GI: Inflammatory Bowel Disease
What are two safe drug classes for inflammatory bowel disease in pregnancy?
1. 5-ASA is safe. 2. Steroids are generally safe. * Azathioprine/6-MP should be used sparingly.
Symptoms of Nutcracker Syndrome (2)
1. Abdominal (Flank) Plain 2. Gross Hematuria
Symptoms of Toxic Megacolon (5)
1. Abdominal Pain 2. Distension 3. Fever 4. Diarrhea 5. Shock
Immune Modifying Drugs (3)
1. Azathioprine or 6-MP: Azathioprine has an efficacy following three weeks. Enzyme activity must be measured prior to starting these drugs to avoid adverse effects. Metabolites can also be measured to determine compliance. 2. MTX 3. Cyclosporine
What are the four major gross histological features of Crohn's disease?
1. Cobblestone Mucosa: The mucosa can appear like cobblestone with normal mucosa being the stones and the fissures forming transmural inflammation. 2. Fistulas/Anal Stenosis: Perianal, abdominal, and bladder (enterovesical) fistulas can form. This can lead to feces or air in the urine or connections with the skin. 3. Creeping Fat: Creeping fat forms due to transmural inflammation healing and the condensed fibrous tissue pulls fat around the bowel wall. Creeping fat can wrap around the bowel. 4. Strictures: Strictures form due to healing that leads to the formation of fibrous tissue. Dense fibrous tissue can narrow the lumen and form the string sign.
What are the two types of atypical colitis?
1. Collagenous Colitis 2. Lymphocytic Colitis
Treatments for IBD (7)
1. Corticosteroids 2. Azathioprine 3. Methotrexate 4. 6-MP 5. Infliximab/Adalimumab 6. Sulfasalazine 7. 5-ASA
Natalizumab Indications (2)
1. Crohn's Disease 2. MS
What are the two inflammatory bowel diseases?
1. Crohn's Disease 2. Ulcerative Colitis (UC)
How are patients with inflammatory bowel disease monitored? (2)
1. Drug and antibody levels are monitored during the maintenance phase of treatment to allow for management changes. 2. Periodic endoscopic evaluation allows for objective evidence of disease activity.
Adverse Effects of Azathioprine/6-MP (7)
1. Fever 2. Rash 3. Pancreatitis (3-4%) 4. Bone Marrow Suppression: A periodic CBC should be performed. 5. Hepatitis: Occasional LFTs should be performed. 6. Increased Lymphoma Risk 7. Non-Melanoma Skin Cancer Risk: As a result, patients need an annual dermatologic screening.
What are the two symptomatologies of Crohn's disease?
1. Fibrostenotic and Obstructing 2. Penetrating and Fistulous
Indications of Glucocorticoids in Ulcerative Colitis (3)
1. For moderate to severe UC, oral prednisone can be used daily. Any more than 40 mg can lead to extra glucocorticoid response (i.e. DM, osteonecrosis, skin changes). 2. For moderate to severe UC, topical steroids can be used for distal colitis induction. 3. For mild to moderate UC, budesonide can be used for induction or short-term therapy.
Side Effects of Sulfasalazine (3)
1. GI Upset: Sulfasalazine can cause nausea, vomiting, and anorexia. 2. Sulfonamide Hypersensitivity 3. Oligospermia in Men: Oligospermia is reversible with drug cessation.
MTX is administered (2) for Crohn's disease induction therapy.
1. IM 2. SQ
Indications for Cyclosporine (2)
1. IV Cyclosporine can be used short-term for severe UC refractory to steroids. 2. Cyclosporine can be used to delay surgery.
Locations of Crohn's Disease (4)
1. Ileocolitis: lower chance of treatment success 2. Ileojejunitis 3. Perianal 4. Gastroduodenal: lower chance of treatment success
Indications for 5-ASA (2)
1. In UC, 5-ASA can be used for induction and maintenance therapy. 2. In Crohn's disease, 5-ASA can be used for induction therapy.
