fever abdominal pain N&Vmalaise lethargy weight loss malabsorption

Question 20

symptoms present in CD

Answer 20

lower right quadrant pain anaemia palpable masses small bowel obstruction abscesses fistulas gut perforation

Question 21

symptoms present with UC

Answer 21

diarrhoea with blood/mucus abdominal pain with fever constipation

Question 22

diagnosis of IBD

Answer 22

• clinical evaluation, history, symptoms - blood tests, abdominal radiography, sigmoidoscopy, colonoscopy, small bowel radiology, ultrasound and tomography

Question 23

how to manage risk of infections in IBD patients

Answer 23

• assess at diagnosis - treat active HBV, TB, HCV, HIV - in acute severe disease - corticosteroids can remain

Question 24

corticosteroid issues

Answer 24

• infection risk - osteoporosis - adrenal suppression - diabetes - weight gain - CVD

Question 25

monitoring requirements for steroids

Answer 25

- fbc - hba1c - lipids - bp - eyes - mood- sleep - calcium! should be given 800-1000iu calcium and 800iu vit d daily

Question 26

risk factors of bone health in IBD

Answer 26

- weight loss - steroids - inflammation - malabsorption - lack of exercise

Question 27

common malnutrition's in IBD and how to treat them

Answer 27

- magnesium : PO/IV - PO can worsen diarrhoea - iron : dietary improvements, IV in active IBD PO up to 100mg in inactive - monitor every 3 months for one year and then every 6-12 months after

Question 28

NSAIDs and IBD

Answer 28

may lead to an increase in disease activity - CD * Short term, low dose, in patients with controlled disease in remission - is potentially safe - not recommended

Question 29

risk of colorectal cancer with IBD

Answer 29

- 8-10 years post diagnosis - UC extensive > distal > proctitis - reduce risk by managing inflammation, reviews, colonoscopies, dietary improvement

Question 30

other pharmaceutical care issues in patients with IBD

Answer 30

adherence stoma short gut syndrome mental health fatigue VTE prophylaxis

Question 31

what is the Montreal classification for

Answer 31

remission in UC S0 - no symptoms - remission S1 - mild S2- moderate S3 - severe

Question 32

how is remission induced in UC - mild/moderate proctitis

Answer 32

topical amino salicylates PLUS oral if remission not achieved within 4 weeks (+ steroids if C/I or further treatment required)

Question 33

how is remission induced in UC - mild/moderate proctosigmoiditis and left sided colitis

Answer 33

topical amino salicylates PLUS high dose oral if remission not achieved within 4 weeks (+ steroids if C/I or further treatment required)

Question 34

how is remission induced in UC - mild/moderate extensive colitis

Answer 34

topical AND oral amino salicylates, if remission not reached within 4 weeks stop topical and add steroids

Question 35

how is remission induced in UC - moderate to severe colitis

Answer 35

corticosteroids 4-60mg a day (side effects >40mg)

Question 36

how is remission induced in UC - moderate to severe active disease

Answer 36

biologics and JAK inhibitors - infliximab/adalimumab after conventional therapy failure - vedolizumab - inadequate/loss of response to others - including tnfa inhib- tofacitinib - if all else fails

Question 37

how to maintain remission in UC - Mild to moderate proctitis AND proctosigmoiditis

Answer 37

- topical aminosalicylate (nightly or every 3 nights) - oral plus topical aminosalicylate - oral alone but not as effective - 2 + exacerbations in 12 months that require corticosteroids OR if remission is not maintained Azathioprine/mercaptopurine

Question 38

how to maintain remission in UC - Mild to moderate left sided and extensive colitis

Answer 38

low dose oral aminosalicylate - □ If 2 + exacerbations in 12 months that require corticosteroids OR if remission is not maintained Azathioprine/mercaptopurine

Question 39

how to induce remission in CD

Answer 39

1. glucocorticoid monotherapy (if C/I - budesonide but less effective then aminosalicylate but less effective than both) 2. >2 exacerbations in 12 months, add- azathioprine/mercaptopurine - mtx if above c/i - tnf inhibitors - infliximab - il inhibitors - ustekinumab - lymphocyte inhibitors - vedolizumab

Question 40

how to maintain remission in CD

Answer 40

- no treatment follow up plans actions if relapse how to access healthcare - treatmentazathioprine/mercaptopurine mtx - if above c/i

Question 41

when would you use budesonide in CD

Answer 41

to induce remission in patients who cannot have steroids with distal ileal, ileocecal and right sided colonic disease

Question 42

CD treatment after surgery

Answer 42

azathioprine with metronidazole (for up to 3 months post op)