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Questions and Answers
Which symptom is most commonly associated with Crohn’s disease affecting the small intestine?
Which symptom is most commonly associated with Crohn’s disease affecting the small intestine?
What is a common sign of malabsorption due to small bowel involvement in Crohn’s disease?
What is a common sign of malabsorption due to small bowel involvement in Crohn’s disease?
What ocular condition is reported in 2-5% of patients with inflammatory bowel disease?
What ocular condition is reported in 2-5% of patients with inflammatory bowel disease?
Which of the following is a potential complication of Crohn’s disease?
Which of the following is a potential complication of Crohn’s disease?
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The presence of mouth ulcers in Crohn's disease is primarily linked to which of the following factors?
The presence of mouth ulcers in Crohn's disease is primarily linked to which of the following factors?
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Which deficiency is associated with inflammation of the terminal ileum in Crohn’s disease?
Which deficiency is associated with inflammation of the terminal ileum in Crohn’s disease?
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What is a possible cause of clubbing in patients with Crohn’s disease?
What is a possible cause of clubbing in patients with Crohn’s disease?
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What can cause the skin manifestations associated with perianal disease in Crohn's patients?
What can cause the skin manifestations associated with perianal disease in Crohn's patients?
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What is the definition of inflammatory bowel disease (IBD)?
What is the definition of inflammatory bowel disease (IBD)?
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Which of the following microscopic changes is typically observed in Crohn's disease?
Which of the following microscopic changes is typically observed in Crohn's disease?
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Which risk factors are associated with ulcerative colitis?
Which risk factors are associated with ulcerative colitis?
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What is a cardinal symptom of inflammatory bowel disease?
What is a cardinal symptom of inflammatory bowel disease?
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Which of the following is NOT a component of the differential diagnosis for colitis?
Which of the following is NOT a component of the differential diagnosis for colitis?
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What type of inflammation is primarily seen in Crohn's disease?
What type of inflammation is primarily seen in Crohn's disease?
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Which complication is associated with inflammatory bowel disease?
Which complication is associated with inflammatory bowel disease?
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What is the primary function of faecal calprotectin in stool sample investigations?
What is the primary function of faecal calprotectin in stool sample investigations?
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Which of the following best outlines the principles of management for IBD?
Which of the following best outlines the principles of management for IBD?
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Which of the following is considered a gold standard investigation for colitis?
Which of the following is considered a gold standard investigation for colitis?
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Which feature is characteristic of ulcerative colitis on colonoscopy?
Which feature is characteristic of ulcerative colitis on colonoscopy?
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What is a histological feature commonly seen in Crohn's disease biopsies?
What is a histological feature commonly seen in Crohn's disease biopsies?
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Which medication is used to induce and maintain remission in ulcerative colitis?
Which medication is used to induce and maintain remission in ulcerative colitis?
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During a colonoscopy of ischemic colitis, which feature is likely to be observed?
During a colonoscopy of ischemic colitis, which feature is likely to be observed?
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What common feature distinguishes Crohn's disease from ulcerative colitis?
What common feature distinguishes Crohn's disease from ulcerative colitis?
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Which laboratory investigation is primarily used to assess inflammatory activity in a patient suspected of having IBD?
Which laboratory investigation is primarily used to assess inflammatory activity in a patient suspected of having IBD?
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What condition is characterized by inflammation, fibrosis, and stricturing of ducts in the biliary tree?
What condition is characterized by inflammation, fibrosis, and stricturing of ducts in the biliary tree?
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Which skin condition is often associated with flares of intestinal disease?
Which skin condition is often associated with flares of intestinal disease?
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What is the most common cause of ischemic colitis?
What is the most common cause of ischemic colitis?
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Which of the following is NOT typically a cause of colitis?
Which of the following is NOT typically a cause of colitis?
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What type of colitis is associated with systemic antibiotic use?
What type of colitis is associated with systemic antibiotic use?
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Which factor is NOT considered in the differential diagnosis of colitis?
