Inflammatory Bowel Disease
If patient not responding to traditional therapy or budesonide, need to advance therapy (pt. has moderate to severe to disease) to what?
Biologic Therapy (Anti-TNF (anti-tumor necrosis factor)
•Cons: expensive and less-potent anti-inflammatory activity. •Pros: gut-specific with few systemic side effects
Budesonide (preferred in mild to moderate disease)
•If you have an IBD patient requesting steroids, they NEED a
GI referral.
What is important to monitor in patients with primary sclerosing cholangitis?
Important to monitor LFTs in IBD patient, especially with UC because of PSC.
Infusion medicine, starts with induction, maintenance dosing is one infusion every 8 weeks for most Pt. (Anti-TNF)
Infliximab (Remicade)
Pt. w/o adequate response symptomatically after 2-4 weeks, consider a course of ________.
Pt. w/o adequate response symptomatically after 2-4 weeks, consider a course of corticosteroids
Where is the MOST COMMON involvement of Crohns located?
80% have small bowel involvement (MC at the terminal ileum) (50% ileocolitis- involvement of ileum and colon) (20% have disease limited to colon-Crohn's colitis) (5-15% will have proximal GI Crohns- mouth, gastroduodenal)
•Fulminant Colitis: ________ bloody stools per day with continuous pain, systemic issues, toxic symptoms
>10
Injection medicine, starts with induction, maintenance dosing is one injection every 2 weeks for most Pt. (Anti-TNF)
Adalimumab (Humira)
•Inflammatory _________ are common (Crohns or UC), they do not undergo neoplastic change or require removal
pseudopolyps
What is the FIRST LINE treatment for Mild to moderate Ulcerative Proctitis or Proctosigmoiditis?
1st line treatment is topical 5-ASA therapy. (5-ASA medications have anti-inflammatory/immunosuppressive properties to help control dz.)
Refer to gastroenterology if previously described symptoms that are recurrent or continuous over a period of _______ OR severe acute symptoms
4 or more weeks (also, systemic symptoms, iron def anemia, or abn imaging of GI tract)
__ years after diagnosis or symptom onset, these patients should have surveillance c-scope with biopsies every _____ years.
8 years. 1-3 years
Who should immunomodulators be avoided in?
>60 yoa (anti-TNF monotherapy preferred) •Young male patients (anti-TNF monotherapy preferred)
Which of the following is a very effective biologic immunomodulator against IBD which works via anti-TNF therapy, however patients can develop antibodies to the drug over time? A) Infliximab (Remicade) B) Methotrexate C) Budesonide D) Mesalamine
A (Remicade) (other biologics include Adalimumab, Certolizumab, Natalizumab, vedolizumab)
_______ therapies are approved as 1st line therapy in patients with moderate to severe UC or persistent UC despite oral medications
Anti-TNF
Which disease process is characterized by inflammation of the mucosal lining of the intestinal tract, causing ulceration, edema, bleeding, and fluid and electrolyte loss. A) Celiac disease B) IBD C) Appendicitis D) lactase deficiency
B (IBD)
A patient with a h/o UC presents with tachycardia, fever, and leukocytosis. Imaging shows dilation of the colon. What is the likely diagnosis? A) bowel obstruction secondary to stricture B) toxic megacolon C) colon cancer D) diverticulitis
B (toxic megacolon)
Which person would be most likely to be diagnosed with IBD? A) 30yo African American woman B) 25yo Hispanic male C) 13yo American Jewish male D) all of the above of the same risk
C (13yo American Jewish male | higher prevalence in Jewish white males -- peak incidences occur in early part of 2nd decade w/ second peak between 60-80yo)
Which medication is a controlled release corticosteroid used in IBD which has less systemic side effects and targets the terminal ileum and colon? A) Infliximab (Remicade) B) Methotrexate C) Budesonide D) Mesalamine
C (Budesonide / Entocort)
Which of the following is not an environmental / lifestyle risk factor for IBD? A) living in an urban area B) smoking C) lower socioeconomic status
C (HIGHER socioeconomic status | decreased risk of UC in smokers w/increased risk in former smokers, but increased risk of CD in smokers)
What is the procedure of choice in evaluating the presence and extent of CD? A) DRE B) EGD C) colonoscopy D) barium study
C (colonoscopy | Barium studies for fistulas and strictures)
Which IBD medication should only be used for short-term therapy in moderate or severe disease, but with long-term use can lead to undesirable or irreversible side effects? A) Infliximab (Remicade) B) Methotrexate C) corticosteroids D) Mesalamine
C (corticosteroids - however note that Budesonide / entocort has less systemic SE's and is targeted to TI and colon)
Which of the following is associated with UC, but not Crohn's? A) may affect any portion of the GI tract, but usually spares the rectum B) presence of skip lesions C) pseudopolyp formation D) bowel loop adhesions
C (pseudopolyp formation)
•Pt's w/ acute/concerning symptoms with abdominal pain, tender exam, likely want a ______ abdomen/pelvis
CT. •May demonstrate marked thickening of colon/rectum. (UC) •"colitis" on CT imaging should always be followed up with a colonoscopy to assess for IBD
•Injection medicine, starts with induction, maintenance dosing is one injection every 4 weeks for most Pt. (Anti-TNF)
Cetolizumab pegol (Cimzia)
What are used to induce remission in a patient with newly diagnosed IBD or known IBD with flaring
Corticosteroids (typically used 4-6 weeks at which point tapered slowly.)
