IBD Flashcards by Zoe Doak

The incidence of Crohn’s disease is higher in the Western world (i.e. UK, Europe and America) than the rest of the world. TRUE/FALSE?

TRUE

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What can be used to prove that there are genetic links in IBD?

Twin studies

- Affected 1st degree relatives

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What genetic mutation is present in 10-20% of caucasians with Crohn’s disease? What does it cause?

NOD2/ CARD15 (IBD-1)

=> Encodes a protein involved in bacterial recognition

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How can adaptive immunity of the mucosa be affected by abnormal T cell function?

Overactive effector T-cells → Inflammation/ Disease

Absence of regulatory T-cells → Uncontrolled Inflammation/ Aggressive Disease

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What cells of the adaptive immune system cause Crohn’s disease, and which cause UC?

Crohn's = Th1 mediated
UC = Mixed Th1/ Th2 or NKCs

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Does smoking aggravate Crohn’s or UC?

Aggravates Crohn’s disease but protects against UC

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Describe the typical clinical presentation of UC?

Female 20-30s
Relapsing course
Affects rectum extending proximally

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How is UC referred to if it only affects a) the rectum? b) the rectum and left-side of the colon? c) the entire colon?

a) Proctitis
b) Left-sided colitis
c) pancolitis

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What symptoms are usually present in UC?

Diarrhoea + bleeding
Increased bowel frequency
Urgency
Tenesmus (incomplete emptying)
Incontinence
Night rising
Lower abdo pain (esp. LIF)

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What should you remember to check in patient’s history if you suspect UC?

Recent travel
Antibiotics
NSAID’s
Family history
Smoking
Skin, eyes, joints

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What criteria is used to assess the severity of UC, and why is this scoring important?

Truelove and Witt criteria:
>6 bloody stools/24 hour
\+
1 or more of:
-  Fever (>37.8°C)
- Tachycardia (>90/min)
- Anaemia (Haemoglobin <10.5g/dl)
- Elevated ESR (>30mm/hr)

Important as Severe UC = 30% risk of colectomy

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What investigations can be used if you suspect UC?

C-reactive protein (CRP)
Albumin (a negative acute phase reactant)
Plain AXR
Endoscopy
Histology

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What can an AXR show you that would point towards a diagnosis of UC?

Stool distribution = Absent in inflammed colon
Mucosal oedema / ‘thumb-printing’
Toxic megacolon:
=> Transverse >5.5cm
=> Caecum >9cm

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What signs at endoscopy indicate UC is present?

Loss of vessel pattern
Granular mucosa
Contact bleeding

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What signs on histology indicate UC is present rather than normal mucosa?

lack of goblet cells
crypt distortion
formation of abscesses (due to crypts closing at surface)

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What complications can arise from UC?

Increased risk of colorectal cancer

- depends on severity and extent of disease

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What extra-intestinal manifestations are common in UC?

Skin - erythema nodosum/ pyoderma gangrenosum
Joint arthritis
Eyes (uveitis)
Deranged LFTs, gallstones/ PSC
Oxalate renal stones

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PSC is more commonly associated with UC than Crohn’s. TRUE/FALSE?

TRUE

- 80% of those with PSC have associated IBD

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When does Crohn’s disease normally present?

90% onset before age 40

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Describe the normal clinical appearance of Crohn’s which distinguishes it from UC?

Affects any region of GI tract from mouth to anus
=> Skip lesions
Transmural inflammation (all the way through wall)

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What peri-anal disease is common in Crohn’s ?

Recurrent abscess formation
Pain
fistula with persistent leakage
Damaged sphincters

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Resections to treat Crohn’s disease are minimised as they are NOT curative. TRUE/FALSE?

TRUE

- many patients require multiple surgeries

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What symptoms can patients with Crohn’s disease experience?

Small intestine disease:

Abdominal cramps (peri-umbilical)
Diarrhoea
Weight loss

Colon:

Cramps (lower abdomen)
Diarrhoea with blood
Wt loss

Mouth:

Painful ulcers
swollen lips
angular chielitis

Anus:

peri-anal pain
abscess

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What may you notice on examination of a patient with suspected Crohn’s disease?

Evidence of wt loss
RIF mass
peri-anal signs

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What blood tests would you consider if you suspected Crohn's disease in a patient?

- CRP - albumin - platelets - B12 (absorbed in terminal ileum) - ferritin

What is usually visible on Crohn's histology that distinguishes it from UC?

- granuloma formation common

What investigations can be used to view the small and large bowel lumens in Crohn's disease?

SMALL: - Barium follow-through - MRI - Technetium-labelled white cell scan LARGE: - colonoscopy

What are the aims of treatment in IBD?

- Control inflammation + heal mucosa - Restore normal bowel habit - Improve quality of life - Avoid long-term complications

What lifestyle advice can be given to help treat patients with Crohn's disease?

- SMOKING aggravates Crohns => makes worse disease outcome => more rapid recurrence post-surgery

What drug therapies are used in UC?

5ASA (mesalazine) Steroids Immunosuppressants (e.g. azathioprine) Anti-TNF therapy

What drug therapies are used to treat Crohn's disease?

Steroids Immunosuppressants (e.g. azathioprine) Anti-TNF therapy

How do 5ASA therapies (e.g. Mesalazine) work to treat IBD?

