Inflammatory Bowel Disease

Front 1

What is a group of chronic inflammatory conditions of the colon and small intestine?

Back 1

IBD

Front 2

What is characterized by a tendency for chronic or relapsing immune activation and inflammation within the GI tract (also as a dysregulation of the immune respond to GI luminal bacteria)? What are the two major forms?

Back 2

Idiopathic inflammatory bowel disease

Crohn disease and ulcerative colitis

Front 3

Name three gene mutations associated with each component of IBD:

Innate immunity, adaptive immunity, and epithelial immunity

Back 3

Front 4

Describe whether each has an increased incidence, decreased incidence, or no effect on UC and CD:

Cigarette smoking, appendectomy, high-sanitation level in childhood, high-intake refined carbohydrates.

Back 4

Front 5

What is the hygiene hypothesis? What is the conflicting data on IBD between the Manitoba case-control and the Montreal case-control?

Back 5

Front 6

Draw the pathogenesis of inflammatory bowel disease. Use bacterial components, macrophage, dendritic cell, neutrophils, CD4 T cell, and the associated cytokines release by each.

Back 6

Front 7

What is a chronic inflammatory disorder of the GI tract affecting the large bowel?

Back 7

Front 8

Where does ulcerative colitis usually begin? Where does it extend? Any skip lesions?

Endoscopically: hyperemia, ____ , granularity with friability, easy bleeding, broad based ulceration, _____, tunnels with mucosal bridges, rarely perforation

Toxic megacolon: shutdown of _____ function secondary to exposure of fecal material to _____ and neural plexus

Rarely pericolonic abscess

Indolent, relapsing disease

Back 8

Front 9

What is shown here? Describe it.

Back 9

Front 10

What is the condition?

Describe: extensive
_____ leaving behind islands of mucosa at the previous
surface level = ______ (not true polyps [bumps
projecting into lumen above normal surface level], but bits of normal level mucosa looking like that because surrounding ______ mucosa is below normal surface level).

Back 10

Front 11

What is a characteristic feature of ulcerative colitis (where layer is the disease limited to)?

Back 11

Muscularis and serosa are NOT affected.

Front 12

What is this characteristic finding in ulcerative colitis? What are they filled with?

Back 12

Front 13

What is this condition called that is associated with UC?

Back 13

Front 14

Identify Proctitis, left-sided, and pancolitis.

Back 14

Front 15

UC:

Up to 30% with disease limited to proctitis or proctosigmoiditis present with what?

Is abdominal pain usually a prominent feature?

Are fistulization, stricture, skip areas, and abscess formation characteristic?

Back 15

Front 16

What percent of patients have rectal sparing? What is this called? If the rectum is normal, what is the disease?

Does Crohn's disease typically have skip areas?

Back 16

Front 17

What is the condition?

Back 17

Ulcerative proctitis

Front 18

What is the condition?

Back 18

Proctosigmoiditis

Front 19

What is the condition?

Back 19

Left-sided colitis

Front 20

What is the condition?

Back 20

Pancolitis

Front 21

What is the condition?

Back 21

Fulminant colitis

Front 22

Which is normal? Which is abnormal? What is the condition?

Back 22

Front 23

Again, what is the condition?

Back 23

UC

Front 24

Condition?

Back 24

UC

Front 25

What is shown in each image?

Back 25

Front 26

Which is normal? Which is UC (toxic megacolon)?

Back 26

Front 27

What study can you use to observe fine mucosal detail in UC?

Back 27

Front 28

Identity severe UC and chronic UC with fibrosis (rigidity and shortening of colon).

Back 28

Front 29

What study is most sensitive for evaluation of free air (which condition would this be useful for)? Does it demonstrate mucosal detail well?

Back 29

Front 30

What is shown here?

Back 30

Thickened mucosa with edema and pericolonic fluid

Front 31

What is the condition?

Back 31

Crohn's disease

Front 32

At what age does Crohn's disease peak in incidence (diagnosis)?

Back 32

Front 33

Crohn's Colitis:

1. _____ (symmetrical or asymmetrical) disease where there is involvement
2. _____ ulcers
3. Rectal _____
4. Skip lesions
5. Deep ulcerations
6. _____ formation
7. Fistula
8. Disease can be limited to _____ colon

Back 33

Asymmetrical disease where there is involvement
Aphthous ulcers
Rectal sparing
Skip lesions
Deep ulcerations
Stricture formation
Fistula
Disease can be limited to right colon

Front 34

Crohn's Disease:

What percent involves small intestine alone, small intestine and colon alone, colon alone? What are four uncommon sites?