lactase deficiency occurs often in patients with celiac disease and _____ disease
Crohn's
•Presenting S/Sx: •Crampy abdominal pain •Constipation or diarrhea •Bloody stools •Unintentional weight loss/food intolerance •Bowel obstruction •Iron deficiency anemia
Crohns Disease
Which of the following is associated with Crohn's, but not UC? A) Always begins distal to the rectum and spreads proximal in continuous fashion B) toxic megacolon C) increased colon CA risk D) abscess and stricture formation
D (abscess and stricture formation)
Which of the following is associated with Crohn's, but not UC? A) bloody diarrhea B) crypt abscesses C) loss of haustral folds D) perforation E) fecal urgency and tenesmus
D (perforation - Penetrating transmural disease leads to abscess and fistula formation with potential to perforate)
______ can provide synergistic effect with biologic therapy and also decreases likelihood of developing antibodies to biologic therapy (i.e. infliximab antibodies)
Dual therapy (immunomodulator + biologic)
Which of the following is associated with UC, but not Crohn's? A) transmural inflammation B) colicky abdominal pain and diarrhea with low grade fever and weight loss C) cobblestone appearance D) creeping fat E) diffuse mucosal inflammation causing bloody diarrhea
E (diffuse mucosal inflammation causing bloody diarrhea - transmural inflammation seen in CD)
Which of the following is a biologic infusion therapy approved for moderate to severe UC which is an integrin receptor antagonist? A) Infliximab (Remicade) B) Adalimumab (Humira) C) Certolizumab (Cimzia) D) Natalizumab (Tysabri) E) vedolizumab (entyvio)
E (vedolizumab)
What is a "sinus tract" , inflammatory tunnel that can present in CD?
Fistula (•Can involve bladder (enterovesicular fistula), skin (enterocutaneous fistula), bowel (enteroenteric fistula), vagina (enterovaginal fistula)) (Have to get SX involved) (Pt. should be on biologic therapy)
Indications for SX in UC includes acute _____ colitis refractory to management with corticosteroids & biologic therapy, colonic ______, and massive colorectal _________.
Indications for SX in UC includes acute fulminant colitis refractory to management with corticosteroids & biologic therapy, colonic perforation, and massive colorectal hemorrhage. (•In emergent surgical setting, typically total abdominal colectomy with end ileostomy is performed)
Mild UC: •_____ stools per day, +/- mild bleeding •Mild abdominal cramping, mild fecal urgency
Mild UC: •<4 stools per day, +/- mild bleeding •Mild abdominal cramping, mild fecal urgency
IBD patients should avoid ______, they can trigger flaring
NSAIDs
What is needed prior to initiating biologic therapy?
Pre-treatment labs. •Medications are immunosuppressants, therefore need vaccination.
•Cons: systemic steroid and more side effects. •Pros: excellent anti-inflammatory activity and very affordable
Prednisone
What extraintestinal manifestations are STRONGLY associated with UC, but is overall a rare condition?
Primary sclerosing cholangitis (Chronic inflammatory condition of fibrosis & stricturing of intra-hepatic & extra-hepatic bile ducts)
What is a fibrotic narrowing/scarring that can present in CD?
Strictures (Can cause an obstruction) (Pt. should be on biologic therapy, may need SX vs endo dilation)
azathioprine (Imuran) , 6-MP (mercaptopurine) •Not regularly used as monotherapy in IBD any longer. •Often used as "dual-therapy" in conjunction with biologic What class of drugs are these?
Thiopurine "immunomodulators"
What would you normally start a pt on who had mild to moderate UC extending beyond the rectum and sigmoid?
Topical 5-ASA is acceptable but usually start oral 5-ASA as well. (Oral mesalamine, 5-ASA molecule, that resists gastric breakdown and has good anti-inflammatory activity in colon) (Expect response after 2-4 wks) (If persistent Sx, r/o concomitant infection (C. diff) vs refractory dz.)
