TBL 1 - Inflammatory Bowel Disease (IBD): Ulcerative Colitis and Crohn's Disease

1. CD is associated with activation of Th1 and Th17 helper T-cells. 2. CD has been associated with polymorphisms at several specific genetic loci, the most studied of which is the NOD2 gene. 3. The protein product of this gene is involved in recognizing intracellular bacterial peptides. 4. Certain polymorphisms of this gene have been identified in families with a strong history of CD and can increase the risk of developing CD by four fold.

Crohn's Disease (CD) - Genetics

1. transmural inflammation of the bowel, meaning that inflammation is not confined to the mucosa or submucosa. 2. This transmural inflammation can lead to formation of bowel wall strictures and extraintestinal complications such as abscesses and fistulae. 3. The MOST common area of the GI tract that is involved with CD is the distal most ileum.

Crohn's Disease (CD) - Hallmark of Disease

Identify involved segments of the GI tract as well as complications such as abscesses. 1. Contrast x-rays, such as an upper GI series, small bowel follow-through, or barium enema, can show areas of inflammation and stenosis. 2. CT is very useful in localizing areas of inflammation in the bowel as well as extraintestinal fistulae, abscesses, and strictures and can quickly visualize the entire abdominal and pelvic GI tract. 3. MRI performed with enterography protocol is one of the best imaging tests for identifying areas of inflammation and stricture in the small intestine and colon. 4. Pelvic MRI is probably the test of choice in evaluating perirectal and perianal Crohn's disease and can reliably identify complex fistulae and abscesses in this area.

Crohn's Disease (CD) - Imaging Studies

1. Systemic corticosteroids --> acutely ill patients. 2. Methotrexate, a folic acid antagonist which acts to prevent T-cell activation, can be very effective in treatment of CD.

Crohn's Disease (CD) - Initial Therapy

Symptoms: 1. diarrhea 2. cramping 3. abdominal pain 4. weight loss ***most common form.

Crohn's Disease (CD) Patterns - Ileum and Colon

1. IBD refers to a group of idiopathic chronic inflammatory disorders involving the gastrointestinal tract. 2. This group includes ulcerative colitis (UC), Crohn's disease (CD), and indeterminate inflammatory bowel disease. 3. Although UC and CD share some postulated pathways and treatment options, they are very different diseases and distinguishing between them is essential.

Inflammatory Bowel Disease (IBD) - Defintion

Associated areas of involvement include... 1. The liver --> primary sclerosing cholangitis (PSC) 2. Eyes --> uveitis, scleritis, episcleritis 3. Skin --> pyoderma gangrenosum and erythema nodosum 4. Joints --> IBD-associated inflammatory arthritis. ***Patients with active UC are also at an increased risk for venous thromboembolism, especially while hospitalized.

Ulcerative Colitis (UC) - Extra-intestinal Inflammatory Disease Processes

1. For mild UC, anti-inflammatory agents. 2. Nonabsorbable 5'-aminosalicylic acid (5-ASA) derivatives such as mesalamine or sulfasalazine are most commonly used. 3. Rectally administered hydrocortisone is also available as an option for mild distal disease.

Ulcerative Colitis (UC) - First-Line Treatment

1. Ulcerative colitis (UC) is a chronic inflammatory condition involving the colon. 2. It involves chronic inflammation of the mucosa, beginning in the rectum (typically at the anorectal junction) and extending proximally.

Ulcerative Colitis (UC) - General

1. In CD, however, biopsies will show inflammation extending well beyond the mucosa. 2. Also, granulomas may be seen on biopsy from CD patients (but are not always present). --> These are NOT found in UC.

What are found on the biopsy of a patient with CD versus UC?

1. Although taken orally, these medications have very poor absorption across the intestinal mucosa, so they essentially constitute topical therapy for the gut mucosa. 2. Controlled-release preparations of these medications are commonly used, so the medication is NOT released until reaching an area with a specific pH (the colon). 3. Mesalamine is available as a suppository and enema for treatment of disease confined to the rectum or distal sigmoid colon.