Which factor is NOT considered in the differential diagnosis of colitis?
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Which of the following is a common infectious cause of colitis?
Which of the following is a common infectious cause of colitis?
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What differentiates diverticular disease from other forms of colitis?
What differentiates diverticular disease from other forms of colitis?
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Which of the following side effects is associated with Azathioprine?
Which of the following side effects is associated with Azathioprine?
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What is the primary action of Methotrexate in treating inflammatory bowel disease?
What is the primary action of Methotrexate in treating inflammatory bowel disease?
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What approach is indicated for low-risk patients with mild disease?
What approach is indicated for low-risk patients with mild disease?
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Which medication is associated with an increased risk of infection and reactivation of latent TB?
Which medication is associated with an increased risk of infection and reactivation of latent TB?
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Which medication should be considered for bone protection during steroid therapy?
Which medication should be considered for bone protection during steroid therapy?
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In treating severe ulcerative colitis, which criterion is NOT part of the Truelove and Witt Criteria?
In treating severe ulcerative colitis, which criterion is NOT part of the Truelove and Witt Criteria?
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Which category of medication is primarily used for its immunosuppressive properties in inflammatory bowel disease?
Which category of medication is primarily used for its immunosuppressive properties in inflammatory bowel disease?
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What is the suggested role of surgery in the management of inflammatory bowel disease?
What is the suggested role of surgery in the management of inflammatory bowel disease?
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What is a characteristic feature observed during a colonoscopy for Crohn’s disease?
What is a characteristic feature observed during a colonoscopy for Crohn’s disease?
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Which pathological feature is typically found in Crohn’s disease biopsies?
Which pathological feature is typically found in Crohn’s disease biopsies?
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Which of the following is an appropriate investigation for detecting inflammation in stool samples?
Which of the following is an appropriate investigation for detecting inflammation in stool samples?
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What is a common characteristic of ulcerative colitis observed during endoscopy?
What is a common characteristic of ulcerative colitis observed during endoscopy?
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Which of the following medications is considered to induce and maintain remission in ulcerative colitis?
Which of the following medications is considered to induce and maintain remission in ulcerative colitis?
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What is the primary indication of faecal occult blood testing in intestinal investigations?
What is the primary indication of faecal occult blood testing in intestinal investigations?
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Which imaging technique is considered the gold standard for direct visualization in the assessment of colitis?
Which imaging technique is considered the gold standard for direct visualization in the assessment of colitis?
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What type of colonic biopsy finding is indicative of chronic inflammation in Crohn’s disease?
What type of colonic biopsy finding is indicative of chronic inflammation in Crohn’s disease?
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What is the primary consequence of the alteration of bacterial flora in IBD?
What is the primary consequence of the alteration of bacterial flora in IBD?
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Which factor is NOT associated with a higher risk of developing ulcerative colitis?
Which factor is NOT associated with a higher risk of developing ulcerative colitis?
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Which symptom is more prominently associated with Crohn's disease than ulcerative colitis?
Which symptom is more prominently associated with Crohn's disease than ulcerative colitis?
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What type of inflammation pattern is characteristic of Crohn's disease?
What type of inflammation pattern is characteristic of Crohn's disease?
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In which age range is the onset of IBD most commonly observed?
In which age range is the onset of IBD most commonly observed?
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Which symptom is least likely to be caused by the inflammation related to ulcerative colitis?
Which symptom is least likely to be caused by the inflammation related to ulcerative colitis?
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What is the primary mechanism leading to diarrhea in patients with IBD?
What is the primary mechanism leading to diarrhea in patients with IBD?
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The term 'leaky' epithelium in the context of IBD refers to which condition?
The term 'leaky' epithelium in the context of IBD refers to which condition?
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Which immunosuppressant is associated with maintaining steroid-free remission in 35-40% of patients?
Which immunosuppressant is associated with maintaining steroid-free remission in 35-40% of patients?
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What side effect is commonly associated with Methotrexate?
