Y4 Gastrointestinal > IBD > Flashcards

IBD Flashcards

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1
Q

What is colitis ?

A

Colitis refers to inflammation of the inner lining of the colon

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2
Q

Define what crohn’s disease (CD) is

A

It is a chronic inflammatory and ulcerating condition of the GI tract that can affect anywhere from the mouth to the anus

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3
Q

What part of the GI tract does crohn’s affect most commonly ?

A

Most common in the terminal ileum and colon

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4
Q

Who is most commonly affected by CD?

A
  • Younger patients (late adolescence or early adulthood) and males
  • Think stew thompson
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5
Q

What are the typical presenting features of CD?

A
  • Abdominal pain - usually tenderness in RLQ
  • Diarrhoea - usually non-bloody
  • Small bowel obstruction
  • Upper gastrointestinal symptoms: mouth ulcers, angular cheilitis
  • Perianal disease: Skin tags, ulcers, abscesses, fistulas (cause peristent leaking)
  • Abdominal mass palpable in the RIF
  • Weight loss & Anaemia (lethargy)
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6
Q

Describe the normal clinical course of CD

A
  • Chronic
  • Exacerbations and remissions
  • Unpredictable response to therapy
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7
Q

List the key pathological features of CD

A
  • Segmental disease (patchy areas affected) from anywhere from mouth to anus
  • Transmural inflammation (affects all layers) - hence prone to strictures, fistulas & adhesions
  • Goblet cells & granulomas seen in inflammation
  • Deep knife-like fissuring ulcers & skip lesions creating ‘cobblestone appearance’
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8
Q

What are the complications which may occur due to CD ?

A
  • Bowel obstruction and potentially perforation
  • Fistulas, strictures & adhesions
  • Colorectal cancer
  • Malabsorption (due to repeated bowel resections) - results in hypoproteineima, Vitamin deficiency (osteoporosis), anaemia
  • Gallstones
  • Perianal disease e.g. skin tags, ulcers, fistulas, abscesses
  • Intractable disease (failure to respond to med therapy) ==> surgical ressection which is not curative
  • Rarely toxic megacolon
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9
Q

What genetic mutations are associated with CD ?

A

HLA-DR1, HLA-DQw5 & NOD2 mutations

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10
Q

What does smoking do to the risk of CD?

A

It increases the risk

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11
Q

What are the initial investigations you should do in someone with suspected CD?

A
  • Blood tests and inflam markers (ESR &CRP)
  • Faecal calprotein (raised suggests CD compared to a normal result suggesting IBS)
  • Coeliac serology
  • Stool microscopy & culture - to exclude infective gastroenteritis or pseudomembraneous colitis
  • Plain AXR to identify small bowel or colonic dilatation, which may indicate obstruction.
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12
Q

Following inital tests what are the specialised tests done to diagnose CD?

A

Coloscopy + multiple mucosal biopsies - key thing used to diagnose

May also do:

  • Upper intestinal endoscopy for children and young people, and if there are upper gastrointestinal tract symptoms in adults.
  • Pelvic MRI to evaluate suspected perianal or small bowel disease, to allow definition of the extent and location of abscesses and fistulas.
  • Computed tomography (CT) to stage Crohn’s disease and look for extraluminal complications, such as abscesses and fistulas.
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13
Q

What initial advice should be given to all patients with CD if they are smoking ?

A

To stop smoking!

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14
Q

What is the treatment of CD to induce remission ?

A
  • 1st line = corticosteroids e.g. prednisolone
  • 2nd line = Aminosalicylates (5-ASA) either mesalazine or sulfasalazine if corticosteroids contraindicated
  • 3rd line = anti-tumour factor alpha-monoclonal antibody agents - inflixumab & adalimumab (for refractory disease & perinanal disease e.g. fistulating CD)
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15
Q

What treatment may be added to someone with CD flare up alongside corticosteroids ?

