IBD

Question 1

What areas of the GIT are affected by ulcerative colitis

Answer 1

Rectum and large intestine

Question 2

What areas of the GIT are affected by crohns disease

Answer 2

Any part of the GIT

Question 3

What gender is CD more common in

Answer 3

Females

Question 4

What gender is UC more common in

Answer 4

Males

Question 5

Peak onset age for UC and CD

Answer 5

20s-30s and elderly 60+

Question 6

What is the aetiology of IBD

Answer 6

More bad bacteria than good, no tolerance to normal microbiota

Question 7

Factors that can aggravate IBD

Answer 7

Stress, diet, smoking (increase CD, decrease UC), medications (NSAIDs, COC, isotretinoin)

Question 8

How are IBD and IBS symptoms different

Answer 8

Chronic ab pain and discomfort, urgency and bloating, diarrhoea, constipation, alternating bouts of diarrhoea and constipation, changes in bowel habits

Question 9

Symptoms of IBD that aren’t in IBS

Answer 9

Weight loss, elevated CRP, nocturnal diarrhoea, blood in stools, fever, obstructive symptoms. anemia, iron deficiency, low albumin

Question 10

Extra intestinal manifestations of IBD

Answer 10

Liver (hepatitis, cirrhosis), joints (arthritis), eye issues, ulcers in oral cavity, increased RBCs, increased RBCs

Question 11

What is toxic megacolon

Answer 11

Gases trapped, colon expands and gets inflammed

Question 12

IBD lab tests

Answer 12

Complete blood count, electrolytes, anemia, CRP and ESR (inflammatory markers), celiac test, FCP, c.diff, endoscopy, pill cam

Question 13

Step up approach for IBD

Answer 13

Mild = antibiotics, aminosalicylates
Moderate = immunomodulators, corticosteroids,
Severe = surgery, biologics

Question 14

Step down approach for IBD

Answer 14

Early = immunomodulators, biologics
Mid = immunomodulators, corticosteroids, aminosalicylates
Late = immunomodulators, surgery, ABX, aminosalicylates

Question 15

Remission induction for mild to moderate Crohns disease

Answer 15

Prednisolone OD mane until clinical response then taper over 6-8 weeks to cease
onset 7-14 days- budenoside daily mane for 6-8 weeks then taper over 2-4 weeks

Question 16

Remission induction for severe Crohns disease

Answer 16

IV corticosteroids hydrocortisone q6h or methylprednisolone daily, for 3-7 days then mild-mod remission induction

Question 17

MOA of corticosteroids

Answer 17

Inhibit neutrophils and monocyte induced oxidative stress, inhibit inflammatory cytokine production and release, inhibit leukocyte migration, inhibit interaction between APCs and T cells

Question 18

Corticosteroid side effects

Answer 18

Buffalo hump, infections, osteoporosis, hyperglycaemia, abnormal hair growth, glaucoma, HTN, rectal use can cause burning

Question 19

Crohns remission induction when intolerance or ineffective for corticosteroids

Answer 19

1st line = azathioprine 2-2.5mg/kg daily or mercaptopurine 1-1.5mg/kg daily
2nd = methotrexate 25mg SC/IM/oral one one day a week + folic acid

Question 20

Side effects azathioprine

Answer 20

Infections, ulcers in oral cavity, GIT symptoms, alopecia

Question 21

MOA of azathioprine

Answer 21

Prodrug converted by glutathione to active form, inhibit purine synthesis, inhibit inflammatory cell synthesis

Question 22

Why is folic acid given with methotrexate

Answer 22

To reduce the side effects

Question 23

Side effects of methotrexate

Answer 23

Nausea, vomiting, ulcers, rashes, photosensitivity, pulmonary toxicity, toxicity to liver and kidneys, neurotoxicity

Question 24

Crohns disease remission for severe disease

Answer 24

1st line: Infliximab IV infusion at week 0, 2 and 6, continue maintenance therapy every 8 weeks or adalimumab 160mg SC at week 0, 80mg at week 2, clinical response continue with maintenance therapy
2nd line: vedolizumab 300mg IV infusion at week 0, 2, and 6, continue with maintenance therapy every 8 wks

Question 25

MOA of adalimumab and infliximab

Answer 25

Inhibit TNF alpha which produces inflammatory cytokines, cytokines no longer produced

Question 26

MOA of vedolizumab

Answer 26

Inhibits activation, adhesion and migration of WBCs

Question 27

Maintenance therapy of crohns disease

Answer 27

1st line: azathioprine or mercaptopurine daily if ineffective or not tolerated Methotrexate and folic acid once weekly ineffective not tolerated or severe 1st line = infliximab IV infusion every 8 weeks or adalimumab SC every 2 weeks 2nd line = vedolizumab IV every 8 weeks

Question 28

Treatment for perianal crohns disease

Answer 28

Antibiotics- 1st line = metronidazole 400mg q12h 2nd line = ciprofloxacin 500mg q12h

Question 29

UC <20cm localised to rectum

Answer 29

Proctitis: suppository

Question 30

UC >20cm proctosigmoiditis

Answer 30

Enema or foam

Question 31

UC distal colitis

Answer 31

Only enema will be effective

Question 32

What is the remission induction treatment for proctitis/distal colitis UC

Answer 32

Mesalazine rectal at standard induction dose + 5-aminosalicylate oral at standard induction dose

Question 33

Examples of 5-aminosalicylic acid

Answer 33

Sulfasalazine, mesalazine, olsalazine, balsalazide

Question 34

MOA of 5-asa

Answer 34

Exact MOA unknown, inhibit prostaglandin, inflammatory leukotrienes and inflammatory cytokines- inhibit inflammation

Question 35

UC remission induction

Answer 35

5-asa rectal and oral if not tolerated rectal corticosteroidd (1st line budenoside foam, hydrocortisone acetate foam, prednisolone enema , 2nd line prednisolone suppository no response or very severe- prednisolone oral once daily in the morning until clinical response then taper over 6-8 wks

Question 36

How do you known if extensive ulcerative colitis is acute severe

Answer 36

6+ bloody stools a day + fever or tachycardia or anemia or ESR increased

Question 37

How do we treat extensive acute severe UC

Answer 37

Hydrocortisone IV or methylprednisone IV If no response after 3-5 days Cyclosporin 24 hr continuous infusion or infliximab IV at week 0, 2 and 6

Question 38

IBD non pharmacological therapy

Answer 38

Balanced healthy diet, probiotic, smoking cessation, remove affected part of bowel, psychological evaluation and support