5-ASA (mesalamine or sulfasalazine) - Characteristics

B.Crohn disease Patients with Crohn disease typically present with inflammatory bowel disease symptoms: abdominal pain, diarrhea, weight loss, and fever. Crohn disease most commonly causes skip lesions in the ileum, but can be seen anywhere in the GI tract (from mouth to anus). The presence of noncaseating granulomas of macrophages on histologic examination can confirm the diagnosis. Inflammation in the ileum can lead to poor reabsorption of bile acids resulting in malabsorption of fats and fat-soluble vitamins, causing significant weight loss.

A 30-year-old man comes to the physician because of a 1-year history of bouts of diarrhea and abdominal pain, often associated with a low-grade fever. He has unintentionally lost 20 lbs over the past 8 months. Endoscopy reveals well-differentiated, focal patches of ulcerated lesions interspersed between normal appearing bowel mucosa in the duodenum and ileum. Which of the following is the most likely diagnosis? A.Chronic mesenteric ischemia B.Crohn disease C.Small bowel adenocarcinoma D.Ulcerative colitis

B.Pathology always involves the rectum. - This patient likely has Crohn disease, as evidenced by his symptoms of abdominal pain, diarrhea, weight loss) along with perianal disease and aphthous ulcers. - Crohn disease is unique in that it can affect any portion of the GI tract, as opposed to ulcerative colitis, in which inflammation involves the rectum and spreads proximally up the colon. - Approximately one-third of patients with Crohn disease have perianal involvement (eg, perianal skin tags, fissures, abscesses, and anorectal fistulas).

A 30-year-old man comes to the physician because of the development of severe pain upon defecation for the past 5 days. He denies bright red blood per rectum. He has a history of intermittent crampy abdominal pain and a 15-lb unintentional weight loss over the past 6 months. He reports that he recently has been getting "canker sores" in his mouth which are painful and unresponsive to over-the-counter remedies. On exam, the patient is found to have a perirectal abscess. All of the following are true about this patient's likely diagnosis EXCEPT: A.Malabsorption of bile acid contributes to significant weight loss. B.Pathology always involves the rectum. C.Severe narrowing of the intestinal lumen is associated with a positive "string sign" on radiographic imaging. D.Ulcers have an interwoven, "cobblestone" appearance on gross pathology.

C.Sacroiliitis Inflammatory bowel diseases (Crohn disease and ulcerative colitis) are associated with several extraintestinal manifestations, the most common of which is arthritis. This type of inflammatory arthritis usually affects the large joints, and affects multiple joints at once with the symptoms in one joint overlapping with the next ("migratory polyarthritis"). Arthritis of the vertebral spine (ankylosing spondylitis) and sacroiliac joints (sacroiliitis) is also common.

A 35-year-old man comes to the physician because of a 3-month history of back pain and buttock pain that has acutely worsened during the past week. He describes a throbbing, aching pain over his lower back. He denies a history of trauma. He has a history of Crohn disease. Medications include sulfasalazine. His vital signs are within normal limits. He cries out in pain upon palpation of the anterior superior iliac spines. Which of the following is the most likely cause of this patient's pain? A.Herniated disc B.Sacroiliac fracture C.Sacroiliitis D.Spinal canal stenosis

D.Rectum

A 38-year-old man with a history of primary sclerosing cholangitis comes to the emergency department after he noticed bright red blood in his stool this morning. For the past 3 months, he has had progressively worse bouts of diarrhea and predominantly left-sided abdominal pain. On exam, the patient is hypotensive and tachycardic, and fecal occult blood test is positive. Light red, tender round nodules (about 2 cm in diameter) are present on the shins. The cause of this patient's symptoms is most likely to be determined by histologic examination of which of the following sites? A.Bile ducts B.Ileum C.Oral cavity D.Rectum

C.Inflammatory dysregulation causes abnormal signaling of neutrophils and neutrophil infiltration to the tissue. Pyoderma gangrenosum (PG) is an inflammatory lesion that may be ulcerated, pustular, bullous or vegetative and can exhibit pathergy (ie, develop at sites of trauma or irritation). PG is idiopathic and associated with underlying systemic diseases in about 50% of cases (about 15% of PG patients will have an inflammatory bowel disease). PG is an inflammatory lesion thought to be caused by immune/inflammatory dysregulation and dysfunction of infiltrating neutrophils. Large, sometimes nasty appearing, ulcerated lesions are one type of PG and characteristically have a violaceous undermining border. Of note, these lesions are sterile, and do not require treatment with antibiotics or antifungals.

