Inflammatory Bowel Disease Overview

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Questions and Answers

Which factor likely increases the risk of Crohn's disease in women?

Age over 40

Genetic predisposition

High fiber diet

20-30% increased risk (correct)

What is the primary method for diagnosing inflammatory bowel disease (IBD)?

MRI imaging

Flexible sigmoidoscopy (correct)

Ultrasound examination

X-ray of the abdomen

What type of inflammation is characteristic of ulcerative colitis?

Deep ulcerative inflammation

Transmural inflammation

Granulomatous inflammation

Superficial non-transmural inflammation (correct)

Which symptom is not typically associated with ulcerative colitis?

Weight gain Signup and view all the answers

What is the approximate prevalence of ulcerative colitis per 100,000 population?

240 Signup and view all the answers

What is a requirement for diagnosing Irritable Bowel Syndrome (IBS)?

Abdominal pain or discomfort relieved by defaecation or associated with altered bowel frequency. Signup and view all the answers

Which of the following is NOT a recommended dietary change for managing symptoms of IBS?

Restrict caffeinated drinks to 5 cups a day. Signup and view all the answers

What should be avoided if diarrhea is a symptom of IBS?

Sorbitol. Signup and view all the answers

Which of the following can be considered a 'red flag' condition when diagnosing IBS?

Coeliac disease. Signup and view all the answers

What is a recommended step to identify potential triggers for IBS symptoms?

Keep a symptom diary to track food intake and symptoms. Signup and view all the answers

What is a major complication associated with the use of ciclosporin?

Renal impairment Signup and view all the answers

Under what condition would azathioprine or mercaptopurine be added to treatment?

Two or more exacerbations in 12 months Signup and view all the answers

What should be monitored due to the narrow therapeutic index of ciclosporin?

Therapeutic drug monitoring (TDM) Signup and view all the answers

Which drug is considered if both ciclosporin and glucocorticosteroids are ineffective?

Infliximab Signup and view all the answers

What enzyme is highly deficient in approximately 1 in 300 individuals affecting mercaptopurine metabolism?

Thiopurine methyltransferase (TMPT) Signup and view all the answers

What is a possible complication for ¼ of individuals with Crohn's disease?

Fistulae formation Signup and view all the answers

What is the primary aim of the treatment strategy for inflammatory bowel disease?

Induce and maintain remission Signup and view all the answers

Which formulation of corticosteroids is used for severe disease in IBD?

Oral or parenteral formulations Signup and view all the answers

For mild to moderate proctitis, what is the first-line treatment?

Topical aminosalicylate Signup and view all the answers

Which route of administration is suitable for a suppository in treating proctitis?

Rectum Signup and view all the answers

What constitutes severe Crohn's disease according to the severity score?

A score of 450 Signup and view all the answers

Which of the following is not a treatment option for IBD?

Homeopathy Signup and view all the answers

In the context of ulcerative colitis, which area could be treated with an enema?

Descending colon to splenic flexure Signup and view all the answers

What is the primary action of the immunosuppressant methotrexate?

Induces T cell apoptosis Signup and view all the answers

Which of the following biologics is specifically licensed for ulcerative colitis?

Golimumab Signup and view all the answers

What is recommended if a patient is experiencing two or more exacerbations that require systemic corticosteroids?

Start azathioprine or mercaptopurine Signup and view all the answers

What is a common side effect associated with the use of infliximab?

Infectious events Signup and view all the answers

What is the primary difference between a colostomy and an ileostomy?

Ileostomy involves the ileum, while colostomy involves the colon. Signup and view all the answers

What is emphasized regarding blood tests for patients starting on immunosuppressive therapy?

Weekly full blood counts for the first month, then every three months Signup and view all the answers

Which extraintestinal manifestation is more commonly associated with Crohn's Disease (CD)?

Anaemia Signup and view all the answers

Which of the following is not a recommended care issue for patients with Inflammatory Bowel Disease (IBD)?

Regular blood tests Signup and view all the answers

Which treatment is not recommended for maintaining remission in Crohn’s disease?

Corticosteroids Signup and view all the answers

What is the typical dosing schedule for methotrexate in this context?

Once weekly Signup and view all the answers

What resources does Crohn’s and Colitis UK provide for patients?

Social media engagement and patient experiences. Signup and view all the answers

What is the primary purpose of surgery in the context of inflammatory bowel disease?