Topical 5-ASA therapy: Rowasa (______ enema) or Canasa (______ suppository)
Topical 5-ASA therapy: Rowasa (mesalamine enema) or Canasa (mesalamine suppository) (Disease remission generally seen after 6 weeks of daily therapy)
(UC / Crohn's) causes diffuse mucosal inflammation that affects the colon only and usually involves the rectum (moving distal to proximal) with pseudopolyp formation
UC
A patient presents with lower abdominal cramping and bloody diarrhea. He also notes fecal urgency and tenesmus. What is the likely diagnosis?
UC
A pt presents with diarrhea, loose stools, fecal urgency/tenesmus, rectal bleeding, abdominal pain, iron deficiency anemia, and nocturnal stooling. What is at the top of your differential?
UC
Surgery is recommended and curative in (Crohn's / UC)
UC
•Histologic features on biopsy: "crypt abscesses, crypt atrophy, architectural distortion, increased lamina propria cellularity"
UC
________ is characterized by recurrent episodes of inflammation of mucosal layer of colon & rectum
UC is characterized by recurrent episodes of inflammation of mucosal layer of colon & rectum
(Crohn's / UC) will have a positive ANCA antibody while (Crohn's / UC) will have a positive ASCA antibody
UC; Crohn's
IBD (inflammatory Bowel Disease) includes what 2 diseases?
Ulcerative colitis and Crohn's disease
•integrin receptor antagonist •Biologic infusion therapy approved for moderate to severe UC
Vedolizumab (Entyvio)
Anyone on immunomodulator needs blood work every 3 months to monitor for what?
adverse effects. (CBC, Hepatic Function Panel) •Monitoring for bone-marrow suppression (cytopenia) , hepatotoxicity
•Treatment of Crohns disease is typically more ______ than UC
aggressive (Given that CD can involve any portion of GI tract, therapeutic effect of oral medications such as mesalamine is going to be limited)
While the definitive cause of IBD is unknown, it is thought to be multi-factorial due to interactions between genes and the environment. It is also though to be ______ in nature as CD4 and T-lymphocytes stimulate macrophages to release pro-inflammatory mediators resulting in the recruitment of leukocytes to the area, stimulating the release of tissue injuring substances
autoimmune
•Pt diagnosed with moderate to severe Crohns based on symptoms and/or mucosal involvement need to be started on ______ therapy early
biologic (usually anti-TNF) (Typically induce remission with prednisone 4-6 weeks followed by slow taper)
In the case of Crohns Disease, "top-down" therapy can also mean initiating a ______ (i.e. infliximab) plus _______ (azathioprine)
biologic plus immunomodulator
•Definitive diagnosis of UC is made by diagnostic biopsies performed during
c-scope (•Endoscopy typically reveals erythema, friability, edema of the rectum and of any proximal colonic involvement)
Definitive diagnosis of Crohns is usually made by diagnostic biopsies performed during what?
c-scope (special attention to the terminal ileum) (•C-scope can only assess for ileocolonic disease and does not 100% rule out Crohns)
When differentiating UC from other GI disorders, check stool studies, may consider fecal _____ which indicates inflammatory diarrhea if abnormal
calprotectin
•Histologic features on biopsy: •"transmural inflammation with lymphoid aggregates, superficial/deep ulceration with granulation tissue, crypt abscess"
crohns disease
•CT ______ can be used to assess small bowel in greater detail
enterography
T/F Due to the increased CRC risk, a patient with Crohn's should have an annual colonoscopy with random biopsy beginning 10yrs after diagnosis
false (UC)
•Due to transmural inflammatory nature of Crohns disease, it can lead to formation of what?
fistulas and strictures
Avoid use of thiopurines in males 20-30 years of age, due to increased risk of what?
hepatosplenic T-cell lymphoma
______ can be described as a chronic immune-mediated inflammatory conditions that affect the GI tract
inflammatory bowel disease (IBD)
corticosteroids ARE NOT an option for maintenance therapy due to what?
long-term side effects (Insomnia, osteoporosis, hyperglycemia, weight gain, skin change, visual disturbance, fluid retention, leukocytosis)
•#1 factor for long-term success of treatment of IBD is what?
medication compliance and routine follow-up
•Normal imaging does _______ inflammatory bowel disease
not exclude
•Ulcerative ____ and ______ not thought to have the same long-term cancer risk as extensive colitis, pancolitis, or Crohns colitis
proctitis and proctosigmoiditis
•Inflammatory _____ are common, they do not undergo neoplastic change or require removal
pseudopolyps
If pt has loss response to biologics, what needs to be checked?