A 46-year-old man with ulcerative colitis develops a tender pink pustule on his leg. Over the course of several days, the lesion becomes painful and ulcerates. On exam, his physician notes a 5-cm diameter irregular ulceration of the skin with a rolled-up, violaceous border. The patient reports "banging" the leg on the side of his bed, and thought it was "just a scratch." He denies recent antibiotic use, insect bites, or new topical cosmetics. Potassium hydroxide preparation is negative. Which of the following best describes the underlying pathology of this patient's skin condition? A.Antigen bound IgE binds to sensitized tissue mast cells causing release of histamine and chemokines B.Compression of soft tissue causes elevated capillary pressure and decreases tissue oxygenation C.Inflammatory dysregulation causes abnormal signaling of neutrophils and neutrophil infiltration to the tissue D.Overgrowth of Group A Streptococcus and other aerobic and anaerobic bacteria that spread through fascial planes causing tissue necrosis

C.Perinuclear anti-neutrophil cytoplasmic antibodies - The findings in the patient described are consistent with a diagnosis of ulcerative colitis (UC). - On gross pathology, affected colonic mucosa may show extensive broad-based ulcers involving the mucosa and submucosa. - Remaining unaffected mucosa regenerates and forms friable, inflamed and raised areas ("pseudo-polyps"). - Histopathology of ulcerative colitis reveals diffuse ulcerations, inflammatory infiltrates, and abscess formation within colonic crypts. - Many patients with UC have elevated perinuclear anti-cytoplasmic antibodies (p-ANCA). p-ANCA can also be positive in Crohn disease, but the test is classically associated with UC.

A patient with symptoms consistent with inflammatory bowel disease receives an upper endoscopy and colonoscopy. A surgical biopsy from an affected portion of bowel shows diffuse ulceration, abscesses within colonic crypts, increased cellularity and basal lymphoid aggregates. Which of the following findings is most likely positive in this patient? A.Carcinoembryonic antigen B.Cytoplasmic anti-neutrophil cytoplasmic antibodies C.Perinuclear anti-neutrophil cytoplasmic antibodies D.anti-Saccharomyces cerevisiae antibodies

1. myelosuppression 2. hepatic toxicity --> hepatic encephalopathy 3. immunosuppression 4. pancreatitis 5. rash --> hyperpigmentation 6. lymphoma 7. fever

CD Drugs - 6-mercaptopurine (6-MP)

1. gastritis 2. nausea/vomiting 3. lymphoma 4. fever 5. may cause --> pancreatitis, leukopenia, anemia, thrombocytopenia

CD Drugs - Azathioprine (Imuran)

1. Diarrhea 2. Nausea 3. Arthralgias 4. Headache 5. Respiratory tract infection --> sinusitis

CD Drugs - Budesonide (Entacart)

1. natalizumab and vedolizumab 2. bind to integrins on the surface of leukocytes, which prevents their binding to endothelial cells and migration into areas of inflammation. 3. Vedolizumab is specific for the intestinal tract, while natalizumab is not. --> NO risk of PML.

CD Drugs - Integrin Blockers

1. Alopecia 2. Photosensitivity 3. Rash 4. Diarrhea 5. Anorexia, nausea, vomiting 6. stomatitis 7. leukopenia 8. pneumonitis

CD Drugs - Methotrexate (MTX)

1. Hypertension (HTN) 2. Fluid retention 3. Hypernatremia (increased Na+) 4. Osteroporosis 5. Depression 6. Increased risk of infection

CD Drugs - Prednisone

1. celiac disease 2. chronic pancreatitis 3. colorectal cancer (CRC) 4. diverticulitis 5. infection (e.g., yersinia, mycobacterium) 6. irritable bowel syndrome (IBS) 7. ischemic colitis 8. lymphoma of small bowel 9. sarcoidosis 10. ulcerative colitis (UC) 11. radiation-induced enteritis or colitis

Complete List of Differential Diagnosis for Crohn's Disease (CD)

1. Formation of fibrotic strictures can lead to obstruction of the involved portion of the GI tract with resultant nausea and vomiting or abdominal distension. 2. Disease that penetrates through the bowel wall can produce abscesses, resulting in pain, fever, and weight loss. 3. Fistula formation is seen in many patients with CD and involves development of tunneling sinus tracts from a loop of bowel to another area. 4. Fistulae can form between adjacent loops of bowel (enteroenteric or enterocolic), to skin (enterocutaneous), to other intraabdominal hollow viscera such as the bladder (enterovesical/colovesical) or vagina (colovaginal/rectovaginal), or rarely to other vital structures (e.g. aortoenteric).

