IBD

Question 2

State the name of this symptom of Crohn’s [1]

Answer 2

Pyostomatitis vegetans: an inflammatory stomatitis

Question 3

What sign of Crohn’s Disease are the arrows pointing to? [1]

Answer 3

Rosehorn ulcer

Question 4

Describe the blood tests used to investigate Crohns [5]

Answer 4

Anaemia:
- is common and may be normocytic, normochromic of chronic disease.
- However, deficiency of iron/folate may occur.
- Despite common terminal ileum involvement, megaloblastic anaemia due to B12 deficiency is unusual

Raised ESR and CRP; raised WCC and platelets

Hypoalbuminemia is present in severe disease

Liver biochemistry may be abnormal

Serological testing; p-ANCA would be negative (ANCAs are more commonly found in ulcerative colitis)

Question 5

Extra-intestinal manifestations (EIM) refer to the collection of clinical features that occur outside the gastrointestinal tract within CD.

What is the most common EIM? [1]
Describe this EIM of CD [2]

Answer 5

Musculoskeletal disease:
Two forms of arthritis are seen, type 1 and type 2.

• Type 1 is a pauciarticular peripheral arthritis related to intestinal disease activity.
• Type 2 is a polyarticular peripheral arthritis independent of intestinal disease activity.

Question 6

Describe the management plan to induce remisison of Crohns in mild-moderate [2] and moderate-severe patients [3]

Answer 6

mild-to-moderate CD:
- a course of exclusive enteral nutrition (EEN) can be considered over an 8 week period
- oral prednisolone (40mg/d for 1 week, then 5mg every week for 7 weeks)

moderate-to-severe CD:
- IV steroids: IV hydrocortisone or methylprednisilone
- there should be consideration of early introduction of immunosuppressive therapy: azathioprine or methotrexate alongside budesonide, prednisilone or hydrocortisone (These medications help with long-term control, but are not useful at initially inducing remission, which is why they are combined with steroids)
- - Biologicals: inflximab, adalimubab (anti-TNF); Vedolizumab (anti-integrins); Ustekinumab (anti-IL12/13)

Question 7

A patient has moved onto maintence therapy for Crohns.
Which one of the following drugs is the most appropriate to prescribe?

Azathioprine

Budesonide

Mesalazine

Methotrexate

Oral glucocorticoids

Answer 7

A patient has moved onto maintence therapy for Crohns.
Which one of the following drugs is the most appropriate to prescribe?

Azathioprine

Budesonide

Mesalazine

Methotrexate

Oral glucocorticoids

Question 8

A 33-year-old man was admitted to the surgical ward due to an exacerbation of Crohn’s disease. He presented with a perianal abscess that has been surgically drained. An MRI confirms a complex perianal fistula.

In addition to an antibiotic and a biologic, what other management would be indicated?

Lidocaine gel
Rectal mesalazine
Seton placement
Surgical resection
Topical glyceryl trinitrate

Answer 8

A 33-year-old man was admitted to the surgical ward due to an exacerbation of Crohn’s disease. He presented with a perianal abscess that has been surgically drained. An MRI confirms a complex perianal fistula.

In addition to an antibiotic and a biologic, what other management would be indicated?

Seton placement

A seton is a piece of surgical thread that is run through the fistula to allow continuous drainage while the fistula is healing. This ensures that the fistula doesn’t heal containing pus within, which would result in further abscess formation.

Question 9

If a Crohn’s patient has had an ileocacel resection, why may diarrhoea occur? [1]

Name a drug that can treat this [1]

Answer 9

The patient most likely has a diagnosis of bile acid malabsorption as a complication of the ileocecal resection.

Treat using: Cholestyramine - bile acid sequestrant with the potential to control diarrhoea induced by bile acid malabsorption.

Question 10

Which drugs are first line to induce remission in CD? [3]

Answer 10

glucocorticoids:
* prednisolone; hydrocortisone oral, topical or intravenous) are generally used to induce remission.
* Budesonide is an alternative in a subgroup of patients

Question 11

Inducing Remission:

Which drugs are used as second-line to glucorticosteroids for CD? [2]
Which drugs may be added alongside ^? [2]
What is important to note about this^ [1]

Answer 11

5-ASA drugs (e.g. mesalazine) are used second-line to glucocorticoids but are not as effective

azathioprine or mercaptopurine may be used as an add-on medication to induce remission but is not used as monotherapy.