What side effect is commonly associated with Methotrexate?
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Which of the following medications is a JAK inhibitor used in the treatment of inflammatory bowel disease?
Which of the following medications is a JAK inhibitor used in the treatment of inflammatory bowel disease?
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What is a common potential complication of Anti-TNF therapy?
What is a common potential complication of Anti-TNF therapy?
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Which therapeutic strategy is primarily indicated for patients with high-risk severe disease?
Which therapeutic strategy is primarily indicated for patients with high-risk severe disease?
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What should be considered alongside immunosuppressants to protect against potential bone issues during steroid therapy?
What should be considered alongside immunosuppressants to protect against potential bone issues during steroid therapy?
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What is a significant side effect of Cyclosporin related to its mechanism of action?
What is a significant side effect of Cyclosporin related to its mechanism of action?
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Which factor is NOT typically included in the assessment of severity for acute severe ulcerative colitis?
Which factor is NOT typically included in the assessment of severity for acute severe ulcerative colitis?
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What type of bowel involvement is primarily indicated by the presence of abdominal pain in the right lower quadrant for Crohn's disease patients?
What type of bowel involvement is primarily indicated by the presence of abdominal pain in the right lower quadrant for Crohn's disease patients?
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Which symptom is particularly associated with bowel inflammation affecting the rectum and sigmoid colon?
Which symptom is particularly associated with bowel inflammation affecting the rectum and sigmoid colon?
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What pathophysiological change is typically linked to the presence of pallor in the conjunctivae of Crohn's disease patients?
What pathophysiological change is typically linked to the presence of pallor in the conjunctivae of Crohn's disease patients?
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Which ocular manifestation is less common but more severe in inflammatory bowel disease?
Which ocular manifestation is less common but more severe in inflammatory bowel disease?
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Which specific symptom may indicate potential intestinal obstruction in Crohn's disease?
Which specific symptom may indicate potential intestinal obstruction in Crohn's disease?
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What condition is strongly associated with primary sclerosing cholangitis in patients with Crohn's disease?
What condition is strongly associated with primary sclerosing cholangitis in patients with Crohn's disease?
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Which symptom is specifically linked to the inflammatory process and molecular mimicry associated with Crohn's disease?
Which symptom is specifically linked to the inflammatory process and molecular mimicry associated with Crohn's disease?
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What sign can indicate malabsorption due to small bowel involvement in patients with Crohn's disease?
What sign can indicate malabsorption due to small bowel involvement in patients with Crohn's disease?
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What is a characteristic of iron deficiency anemia in terms of mean corpuscular hemoglobin concentration (MCHC)?
What is a characteristic of iron deficiency anemia in terms of mean corpuscular hemoglobin concentration (MCHC)?
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Which of the following complications is specifically associated with Crohn's disease?
Which of the following complications is specifically associated with Crohn's disease?
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Which deficiency is linked to terminal ileum resection and Crohn's disease?
Which deficiency is linked to terminal ileum resection and Crohn's disease?
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In the assessment of anemia, which red blood cell size measurement identifies microcytic anemia?
In the assessment of anemia, which red blood cell size measurement identifies microcytic anemia?
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What type of anemia results from inadequate intake or insufficient absorption of folate?
What type of anemia results from inadequate intake or insufficient absorption of folate?
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Which ocular manifestation is a known complication of Crohn's disease?
Which ocular manifestation is a known complication of Crohn's disease?
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What is the condition characterized by inflammation leading to fibrosis in the biliary tree, often seen in patients with inflammatory bowel disease?
What is the condition characterized by inflammation leading to fibrosis in the biliary tree, often seen in patients with inflammatory bowel disease?
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Which extra-intestinal manifestation is particularly associated with inflammatory bowel disease?
Which extra-intestinal manifestation is particularly associated with inflammatory bowel disease?
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Which type of anemia is most commonly associated with chronic blood loss in Crohn’s disease?
Which type of anemia is most commonly associated with chronic blood loss in Crohn’s disease?
