Inflammatory Bowel Disease

Front 1

How does Inflammatory Bowel Disease present?

Back 1

1. Chronic Diarrhoea +/- malabsorption
2. Pain
3. Bleeding
4. Obstruction/Mass
5. Fistula (usually Crohn''s)
6. Altered bowel habit
7. Anaemia
8. Weight loss (due to malabsorption)
9. Extra-intestinal manifestations
10. Colorectal Cancer

Front 2

What would be the dDx for UC?

(Bloody diarrhoea)

Back 2

• IBS + Haemhorrhoidal Bleeding
• Acute Self-limiting colitis (infection/NSAID)
• Ischaemic Colitis (usually older pts.)
• Pseudomembranous colitis (antibiotic use)

Front 3

What would be the dDx for Crohn's?

(Non-bloody diarrhoea)

Back 3

• IBS (20x more common than any IBD)
• Acute self-liming colitis/ileitis (Infection/NSAID)
• Coeliac's
• C. difficile diarrhoea
• Bile Salt diarrhoea (gallbladder removed)

Front 4

Where might ischeamic colitis occur?

Back 4

At the splenic flexure of the colon (watershed area)

Front 5

What type of cell lines the large intestine?

Back 5

Columnar Epithelium

Front 6

What types of mucosal cells are found in the colon?

Back 6

1. Goblet Cells (in the crypts)
2. Paneth Cells (in caecum and ascending colon)
3. Endocrine Cells (modulate digestive functions)

Front 7

What are the 4 types of IBD?

Back 7

1. Ulcerative Colitis
2. Crohn's Disease
3. Indeterminate Colitis (10% of IBD)
4. Microscopic Colitis (abnormal only biopsy and inflammatory markers, gross is fine)

Front 8

What is the relationship between the environment and genetics in the cause of UC and Crohn's?

Back 8

UC --> Environment > Genetics

Crohn's --> Genetics > Environment

Front 9

What is the final common pathway of Idiopathic Inflammatory Disease?

NB: Recall, mechanism cause is still debated.

Back 9

Final Common Pathway = Inflammation

1. Impaired mucosa integrity/destruction
2. Loss of absorptive function (diarrhoea)
3. Loss of blood (anaemia) & protein (malnutrition)
4. Increased secretory function (diarrhoea)
5. Therapy - downregualte immune response

Front 10

What is the epidemiology of Crohn's?

Back 10

1-3/100,000/year

Mostly western populations

More common in Female, White, Jewish

Incidence - Teens, Peak in 20's

NB - Smaller peak in 50's/60's

Front 11

What are the gross features of Crohn's?

Back 11

• Can affect any portion of the GIT
• Is segmental with skip lesions
• Transmural involvement

• Will see creeping fat, dull serosa
  
• Thickened wall b/c oedema, inflammation, fibrosis
  
• Strictures/narrow lumen
• Aphthous mucosal ulcers (cobble-stone)
• Fissures/Fistulas/Sinus Tracts

Front 12

What are the microscopic features of Crohn's?

Back 12

• Chronic Mucosal damage wth crypt architectural distortion
• Mucosal ulceration + fissuring
• Inflammation

Transmural

Cryptitis (neutrophils in crypt walls)

Crypt abscess (neutrophils in crypt lumen)

Lymphoid aggregates

+/- non-caseating granuloma

• May dysplasia if late disease

Front 13

What are the clinical features of Crohn's?

Back 13

• Variable, relapse and remitting
  
• Intermittent diarrhoea, abdominal pain, fever
• Attacks may be precipitated by stress
• Occult or overt faecal blood loss -> anaemia

Megablastic anaemia (B12 Malabsorption)

NB - B12 absorbed in terminal ileum

• Weight loss

Front 14

How is Crohn's diagnosed?

Back 14

Small bowel or colon biopsy

Front 15

What are complications of Crohn's?

Think: What happens if inflamed?

Back 15

• Obstruction (b/c fibrosis)
• Adhesions (inflammation)
• Fistula (inflammation)
• Malabsorption (destruction of mucosa)
• Slight increase carcinoma risk (SB)

Front 16

What are the systemic manifestations of Crohn's?