- produces a Topical effect - Anti-inflammatory - Reduces risk of colon cancer

What are the side effects of using 5ASA therapies?

- diarrhoea | - idiosyncratic nephritis

How are 5-aminosalicylic acid (5ASA) preparations delivered topically to the bowel mucosa?

- suppositories | - enemas

5ASA drugs can also be taken orally. TRUE/FALSE?

TRUE - these may come in granules/ sachets rather than a tablet/capsule form They can be: - Prodrugs - pH dependent release (Asacol) - delayed release (Pentasa)

Why are different preparations of oral 5ASA agents made?

They act on different areas of the GI Tract e. g. - Sulphasalazine only acts on colon - Asacol acts on ileum and colon - Pentasa acts on duodenum, jejunum, ileum and colon

What arer the advantages and disavantages of using suppositories or enemas?

- Suppositories coat <20cm BUT have better mucosal adherence than enemas - Reflex contraction aids proximal spread of enemas - <10% enemas actually remain in the rectum

What corticosteroids are used to treat IBD and what is the aim of using this treatment?

- Prednisolone: oral / topical => short course used to induce remission - high dose initially, reducing over 6 - 8 weeks

What are the potential side effects of using steroid treatments?

MSK: - Avascular necrosis - Osteoporosis DERM: - Acne - Thinning of skin Metabolic: - Weight gain - Diabetes - hypertension Others: - Cataracts - Growth failure

What immunosuppressants can be used as a more potent suppressor of inflammation in IBD?

- azathioprine / mercaptopurine | - methotrexate

Azathioprine has a slow onset of action. TRUE/FALSE?

TRUE | - 16 weeks

Why should Allopurinol not be co-prescribed with azathioprine?

Allopurinol inhibits Xanthine oxidase | - XO enzyme is involved in the activation of azathioprine to its active product

What are the main side effects of Azathioprine use?

- Pancreatitis - Leucopaenia - Hepatitis - Small risk of lymphoma or skin cancer

What is anti-TNF therapy and how does it work?

Tumour Necrosis Factor α = proinflammatory cytokine => this drug provides antibodies to TNF => Promote apoptosis of activated T- lymphocytes

How can anti-TNF drugs be delivered?

infliximab; IV | adalimumab; S/C injection

Anti-TNF drugs have a rapid onset of action. TRUE/FALSE?

TRUE | - 30-40% remission after single infusion

When do the NICE guidelines indicate use of anti-TNF alpha in IBD?

- part of long term strategy (inc. immunosuppression, surgery (Crohns), supportive therapy etc) - Used if refractory / fistulising disease - (make sure to exclude current infection / TB before use)

What are the two main types of surgery used in IBD?

Emergency - Failure to respond to medical therapy, small bowel obstruction, abscess, fistulae Elective - Failure to respond to medical therapy - Dysplasia of colon mucosa

Crohn's surgery is NOT curative. TRUE/FALSE?

TRUE | - minimal resections each time

Repetitive surgery for Crohn's can result in what clinical outcome?

‘short gut syndrome’ | => May require lifelong total parenteral nutrition (reduced life expectancy)

Surgery for UC is normally curative. TRUE/FALSE?

TRUE

What surgeries can be offered to UC patients?

- Permanent ileostomy OR - Restorative proctocoloectomy and pouch

What emergency surgeries for IBD are considered "planned"?

- Sub total colectomy for UC | - Resection of Crohn’s disease

Why may a patient with Crohn's disease undergo elective operations?

- Resection - Stricturolplasty - Fistulas - Anal disease

What elective operations can be done to help with UC?

- Proctocolectomy with end ileostomy | - Proctocolectomy with ileorectal anastomosis

What indications are there for elective surgery in UC?

- Medically unresponsive disease - Dysplasia/malignancy - Growth retardation in children - Attempted resolution of extra-intestinal disease

What different types of ileorectal anastomosis can be created after surgery for UC?

W pouch J pouch S pouch

Pouches are usually more popular with younger patients. TRUE/FALSE?

TRUE | - means they don't have colostomy/ ileostomy bag to change/ wear for the rest of their life

What immediate local complications can occur during IBD surgery?

- haemorrhage | - enterotomy

What early complications can present due to IBD surgery?

- urinary dysfunction - wound infection/ abscess - anastomotic leak - ileus - portal vein thrombosis

WHat complications of IBD surgery present late?

- impotence - infertility - pouchitis - DVT/PE - small bowel obstruction

What criteria is used to assess the severity of a UC attack?

Truelove and Witt Criteria - ESR/PV - Haemoglobin - Bloody Stools - Temperature - Heart rate

Removal of the colon in IBD tends to settle rectal disease (even though the rectum itself is not removed). TRUE/FALSE?

TRUE | - rectal problems can be managed medically with enemas/ medication

What are the main indications for surgery in Crohn's disease?

- Stenosis causing obstruction - Fistulae - Abscesses - Bleeding (acute or chronic) - Free perforation

What surgery can be completed if patients with Crohn's experience gastro-duodenal disease?

Gastrojejunostomy | - allows to avoid duodenal or pyloric stenosis

Pouches for Crohn's disease patients is controversial. TRUE/FALSE?

TRUE

Squamous cell carcinoma may occur after peri-anal Crohn's disease. TRUE/FALSE?

TRUE

IBD Flashcards

(67 cards)