Inflammatory bowel disease
How can the range of pain in IBD present?
From crampy pain associated with tenesmus to severe pain or complicated colitis (toxic megacolon, perforation)
How fast does ciclosporin and inflixumab work?
Rapidly
What is commonly seen in UC that isn't commonly seen in Crohn's
Rectal bleeding, Mucus or Pus PR
Which parts of the colon are effected are what are their names?
Rectum - Proctitis, Can extend to parts of the colon (left sided colitis) Or can extend to all parts of the colon (Pancolitis)
What are the SE for ciclosporin?
Renal failure, fits
What treatment should be given if severe UC does not show any signs of improvement (CRP>45) after 3-5 days?
Rescue therapy of IV ciclosporin or inflixumab or colectomy
What is the severe classification of the Montreal classification?
S0 - clinical remission (asymptomatic) S1 - mild UC <4stools a day, absence of systemc illness S2 - moderate UC >4stools a day with minimal signs of systemic toxicity S3 - severe UC >6bloody stools a day, systemic response and anaemic
How is Crohn's managed?
Same way as UC except dietary modification can be used
How is the inflammation in Crohn's characterised?
Segmental transmural inflammation
When is IV ciclosporin indicated in UC?
When there is a severe flair up of the disease and there is contraindication for IV steroids
When is IBD suspected in patients?
When they present with bloody diarrhoea or diarrhoea with systemic inflammation for >3weeks with a -ve stool culture
Which section of the colon does UC not extend to (unless in backwash ileitis)
ileocaecal valve
If a patient with mild to moderate UC what is the aim of the treatment?
induce remission
Define subacute UC
moderately to severely active ulcerative colitis that would normally be managed in an outpatient setting and does not require hospitalisation or the consideration of urgent surgical intervention
Which corticosteroids are used in inducing remission?
oral Prednisolone, broclometasone and tacrolimus
What does a stool MC&S/CDT stand for?
stool microscopic culture and sensitivity /Clostridium difficile toxin
What are the structural, bacterial and immunological cause of IBD?
-Bacterial dysbiosis -The barrier becomes defective and permeable -Neutrophils migrate into the epithelium and are activated without the presence of a pathogen -Cytokines are released (TNFalpha) -T-cell dysregulation
What is the rate of Crohn's affecting the different sections of bowel?
40% ileal 30% colonic 30% ileocolonic
What are the defiing values for moderate UC?
5 motions a day moderate rectal bleeding 37.1-37.8 70-90bpm Hb 105-110
When is colorectal cancer screening started after an IBD diagnosis?
8 years
What are the defining values for mild UC
<4 motions a day small rectal bleeding apyrexic <70bpm Hb >110 ESR <30
What happen in fulminant disease?
>10 stools, bleeding, toxicity, abdo tenderness and distension, requires blood transfusion and dilation
What are the defining values for severe UC?
>6 motions a day larage rectal bleeding >37.8 >90bpm Hb <105 ESR >30
How is UC distinguished from Crohn's?
A biopsy to show inflammation not extending further than the muscularis mucosa, non depletion of goblet cells and no granulomata. UC also only effects the large bowels
Define and describe Crohn's
A disorder of unknown aetiology characterised by transmural inflammation of the GI tract. CD may involve any or all parts of the entire GI tract from mouth to perianal area, although it is usually seen in the terminal ileal and perianal locations. Unlike ulcerative colitis (UC), CD is characterised by skip lesions (where normal bowel mucosa is found between diseased areas). The transmural inflammation often leads to fibrosis causing intestinal obstruction. The inflammation can also result in sinus tracts that burrow through and penetrate the serosa, thereafter giving rise to perforations and fistulae.
Define ulcerative colitis
A form of IBS characterised by relapsing remmitting inflammatory disorder of the colonic mucosa only
What are the other diagnositic factors for OBD apart from bloody stools, PR bleeding and diarrhoea
Abdominal pain, arthropathy and spondylitis, malnutrition, abdominal tenderness, fever and weight loss, skin rashes and constipation
What are the extra intestinal symptoms of IBD?