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What is typically observed in blood films of patients with B12 deficiency?
What is typically observed in blood films of patients with B12 deficiency?
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Study Notes
Inflammatory Bowel Disease (IBD) - Definition
- Chronic, relapsing inflammatory intestinal disorders of unknown cause
- Two main types: Crohn's Disease and Ulcerative Colitis
- Incidence is rising
- Possible factors involved: genetic susceptibility, intestinal flora, abnormal T-cell response, emotional stress, and diet
IBD - Pathophysiology
- Inflammation is a key feature
- Crohn's Disease: inflammation affects the whole bowel wall
- Ulcerative Colitis: inflammation is continuous and primarily affects the colon's lining
IBD - Symptoms
- Crohn's Disease: abdominal pain (often in the right lower quadrant), diarrhea, weight loss, fatigue, fever, and intestinal obstruction
- Ulcerative Colitis: bloody diarrhea, rectal bleeding, abdominal cramps, urgency, tenesmus, weight loss, and fatigue
IBD - Signs
- Low BMI: due to malabsorption from small bowel involvement
- Clubbing: unclear cause, potentially related to platelet-derived growth factor (PDGF)
- Pallor of palmar creases/conjunctivae: anemia caused by iron deficiency (blood loss and malabsorption), vitamin B12 deficiency (terminal ileum inflammation leading to malabsorption of B12)
- Koilonychia: iron deficiency anemia
- Scleritis/Episcleritis: inflammation of the eye, thought to be secondary to IBD
- Uveitis: less common than episcleritis, inflammation inside the eye
- Cataracts: long-term glucocorticoid use
- Mouth ulcers: inflammatory process, antibodies against shared antigens, or drug side effects
- Cirrhosis: primary sclerosing cholangitis (PSC), a strong association with Ulcerative Colitis
- Erythema Nodosum: raised, tender, red or violet subcutaneous nodules, often on the legs, associated with IBD flares
- Pyoderma Gangrenosum: single or multiple erythematous papules or pustules, often preceded by skin trauma, tends not to parallel disease activity
IBD - Differential Diagnosis
- Idiopathic Inflammatory Bowel Disease: Ulcerative Colitis or Crohn's disease
-
Infective Colitis: acute onset, short history, caused by viruses, bacteria, or protozoa
- Pseudomembranous colitis: Clostridium difficile overgrowth following antibiotic use
-
Ischaemic Colitis: usually affects older patients with a history of heart disease; sudden pain and bloody diarrhea
- Occlusive: thrombosis or embolism
- Non-occlusive: cardiac failure, shock, radiation
- Diverticular Disease: left side colon/sigmoid, age usually >50 years, inflammatory changes may cause abscess, fibrosis and strictures
- Malignancy: cancer of the bowel
- Drugs: NSAIDs (non-steroidal anti-inflammatory drugs)
IBD - Investigations
- Blood Tests: FBC (full blood count), U&E (urea and electrolytes), CRP (C-reactive protein), Folate, B12, iron studies, calcium, magnesium, liver function tests (LFTs), albumin
- Stool Samples: fecal occult blood, stool culture for microorganisms, fecal calprotectin (indicates inflammation)
- Radiology/Direct Visualization:
- Endoscopy + Biopsy (lower +/- upper): gold standard
- Colonoscopy: large bowel, can access terminal ileum
- OGD (Oesophagogastroduodenoscopy): if upper GI symptoms
- SBFT (Small Bowel Barium Follow Through): small bowel
- CT colonography: alternative to endoscopy
- CT scan: imaging of the abdomen
- Ultrasound: disease in ileum and colon
- Capsule endoscopy: small bowel
- Endoscopy + Biopsy (lower +/- upper): gold standard
### IBD - Treatment Principles
- Conservative: smoking cessation, nutritional management
- 5-ASA (Aminosalicylic Acids): mesalazine or sulphasalazine, used to induce and maintain remission in Ulcerative Colitis
- Antibiotics: metronidazole or ciprofloxacin
- Steroids: oral, IV, or PR, used in short courses