Adverse Effects of Anti-TNF Drugs (8)
1. Increased Risk of Lymphoma: This is a maybe? 2. Risk of Infection: Patients have an increased risk of TB, blastomycosis, and hepatitis B. If tuberculosis is latent, then treatment for the tuberculosis must be performed prior to starting the anti-TNF drug. 3. Infusion Reactions 4. Immunogenicity: Allergic reactions to these drugs can be acute or delayed. Often, these reactions are not IgE mediated and not anaphylactic. 5. Demyelinating Diseases: These drugs can induce these diseases or worsen an existing condition. Diseases include MS, optic neuritis, and others. 6. Hepatotoxicity: Hepatotoxicity is often hepatocellular in nature over cholestatic with autoimmune characteristics. 7. Neutropenia 8. Skin Reactions: Skin reactions to TNF drugs include psoriasis or psoriatic like skin changes, injection site reactions, infection from Zoster and varicella, and eczema.
Anti-TNF Antibodies for Active Crohn's Disease (3)
1. Infliximab: IV for induction/maintenance every 8 weeks 2. Adalimumab: SQ every 2 weeks 3. Certolizumab: SQ every 4 weeks
Anti-TNF Antibodies for Active Ulcerative Colitis (3)
1. Infliximab: IV for induction/maintenance every 8 weeks 2. Adalimumab: SQ every 2 weeks 3. Golimumab: IV every 4 weeks
Anti-TNF Drugs (4)
1. Infliximab: chimeric human/mouse antibody 2. Adalimumab: humanized antibody 3. Certolizumab: modified Fab fragment with PEG 4. Golimumab: humanized antibody
Adverse Effects of MTX (4)
1. Leukopenia: CBC should be monitored. 2. Hepatic Fibrosis: LFTs should be monitored. 3. Hypersensitivity Pneumonitis 4. Teratogenic
Symptoms of Colitis/Perianal Disease in Crohn's Disease (10)
1. Low-Grade Fevers 2. Malaise 3. Diarrhea: Diarrhea can occur due to decreased rectal compliance. 4. Crampy Abdominal Pain 5. Hematochezia: Hematochezia presents in Crohn's disease less than UC. 6. Strictures: Strictures can lead to bowel obstruction and fistulization. There is pain with passage of stool though stenosis. 7. Incontinence: This is seen in perianal Crohn's. 8. Hemorrhoids: This is seen in perianal Crohn's. 9. Anal Strictures: This is seen in perianal Crohn's. 10. Fistulae: This is seen in perianal Crohn's.
Symptoms of Jejunoileitis in Crohn's Disease (5)
1. Malabsorption: Malabsorption leads to nutritional deficiencies, such as hypoalbuminemia, hypocalcemia, hypomagnesemia, vertebral fractures from Vitamin D deficiency, hypocalcemia, and steroids, pellagra from niacin deficiency, megaloblastic anemia from Vitamin B12 anemia, and pica (flour) from Zn deficiency. 2. Steatorrhea 3. Coagulopathy 4. Calcium Oxalate Kidney Stones 5. Watery Diarrhea: Watery diarrhea can occur due to bacterial overgrowth, bile acid malabsorption, or inflammation.
Symptoms of Crohn's Disease
1. Malabsorption: Vitamin B12 deficiency is common. Since bile salts are unable to be reabsorbed, gallstones as well as non-bloody diarrhea may occur. 2. RLQ Pain
Extraintestinal Features of Crohn's Disease (12)
1. Migratory Polyarthritis: Migratory polyarthritis is the most common extraintestinal manifestation of Crohn's disease and correlates with disease activity. It is arthritis of the large joints, including the knees and hips. However, small joint peripheral arthritis can also occur independent of disease activity. 2. Erythema Nodosum: Erythema nodosum is inflammation of the fat ulcers the skin. It presents with red, painful splotches on the skin that correlates with disease activity. 3. Kidney Stones: Patients with Crohn's disease have an increased risk of calcium oxalate kidney stones. This is because high oxalate levels are seen in Crohn's disease due to fat malabsorption. Fat binds to Ca+, leaving oxalate free to be absorbed in the gut. As a result, there is a higher concentration of oxalate in the serum and urine of patients with Crohn's disease, increasing the rate of calcium oxalate stones. 4. Sacroiliitis/Ankylosing Spondylitis: AS occurs independently of disease activity. 5. Anterior Uveitis/Iritis 6. Episcleritis 7. Hepatic Steatosis: Hepatic steatosis is associated with malabsorption. 8. Gallstones: Gallstones form due to bile acid malabsorption. 9. Osteoporosis: Patients with inflammatory bowel disease are at a higher risk of osteoporosis, so they require Ca+ supplementation. 10. Osteonecrosis: Patients with inflammatory bowel disease are at a higher risk of osteonecrosis of the hips due to steroid supplementation. 11. Venous/Arterial Thrombosis: Thrombosis occurs independently of disease progression. 12. Vasculitis
Symptoms of Gastroduodenal Disease in Crohn's Disease (6)
1. Nausea 2. Vomiting 3. Epigastric Pain 4. H. pylori Negative Gastritis: PPIs are a mainstay of treatment in these individuals. 5. Fistula in Duodenum 6. Gastric Outlet Obstruction
Symptoms of Ulcerative Colitis (4)
1. Nocturnal Postprandial Diarrhea: The diarrhea of UC can present as rectal bleeding, tenesmus, and mucus passage. 2. Vague Cramping Abdominal Pain: The abdominal pain of UC is often LLQ pain. 3. Proctitis: Proctitis can present with fresh blood or blood-stained mucus in stool with incomplete evacuation. 4. Toxic Colitis: Toxic colitis presents with severe pain and bleeding.