Crohn's Disease (CD) - Complicated Clinical Manifestations

1. Geographic distribution of CD is similar to that of UC. --> North America and Northern Europe. 2. Bimodal age distribution of CD incidence, with most cases being diagnosed between the ages of 15-35, but a second peak of incidence occurring between the ages of 50-60. 3. There is an increased risk of developing CD in first degree family members of CD patients, and this risk is HIGHER than that seen in UC. 4. In contrast to UC, the risk and severity of CD increase with cigarette smoking. --> The risk of developing CD is also increased in patients with a prior history of appendectomy.

Crohn's Disease (CD) - Epidemiology

1. Chronic idiopathic inflammatory condition of the gastrointestinal tract. 2. Unlike ulcerative colitis (UC), CD can involve any area of the GI tract, including the oral cavity and perianal skin. 3. CD does NOT produce continuous inflammation, rather it can involve inflammation of localized segments of the GI tract with completely normal areas between involved areas. --> "cobblestoning"

Crohn's Disease (CD) - General

1. Diarrhea, abdominal pain, and weight loss. --> fever is NOT uncommon. 2. Oral aphthous ulcers (canker sores) are common. 3. Children and adolescents may present with impaired growth. 4. Bloody diarrhea can be seen in patients with active distal colonic disease, which can be difficult to differentiate from UC in some cases (at least initially).

Crohn's Disease (CD) - General Clinical Manifestations

1. Vitamin B12 malabsorption and deficiency are common in patients with CD, either due to chronic disease of the distal ileum or surgical resection of the distal ileum. --> Anemia is common and can be multifactorial, due to B12 deficiency, chronic blood loss, or medication side effects. 2. Bone Mineral Loss --> due to malabsorption of vitamin D as well as a consequence of chronic corticosteroid therapy. 3. Diabetes Mellitus 4. Bile salt malabsorption due to terminal ileal disease/removal can result in chronic diarrhea (independent of disease activity), malabsorption of dietary fat/fat-soluble vitamins, and gallstone formation. 5. Nephrolithiasis --> calcium oxalate stones due to malabsorbed free fatty acids that complex with calcium ions.

Crohn's Disease (CD) - Malabsorption

1. Overall prognosis in patients with CD is not as good as for patients with UC. 2. There is an increased risk of cancer in patients with CD. --> CRC risk is increased in patients with extensive chronic colon involvement and such patients should undergo colon cancer screening similar to UC patients. 3. There is an increased risk of squamous cell carcinoma of the anus in patients with anal/perianal CD. 4. There is a significantly increased risk of small intestinal adenocarcinoma in patients with CD.

Crohn's Disease (CD) - Prognosis

1. Unlike UC, CD is NOT curable with surgical therapy. 2. Surgery is often required in patients with CD due to development of large abscesses, obstructing strictures, or fistulae that are causing other problems (such as recurrent UTI). 3. The most common area to be resected in CD is the terminal ileum/cecum. 4. Whenever resection is performed, an attempt is generally made to remove only as much bowel as necessary.

Crohn's Disease (CD) - Surgical Therapy

1. Most effective when used in conjunction with another medication, particularly biologic agents. 2. TNF blocking agents such as infliximab, adalimumab, and certolizumab, are used more often and earlier in CD as compared with UC. 3. They have been shown to reduce inflammation and can heal fistulae in many patients. 4. Integrin a4b7-blocking therapy with vedolizumab is also effective in CD. 5. Another new biologic option is ustekinumab, which is a monoclonal antibody targeting interleukins 12 and 23. --> This has shown good effect in patients with CD, including those with severe disease.

