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98 Cards in this Set
- Front
- Back
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compare the part of the GI tract affected in UC and CD
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UC is colon only and CD can affect any segment
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compare the gross inflammation pattern of UC and CD
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UC is diffuse, contiguous and CD is focal and assymetric
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compare the microscopic inflammation pattern of UC and CD
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UC is mucosal, CD is transmural
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what is the effect of smoking on ulcerative colitis
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may decrease disease activity
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what is the effect of smoking on crohns
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worsens disease activity
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what are complications seen in crohn's
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fistulas, perianal and perineal disease, abscesses, onstruction
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what is a path hallmark in crohns
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granulomas
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what is the age of onset of IBD
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15-30
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what ethnic group is more likely to get UC
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white > non whites, jews> non jews
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what genetic mutation is associated with crohns
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NOD2 in 27-39% of patients (on chr 16)
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compare the role of appendectomy in UC and CD
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protective in UC, no role in CD
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what is the pathogenesis theory in IBD
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overly aggressive T cells against env factors and/or a subset of commensal bacteria/pathogens that live in the GI tract
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IBD is a __ __ genetic disorder
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complex, non-medilian
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chromosomes implicated in IBD
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12 and 16
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what is the role of NOD2
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role in innate immunitiy
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how are NOD2 variants associated with crohn's
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younger age of onset, fibrostenosing dz, small bowel involvement
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how does NOD2 affect management of crohns
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might predict disease course, not all that useful in general
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what is one hypothesis as to why IBD is increasing in developed and developing nations
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hygiene hypothesis (improvements in hygiene decrease exposure to microorganisms and establish the balance between Th1 and Tregs)
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the majority of crohn's occurs in what part of the intestine
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ileocolitis (40%), most adults present with this
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what part of the GI tract is usually affected in kids presenting with crohns
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gastroduodenitis
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clinical presentation of crohn's
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abdominal pain, diarrhea, weight loss, growth retardation in kids, fever and perianal dz
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what are three abnormal labs that would be seen in IBD
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CBC (anemia), CRP or sed rate, and albumin (drops due to leaky gut)
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would bowel strictures be seen in UC, CD, or both
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CD only
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are punched out chronic ulcers are seen in: UC, CD, or both
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CD only
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what is the pathological hallmark seen in CD that distinguishes it from UC
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skip areas (alternating inflammation and nl areas)
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what causes diarrhea in crohns
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protein leaking into the gut from the inflammation and fistulas
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what are the clinical manifestations of inflammation in crohns
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pain, tenderness, diarrhea
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what are the clinical manifestations of obstruction in crohns
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cramps, distention, vomitting
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what are the clinical manifestations of fistulas in crohns
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diarrhea, damage to skin, air/feces in urine,
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what are the 4 types of fistuals that are seen in crohns
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enteroenteric, enterovesical, retroperitoneal, enterocutaneous
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what is a side effect of resection of terminal ileum
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since bile salt and B12 absorption occurs in the terminal ileum, pts can get bile salt diarrhea and B12 deficiency. they can also get fat malabsoprtion if >100cm
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ddx for colitis
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crohns, radiation damage, ischemia, infx (shigella, salmonella, e histolytica, e coli, c diff, CMV), abx, NSAIDS, diversion colitis, diverticular
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UC starts in the ___ and goes up the ___ as the disease progresses
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RECTUM (proctitis), COLON (proctitis--> left sided--> extensive -->pancolitis)
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clinical presentation of UC
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bloody diarrhea, tenesmus (urgency), crampy abd pain with BMs, weight loss, fever, growth retardation in kids
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what is a complication seen in 15-20% of UC pts
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toxic megacolon
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describe the clinical picture of fulminant presentation of UC
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toxic megacolon (15-20%)
extensive colonic involvement >10 stools/day severe cramps fever to 39.5 need for blood transfusion rapid weight loss |
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UC pts have increased risk of developing ___
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colon cancer (screen for dysplasia with colonoscopy 10 years after dx)
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what do you do if a UC pt has dysplasia on colonoscopy
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colectomy
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what are some skin disorders seen in IBD
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erythema nodosum, pyoderma gangrenosum, cutaneous CD
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what are three MSK disorders seen in IBD
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peripheral arthritis, sacroileitis, ankylosing spondylitis
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what are two ocular disorders seen in IBD
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uveitis, scleritis/episcleritis
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what are four hepatobiliary disorders seen in IBD
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PSC, pericholangitis, cholangiocarcinoma, gallstones
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other complications of IBD include ___ and ___
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aphthous stomatitis, thromboembolitic complications
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which IBD frequently has systemic complications
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crohns (UC has them occasionally)
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do you see abd masses in UC
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rarely
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do crohns dz pts respond to abx
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yes
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do UC pts respond to abx
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no
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do CD pts recur after surgery
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yes (up to 70%)
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does cobblestoning occur in UC, CD or both
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CD only
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if you find a granuloma on bx of someone with IBD, which IBD is it
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CD
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does rectal sparing occur in CD, UC or both or neither
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frequently occurs in CD, rarely occurs in UC
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Are biopsy findings in IBD specific?