Symptoms of Anterior Uveitis (3)
1. Pain 2. Photophobia 3. Loss of Vision
What are the two major gross morphological findings of ulcerative colitis?
1. Pseudopolyps: Pseudopolyps form with the healing of ulcers. 2. Loss of Haustra: This leads to a lead pipe appearance on XR and CT.
Eight Extraintestinal Features of Ulcerative Colitis
1. Pyoderma Gangrenosum: Pyoderma gangrenosum is a deep, necrotic skin ulceration. It is unknown if it is independent or dependent of disease activity. 2. Primary Sclerosing Cholangitis: This is a biliary disorder in which strictures form in the bile tree. This generally occurs only in patients with UC. 3. Sacroiliitis/Ankylosing Spondylitis: Ankylosing spondylitis is inflammation of the spine, leading to back pain. 4. Anterior Uveitis/Iritis: Uveitis is inflammation of the middle layer of the eye. 5. Osteoporosis: Patients with inflammatory bowel disease are at a higher risk of osteoporosis, so they require Ca+ supplementation. 6. Osteonecrosis: Patients with inflammatory bowel disease are at a higher risk of osteonecrosis of the hips due to steroid supplementation. 7. Venous/Arterial Thrombosis: Thrombosis occurs independently of disease progression. 8. Vasculitis
Symptoms of Ileocolitis in Crohn's Disease (4)
1. RLQ Pain: The RLQ pain of Crohn's disease can mimic appendicitis. It presents as a colicky form of pain. 2. Diarrhea 3. Obstruction: Obstruction can be an intermittent, postprandial, or chronic obstructive process. 4. Fistulas: Fistula formation can occur between the skin, urinary bladder, and mesentery. A fistula between the intestine and bladder can present with pneumaturia, or air in the urine. It presents with a sputtering stream.
Adverse Effects of Cyclosporine (4)
1. Renal Toxicity 2. Hypertension 3. Headache 4. Pneumocystis carinii Pneumonia Risk
What are four feared complications of ulcerative colitis?
1. Toxic Megacolon 2. Adenocarcinoma 3. Massive Hemorrhage 4. Strictures
What are the three major pathological features of ulcerative colitis?
1. Ulcers form in the intestinal tract, typically in the colon. In this condition, there is continuous inflammation of the mucosa and sometimes submucosa. However, it is NOT full thickness inflammation of the lining. 2. Ulcerative colitis always starts in the rectum and works upward. It ALWAYS has rectal involvement. 3. Ulcerative colitis never involves the small intestine.
Classic Presentation of Inflammatory Bowel Disease
1. White Woman in 30s 2. Jewish Descent
Inflammatory Bowel Disease Antibodies (2)
1. p-ANCA: p-ANCA is an antibody seen in vasculitis syndrome. p-ANCA is seen in 60-70% of individuals with UC and 5-10% of individuals with Crohn's disease. 2. Anti-saccharomyces cerevisiae antibodies (ASCA): Saccharomyces cerevisiae is a type of yeast. Antibodies against this yeast are elevated in UC (10-15%) and Crohn's disease (60-70%). * While both tests suggest IBD, they are not reliable for clinical use. Their combined specificity is 94% and sensitivity of 64%.
p-ANCA may identify (4).