Question 12

Inducing Remission:

Which drug is used to treat refractory CD? [1]

Answer 12

infliximab .

Question 13

Inducing Remission:

Describe the management plan for treating fistulaes [3]

Answer 13

patients with symptomatic perianal fistulae are usually given oral metronidazole
(+)
Infliximab
(+)
draining seton
a seton is a piece of surgical thread that’s left in the fistula for several weeks to keep it open. This is useful because persisting fistula tracks after premature skin closure predispose to abscess formation

Question 14

Maintaining remission

Which drugs are used as first line maintainene for CD? [2]
What is second line? [1]

Answer 14

azathioprine or mercaptopurine is used first-line to maintain remission

methotrexate is used second-line

Question 15

Fistulas

In a patient with CD fistulas, what drugs are used if:

Symptomatic peri-anal fisutlae? [1]
To help close and maintain perianal fistulas? [1]
For complex fistulae? [1]

Answer 15

• patients with symptomatic perianal fistulae are usually given oral metronidazole
• anti-TNF agents such as infliximab may also be effective in closing and maintaining closure of perianal fistulas
• a draining seton is used for complex fistulae

Question 16

What treatment is given for Crohn’s patients who develop a perianal fistula? [1]

Answer 16

Oral metronidazole

Question 17

A 22-year-old lady has a long history of severe perianal Crohns disease with multiple fistulae. She is keen to avoid a stoma. However, she has progressive disease and multiple episodes of rectal bleeding. A colonoscopy shows rectal disease only and a small bowel study shows no involvement with Crohns.

What is the best surgical option? [1]

Answer 17

Proctectomy

Question 18

Define short bowel syndrome [3]

Answer 18

Short bowel syndrome (SBS) refers to a condition wherein substantial portions of the small intestine are absent, either congenitally or due to resection

Typically, less than 200 cm of residual short bowel is present.

This results in a loss of surface area for fluid, nutrient, and medication absorption, causing an inability to maintain protein-energy, fluid, electrolyte, or micro-nutrient balance when ingesting a conventionally accepted, normal diet.

Question 19

Terminal ileal Crohns remains the commonest disease site. How might patients be treated surgically? [1]

Answer 19

Terminal ileal Crohns remains the commonest disease site and these patients may be treated with limited ileocaecal resections.

Question 20

What pathology may terminal ileal Crohns lead to? [1]

Answer 20

Terminal ileal Crohns may affect enterohepatic bile salt recycling and increase the risk of gallstones.

Question 21

Descricbe characteristic findings of colonoscopy in UC patients [4]

Answer 21

• rectal involvement
• continuous uniform involvement
• loss of vascular marking
• diffuse erythema
• mucosal granularity

Question 22

How can you differentiate between UC and CD via endoscopy? [6]

Answer 22

UC:
- continuous inflammation:
- there is no areas of normal mucosa in-between areas of inflammation
- diffuse erythema
- friability, granularity
- loss of vascular pattern in the colon.

CD:
- incontinuous areas of inflammation normal bowel in-between inflammatory segments
- deep fissuring ulcers
- “cobblestoned” mucosa are present.

UC above, CD below

Question 23

Describe how you differentiate between recent v chronic UC via a histology sample? [1]

Answer 23

Chronic:
- crypt architecture distortion: they look twisted and disorganised

Question 24

(Zero to finals)

Mild to moderate acute ulcerative colitis is treated with [2]

Severe acute ulcerative colitis is treated with [1]

Other options for severe acute ulcerative colitis include: [3]

Answer 24

Mild to moderate acute ulcerative colitis is treated with:
* Aminosalicylate (e.g., oral or rectal mesalazine) first-line
* Corticosteroids (e.g., oral or rectal prednisolone) second-line

Severe acute ulcerative colitis is treated with:
* Intravenous steroids (e.g., IV hydrocortisone) first-line

Other options for severe acute ulcerative colitis include:

• Intravenous ciclosporin
• Infliximab
• Surgery

Question 25

# Zero to finals Options for maintaining remission in ulcerative colitis are? [3]

Answer 25

Options for maintaining remission in ulcerative colitis are: - **Aminosalicylate** (e.g., oral or rectal mesalazine) first-line - **Azathioprine** - **Mercaptopurine**

Question 26

State acute [2] and chronic [1] risks of UC

Answer 26

Acute: - **Toxic megacolon** (diameter > 6cm) + risk of perforation - **VTE** Chronic: - **Colon cancer**