A
  • 1st line = Thiopurines (azathioprine or mercaptopurine)
  • 2nd line = methotrexate
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16
Q

What treatment is used as an alternative to corticosteroids in children & young people who have faltering growth or development or there is concerns about steroid adverse effects?

A

Specialist enteral feeding may be used

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17
Q

What is often used for treatment of isolated peri-anal disease in CD?

A

Metronidazole

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18
Q

What is the maintanence treatment of CD?

A
  • 1st line = thiopurines (azathioprine or mercaptopurine)
  • 2nd line = methotrexate

For patients whom have had complete macroscopic resection 1st line = azathioprine + metronidazole for 3 months (aza on its own if metronidazole contraindicated)

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19
Q

What do you need to assess prior to prescribing thiopurines ?

A

Thiopurine methyltransferase (TPMT) activity

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20
Q

What will 80% of CD patients despite medical therapy go onto recivieving ?

A

Surgery - usually subtotal colectomy, panproctocolectomy or staged sub-total colectomy & proctectomy

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21
Q

What should you asses the risk of in all patients with CD?

A

Risk of osteoporosis

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22
Q

What should you monitor in patients with CD?

A

Ferritin, vit B12, folate, calcium, & vit D levels - arrange supplementation if low

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23
Q

Define what ulcerative colitis (UC) is

A

It is a chronic inflammatory disorder confined between the rectum and ileocaecal valve

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24
Q

When is the peak incidence of UC occuring ?

A

In people aged 15-25 years and in those aged 55-65 years.