1. pancolitis. 2. patients who require early surgery. 3. pouchitis. 4. PSC.
Complications of Crohn's disease include: (11)
1. perforation (1-2%) 2. intra-abdominal/pelvic abscesses (10-30%). 3. intestinal obstruction (40%). 4. massive hemorrhage. 5. malabsorption. 6. severe perianal disease. 7. wasting. 8. sepsis. 9. cancers. 10. social and occupational complications. 11. insurance loss due to effect on life.
Typical studies performed when considering IBD include: (3)
1. stool cultures for Salmonella, Shigella, Campylobacter, and Yersinia. 2. testing for E. coli O157:H7. 3. other studies (C. diff., ova, and parasites).
If dysplasia is seen on a colon biopsy, then (3).
1. the lesion can be observed. 2. the lesion can be removed via EMR. 3. the colon can be removed.
The highest mortality from IBD is seen (2).
1. within the first year. 2. colon cancer in long-term disease.
Vaccinations that are recommended in patients with inflammatory bowel disease include: (11)
8. MMR: If a patient does not have an MMR vaccine, then these patients should receive this vaccination prior to starting therapy, as after therapy, it is contraindicated. 9. Varicella: Varicella is a live vaccine that should be administered prior to the start of therapy. 10. Herpes Zoster: Herpes zoster is an inactivated vaccine that can be given to patients over 50. 11. COVID-19: All individuals over the age of 16 can receive the COVID-19 vaccine.
Anterior uveitis is independent of inflammatory bowel disease activity. What does this mean?
Anterior uveitis is independent of inflammatory bowel disease activity. This means that uveitis may occur without bowel manifestations (i.e. bowel is controlled, but uveitis is present).
What is the mechanism of action of anti-TNF drugs?
Anti-TNF drugs inhibit the inflammatory effects of TNFα that is released from activated macrophages during inflammatory bowel disease.
What is an atypical colitis?
Atypical colitis is a subtype of colitis with a normal colonoscopy, but abnormal microscopic features.
How is atypical colitis treated?
Atypical colitis is treated with a combination therapy of budesonide, bismuth, and loperamide. Azathioprine can be used if refractory diarrhea is present.
Indication for Azathioprine/6-MP
Azathioprine/6-MP are used as a steroid sparing agent for maintenance with a biologic.
What is backwash ileitis?
Backwash ileitis is found in 10-20% of patients with extensive ulcerative colitis. This condition is characterized by "spillover" colonic inflammation in the terminal ileum. Upon endoscopy, the colon appears to present as ulcerative colitis; however, small bowel imaging should be performed to exclude Crohn's disease.
Crohn's Disease Labs CRP: Hemoglobin: Albumin: Leukocyte Count:
Crohn's Disease Labs CRP: elevated Hemoglobin: decreased Albumin: decreased Leukocyte Count: elevated
Abdominal Pain + Bloody Diarrhea + Migratory Polyarthritis =
Crohn's disease
What is the natural history of Crohn's disease?
Crohn's disease begins as inflammation followed by stricturing followed by fistula formation followed by surgery just to start the process all over again.
MTX is administered IM and SQ for _______.
Crohn's disease induction therapy
Epidemiology of Inflammatory Bowel Disease Sex: Age: Race: Ethnicity: Geographic Location:
Epidemiology of Inflammatory Bowel Disease Sex: F > M Age: The age of onset is usually 15 to 40 years, although, some studies suggest a second spike in 50 to 80 years. Race: White Ethnicity: Jewish Geographic Location: IBD has the highest incidence in the UK and North America, but a rising incidence in Japan, South Korea, Singapore, northern India, and Latin America.
True or False: Azathioprine can be used for induction therapy.
False: These drugs have side effects.
Indicationsof Glucocorticoids in Crohn's Disease
For moderate to severe Crohn's disease, particularly ileal disease, budesonide can be used for induction or short-term (3 month) therapy. It has heavy first pass metabolism, so it has few side effects.
How does an individual with long-standing ulcerative colitis present grossly?
Grossly, long-standed ulcerative colitis presents with inflammatory polyps, or pseudopolyps.
