أسئلة الثامنة GIT الدلتا

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Questions and Answers

Which of the following is a typical intestinal manifestation of ulcerative colitis?

  • Absence of abdominal pain.
  • Constipation with lower abdominal cramping.
  • Bloody diarrhea with mucus, accompanied by urgency and tenesmus. (correct)
  • Weight gain due to increased nutrient absorption in the colon.

A patient with ulcerative colitis presents with arthritis, erythema nodosum, and aphthous ulcers. How are these manifestations typically related to the activity of colitis?

  • These manifestations indicate a severe, acute exacerbation of colitis requiring immediate surgery.
  • These manifestations are related to the activity of colitis. (correct)
  • These manifestations are unrelated to the activity of colitis and require separate evaluation.
  • These symptoms typically develop after complete resolution of the colitis.

According to the Truelove and Witts criteria, how is moderate ulcerative colitis defined?

  • No bloody stools but frequent abdominal pain.
  • 4-6 bloody stools per day with minimal systemic disturbance. (correct)
  • More than 6 bloody stools per day with severe systemic disturbance.
  • Less than 4 bloody stools per day without systemic disturbance.

Which of the following laboratory findings indicates the severity of ulcerative colitis?

<p>Elevated C-reactive protein (CRP). (C)</p> Signup and view all the answers

What endoscopic finding is associated with ulcerative colitis?

<p>Marked erythema, absent vascular markings, and friability. (C)</p> Signup and view all the answers

What percentage of ulcerative colitis cases involve the recto-sigmoid region?

<p>50% (D)</p> Signup and view all the answers

Which microscopic feature is characteristic of ulcerative colitis?

<p>Inflammation confined to the mucosa with crypt distortion. (B)</p> Signup and view all the answers

Elevated fecal calprotectin levels can differentiate between IBD and IBS. How is it used in the follow up?

<p>As a follow up of response to treatment. (A)</p> Signup and view all the answers

A patient with ulcerative colitis is not responding to medical therapy and has developed dysplasia. Which of the following surgical options is typically the operation of choice?

<p>Colectomy with pouch formation. (C)</p> Signup and view all the answers

A patient with pancolitis is undergoing surveillance for colorectal cancer. When should the initial screening colonoscopy be performed?

<p>8 years after the onset of pancolitis. (D)</p> Signup and view all the answers

A patient with ulcerative colitis is undergoing a colonoscopy, and the images reveal erythema, absent vascular markings, granularity, and friability with minimal trauma but no ulcerations. According to the Mayo score of endoscopic severity of the disease, what is the likely severity of the patient's condition?

<p>Moderate (B)</p> Signup and view all the answers

A patient with ulcerative colitis develops severe disease unresponsive to medical therapy, complicated by a perforation. What surgical intervention is MOST appropriate?

<p>Total colectomy with ileostomy (A)</p> Signup and view all the answers

What is the MAIN purpose of performing follow-up colonoscopies in patients with ulcerative colitis?

<p>To detect early signs of colorectal cancer due to the increased risk in long-standing cases (C)</p> Signup and view all the answers

In a patient with ulcerative colitis, which of the following extraintestinal manifestations is LEAST likely to correlate with the activity of the colitis itself?

<p>Primary sclerosing cholangitis (B)</p> Signup and view all the answers

A patient presents with left-sided ulcerative colitis. According to guidelines, when should the initial screening colonoscopy be performed to assess for colorectal cancer?

<p>12 to 15 years after the onset of symptoms (D)</p> Signup and view all the answers

A patient with ulcerative colitis has been treated with topical and oral 5-ASA, but continues to experience symptoms. What is the next appropriate step in managing their condition?

<p>Consider adding steroid enemas to existing therapy (D)</p> Signup and view all the answers

A patient with ulcerative colitis is suspected of having toxic megacolon. Which imaging modality is MOST appropriate for initial diagnosis?

<p>Plain abdominal X-ray (B)</p> Signup and view all the answers

A patient's lab results show anemia, elevated white blood cell count, and increased platelet count. Which condition might this indicate in the context of ulcerative colitis?

<p>An acute exacerbation of ulcerative colitis with systemic inflammatory response (A)</p> Signup and view all the answers

In ulcerative colitis, what microscopic feature is least likely to be observed?

<p>Inflammation extending beyond the submucosa (B)</p> Signup and view all the answers

After achieving remission with steroid therapy, a patient with moderate ulcerative colitis experiences rapid relapses whenever steroids are tapered. What is the MOST appropriate next step in management?