To create an ostomy for elimination of waste Signup and view all the answers

What is a common clinical feature of both Ulcerative Colitis (UC) and Crohn's Disease (CD)?

Abdominal pain Signup and view all the answers

Which type of ostomy bag allows the patient to drain output without removing it?

Drainable bag Signup and view all the answers

What is a significant mental health concern for IBD patients?

Anxiety related to symptom unpredictability Signup and view all the answers

Which of the following does not contribute to the management of extraintestinal manifestations in IBD?

Increase in smoking habits Signup and view all the answers

Study Notes

Patient - GIE

The lecture covers Irritable Bowel Syndrome (IBS) and Inflammatory Bowel Disease (IBD)
IBS is a chronic condition affecting the gastrointestinal tract
IBS symptoms vary between people, and some are more severely affected than others
IBS is estimated to affect around 15% of the adult population, with women being more likely to be affected
The cause of IBS is not fully understood but thought to relate to increased gut sensitivity and digestion problems. Stress can trigger symptoms and certain foods might also trigger them.
IBS symptoms can include abdominal pain, cramping, changes in bowel habits (constipation, diarrhoea, or both), bloating, flatulence, tenesmus (urgency to defecate), and passing mucus from the rectum.

Lower GI Anatomy

A diagram of the lower gastrointestinal tract was presented, labelling various parts
The diagram depicts the stomach, small intestine (with duodenum, jejunum, and ileum labelled), and large intestine segments (colon).

Irritable Bowel Syndrome (IBS) Overview

IBS is a chronic condition affecting the gastrointestinal tract.
IBS symptoms are variable from person to person.
It's believed to affect about 15% of adults, with women being more likely to be affected.
The exact cause of IBS is unknown, but increased gut sensitivity and issues digesting food are suspected factors.

IBS Symptoms

Abdominal pain and cramping
Changes in bowel habits (constipation, diarrhea, or both)
Bloating
Flatulence
Tenesmus (urgency to defecate)
Passing mucus from the rectum
Symptoms like lethargy, nausea, backache, and bladder symptoms might also be present.

Types of IBS

IBS-C (Constipation): Hard/lumpy stools for at least 25% of bowel movements, with loose/watery stools for less than 25%.
IBS-D (Diarrhoea): Loose/watery stools for at least 25% of bowel movements, with hard/lumpy stools for less than 25%.
IBS-M (Mixed): Hard/lumpy stools for less than 25% of bowel movements and loose/watery stools for less than 25%.
Unspecified IBS: Insufficient stool consistency abnormality to meet IBS-C, IBS-D, or IBS-M criteria.

IBS Diagnosis

Consider IBS if symptoms have persisted for at least 6 months
Symptoms include abdominal pain/discomfort, bloating, and altered bowel habits.
Rule out other conditions like cancer, inflammatory bowel disease, and coeliac disease
IBS is diagnosed if abdominal pain or discomfort is eased or linked with bowel changes together with at least two of the following: altered bowel frequency or stool consistency; abdominal bloating, distention, or hardness; worsened by eating; mucus passage.

Management of IBS (Dietary and Lifestyle)

Maintain a balanced and well-structured diet.
Prioritise unhurried meals.
Ensure adequate non-caffeinated water intake (at least 8 cups) and restrict caffeinated drinks (limit to 3 cups daily).
Minimise alcohol and fizzy drinks consumption.
Reduce high-fiber food (especially insoluble fiber) intake.
Limit high-fiber foods, particularly insoluble fiber.
Limit the intake of fructose, lactose, fructans, and polyols.
Consider an elimination diet if symptoms persist.
Regularly maintain a detailed diary to identify triggers and keep track of the symptoms and foods consumed and their relation.
Prioritise activities that induce relaxation.

Management of IBS (Pharmacological Therapy)

Antispasmodic agents (e.g., hyoscine butylbromide, mebeverine, peppermint oil) are used to manage pain or cramps.
Loperamide is the first-line antimotility drug for diarrhea.
Macrogol is preferred for chronic constipation.
Additional medications (e.g., laxatives like ispaghula husk, linaclotide, prucalopride, tricyclic antidepressants, selective serotonin reuptake inhibitors) can be considered.

Inflammatory Bowel Disease (IBD)

IBD describes two conditions: Crohn's Disease (CD) and Ulcerative Colitis (UC)
Both are chronic and relapsing conditions that cause inflammation in the gastrointestinal tract.