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No! Any longstanding inflammatory process looks like chronic colitis. You must correlate the biopsy findings with the clinical picture.
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Flashback: What layers compose the mucosa?
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Surface epithelium + Lamina Propria + Muscularis Mucosa
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Flashback: What layers compose the Muscularis Propria?
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Inner circumferential layer + Outer longitudinal layer + Serosa
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True of False: Inflammation is typically seen in the submucosa
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False! It is largely acellular and only contains loose CT and some vessels.
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What does active colitis imply?
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That neutrophils are present
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What are some common histological findings in active colitis?
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Cryptitis (PMNs w/in the crypts)
Crypt Abscess (PMNs w/in the crypt lumen) Ulceration (disruption of the mucosa) |
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What are some common histological findings in chronic colitis?
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Altered crypt architecture (disarray) and increased lamina propria inflammation
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What is Basal plasmacytosis?
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increased numbers of plasma cells b/w crypt bases and muscularis mucosa --> seen in chronic colitis
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What do lots of eosinophils typically indicate?
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inactive chronic colitis
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UC or Crohn's: Pseudopolyps
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UC
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What are pseudopolyps?
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islands of hyperplastic/regenerative mucosa seen in UC
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Into what layers is the inflammation in UC?
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Limited to the mucosa and superficial submucosa
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UC or Crohn's: Skip lesions
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Crohn's
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UC or Crohn's: Cobblestoning, linear ulcers, fissures, fistulas, fat wrapping
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Crohn's
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Into what layers is the inflammation in Crohn's?
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It is transmural!!!
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UC or Crohn's: Epithelioid granulomas unrelated to ruptured cysts
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Crohn's
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UC or Crohn's: Disease is worse distally
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UC
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UC or Crohn's: Transmural lymphoid aggregates
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Crohn's
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UC or Crohn's: No ileal involvement
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UC
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UC or Crohn's: Granulomas only seen in association with ruptured cysts
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UC
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What are the indications of the 5-Aminosalicylates?
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1. Maintaining remission in UC
2. Inducing remission in UC/CD (higher doses) |
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True or False: 5-ASAs are effective for maintenance in CD.
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FALSE
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What are some properties of 5-ASAs that make them useful?
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1. Inhibit prostaglandin and leukotriene synthesis
2. Scavenge free radicals 3. Some immunosuppresant activity 4. Inhibit activation of PPAR-gamma |
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What was the first 5-aminosalicylic acid drug produced?
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Sulfasalazine
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What is another name for 5-ASA?
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mesalamine
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How is 5-ASA activated in the large intestine?
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bacteria in the gut hydrolyze the amide bond connecting the two big structures and 5-ASA topically coats the gut lining
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What is Asacol?
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A form of 5-ASA that is activated by pH ~ 7 so it gets to work in the distal ileum and large intestine
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What is Pentasa?
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A delayed release 5-ASA that works in the distal stomach and throughout the SI and LI
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UC or Crohn's: Budesonide
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Crohn's
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How does Budesonide work?
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Ileal release based on pH.
It is a steroid with a rapid 1st pass effect --> less systemic effects |
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Is Budesonide useful for pancolitis?
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No b/c it isn't activated until it reaches the distal ileum --> only good for Crohn's
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What is Budesonide indicated for?
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mild to moderate ileal Crohn's disease
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What is the initial drug of choice for mild to moderate ileal Crohn's disease?
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Budesonide
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When are corticosteroids indicated?
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Moderate to severe UC and Crohn's
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What is the role of corticosteroids in maintenance therapy of UC and Crohn's?
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None!
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When are steroid sparing agents indicated?
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very severe disease and maintenance of remission
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Name two steroid sparing agents used in the treatment of IBD
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Azathioprine and MTX
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How long do corticosteroids take to become effective?
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not long..hours
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How long do steroid sparing agents take to become effective?
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3 months
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What class of drug is azathioprine?
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Purine analog (metabolized to 6-MP)
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Flashback: What is the mechanism of MTX
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Inhibits DHFR
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What is the indication for Anti-TNF monoclonal Abs?
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Active, severe Crohn's (both luminal and fistulizing)
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How long do monoclonal Abs take to become effective?
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not long..hours
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What is the primary therapy for aggressive Crohn's disease?
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Anti-TNF Abs
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What are 3 anti-TNF Abs?
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Infliximab (UC & CD)
Adalimumab (CD) Certolizumab (CD) |
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Describe the tx pyramid for UC from the bottom up.
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5-ASAs --> Steroids +/- Infliximab --> Immunomodulators +/- Infliximab --> Surgery, Cyclosporin, Infliximab
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Describe the tx pyramid for CD from the bottom up.
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5-ASAs, Budesonide, Abx --> Steroids, Immunomodulators --> Surgery
NOTE: All steps can use Infliximab, Adalimumab, Certolizumab if prognosis is bad |