<p>Start a second-line treatment with an immunosuppressive agent such as azathioprine (C)</p> Signup and view all the answers

Flashcards

Ulcerative Colitis Definition

Chronic inflammatory condition affecting the rectum and extending proximally, involving a variable length of the colon.

UC Intestinal Symptoms

Bloody diarrhea, mucus per rectum, urgency, and tenesmus.

UC-Related Extraintestinal Manifestations

Peripheral arthropathy, erythema nodosum, episcleritis, aphthous ulcers, pyoderma gangrenosum, anterior uveitis.

Mild Ulcerative Colitis

< 4 bloody stools per day with no systemic disturbance.

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Truelove and Witts Criteria

The clinical criteria used to guide admission and IV therapy in Ulcerative Colitis.

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Markers of UC Severity (Labs)

High CRP, high platelets, low albumin, low Hb.

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Role of Colonoscopy

Determine disease extent and severity using the Mayo score.

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Abdominal X-Ray Use

Diagnose toxic megacolon.

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Stool Test Utility

Elevated fecal calprotectin or fecal lactoferrin differentiate between IBD and IBS.

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Treatment for Proctitis

5-ASA (mesalazine) or steroid enemas

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UC Epidemiology

Affects males and females equally, typically with peak onset between 20-40 years old.

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UC Clinical Signs

Tender bowel, normal bowel sounds (unless in toxic megacolon), signs of dehydration, fever, weight loss and tachycardia.

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Moderate Ulcerative Colitis

4-6 bloody stools per day, minimal systemic disturbance.

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Severe Ulcerative Colitis

6 bloody stools per day with systemic disturbance (fever, tachycardia, anemia).

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Toxic Megacolon Diagnosis

Plain abdominal X-ray reveals colon diameter >=6 cm.

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Longstanding UC Risks

High risk of colorectal cancer (CRC).

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UC Colonoscopy Screening

After 8 years for pancolitis, or 12-15 years for left-sided disease, repeat every 2-3 years.

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Mild to Moderate UC Treatment

Utilize oral mesalazine, oral steroids in moderate dose (prednisolone 20mg/day).

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UC Surgery indications

Severe attacks not responding to medications, complications, or refractory disease.

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Study Notes

  • Ulcerative colitis is a chronic inflammatory condition affecting the rectum and extending proximally to involve a variable length of the colon.
  • Males and females are equally affected.
  • Peak onset age is between 20 to 40 years, with a second smaller peak in older adults.
  • The etiology and pathogenesis are the same as Crohn's disease.

Intestinal Manifestations

  • Symptoms of intestinal manifestations include bloody diarrhea and mucus per rectum.
  • Patients commonly experience urgency of defecation and tenesmus.
  • Abdominal pain occurs but is usually not as prominent as in Crohn's disease.
  • Systemic symptoms are common in severe attacks, including anorexia, vomiting, fever, and symptoms of anemia.
  • Signs of intestinal manifestations include a tender bowel on abdominal examination.
  • Bowel sounds are normal unless in toxic megacolon.
  • Signs of dehydration, fever, weight loss, and tachycardia can be seen in acute severe colitis.

Extraintestinal Manifestations

  • Peripheral arthropathy, erythema nodosum, episcleritis, and aphthous (mouth) ulcers are related to the activity of colitis.
  • Pyoderma gangrenosum and anterior uveitis are usually related to the activity of colitis.
  • Sacroiliitis, ankylosing spondylitis, and primary sclerosing cholangitis are unrelated to the activity of colitis.
  • Pericarditis and amyloidosis are rare extraintestinal manifestations.

Assessing Disease Severity

  • The clinical criteria of Truelove and Witts are still used as a guide to decide on admission and IV therapy.
    • Mild UC involves < 4 bloody stools per day, with no systemic disturbance.
    • Moderate UC involves 4-6 bloody stools per day, with minimal systemic disturbance.
    • Severe UC involves > 6 bloody stools per day, with systemic disturbance (fever, tachycardia, anemia, or ESR/CRP >30).
  • Markers of severity include:
    • High CRP
    • High platelets
    • Low albumin
    • Low Hb

Additional Notes

  • Venous and arterial thromboembolic disease can result from hospitalization, immobility, malnutrition, increased platelet count, and clotting factors.
  • Dermatological manifestations include aphthous stomatitis, erythema nodosum, psoriasis, and pyoderma gangrenosum.
  • Ocular manifestations include uveitis, scleritis, and episcleritis.
  • Vascular manifestations include portal hypertension, thromboembolism, thrombosis, and pulmonary embolism.
  • Respiratory manifestations include obstructive sleep apnea and chest infections.
  • Arthropathy includes arthritis, ankylosing spondylitis, and sacroiliitis.
  • Hepatobiliary manifestations include primary sclerosing cholangitis, cirrhosis, colorectal cancer, and small-bowel cancer.
  • Inflammatory manifestations include asthma, bronchitis, pericarditis, rheumatoid arthritis, and multiple sclerosis.
  • Other manifestations include metabolic bone disease.