IBD: Epidemiology

IBD is more common in Northern Europe and North America, with Caucasians being more commonly affected.
Incidence is rising in Asian countries.
Women with CD have a slightly higher risk (20-30%) compared to men.
UC and CD peak in patients aged 10-40, affecting 10-20/100,000 people per year with a similar prevalence (approximately 240/100,000 for UC and 145/100,000 for CD.

IBD: Aetiology

A combination of genetic and environmental factors contributes to IBD.
Stress, antibiotics, and dietary factors are also implicated. Host genetic factors, environmental factors and microflora are important causal elements.

IBD Diagnosis

Faecal calprotectin, full blood count (FBC), erythrocyte sedimentation rate (ESR), C-reactive protein (CRP), iron studies, B12, and folate levels are checked.
Flexible sigmoidoscopy, colonoscopy, and upper GI endoscopy (for CD) are performed.
Biopsies are sometimes necessary.

Ulcerative Colitis (UC)

UC inflammation is always continuous and limited to the colon and rectum (non-transmural).
Different types of UC include proctitis, proctosigmoiditis, left-sided colitis, and pancolitis, depending on the affected areas.

UC: Aetiology

A combination of genetic and environmental factors are involved.
Stress, infections and dietary habits are among environmental risk factors.

UC: Clinical Features

Bloody diarrhea
Rectal bleeding
Colicky abdominal pain
Abdominal urgency for defecation
Tenesmus (rectal urgency)

UC: Assessment of Severity

The Truelove and Witts system is used to assess the severity of UC, based on various clinical findings (bow movements, blood in stools, fever, pulse rate, anaemia, ESR) which are scored into mild, moderate, and severe categories.

Crohn's Disease (CD)

CD can affect any part of the gastrointestinal tract.
Inflammation is typically discontinuous and transmural.
Common classification involves ileocolitis, with other forms based on location or pattern.

CD: Aetiology

Genetic factors and environmental factors such as infections, psychosocial stress and smoking are involved (the interaction of both is thought to cause inflammatory responses).
Refined carbs are also often linked to increased risk in patients with the disease.

CD: Clinical Features

Abdominal pain
Weight loss
Diarrhea
Intestinal obstruction (due to strictures, fistulae, or abscesses)

Fistulas

Fistulas are abnormal tunnels that emerge between two body cavities or from a cavity to the skin.
They are often linked to inflammation and ulcer/abscess formation.
Enterocolic fistula are specifically linked with the small or large intestine.

CD: Assessment of Severity

The Harvey Bradshaw index gauges CD severity (based on clinical indicators e.g. well being, abdominal pain, liquid stool regularity, abdominal mass).

IBD Treatment and Management

Treatment varies depending on the type and severity
Dietary modifications, relaxation, and lifestyle counselling are often advisable in conjunction with medical intervention and monitoring/control of side-effects.
Medications frequently administered in IBD treatments include corticosteroids, aminosalicylates, immunosuppressants, and biologics.
When appropriate surgically removing/resectioning damaged parts of the GI tract might be implemented.

IBD: Treatments - Specifics

Corticosteroids: Effective for acute attacks and inducing remission, used in liquid or foam enema forms in localised disease or oral/parenteral options in severe/extensive disease.
Aminosalicylates: Induce and maintain remission in UC, administered orally or topically/rectally.
Immunosuppressants, such as azathioprine and mercaptopurine, often used as maintenance therapies to maintain treatment response.
Methotrexate may serve in those resistant to azathioprine or mercaptopurine treatments.
Biologics, such as infliximab and adalimumab, are used in severe/non-responsive cases.

IBD: Maintenance Treatment for specific conditions

UC proctitis and proctosigmoiditis: Topical aminosalicylates, oral aminosalicylates, or both, are options for treatment.
UC left-sided and extensive disease (topical/oral aminosalicylates can be administered in conjunction with oral aminosalicylate high doses for maintenance).
CD: Azathioprine or mercaptopurine, methotrexate (if used initially to induce remission but did not tolerate it or contraindications exist for aza/mp or other options) are potential alternatives or corticosteroids should be avoided as maintenance treatment options.
Corticosteroids (e.g hydrocortisone, prednisolone) may be initially considered for acute exacerbations and are not generally appropriate for remission maintenance. Instead, treatment should focus on immunomodulatory or biologic agents when appropriate.