How does an individual with mildly inflammatory Crohn's disease present grossly?
Grossly, mild Crohn's disease presents with aphthous or small superficial ulcerations.
How does an individual with mildly inflammatory ulcerative colitis present grossly?
Grossly, mild inflammation presents with an erythematous and granular surface of the intestinal mucosa.
How does an individual with severe ulcerative colitis present grossly?
Grossly, severe ulcerative colitis presents with hemorrhagic, edematous, and ulcerated intestinal mucosa.
Anti-TNF drugs should be used with caution in patients with ______.
HF
_______ is the goal of treatment in Crohn's disease.
Histological remission
How does Crohn's disease present histologically?
Histologically, Crohn's disease presents with aphthous ulcerations, focal crypt abscesses, and loose aggregation of macrophages with noncaseating granulomas in all layers of bowel wall. Submucosal/subserosal lymphoid aggregates are also present with microscopic skip areas, transmural inflammation, fistulous tracts, and local abscesses.
What is indeterminate colitis?
Indeterminate colitis is a form of colitis that cannot be categorized. It is seen in about 10% of patients.
Why is LLQ pain a major symptom of ulcerative colitis?
LLQ pain is a major symptom of ulcerative colitis because UC always involves the rectum.
What is the most common extraintestinal manifestation of Crohn's disease?
Migratory polyarthritis is the most common extraintestinal manifestation of Crohn's disease.
Natalizumab MOA
Natalizumab is a recombinant monoclonal antibody that binds to α4β1 on leukocytes to keep them inside the capillaries, reducing inflammation in the brain and GI tract.
What is the major histological feature of Crohn's disease?
Non-caseating granulomas is the major histological feature of Crohn's disease.
How does Crohn's disease present on CT?
On CT, Crohn's disease presents with small bowel inflammation.
How does Crohn's disease present on MRI?
On MRI, Crohn's disease can present with pelvic abscesses and fistulas.
How does Crohn's disease present on x-ray?
On x-ray, Crohn's disease presents with thickened folds, aphthous ulcerations, strictures, fistulas, inflammatory masses, and abscesses.
(2 methods of delivery) of mesalamine is best for induction therapy in ulcerative colitis.
Oral/topical combination
Why do patients with Crohn's disease have a higher rate of calcium oxalate kidney stones?
Patients with Crohn's disease have an increased risk of calcium oxalate kidney stones. This is because high oxalate levels are seen in Crohn's disease due to fat malabsorption. Fat binds to Ca+, leaving oxalate free to be absorbed in the gut. As a result, there is a higher concentration of oxalate in the serum and urine of patients with Crohn's disease, increasing the rate of calcium oxalate stones.
What is primary sclerosing cholangitis?
Primary sclerosing cholangitis is a biliary disorder in which strictures form in the bile tree. This generally occurs only in patients with UC.
What is pyoderma gangrenosum?
Pyoderma gangrenosum is a deep, necrotic skin ulceration associated with UC.
How is sulfasalazine metabolized?
Sulfasalazine is metabolized in the colon by colonic bacteria, which split the drug into sulfapyridine and 5-ASA. This is a useful drug for ulcerative colitis because it is not active until it reaches the colon.
Ustekinumab may alter the _______ lineage.
Th17 cell
What is the goal of treatment in inflammatory bowel disease?
The goal of treatment in inflammatory bowel disease is remission. There is no cure for IBD, but to maintain these patients in the best state that they can be.
What is the major microscopic feature of ulcerative colitis?
The major microscopic feature of ulcerative colitis is crypt abscesses. Neutrophils infiltrate the crypts.
What is the nutcracker syndrome?
The nutcracker syndrome is compression of the left renal vein between the superior mesenteric artery and aorta.
What is the problem with mesalamine (5-ASA)?
The problem with mesalamine (5-ASA) is that it is absorbed in the jejunum. So, while it has less side effects with elimination of the sulfa moiety, there is less delivery to the colon. However, modified, mesalamine (5-ASA) resist absorption, include asacol and pentasa. These drugs are coated to reach the ileum and colon.
What is the most common location of Crohn's disease?
The terminal ileum is the most common location of Crohn's disease.