Pathology

  • Distribution:
    • 50% involves the recto-sigmoid area.
    • 30% has left-sided disease (up to the splenic flexure).
    • 20% has pancolitis.
  • Shortening and narrowing of the colon can occur due to chronic inflammation.
  • Fibrosis and strictures are uncommon.
  • Microscopic features include:
    • Inflammation confined to the mucosa
    • Crypt distortion (cryptitis, crypt abscess, crypt atrophy)
    • Irregular mucosal surface
    • Basal lymphoid aggregates
    • Chronic inflammatory infiltrate
    • Goblet cell depletion

Differential Diagnosis

  • Crohn's disease
  • Infective colitis
  • Ischemic colitis
  • Radiation colitis
  • Microscopic colitis
  • Drug-induced colitis (NSAIDs, antibiotics, and immune checkpoint inhibitor induced enterocolitis)

Laboratory Investigations

  • CBC: Anemia, elevated WBC, and elevated platelets can be observed.
  • High CRP is typically present.
  • LFTs may show low serum albumin.
  • Abnormal liver function and elevated alkaline phosphatase enzyme occur in primary sclerosing cholangitis (PSC).
  • Stool tests:
    • Elevated fecal calprotectin or fecal lactoferrin can differentiate between IBD and IBS and can be used to follow up on response to treatment instead of colonoscopy.
    • Stool culture and sensitivity, Clostridioides difficile toxin, should be performed to exclude infectious colitis.
  • Immunological markers:
    • pANCA is found in 70% of UC (only 15% of CD).
    • Antibodies to Saccharomyces cerevisiae (ASCA) are less common in UC than in CD.
  • Common causes of high fecal calprotectin levels include Crohn's disease, ulcerative colitis, ischemia colitis, infectious colitis, and colorectal cancer.

Colonoscopy or Sigmoidoscopy

  • Determine disease extent (proctitis, left-sided colitis, pancolitis) and severity (Mayo score).
  • Take biopsies for histology.
  • Take biopsies for Cytomegalovirus (CMV) histology in refractory or severe disease (inclusion bodies).
  • Take biopsies for diagnosis of dysplasia and cancer.

Radiology

  • Plain Abdominal X-Ray: To diagnose toxic megacolon (colon diameter ≥6 cm).
  • Barium enema: Shows pipe stem appearance of the colon.
  • Contrast CT (colography): Gives much more information and shows colonic wall thickening.
  • Intestinal US: Can give information about some areas of the colon (including sigmoid and caecum).
  • MRI (colography): Of the pelvis and abdomen to characterize colitis.

Surveillance for CRC in Ulcerative Colitis

  • Longstanding ulcerative colitis is associated with an increased risk of colorectal cancer (CRC) (High-risk group).
  • Patients should receive initial screening colonoscopy:
    • 8 years after the onset of pancolitis.
    • 12 to 15 years after the onset of left-sided disease.
  • Follow-up colonoscopy should be repeated every two to three years.

Treatment of UC

  • Proctitis treatment includes topical 5-amino-salicylic acid (5-ASA) (mesalazine) or steroid enemas, or a combination of both.
  • Suppositories are effective for pure proctitis.
  • If symptoms continue, add oral 5-ASA.

Mild or Moderately Active and Severe Colitis

  • Use oral mesalazine, oral steroids in moderate dose (prednisolone 20mg/day).
  • If relapses rapidly on tapering steroids, start 2nd line treatment with an immunosuppressive agent (azathioprine, 6-mercaptopurine).
  • If persistent despite receiving steroids and immunosuppressive drugs, shift to biologic drugs (Infliximab, Vedolizumab, Adalimumab, Ustekinumab, or Tofacitinib) or surgery.

Maintenance Treatment

  • Use mesalazine indefinitely at a dose of 1200-2400mg/day.

Surgery

  • Indications for surgery in ulcerative colitis include:
    • Severe attacks not responding to medical therapy.
    • Complications of severe attack (perforation, acute megacolon).
    • Refractory chronic continuous disease with impaired quality of life.
    • Dysplasia or carcinoma.
  • Choice of operation:
    • Total colectomy with permanent ileostomy.
    • Total colectomy with ileoanal pouch formation.
    • Colectomy with pouch formation is the operation of choice.

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