Crohn's Disease (CD) - Thiopurines

1. Patients being considered for treatment with these agents, particularly the TNF-blocking drugs, should be screened for chronic or latent infections with hepatitis B or Mycobacterium tuberculosis. --> vedolizumab does not appear to carry the same risk of infections. 2. There is an increased risk of developing certain cancers in patients on chronic immunosuppressive therapy. --> Thiopurine medications are associated with an increased risk of lymphoma.

Crohn's Disease (CD) -Considerations when Administering Biological Agents

Symptoms: 1. diarrhea 2. rectal bleeding 3. perirectal abscess 4. fistula 5. perirectal ulcer ***skin lesions and arthralgias more common.

Crohn's Disease (CD) Patterns - Colon Only

Symptoms: 1. anorexia 2. weight loss 3. nausea 4. vomiting ***rare form, may cause bowel obstruction.

Crohn's Disease (CD) Patterns - Gastroduodenal Region

Symptoms: 1. diarrhea 2. cramping 3. abdominal pain 4. weight loss ***complications may include fistula or abscess formation.

Crohn's Disease (CD) Patterns - Small Bowel Only

1. The differential diagnosis of CD includes most of the same processes that must be ruled out in UC. 2. Another condition to be excluded is Behcet's disease, an autoimmune condition that is associated with ulcers throughout the GI and GU tract. 3. Of particular importance in diagnosing CD is ruling out atypical infections such as mycobacterial (TB) or fungal (histoplasmosis, blastomycosis) infections, which can cause localized inflammation in the small intestine and also have granulomas on biopsy.

Differential Diagnosis for CD

D.Ulcerative colitis: D; Crohn's disease: A, B, C Because Crohn's disease causes transmural inflammation of the bowel wall and can affect the entire length of the GI tract, there are a number of associated GI complications. Fibrotic strictures with narrowing of the bowel lumen can develop as a result of transmural pathology. Transmural inflammation can also lead to re-epithelization to other organs, creating fistulas (aberrant connections between bowel and other sections of bowel, bladder, skin or vagina). Most patients with Crohn's have small bowel involvement, especially of the distal ileum. This can lead to impaired bile salt absorption resulting in malabsorption of fats and fat-soluble vitamins. Ulcerative colitis is confined to the colon and rectum and histopathologically, limited to the mucosa and submucosa. In advanced disease, inflammation may extend to the smooth muscle of the colon, causing paralysis and development of toxic megacolon. Severe dilation can lead to large bowel obstruction, perforation, and systemic toxicity.

Match the following gastrointestinal complication to the associated disease (Ulcerative colitis (UC), Crohn disease (CD)). A. Colovesical fistula B. Fibrotic strictures C. Malabsorption of fat-soluble vitamins D. Toxic megacolon A.Ulcerative colitis: A, B, D; Crohn's disease: C B.Ulcerative colitis: A, B; Crohn's disease: C, D C.Ulcerative colitis: C, D; Crohn's disease: A, B D.Ulcerative colitis: D; Crohn's disease: A, B, C

1. Enteric pathogens such as Campylobacter or Salmonella have been noted to increase the risk for the development of UC. 2. It is thought that these agents may help trigger an inflammatory response that continues even after the acute infection has resolved.

Ulcerative Colitis (UC) - Acute Infections

1. Inflamed mucosa with formation of ulcers, although the inflammation does NOT generally extend beyond the submucosa. 2. Bowel involvement in UC is confined to the colon and always in a CONTINUOUS fashion, from distal to proximal. 3. The extent of inflammation varies among individuals, with some patients having inflammation in the rectum only (ulcerative proctitis), some extending to the sigmoid or descending colon (left-sided colitis), and some with inflammation extending to the right colon or even the cecum (pancolitis).

Ulcerative Colitis (UC) - Bowel Pattern

1. Most common in Northern Europe and North America. --> However, for migrants from low to high prevalence, the risk of developing UC in their children matches that of non-immigrants (STRONG ENVIRONMENTAL ASSOCIATION) 2. The peak age of onset is between ages 30 and 40, but the disease can be diagnosed at any age. 4. There is an increased risk of developing the disease among first-degree family members of patients with UC. 5. Interestingly, the risk of developing UC is decreased in smokers and in patients who have undergone an appendectomy.