Question 27

[] are the investigations of choice in primary sclerosing cholangitis. What sign would indicate a positive result? [1]

Answer 27

**ERCP/MRCP** are the investigations of choice in primary sclerosing cholangitis Multiple biliary strictures giving a '**beaded**' appearance

Question 28

If a patient with ulcerative colitis has had a severe relapse or >=2 exacerbations in the past year they should be given either oral **[]** or oral **[]** to maintain remission

Answer 28

If a patient with ulcerative colitis has had a severe relapse or >=2 exacerbations in the past year they should be given either **oral azathioprine** or **oral mercaptopurine** to maintain remission

Question 29

What would indicate that a UC flair up is: - Mild [1] - Moderate [1] - Severe [2]

Answer 29

- **Mild**: Fewer than four stools daily, with or without blood - **Moderate**: Four to six stools a day, with minimal systemic disturbance - **Severe**: More than six stools a day, containing blood & Evidence of systemic disturbance

Question 30

In a mild-moderate flare of distal ulcerative colitis, the first-line treatment is [1]

Answer 30

In a mild-moderate flare of distal ulcerative colitis, the first-line treatment is **topical (rectal) aminosalicylates**

Question 31

If a mild-moderate flare of distal ulcerative colitis doesn't respond to topical (rectal) aminosalicylates then what is the next treatment line? [1]

Answer 31

If a mild-moderate flare of distal ulcerative colitis doesn't respond to **topical (rectal) aminosalicylates** then **oral aminosalicylates should be added**

Question 32

[] is not recommended for the management of UC (in contrast to Crohn's disease)

Answer 32

**methotrexate** is not recommended for the management of UC (in contrast to Crohn's disease)

Question 33

Aminosalicylates are associated with a variety of haematological adverse effects, including **[]** What is a key investiation? [1]

Answer 33

Aminosalicylates are associated with a variety of haematological adverse effects, including **agranulocytosis** **FBC** is a key investigation

Question 34

State a key finding of UC under endoscopy [1]

Answer 34

**Pseudopolyps**: widespread ulceration with preservation of adjacent mucosa which has the appearance of polyps

Question 35

Describe a structural change that occurs as a response to active inflammation in UC patients [3]

Answer 35

**Crypt abscesses** form as a response to active inflammation. Crypt abscesses are the **accumulation of inflammatory cells within crypts,** which are tube-like glands found in the lining of the gastrointestinal system (i.e., digestive tract). The accumulation of inflammatory cells can **cause damage to the surrounding cells**, thereby **preventing the gland from functioning properly and secreting various substances**. The abscesses are **commonly neutrophilic** in UC.

Question 36

Which cell types are depleted in UC? [1]

Answer 36

**depletion of goblet cells** and mucin from gland epithelium

Question 37

The Truelove and Witts' severity index is recommended by NICE when assessing the severity of ulcerative colitis in adults. Ulcerative colitis is classified as 'severe' in which instances? [5]

Answer 37

TRUElove and Witt's when the patient has **blood** in their **stool**, or is passing **more than 6 stools** per **day** plus at least one of the following features: * T - Temp **> 37.8** * R - Rate **> 90** * U - (Uh)naemia **Hb < 105** * E - ESR **>30**

Question 38

Sulphasalazine may be used to treat UC. Name a haematological SE of this treatment [1] and describe how this may present on blood smear [1]

Answer 38

Sulphasalazine may cause **haemolytic anaemia** this can present with**Heinz bodies** | Sulphasala**z**ine **Heinz body**

Question 39

What is a proctocolectomy? [1]

Answer 39

the large intestine (the colon) and rectum are removed, leaving the small intestine disconnected from the anus.

Question 40

What is an indication for proctocolectomy in UC patients? [1]

Answer 40

**Dysplastic transformation of the colonic epithelium** with associated **mass lesions** is an absolute indication for a proctocolectomy.

Question 41

What would indicate sub total colectomy in UC patients? [1]

Answer 41

Emergency presentations of poorly controlled colitis that fails to respond to medical therapy

Question 42

Patients with IBD have a high incidence of [] and appropriate [] is mandatory.

Answer 42

Patients with IBD have a high incidence of **DVT** and appropriate **thromboprophylaxis** is mandatory.

Question 43

Name a restorative option in UC [1]

Answer 43

Restorative options in UC include an **ileoanal pouch**. This procedure can only be performed whilst the rectum is in situ and cannot usually be undertaken as a delayed procedure following proctectomy.