Clubbing, aphthous oral ulcers, erythema nodosum, pyoderma gangrenosum, conjunctivitis, iritis, episcleritis, arthritis, ankylosing spondylysis, sacroilitis, liver disease
What is the cause of UC?
An autoimmune inappropriate immune response against colonic flora in genetically susceptible individuals
What is Azathioprine?
An immunosuppressant
What causes backflow ileitis?
An incompetent ileocaecal valve
What 3 things may an FBC show in UC?
Anaemia, Leukocytosis and Thrombocytosis
What are the tests to be carried out if some presents with symptoms of UC
Blood tests (FBC, LFT, U&E, CRP, blood culture) Stool MC&S/CDT Faecal calprotectin
What do ulcerative colitis patients experience?
Bloody diarrhoea, chronic diarrhoea, lower abdominal pain, faecal urgency and extraintestinal manifestation
In which IBD disease is extra-intestinal features seen?
Both UC and Crohn's
What is a Stool MC&S/CDT used to exclude?
Camp, Ecoli, Salmonella, C. diff, Shigella
Why is an LFT important in UC and what can it show in UC?
Can show primary sclerosing cholangitis, hypocalaemia, hypoalbuminaemia
Which disease do both IBD disease increase the risk of?
Cancer
What are the environmental factors in IBD?
Childhood hygiene Smoking - Crohn's Non smoking - UC Drugs - NSAIDs Dietary factors Depression Gut microflora Stress
What are the half lives for ciclosporin and inflixumab?
Ciclosporin is for 8 hours Inflixumab for 9 days
Why does Crohn's cause fistulas where UC does not?
Crohn's is transmural
What are the 4 diagnisis of IBD?
Crohn's, Ulcerative colitis, Irritable bowel disease of unknown origin (IBDU) and colotis of unknown type (CUTE)
What are the classes in the Montreal classification?
E1 - ulcerative colitis (distal to the rectosigmoid junction) E2 - left sided colitis (involvement distal to the splenic flexure) E3 - pancolitis (extended colitis) (extends proximal to the splenic flexure)
How is UC diagnosed?
Endoscopy with a biopsy and a negative stool culture
What are the symptoms of systemic symptoms in UC?
Fever, malaise, weight loss, anorexia
What is the anti-TNF now commomly used instead of inflixumab?
Humira (Adalimumab)
What is HLA-B27 a risk factor for?
IBD
How is severe (flair) UC treated?
IV steroids 100mg/h prednisolone or hydrocortisone IV hydration and electrolytes Stool MC&S/CDT Thromboembolism prophylaxis
Which two surgical procedures are recommended for UC flair ups?
Ileostomy and a ileoanal pouch
Whan is inflixumab used?
In acute exacerbations
What is the aim of the treatment for UC?
Induce and maintain remission
How is moderate UC treated?
Induce remission with oral 40mg/d of prednisolone for 1week, taper the dose down then maintain remission with 5-ASA and 5mg perdnisolone
What condition can cause a Crohn's disease to flair up?
Infection therefore stool samples should be taken
What are the SE for inflixumab?
Infection, hypersensitivity
What are the differentials for IBD?
Infective colitis (c. diff, camp, salmonella, shigela, amoeba) IBS, coeliacs, colorectal cancer, ischaemic colitis, diverticulitis
What happens in sclerotic cholangitis?
Inflammation and fibrotic obliteration of the bile ducts
In UC, how far does the disease extend to in extended colitis (pancolitis)?
Inflammation beyond that splenic flexure
In UC, how far does the disease extend up to in left sided colitis?
Inflammation up to the splenic flexure
What does 5-ASA do?
Inhibits inflammatory mediator actions
How are parts of the colon effected?
Involves the rectum and extends proximally to affect variable parts of the colon
Where is the inflammation in Crohn's disease?
Is located at any part of the GI tract from mouth to anus
How can a sigmoidoscopy be helpful in UC?
It can assess the rectum for inflammation and bleeding, it is also cheap and done under no anaesthetic
How can CRP be helpful in managing a patient with UC?