Ulcerative Colitis (UC) - Epidemiology

1. Association with genetic defects in mucosal barrier function --> development is related to "leaky gut." 2. Immune dysregulation and loss of tolerance to normal constituents of the microbiome. --> Activation of T-cells, particularly Th2 cells, has been noted and appears to be a key component of the inflammatory process. 3. Strong associations with specific genetic loci have not been identified (unlike in Crohn's disease).

Ulcerative Colitis (UC) - Pathogenesis

1. Generally very good with appropriate care. --> It is a chronic condition with acute flares and relapses. 2. Most patients will require ongoing medical treatment for life, although most patients can be controlled well with medical management only. 3. Noncompliance with therapy and lack of followup care can be major problems, particularly for patients diagnosed in childhood or adolescence. 4. Annual screening colonoscopy is recommended for all patients with UC beginning 8-10 years after diagnosis.

Ulcerative Colitis (UC) - Prognosis

1. Dehydration (due to excessive diarrhea). 2. Anemia (due to chronic blood loss in stool) 3. Weight loss. 4. The MOST dreaded ACUTE complication is toxic megacolon. --> the colon becomes dilated, either partially or in total, with loss of colonic motility, bacterial overgrowth, and sepsis. --> Dilation of the colon is also associated with thinning of the colon wall and can result in bacterial invasion and PERFORATION. ***This typically develops in patients with longstanding extensive, uncontrolled disease with deep ulcerations.

Ulcerative Colitis (UC) - Severe Cases

1. Azathioprine and 6-mercaptopurine (6-MP) can be used in UC to help maintain long-term remission. 2. Reduce mucosal inflammation by inhibiting T-cell function. 3. However, their onset of action is very slow, so they are NOT effective treatments for managing acute flares of disease.

Ulcerative Colitis (UC) - Thiopurine Drugs

1. As this is a chronic disease, patients will usually present with symptoms lasting for several weeks or months. 2. Care must be taken in patients presenting with acute onset symptoms, as other acute processes affecting the colon (such as infectious, ischemic, or drug-induced colitis) can be mistaken for UC.

Ulcerative Colitis (UC) - Timing

These are typically monoclonal antibodies that target specific molecular targets in the body to suppress the inflammatory response.... 1. Medications that target tumor necrosis factor-alpha (TNF), which is a key signaling cytokine in mucosal inflammation in UC. --> Examples of these medications include infliximab, adalimumab, and certolizumab. o These medications can be given as an IV infusion or subcutaneous injection, and are given at intervals ranging from 2 to 8 weeks. 2. Vedolizumab, which is a monoclonal antibody targeting integrin a4b7, a specific cell adhesion molecule found on lymphocytes. --> Inhibition of this molecule interferes with the ability of activated lymphocytes to migrate to the intestinal mucosa. ***All of these medications are effective at inducing and maintaining remission in patients with UC.

Ulcerative Colitis (UC) - Treatment of REFRACTORY, severe disease

1. Systemic corticosteroids are typically used. 2. Very effective at bringing disease under control, but NOT as effective at maintaining remission. 3. Oral steroids (e.g. prednisone) are commonly used, but intravenous corticosteroids can be used acutely in patients who require hospitalization. 4. Once clinical improvement is seen, another medication such as mesalamine or azathioprine (immunosuppressant) is added to help maintain disease remission as the steroid dose is gradually tapered.

Ulcerative Colitis (UC) - Treatment of Severe Cases

1. Surgery is the ONLY option. --> involves removal of the entire colon and rectum (total proctocolectomy). 2. Most patients do not require permanent ileostomy, as creation of an ileoanal anastomosis (typically with ileal pouch-anal anastomosis (IPAA)) is possible. 3. However, in cases of severe inflammation, a staged procedure may be used in which an ostomy is created when the colectomy is performed, and a second surgery is performed a few months later to take down the ostomy and create the anastomosis once the inflammation has subsided. ***In patients with UC, total proctocolectomy is curative, since bowel inflammation in this condition is confined only to the colon. ***Some extraintestinal conditions also resolve after colectomy, but others (such as PSC) do not.