Back 16

1. Aphthous mouth ulcers, stomatitis
2. Arthritis (esp asymmetrical)
3. Uveitis > episcleritis
4. Erythema nodosum, pyoderma gangrenous
5. Primary Sclerosing Cholangitis
6. Clubbing

Front 17

What is the epidemiology of Ulcerative Colitis?

Back 17

4-12/100,000 annually

Mostly caucasian, M=F

All ages affected, peak in (early) 20's

Front 18

What is the gross pathology of UC?

Back 18

• Begins in rectum and extends proximally in continuous fashion
  
• Can involve entire colon
• Colon will be red with large areas of ulceration that is confined to the mucosa

• Wall is NOT thickened (b/c not transmural)
• Normal Serosa (unlike Crohn's)

Front 19

What is the microscopic pathology of UC?

Back 19

Inflammation is confined to the mucosa

• Cryptisis and Crypt access (same as Crohn's)
• Ulceration
• May show dysplasia
• No granuloma (Crohn's may)

Front 20

What are the clinical features of UC?

Back 20

1. Replacing and remitting
2. Triggered in some who quit smoking
3. Precipitated by stress/NSAIDS/Infection
4. Intermittent bloody diarrhoea, urgency, abdominal pain, tenesmus
5. Fever/Weight loss (inflammation/Malabsorp)
6. Anaemia (blood loss)
7. Extra-intestinal manifestations (UC>CD)

Front 21

How is UC diagnosed?

Back 21

Colon biopsy

Front 22

What are complications of UC?

Back 22

Toxic Megacolon

• Acute dilation of colon due to toxic damage to muscular propria and neural plexus with shutdown of neuromuscular function

Increase colorectal cancer risk (10x risk at 10yrs)

Further increase is PSC of family Hx

Front 23

What are the systemic manifestations of UC?

Back 23

Joint --> Migrating polyarthritis, Ankylosing Spondylitis

Skin --> Erythema nodusum, pyoderma gangrenous, clubbing

Liver --> PSC

Uveitis + Mouth Ulcers (CD > UC)

Front 24

What are the differences between UC and CD?

Back 24

UC then Crohn's

Site: Colon/anywhere

Patchy: No/Yes

Continuous: Yes/No

Strictures: Rare/Yes

Fistula: No/Yes

Bloody Diarrhoea 90-100%/50%

Pain Rare/Common

Mouth Ulcers Rare/Common

Front 25

Features distinguishing UC and CD

Back 25

Localisation: UC = Distal/ CD = Segmental+prox

Rectum affected: UC = Always/ CD = 50%

Intestinal Wall: UC = Normal/ CD = thick

Adhesions: UC = Rare/ CD = common

Inflammation: UC = Superficial/ CD all layers

Ulceration: UC = superficial/ CD = deep

Mucous membrane: UC = Denuded/ CD = Cobble

Granulomas: UC = 0%/ CD = 30-40%

Lymphocyte infiltrate: UC=Rare/CD=Always

Fistulae: UC=Rare/CD=Common

Front 26

How common in UC with:

a) Rectal involvement

b) Left-sided colitis

c) Pancolitis

Back 26

a) 95%

b) 75%

c) 15-25%

Front 27

How common is CD with:

a) Small intestine only

b) Ileocolonic disease

c) Colon only

Back 27

a) 40%

b) 30%

c) 30%

Front 28

How is diagnosis of IBD made?

Back 28

1. History
2. Physical Exam
3. Labs
4. Stool Cultures
5. Colonoscopy
6. CT
7. MRI pelvis
8. Laparoscopy

Front 29

What bloods should be looked at for IBDs?

Back 29

Inflammatory Markers

• FBC (also anaemia)
• ESR
• CRP
• Albumin
• Feral Calprotectin

Others

• U&Es, LFTs, Iron, B12, Folate, Calcium, Mg

Front 30

How is Ulcerative Colitis Managed?

Back 30

Drugs

• 5-ASAs
• Steroids
• 6MP
• Anti-TNFs
• Cyclosporin A

Surgery (if severe acute or unresponsive)

Front 31

How is Crohn's managed?

Back 31

Drugs

• 5-ASAs
• Steroids
• Antibiotics
• 6MP
• Methotrexate
• Anti-TNFs

Surgery (60%)