Rectal Administration of Medication in IBD

Medication can be delivered rectally via suppositories or foam and enema routes to target specific parts of the large intestine.

Aminosalicylates

Aminosalicylates are anti-inflammatory drugs used in IBD management, particularly in UC.
Sulfasalazine is a prodrug, converting to 5-aminosalicylic acid in the intestines.
Various formulations of aminosalicylates (mesalazine, olsalazine, balsalazide) exist with different targets and side effects (e.g. rectal-administered mesalazine is available via suppositories).

Aminosalicylates: Side Effects

Common side effects include diarrhea, nausea, vomiting, and abdominal pain.
Rare, but more serious side effects include pancreatitis, hepatitis, skin reactions, and blood dyscrasias.

UC: Acute Severe Disease

Hospital treatment might be needed for severe cases, possibly involving IV corticosteroids (e.g hydrocortisone) and/or IV ciclosporin, especially in those whose treatment responses are poor or insufficient.
Immunosuppressive therapy could be beneficial, particularly in unresponsive cases of UC acute severe disease.
Infliximab might prove useful in persistent or non-responsive cases, but it is crucial to monitor for major complications such as renal impairment and electrolyte disturbances.

CD: Inducing Remission

First-line treatment for new onset or single exacerbation within a 12-month timeframe typically involves conventional glucocorticoid treatment such as prednisolone, methylprednisolone, or IV-administered glucocorticoid drugs.
Additional therapy using azathioprine, mercaptopurine, or methotrexate is considered if warranted based on exacerbations or other factors.
Infliximab or adalimumab are possible choices if the disease is not controlled by conventional therapies.

Immunosuppressants

Azathioprine is metabolised to mercaptopurine.
Approximately 1/300 patients are deficient in TMPT (thiopurine methyltransferase) which is essential for mercaptopurine metabolism. This can lead to drug toxicity or blood dyscrasias.
TMPT deficiency results in altered mercaptopurine metabolism potentially causing complications.
Monitor TMPT activity prior to initiation and blood counts (complete blood count – FBC – at least initially weekly) during the initial 4 weeks and periodically during maintenance treatment.
Regular monitoring for toxicities is critical, especially blood dyscrasias. Methotrexate is an alternative option for immunomodulation if azathioprine/mercaptopurine cannot be used or tolerated, potentially useful in refractory cases.

Biologics

Infliximab is a chimaeric monoclonal antibody targeting TNFa.
It neutralises TNFa and might induce cell apoptosis. A single 5 mg/kg dose is often administered as an infusion.
Biologic therapies can potentially be suitable for various specific uses, but detailed patient monitoring and close investigation/treatment of potential side effects should be part of treatment protocols.
Adalimumab, vedolizumab, ustekinumab, and golimumab (for UC only) are other biologics used in IBD cases.

Surgery

Ostomy surgery involves creating a surgical opening in the abdominal wall for waste removal, which could either be temporary or permanent.
Colostomy involves a section of the colon, whilst ileostomy uses an intestinal section.

Stoma Care and Ostomy Bags

Various stoma care resources are available online, mainly focused on patient education and care guidance, including videos.

IBD: Extraintestinal Manifestations

IBD can affect areas outside the GI tract, though more commonly in CD than UC.
Symptoms can include anaemia, arthropathy, skin effects, eye effects, hepatobiliary problems, mucocutaneous lesions, fever, and tachycardia.

IBD: Associated Care Issues

Associated care issues include managing smoking, vaccinating, pain management, monitoring for colonic carcinoma, providing nutritional advice, and managing extraintestinal manifestations.

IBD: Patient Experience

Information about IBD can be found via dedicated national organisations (such as Crohn's and Colitis UK).
Organisations often provide patient-focused resources, information about awareness campaigns and patient experiences, usually in the form of webpages and social media channels.

IBD: Check your Learning

A table comparing the common features of UC (Ulcerative Colitis) and CD (Crohn's Disease) is provided in this section for a quick reference summary.

Studying That Suits You

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Description

Test your knowledge on inflammatory bowel diseases such as Crohn's disease and ulcerative colitis. This quiz covers diagnosis methods, symptoms, dietary changes, and treatment options. It's perfect for anyone studying or interested in gastrointestinal health.