What layers of the wall are involved? Do you often see non-caseating granulomas? Fissuring with fistula? What types of lesions?

Back 34

Front 35

What is the incidence of Crohn's disease? At what ages does it peak (bimodal)? What race?

What are three recurrent symptoms? What will you see in 50% of cases (mild)?

Back 35

Front 36

What is characteristic of Crohn's disease (in terms of wall involvement)?

Back 36

Front 37

What is the descriptive term for the mucosa in Crohn's disease?

Back 37

Front 38

What are "skip lesions" in Crohn's disease?

What are areas on the serosa extending to seal off areas of transmural inflammation?

Back 38

Front 39

What is the disease? What is characteristic of the disease that is shown here (branching on the right side)?

Back 39

Front 40

What is the disease?

Back 40

Crohn's disease

Front 41

What is the arrow pointing to? What disease is this characteristic of? In what layer is this typically present? What other cells do you see?

Back 41

Front 42

What is shown and what is the condition? What cell type is present (like in TB)? Is it usually necrotizing?

Back 42

Front 43

What are the three patterns of Crohn disease?

Back 43

Front 44

What do you see in this endoscopy? What could this?

Back 44

Ulcerations => Crohn's disease

Front 45

What two things do you see here? What condition could this be?

Back 45

Front 46

?

Back 46

Front 47

What do the white arrows and black arrows show? What disease?

Back 47

White arrow = mural stratification (mesenteric hypervascularity?) of the terminal ileum

Black arrow = mucosal hyperenhancement

Front 48

Back 48

Front 49

What is this tender subcutaneous nodule with an erythematous or dusky appearance that tends to parallel the activity of IBD (may also see it in Crohn's)?

Back 49

Erythema nodosum

Front 50

Fibrosis

What is this?

Description:

Swollen venules
Granulation tissue can be seen between adipose tissue lobules and the connective tissue septa.

What cells are involved?

Back 50

Front 51

Appears first as a papule or nodule usually on the anterior aspect of the shin. May occur anywhere. Progresses to an ulcer with undermined borders. Not usually painful
Heals with a cribriform or pocked scar
In Crohn’s it often occurs without an associated flare.

What is this?

Back 51

Pyoderma gangrenosum (mild)

Front 52

What is this?

Back 52

Pyoderma gangrenosum (severe)

Front 53

What is episcleritis? What percent of Crohn's disease? It is an emergency?

Back 53

Infection of the sclera and conjunctiva => parallels activity of UC and Crohn's (6% of Crohn's). Involves deeper structures of eye => requires urgent care.

Front 54

What are all these?

Back 54

Extra-intestinal manifestations of Crohn's

Front 55

What is the current theory of IBD? What three things does the pathogenesis involve?

Back 55

Chronic relapsing, and remitting inflammatory disorder(s) of unknown etiologies:
Ulcerative colitis (UC) and Crohn disease
Current theory: Abnormal local immune response to microbacterial flora or self-antigens in genetically susceptible patients.
Pathogenesis involves:
Genetic susceptibility
Triggered by microbacterial flora
Failure of immune regulation
Activation of T lymphocytes with release of inflammatory mediators that activate PMNs, lymphocytes, and macrophages.

Front 56

Back 56

Front 57

St. Mark’s London followed 600 patients with extensive UC for 5932 patient years
A repeat meta-analysis presented at DDW 2008
Overall Cumulative risk at 10, 20 and 20+ years is
10 years – 1%
20 years – 3%
20+ years – 7%
Long-standing UC and extensive Crohn's disease
Longer duration
Young age at onset of disease
Extensive severe colitis
Family history of CRC
Presence of backwash ileitis
Personal history of sclerosing cholangitis
Stricture in UC and/or shortened colon
Multiple Post Inflammatory Pseudopolyps
Active ongoing inflammation

Back 57

Front 58

What are all of these patients with IBD at risk for?

Do patients with Crohn's disease respond to TNF antagonists?

Back 58

Colorectal cancer, yes