Ulcerative Colitis (UC) - Treatment of the VERY severe disease (including megacolon)

1. diarrhea, often containing red blood. 2. abdominal pain, in the lower abdomen or LEFT lower quadrant. 3. urgency with stools, feelings of incomplete defecation, or pain that is relieved after a bowel movement. 4. fever 5. over time, patients may develop anemia from blood loss. --> in rare cases, patients can develop severe acute blood loss.

Ulcerative Colitis (UC) - Typical Presentation

Colorectal Cancer (CRC) 1. Risk of adenocarcinoma of the colon is increased significantly in the setting of longstanding mucosal inflammation. 2. This risk develops in patients after 8-10 years of UC and continues to increase with time. 3. The risk also increases with extent of inflammation, so that patients with pancolitis have a greater risk than those with less-extensive disease. ***The risk of colon cancer is NOT increased in patients with disease confined to the rectum only (ulcerative proctitis).

What is the most feared LONG-term complication of UC?

Endoscopy. 1. The terminal ileum can usually be reached during colonoscopy which allows for biopsies to be performed. 2. Endoscopically, involved mucosa appears inflamed and ulcerated. 3. Inflamed mucosa will have a red, swollen appearance and is sometimes described as having a "cobblestone" appearance. --> areas of inflammation separated by stretches of normal mucosa ("skip lesions").

What is the test of choice for confirming the diagnosis of CD?

A. Migratory polyarthritis The most common extraintestinal manifestation of inflammatory bowel disease (IBD) is arthritis, which is associated with HLA-B27 positivity. It is typically a migrating polyarthritis--occurs in multiple joints and onset overlaps, giving the appearance that the arthritis is "migrating" from joint to joint. Knees, ankles, elbows, and wrists are most commonly affected. Arthritis involving the vertebral spine (ankylosing spondylitis) or sacroiliac joints (sacroiliitis) can also occur.

Which clinical variant of arthritis would be most likely in an HLA-B27-positive young man with a history of ulcerative colitis? A.Migratory polyarthritis B.Monoarticular arthritis C.Reactive arthritis D.Rheumatoid arthritis

D.Pseudopolyps he endoscopic findings of ulcerative colitis (UC) and Crohn disease are non-specific and share many similarities: erosions, ulcerations, edema, and friability. In both of these inflammatory bowel diseases, ulcerations of the bowel mucosa which can be depressed below normal mucosa. This allows normal mucosa to proliferate and appear as non-neoplastic pseudopolyps. In Crohn disease, ulcerations tend to be deeper, more linear, and serpiginous, and areas of normal mucosa create a "cobblestone" appearance. Pseudopolyps are more characteristic and more common in UC. The diagnosis of Crohn disease versus UC requires corrabotory histological evidence of disease: transmural inflammation and "skip" lesions in Crohn disease and abscess formation within crypts in ulcerative colitis only affecting mucosa and submucosa.

Which endoscopic finding is more commonly found in patients with ulcerative colitis as compared to Crohn disease? A.Aphthous ulcers B.Bowel strictures C.Fistula D.Pseudopolyps

B.A, C, D, F, G

Which of the following is an extraintestinal manifestation associated with ulcerative colitis (UC)? A. Anterior uveitis B. Cardiomyositis C. Migrating polyarthritis D. Nephrolithiasis E. Erythema elevatum diutinum F. Erythema nodosum G. Pyoderma gangrenosum A.A, B, C, E, F and G B.A, C, D, F, G C.All (A through G) D.B, C, F, G

C.Vitamin B12 Deficiency of B12, a water-soluble vitamin, is more likely to be associated with another gastrointestinal disorder, atrophic gastritis, which is due to decreased production of intrinsic factor. As the intrinsic factor-B12 complex is absorbed in the terminal ileum, Vitamin B12 deficiency is possible in Crohn disease, particularly in patients who have undergone ileal resection with a large reduction in the length of the ileum. However, this is less much likely to occur than malabsorption of fat-soluble vitamins (leading to a deficiency of vitamin A, D, E, or K).

Which of the following nutritional deficiencies is LEAST likely in a 40-year-old man with a long history of Crohn disease? A.Iron B.Vitamin A C.Vitamin B12 D.Vitamin D