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25
List the key pathological features of UC
* Inflammation is continuous & almost always starts in the rectum. It then spreads proximally for varying lengths but never extends beyond the ileocaecal valve * No inflammation beyond the submucosa * Widespread superficial ulceration which has the appearance of polyps 'pseudopolyps' * No granulomas * Crypt abscesses * Decreased goblet cells
26
What are the genetic mutations linked to UC ?
HLA-DR2 and NOD2 gene
27
What are the typical presenting features of UC ?
* **Bloody diarrhoea + mucus** * Urgency * Tenesmus (a continual or recurrent inclination to evacuate the bowels) * **Abdo pain,** particularly in the left lower quadrant - **particular LIF** * Extra-intestinal features * colon is narrow and short -'drainpipe colon' on AXR
28
What complications may arise in patients with UC?
* Intractable disease - causing continuous diarrhoea which may then require total colectomy * Toxic megacolon - requries emergency colectomy (as it will rupture) * Colorectal carcinoma - requires survellience (risk much higher in UC than CD) * Malabsorption (due to repeated bowel resections) - results in hypoproteineima, Vitamin deficiency (osteoporosis), anaemia * Blood loss may also cause anaemia * Electrolyte distrubance - hypokalaemia * Rarely anal fissures * Extra GI manifestations - uveitis, primary sclerosing cholangitis, ankylosing spondylitis, arthritis, pyoderma gangrenosum, erythema nodosum
29
What extra GI complications which arise in UC may also arise in CD ?
arthritis, pyoderma gangrenosum, erythema nodosum
30
How does toxic megacolon typically present ?
* Patients usually hospitalised for exacerbation of Crohn’s, UC or Cl. diff colitis * Sudden onset of worsening of abdominal pain * Abdominal distension, tender RIF
31
What pathology is shown in this AXR ?
Toxic megacolon (dimensions for diagnosis): * Transverse \>5.5cm * Caecum \>9cm
32
Is smoking associated with UC?
No
33
What are the initial tests done for UC (hint same as CD except one or two)
* Bloods & inflam markers (CRP & ESR) * TFT's - exclude hyperthyroidism * Faecal calprotein (raised suggests UC compared to a normal result suggesting IBS) * Coeliac serology * Stool microscopy & culture - to exclude infective gastroenteritis or pseudomembraneous colitis * Plain AXR to identify colonic dilatation, which may indicate complications such as bowel obstruction and toxic megacolon.
34
How is UC diagnosed following initial tests?
**1st line = colonoscopy + multiple mucosal biopsies** Other investigations which may be done include: * Upper intestinal endoscopy for children and young people - this is important to differentiate Crohn's disease from ulcerative colitis * CT to stage UC and look for extraluminal complications, such as abscesses and fistulas.
35
How is the severity of UC graded ?
1. mild: \< 4 stools/day, only a small amount of blood 2. moderate: 4-6 stools/day, varying amounts of blood, no systemic upset 3. severe: \>6 bloody stools per day + ≥ 1 of systemic upset (pyrexia, tachycardia, anaemia, raised inflammatory marker - ESR ) If severe UC admit to hospital.
36
What is treatment of mild-moderate UC ?
* 1st line = 5-ASA (mesalazine or sulfasalazine) for proctitis, proctosigmoiditis, or left-sided UC (initially given topically but if not achieved remission within 4weeks then add PO 5-ASA. (If extensive disease then give Topical & PO together initially) * 2nd line = 5-ASA + oral corticosteroids (if 5-ASA contraindicated, corticosteroid used as monotherapy) * 3rd line = anti-TNF monoclonal antibodies (infliximab, adalimumab, or gloimumab if unresponsive to standard treatments)
37
What can be given to patients with mild-moderate UC to help induce remission when treating them with oral corticosteroids if there is an inadequate response ?
Calcineurin inhibitors - tacrolimus or ciclosporin
38
What is the treatment of severe UC to induce remission ?
* 1st line = IV corticosteroids * 2nd line = if steroids ineffective after 72hrs IV corticosteroids + IV ciclosporin OR surgery. (if corticosteroids contraindicated monotherapy can be done)
39
What is the treatment of mild-moderate UC to maintain remission ?
Following a mild-to-moderate UC flare - proctitis and proctosigmoiditis: * 1st line = Topical 5-ASA +/- oral 5-ASA Following a mild-to-moderate UC flare - left-sided and extensive ulcerative colitis: * 1st line = Oral 5-ASA
40
What is the maintanence treatment of severe UC or if there \>= 2 inflammatory exacerbations in a 12-month period that require treatment with oral corticosteroids, or if remission cannot be maintained by 5-ASA ?
* 1st line = thiopurine * 2nd line = methotrexate
41
Go over this slide
42
What are the 3 conditions caused by ischaemia to the lower GI tract ?
1. Acute mesenteric ischaemia 2. Chronic mesenteric ischaemia 3. Ischaemic colitis
43
What are the risk factors for bowel ischaemia ?
* Increasing age * AF other causes of emboli: endocarditis, malignancy - particularly for acute mesenteric ischaemia * CVD risk factors: smoking, hypertension, diabetes * Shock * Strangulation obstructing venous return (e.g. hernia, adhesion) * cocaine: ischaemic colitis is sometimes seen in young patients following cocaine use
44
What happens the longer the period of time the bowel is ischaemic ?