Tofacitinib Pharmacodynamics Speed of Response: Route of Administration:
Tofacitinib Pharmacodynamics Speed of Response: fast Route of Administration: oral
What is toxic megacolon?
Toxic megacolon is a rare complication of ulcerative colitis and infectious colitis where there is cessation of colonic contraction. There is evidence that nitric oxide is synthesized and released, which inhibits smooth muscle tone in the colon. This results in intestinal dilation and rapid distension. The wall thins, leaving the walls prone to rupture and perforation.This causes peritonitis.
How is toxic megacolon diagnosed?
Toxic megacolon is diagnosed via a flat plate abdominal x-ray.
True or False: Elemental diets are not palatable for inflammatory bowel disease.
True
Primary sclerosing cholangitis is associated with ____.
UC
Ulcerative Colitis Labs CRP: Platelets: Hemoglobin: Albumin: Fecal Calprotectin: Leukocyte Count: OCP/Bacteria/C. diff Toxin:
Ulcerative Colitis Labs CRP: elevated Platelets: decreased Hemoglobin: decreased Albumin: decreased in severe disease Fecal Calprotectin: elevated Leukocyte Count: elevated (occasionally) OCP/Bacteria/C. diff Toxin: negative
What is the pathophysiology of inflammatory bowel disease?
Under normal conditions, the mucosal immune system is not reactive to luminal contents via a process known as oral tolerance. Also under normal conditions, T-cells suppress gut inflammation through interleukin 10 and transforming growth factor beta. However, in IBD, an inflammatory pathway emerges with inflammatory cytokines (IL-1, IL-6, and TNF). Exogenous pathogens may initiate IBD while psychosocial factors can contribute to the worsening of symptoms.
Vedolizumab MOA
Vedolizumab is a recombinant monoclonal antibody that binds to α4β7 on leukocytes to keep them inside the capillaries, reducing inflammation in the GI tract.
Indication for Vedolizumab
Vedolizumab is used in moderate to severe UC and Crohn's disease for induction and maintenance therapy.
What genetic mutation is associated with Crohn's disease? What is the function of this gene?
While Crohn's disease is a polygenic disorder, a gene known as CARD15 (caspase-associated recruitment domain containing protein 15) on chromosome 16 has been associated with Crohn's disease. CARD15 senses bacterial muramyl dipeptide and regulates intracellular signaling. A loss of function mutation of CARD15 are highly associated with Crohn's disease.
How does inflammatory bowel disease affect fertility?
With quiescent ulcerative colitis and Crohn's disease, a woman has normal fertility. However, with increased disease activity, fertility is affected, with an increase in spontaneous abortions, stillbirths, and developmental defects in the child. As a result, women should allow for six months of remission before conceiving.
Antibiotics have no role in _______.
active or quiescent UC
Ulcerative colitis carries a risk of (cancer).
adenocarcinoma
Strictures from ulcerative colitis increase the risk of _______.
cancer within the stricture
Patients with inflammatory bowel disease are at an increased risk of _______.
cervical cancer
Ileal pouch anal anastomosis ________ fertility in women with ulcerative colitis.
decreases * Scarring from surgery impedes fertility, so egg banking should be considered in these women.
Crohn's disease is a (granuloma formation) disease mediated by (T-cell).
granulomatous; Th1 T-cells
A major cause of bloody diarrhea other than IBD is ______.
infection
MTX should be used with caution in patients with _____.
kidney disease
Ulcerative colitis is a (granuloma formation) disease mediated by (T-cell).
non-granulomatous; Th2 T-cells
A specific indication for infliximab in Crohn's disease is ______.
perianal and fistulizing disease
In Crohn's disease, there is a risk of adenocarcinoma only when _______.
the colon is involved
Induction
the initial treatment phase for active disease
Maintenance Therapy
the phase of treatment once the disease is under control or quiescent
Smoking ________ outcomes in Crohn's disease.
worsens
Predictors of Severe Crohn's Disease (6)
1. Age: younger (< 30 y/o) 2. Anatomic Involvement: extensive 3. Perianal Disease: present 4. Ulcers: deep 5. Prior Surgical Resection: present 6. Stricturing or Penetrating Behavior: present * This indicates more aggressive therapy.
What are two extraintestinal features shared by UC and Crohn's disease?