serum antibodies
A pt with mild to moderate crohns may be able to try an initial Tx with ______ induction followed by oral ______daily
steroid induction. oral mesalamine daily (Pentasa, Asacol)
In process of referral, PCP should consider ordering _______ to rule out common infectious pathogens +/- baseline serologies such as CBC, CMP, C-reactive protein
stool studies
(topical / oral) mesalamine delivers the highest concentration of 5-ASA to the distal colon and rectum
topical (side effects are uncommon)
T/F Extra-intestinal manifestations associated with IBD (which may affect the skin, joints, eyes, and hepatobiliary tree) can occur with flares or during remission of symptoms
true (seen in 25% of cases)
(Crohn's disease / ulcerative colitis) is more prevalent
ulcerative colitis (15/100K vs 5/100K)
• UC involves rectum and extends ______ in continuous and circumferential pattern
• UC involves rectum and extends proximally in continuous and circumferential pattern
What should an abnormal CT imaging of colitis be followed up with?
•Abnormal CT imaging of colitis should be followed up with a colonoscopy to rule out IBD (UC or Crohns)
•Age of onset of IBD tends to be 15-40 years of age, though ________
•Age of onset of IBD tends to be 15-40 years of age, though can present at any time
These medications are antibodies directed against TNF-alpha, which plays a role in pathogenesis of inflammatory bowel disease
•Anti-TNF (anti-tumor necrosis factor)
•______ slightly more common in females, ______ slightly more common in males
•Crohns slightly more common in females, UC slightly more common in males
How is a toxic megacolon diagnosed?
•Diagnosed with CT imaging
In Crohns, Endoscopy typically reveals focal ulcerations adjacent to normal mucosa along with polypoid mucosal changes, giving a "______" appearance, "______ lesions" •_________ sparing is common
•Endoscopy typically reveals focal ulcerations adjacent to normal mucosa along with polypoid mucosal changes, giving a "cobblestone" appearance, "skip lesions" •Rectal sparing is common
•IBD tends to be more prevalent in individuals with a ______ heritage
•IBD tends to be more prevalent in individuals with a Jewish heritage
•Inflammation in UC affects _____ layer of colon and extends in a continuous fashion in the colon. •Crohn's disease has ______ inflammation and skip lesions of involvement
•Inflammation in UC affects mucosal layer of colon and extends in a continuous fashion in the colon. •Crohn's disease has transmural inflammation and skip lesions of involvement
What is the cornerstone to long-term remission in mild to moderate UC?
•Maintenance therapy (i.e. oral mesalamine) is the cornerstone to long-term remission in mild to moderate UC and a short-course of steroids just helps you get there
•Moderate UC: ______ ______, loose stools per day •Abdominal cramping, fecal urgency •+/- mild anemia, +/- mild fever
•Moderate UC: •>4 bloody, loose stools per day •Abdominal cramping, fecal urgency •+/- mild anemia, +/- mild fever
How is toxic megacolon treated?
•Need IV corticosteroids, biologic therapy, surgical evaluation
Describe the specific lab findings for diagnosis of IBD
•No specific lab findings for diagnosis - some labs may be indicative
Rectal bleeding is always _____ unless clearly hemorrhoidal.
•Rectal bleeding is always abnormal unless clearly hemorrhoidal (refer to gastroenterology)
•Severe UC: •______ ______ loose stools per day with severe cramping/pain •+fevers and anemia common, tachycardia
•Severe UC: •>6 bloody loose stools per day with severe cramping/pain •+fevers and anemia common, tachycardia
•Smoking is a risk factor for _____ but not ________
•Smoking is a risk factor for Crohn disease but not ulcerative colitis (data suggests smoking can be preventative in UC)
Indications for ELECTIVE surgery include what?
•Symptoms refractory to maintenance medication. •Patients with UC and advanced colon polyps. •Surgery can be curative in UC*
______ is limited to the rectum and colon while _____ can involve any portion of the GI tract.
•UC is limited to rectum and colon •Crohn's disease can involve any portion of GI tract
______ - disease limited to rectum. _______ - disease limited to rectum and sigmoid colon. ________ - disease extending from rectum distal to splenic flexure. ________ - disease extending from rectum proximal to splenic flexure and involving cecum.
•Ulcerative Proctitis - disease limited to rectum. •Ulcerative Proctosigmoiditis - disease limited to rectum and sigmoid colon. •Left-sided (distal) colitis - disease extending from rectum distal to splenic flexure. •Pancolitis - disease extending from rectum proximal to splenic flexure and involving cecum.