- Immunosuppressants: azathioprine, methotrexate, or cyclosporine
- Biologics: anti-TNF (infliximab, adalimumab, golimumab), vedolizumab, ustekinumab, tofacitinib
- Surgery: reserved for severe cases unresponsive to medical management
IBD - Treatment Pyramid
- Step-Up Approach: for low-risk patients with mild disease, begins with less potent medications, progressing to more potent medications if needed
- Top-Down Approach: for high-risk patients with severe disease, begins with more potent therapies, then scaled back to less potent medications
### Acute Severe Ulcerative Colitis
- Truelove and Witt Criteria: tool to assess disease severity
IBD - Medical Rescue Therapy
- Used in acute severe cases of ulcerative colitis
- Aims to rapidly resolve symptoms
- Includes: IV fluids, steroids, and antibiotics
IBD - Surgery
- Avoided when possible
- Used in cases non-responsive to medical treatment
- Minimal resections are preferred
Crohn's Disease - Endoscopy Features
- Ulceration: deep, transmural, or aphthous
- Cobblestone mucosa: ulcerated areas form crevices between normal tissue
- Skip lesions: discontinuous inflammation
- Normal appearing rectal mucosa
- Inflammation of the terminal ileum (can occur in ulcerative colitis)
Crohn's Disease - Colon Biopsy Findings
- Loss of architecture
- Cryptitis (inflammation of the crypts)
- Crypt abscess
- Granulomas
- Acute and Chronic changes
Pathophysiology of IBD
- Alterations in gut microbiome, including increased adherence of E. coli to ileal epithelial cells
- "Leaky gut" allows luminal antigens to enter the body, triggering an inappropriate immune response
- Inflammation is the final common pathway in IBD
- Impaired mucosal integrity and destruction, leading to malabsorption and increased secretion
IBD Risk Factors
- Family history is a significant risk factor but not the only one
- Multiple susceptibility loci for both UC and CD, indicating a complex interaction between genetic, environmental, and epigenetic factors
- Recent smoking cessation is a risk factor for UC
- More prevalent in Western/developed countries
- Jewish ethnicity, specifically Ashkenazi, is a significant risk factor
- Bimodal age distribution, with peaks in the 2nd and 3rd decades and a smaller peak in the 60s
Cardinal Symptoms of IBD
- Diarrhea: More than 30 days, varying severity, bloody (more common in UC than CD), urgency, frequency, tenesmus, pain relieved by defecation
- Weight loss: More common in CD, due to catabolism and malabsorption
- Fever:
- Abdominal pain: More common in CD
- Perianal pain and abscess: Common in CD
- Extraintestinal features: Eye, skin, joint, mouth, and liver/biliary tract involvement
- Fatigue:
- Delayed puberty:
Signs of IBD
- Low body mass index (BMI): Malabsorption due to small bowel involvement
- Clubbing: Uncertain etiology, potentially related to platelet-derived growth factor (PDGF)
- Pallor of palmar creases/conjunctivae: Anemia (iron deficiency due to blood loss, malabsorption, vitamin B12 deficiency)
- Koilonychia: Iron deficiency anemia
- Scleritis/episcleritis: Inflammation of the sclera and episcleral tissues, thought to be secondary to the inflammatory process, possibly due to antibodies against shared antigens or molecular mimicry
- Uveitis: Less common than episcleritis, more severe, often bilateral, insidious onset, chronic duration
- Cataracts: Long-term glucocorticoid use
Investigations in IBD
- Stool samples: Faecal occult blood, stool culture for microorganisms, faecal calprotectin (indicates neutrophil migration into intestinal tissue)
- Radiology/direct visualization: Endoscopy with biopsy (gold standard), SBFT, CT colonography, CT scan, ultrasound, capsule endoscopy
Colonoscopy Findings in IBD
- Ulcerative colitis: Loss of vascular markings, erythema, petechiae, exudates, edema, erosions, touch friability, spontaneous bleeding. Mayo score for severity assessment.