It can monitor the effectiveness of the treatment (IV hydrocortisol) and whether or not surgery may be needed
How is stress a factor for IBD?
It is involved with the psychoimmunilogy mechanism which results in an indirect interaction with the gut
How are genetics a factor in IBD?
It is polygenic
What is given to prevent thromboembolism?
LMW heparin
What supportive management is given for UC?
LMWH Blood transfusions K Nutritional supplements
How is methotrexate used in treating IBD?
Maintains remission
What are the different classifications of Truelove and Will severity index?
Mild UC Moderate UC Severe UC
What is the name of the classification used in UC?
Montreal classification
What are aphthous oral ulcers?
Non contagious reoccurring benign ulcers
What is not seen in UC but is seen in Crohn's?
Obstruction caused by strictures, Fistulas and perianal disease
What are the microscopic features of UC?
On involves the mucosa: Crypts abscesses, depletion of goblet cells, ulcerated tissue are covered in granulated tissue,
What is the choice of treatment for subacute proctitis and prosigmoiditis?
Oran prednisolone
What are the features seen in Crohn's and not UC
Perianal fistula/abscess/skin tags, strictures, ulcers
Pseudopolyps can form in 15-20% of chronic cases, what do these sections exhibit?
Precancerous changes such as carcinoma in situ
What are the liver diseases found in the extra intenstinal symptoms of IBD?
Primary sclerotic cholongitis (jaundice, itching) fatty liver and autoimmune hepatitis
How is remission mainainted in mild to moderate UC?
Topical (enema or supository) Mesalazine 5-ASA with oral Mesalazine 5-ASA Retension prednisolone 20mg suppository
How does smoking effect Crohn's?
Smoking accelerates the disease progression and makes treatment less effective While smoking cessation can be a form of treatment
How does smoking effect UC?
Smoking cessation can cause the onset of UC Nicotine patches are as effective as a treatment as 5 ASA treatment
What does a faecal calprotectin detect?
Specific inflammation of the bowel
Go through the steps in a fistula formation in Crohn's
Starts with an ulcer which become infected causing an abscess to form, the abscess erodes through the gut and forms a communication
What are the significant abdominal complications of Crohn's disease?
Strictures leading to obstruction, abscesses, fistula formation
What are the macroscopic features of UC?
The presence of oedema, accumulation of fat and hypertrophy of the muscular layers giving the wall a thickened appearance, inflammatory polyps
How far can UC extend to if severe?
The submucosa and the muscularis mucosa
How is diet a factor for IBD?
There are only likely suspects such as high animal fat intake, low fibre intake and thickeners
Steroids are not useful in maintaining remission of UC, but what are they good for instead?
They are good at inducing remission
How do pathogens effect UC?
They can cause relapses and so causes the disease to flair up
What is special about arthritic and spondylitis and other spondylarthropathy in a UC patient?
They will usually present with arthritis as a extra intestinal feature of UC
How will UV appear on an X-ray?
Thickened walls
What is fulminant colitis or toxic megacolon characterised with?
Thin-walled, dilated colon that can eventually perforate
In UC, which complication can acute colitis result in?
Toxic megacolon or fulminant colitis
What are the acute complications of UC?
Toxic megacolon, low potassium, venous thromboembolism
What is the name of the classification used to assess the severity of UC?
Truelove and Will severity index
What causes inflammatory polyps to form in UC?
Undermining of mucosa and the excess granulation tissue forming polypoid excrescences
What is commonly seen in Crohn's and not in UC?
Weight loss, abdominal abscess, Obstruction and strictures, Fistulas, Perianal disease
What is the diagnosis of CUTE given?
When it is unknown whether or not to give a diagnosis of Crohn's or UC
What mechanisms in IBD cause thromboembolism?
acute inflammation, dehydration, malnutrition, impaired fibronolysis
What are the symptoms of UC?
episodes of bloody&mucous diarrhoea crampy abdominal discomfort, urgency/tenesmus (proctitis) systemic symptoms