Progresses from mucosal to mural to transmural infarction
45
What are the common features of bowel ischaemia ?
* Abdo pain - in acute mesenteric ischaemia this is often of sudden onset, severe and out-of-keeping with physical exam findings * Rectal bleeding * Diarrhoea * Fever * Bloods typically show an elevated WBC count associated with a lactic acidosis (low pH, high H+, high BE, lactate elevated)
46
How is bowel ischaemia diagnosed?
CT
47
Alongside the general features of bowel ischaemia what are the features which would suggest acute mesenteric ischaemia ?
* Patient has a PMH of AF or other causes of emboli as its caused by an embolus * Abdo pain is typically severe, of sudden onset and out-of-keeping with physical exam findings.
48
What is the treatment of acute mesenteric ischaemia ?
Surgery
49
Alongside the general features of bowel ischaemia what are the features which would suggest chronic mesenteric ischaemia ?
* May be thought of as 'intestinal angina'. * Colickly, intermittent abdo pain occurs. * Abdo bruit
50
What artery is usually the problem in acute or chronic mesenteric ischaemia?
SMA
51
Describe what ischaemic colitis is
* It is an acute but transient compromise in the blood flow to the large bowel. * This may lead to inflammation, ulceration and haemorrhage.
52
What classical feature is seen on AXR suggestive of ischaemic colitis ?
'thumbprinting' due to mucosal oedema/haemorrhage
53
What is the treatment of ischaemic colitis ?
Supportive
54
What are the potential side effects of 5-ASA's?
* Diarrhoea * Idiosyncratic nephritis (i.e. drug induced interstitial nephritis which is a common cause of AKI)
55
What are the side effects of corticosteroid use ?
* Musculoskeletal - AVN, Osteoporosis * Cutaneous - Acne, Thinning of skin * Metabolic -Weight gain, Diabetes, HTN * Cataracts * Growth failure
56
What should azathioprine not be prescribed with ?
Allopurinol
57
What are the potential side effects of azathioprine use ?
* Pancreatitis * Leucopaenia * Hepatitis * Small risk of lymphoma, skin cancer
58
What are the side effects of anti-TNF alpha drugs ?
* Infusion reactions * Infections - TB * Cancer - lymphoma and solid tumours
59
When is surgery done in IBD?
1. Emergency - Failure to respond to medical therapy, small bowel obstruction, abscess, fistulae 2. Elective - Failure to respond to medical therapy or Dysplasia of colon mucosa, Growth retardation in children
60
Is surgery for CD curative and what can it result in ?
* Surgery is not curative * Repeated resection of small intestine can result in ‘short gut syndrome’ and requirement of lifelong total parenteral nutrition (reduced life expectancy)
61
Is surgery for UC curative and what are the main 3 options for surgery?
Yes it is curative 1. Proctocolectomy with end ileostomy 2. Proctocolectomy with pouch (creates a resevoir and popular in young people but do have problems e.g. frequency etc) 3. Proctocolectomy with ileorectal anastomosis
62
What should be done for patients with IBD 10 years after diagnosis ?
Colonoscopy for cancer screen
63
How does colonic GI bleeding tend to present ?
* As bright red or dark red blood per rectum. * As a general rule right sided bleeds tend to present with darker coloured blood than left sided bleeds. * Upper GI classically present as malaena
64
What are the main causes of colonic GI bleeding
* Colitis (IBD) * Diverticular disease * Cancer * Haemorrhodial bleeding * Angiodysplasia
65
What are the typical features suggestive of bleeding because of colitis (IBD)?
* Bleeding may be brisk in advanced cases, diarrhoea is commonly present. * AXR may show featureless colon.
66
What are the typical features suggestive of bleeding because of diverticular disease?
* Acute diverticulitis often is not complicated by major bleeding and diverticular bleeds often occur sporadically. * 75% all will cease spontaneously within 24-48 hours. * Bleeding is often dark and of large volume.
67
What are the typical features suggestive of bleeding because of cancer?
* Colonic cancers often bleed and for many patients this may be the first sign of the disease. * Major bleeding from early lesions is uncommon
68
What are the typical features suggestive of bleeding because of haemorrhoids?
* Typically bright red bleeding occurring post defecation. * Although patients may give graphic descriptions bleeding of sufficient volume to cause haemodynamic compromise is rare.
69
What are the typical features suggestive of bleeding because of angiodysplasia?
* Apart from bleeding, which may be massive, these arteriovenous lesions cause little in the way of symptoms. * The right side of the colon is more commonly affected.
70
What is the management of colonic GI bleeding ?
ABCDE followed by: 1. If haemodynamically unstable CT angiogram (attempts can be made to address the lesion in question such as coiling, Otherwise surgery will be necessary.) 2. If haemodyanmically stable colonoscopy in the elective setting. 3. In patients with UC who have significant haemorrhage the standard approach would be a sub total colectomy, particularly if medical management has already been tried and is not effective.
71
What is radiation colitis
Diarrhoea, nausea, vomiting and stomach cramps in people receiving radiation aimed at the abdomen, pelvis or rectum.
Y4 Gastrointestinal
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