- Crohn's disease: Deep transmural ulceration, aphthous ulcers, cobblestone mucosa (ulcerated areas surrounded by normal tissue), skip lesions (discontinuous inflammation), normal appearing rectal mucosa, terminal ileum inflammation.
Colon Biopsy Findings in Crohn's Disease
- Loss of architectural integrity
- Cryptitis (inflammation of the crypts of Lieberkühn)
- Crypt abscesses
- Granulomas
- Both acute and chronic changes
Overarching Principles of IBD Management
- Conservative: Smoking cessation, dietary modifications
- 5-ASA (aminosalicylic acids): Mesalazine, sulfasalazine. Induce and maintain remission in UC. Limited role in CD.
- Antibiotics: Metronidazole, ciprofloxacin
- Steroids: Oral, IV, PR. Short-course use.
- Immunosuppressants: Azathioprine (thiopurine), methotrexate, cyclosporine.
- Biologics: Anti-TNF (infliximab, adalimumab, golimumab), vedolizumab, ustekinumab, tofacitinib.
- Surgery: Reserved for severe cases unresponsive to medical management.
Treatment Pyramid for IBD
- Step-up approach: Progressive escalation of treatment intensity from less potent to more potent medications, starting with mild disease and progressing with worsening symptoms
- Top-down approach: Initiating with more potent therapies for high-risk patients with severe disease, then scaling back as symptoms improve
- Considering disease site, severity, patient factors, and treatment goals
Acute Severe Ulcerative Colitis
- Truelove–Witt criteria: Severity assessment tool
Medical Rescue Therapy for Severe UC
- High dose intravenous steroids and IV fluids
- Antibiotics
- Immunosuppressants (cyclosporin)
- Surgery as last resort
Surgery in IBD
- Avoided where possible, minimal resections
- Reserved for severe cases unresponsive to medical treatment
- Recurrence of disease at anastomosis sites
- Terminal ileum resection: B12 deficiency, bile salt malabsorption, steatorrhea
- Types of anemia in Crohn's disease: B12, folate, and iron deficiency
Investigations for Anemia
- FBC: RBC size / Mean corpuscular volume (MCV), RBC count, Hb, MCHC
- Blood film
Complications of IBD
- Intestinal complications: Strictures, fistulas, sinus tracts, abscesses, perforations, toxic megacolon
- Extraintestinal manifestations: Eye (uveitis, episcleritis), skin (erythema nodosum, pyoderma gangrenosum), mouth (stomatitis, aphthous ulcers), joints (spondylitis, sacroiliitis, peripheral arthritis), liver/biliary tract (steatosis, sclerosing cholangitis), kidneys (stones, hydronephrosis, fistulas, infections)
Gross and Microscopic Features of IBD
- Crohn's disease: Skip lesions, transmural inflammation, cobblestone mucosa, aphthous ulcers, terminal ileum inflammation
- Microscopy: Loss of architectural integrity, cryptitis, crypt abscesses, granulomas, acute and chronic changes
- Ulcerative colitis: Continuous inflammation, mucosal and submucosal layers, loss of vascular marking, erythema, petechiae, exudates, erosions
Additional Complications of IBD
- Ulcerative colitis specific: Sclerosing cholangitis , iron deficiency anemia, dysplasia
- Crohn's disease specific: Vitamin B12, folate deficiency, erythema nodosum, eye symptoms
Dysplasia in Ulcerative Colitis
- Associated with severe colitis lasting over 10 years
References
- UpToDate: Information about dermatologic and ocular manifestations of IBD, arthritis associated with IBD
- NCBI: Research articles on IBD
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Description
Explore the complexities of Inflammatory Bowel Disease (IBD), including its definitions, pathophysiology, symptoms, and signs. Understand the differences between Crohn's Disease and Ulcerative Colitis, as well as the factors contributing to this chronic condition.