1. Ankylosing Spondylitis 2. Uveitis
Similarities between Crohn's Disease and Ulcerative Colitis (2)
1. Both conditions are chronic, inflammatory conditions with a relapsing, remitting course with patients that have flares. Then, medication requirements are increased in order to maintain control of the disease process. 2. Both conditions have similar symptoms, including recurrent episodes, abdominal pain, and bloody diarrhea.
What are two nutritional therapies for severe Crohn's disease?
1. Bowel Rest 2. TPN
p-ANCA antibodies are seen in (3):
1. Churg-Strauss. 2. microscopic polyangiitis. 3. UC.
What are the major pathological features of Crohn's disease?
1. Granulomatous Transmural Inflammation: Granulomas are present in Crohn's disease and not ulcerative colitis. Further, the entire intestinal wall is affected. 2. The entire GI tract can be affected from the mouth to the anus. However, the terminal ileum is the most common location. About 30-40% have small bowel involvement, about 40-50% have small and large bowel involvement, and 15-25% have just large bowel involvement. 3. Crohn's disease often spares the rectum and skips sections.
(2 antibiotics) can be used for inflammatory, perianal, and fistulous Crohn's disease for induction and short-term maintenance therapy.
1. Metronidazole 2. Ciprofloxacin
(2) can be prescribed for pouchitis following ileal pouch anal anastomosis.
1. Metronidazole 2. Ciprofloxacin
Primary sclerosing cholangitis is diagnosed via _______.
ERCP/MRCP
_______ is the goal of treatment in ulcerative colitis.
Endoscopic remission
True or False: Ulcerative colitis involves full thickness inflammation of the GI lining.
False
How does ulcerative colitis present histologically?
Histologically, ulcerative colitis presents with mucosa and superficial submucosal inflammation with distorted crypt architecture and basal plasma cell and lymphoid aggregates. The mucosa is edematous with focal hemorrhage. Cryptitis and crypt abscesses are present in long-term disease.
What is the consensus hypothesis of how IBD develops?
In genetically predisposed individuals, both exogenous factors (luminal flora) and host factors (intestinal epithelial cell barrier function and innate/adaptive immune function) along with a dysregulated mucosal immune function modified by environmental factors (smoking) results in inflammatory bowel disease.
How does ulcerative colitis present on x-ray?
On x-ray, ulcerative colitis presents with fine mucosal granularity with ulcers and thickened folds in mild disease and loss of haustration (lead pipe sign) in severe disease.
Proximal ulcerative colitis presents with (2).
1. bloody diarrhea. 2. liquid stool with blood, pus, and fecal matter.
Risk factors for adenocarcinoma in ulcerative colitis include: (4)
1. duration of disease (> 10 years before most cancers form). 2. extent of disease. The more disease, the more risk. 3. involvement of the right colon. Involvement of the right colon means more disease. 4. pancolitis.
Crohn's disease increases the risk of these cancers: (4)
1. non-Hodgkin's lymphoma. 2. leukemia. 3. MDS. 4. small bowel adenocarcinoma.
Indication of Tofacitinib
Tofacitinib is used for moderate to severe UC.
Patients with primary sclerosing cholangitis along with inflammatory bowel disease need to begin ______.
colon cancer screening
The major adverse effect of tofacitinib is _______.
pulmonary embolism
Symptoms of Inflammatory Bowel Disease (2)
1. Abdominal Pain 2. Bloody Diarrhea
Anti-Adhesion Molecules (2)
1. Natalizumab 2. Vedolizumab
How does an individual with active Crohn's disease present grossly?
Grossly, active Crohn's disease presents with stellate ulcerations that merge, forming a cobblestoning pattern.
Why is natalizumab no longer used?
Natalizumab is no longer used due to the risk of progressive multifocal leukoencephalopathy (PML) via JC virus.
(Immune Cell) is a major contributor to inflammatory bowel disease.
T-cells
Jak Inhibitor
Tofacitinib
Anti-IL-12/Anti-IL-23 Drug
Ustekinumab
Due to the risk of adenocarcinoma in ulcerative colitis, _______ is recommended.
colonoscopy
Sulfasalazine requires _______ supplementation.
folate
Smoking ________ outcomes in ulcerative colitis.
improves
Top-down therapy avoids ______.
steroids