Med IV exam 2 - IBD: CD & UC

recurrent slowly progressive relentless and disabling transmural chronic inflammatory bowel dz of unknown etiology

Crohn’s dz

what part of the body is affected by Crohn’s dz

ileum and colon. may affect any region of the GI tract from the mouth to the anus

clinical hallmark of Crohn dz

nonbloody diarrhea

forms of Crohn’s dz

regional enteritis, ileocolitis, granulomatous colitis

age distribution of Crohn dz

15-30, then after 60

what pop of people are more affected by Crohn dz

Caucasians w euro origin. very hi in Ashkenazi jews

what pop of people are less affected by crohn dz

african americans or asians

what are possible causes of crohn dz

autoimmunity and infectious agents

how does family hx play a role in getting Crohn dz

some pts have a + fhx of it. first degree relatives w dz give you a hi chance of having it too. genetic markers (HLA-DR2) are commonly seen in pts with this dz

what genes have been linked to crohn dz

IBD 1 (on cr. 16) and colony-stimulating factor IR

what is a self induced risk for crohn dz

smoking

what are some possible infectious causes for Crohn dz

Chlamydia, mycoplasma, viruses

what happens to the bowel wall in pts with crohn dz

bowel wall infiltrated w lymphocytes, macrophages (attracted by T cell cytokines), multinucleated giant cells, and neutrophils

the systemic manifestations of crohn dz (arthritis, uveitis) are caused by

immunologic reasons

attacks of crohn dz respond well do what type of drugs

immunosuppressive drugs, like prednisone and azathioprine

what cell in crohn dz is excessive and what happens as a result of that

t helper cell 1 cytokines (enhance cell mediated immune response). causes inappropriate T cell responses to antigens from their own intestinal flora

what does the IBD1 gene do in Crohn dz pts

encodes a product that activates macrophages to respond to bacterial lipopolysaccharides (outer membrane of gm- bacteria).

what does the colony stimulating factor IR gene do in Crohn dz pts

regulates differentiation of monocytes to macrophages.

what do activated macrophages do in Crohn dz

produce many potent inflammatory mediators in intestinal wall, like TNFalpha, IL-1, and IL-6

what does TNFa do in Crohn dz

attracts inflammatory cells

1/3 of cases of crohn dz involves what part of the GI tract

only the small intestine, m/c at the terminal ileum (causing ileitis)

½ of crohn dz cases involve what parts of the GI tract

small intestine and colon (ileocolitis)

1/5 of crohn dz cases involve what part of the GI tract

only the colon (colitis)

sharply defined inflammatory lesions that are surrounded by nl appearing tissue on the mucosal surface of the bowel

skip lesions

what exam findings are found in crohn dz

skip lesions, cobblestoning, fibrosis, strictures, fistula formation, multinucleated giant cell, toxic megacolon

entire thickness of the bowel wall is inflamed. begins in the submucosa and spreads up into the mucosa and down into the muscular layer. causes extensive tissue injury where the bowel manifests this appearance from the fissures and ulcers that develop

cobblestoning

cobblestoning is visualized on

colonoscopy

as inflammation subsides scar tissue is produced

fibrosis

with time the intestinal wall becomes thickened and inflexible and the lumen of the small bowel is narrowed and causes an obstruction

strictures

abnl tube like structures created by dz that connects the surfaces of the same organ or surfaces of 2 diff organs at sites of bad inflammation (bowel to bladder would create an enterovesicular fistula). Can lead to bacterial overgrowth serious infections and abscesses.

Fistula formations

Common histopathologic feature of various chronic granulomatous diseases. Non caseating granulomas are hallmark for crohns

Multinucleated giant cell

Life-threatening dilation of the colon can develop when inflammation extends into the muscle layers of the G.I. wall and weakens muscle tone

Toxic megacolon

Patient has malaise lack of energy, weight, loss episodes of low-grade fever, fecal urgency with non-bloody diarrhea multiple bowel movements (six daily if severe dz), colicky or steady right lower quadrant abdominal pain a palpable and tender, right lower quadrant mass representing thickened loops of inflamed intestine, painful abscesses and ulcers in the anal region

Crohn’s disease

Extra intestinal symptoms are especially visualized with what form of Crohn’s disease

Colitis form

painful nodules that form suddenly on the extensor surfaces of the arms and legs and are caused by inflammation of subcutaneous adipose tissue

Erythema nodosum

A chronic non-infective eruption of spreading ulcers in the skin that most commonly develops on the lower extremities

Pyoderma gangrenosum

Inflammation of the outermost connective tissue layers of the sclera of the eye

Episcleritis

With Crohn’s disease, what is a result of hypercoagulability of the blood?

Thrombosis

How does arthritis present in Crohn’s disease?

Migratory non-destructive arthritis affecting the large joints of the arms and legs

Information of the iris, ciliary body and choroid of the eye that causes blurred vision, eye pain, and sensitivity to light

uveitis

What is an oral manifestation of Crohn’s disease?

Painful oral ulcers

Arthritis of the spine associated with gene HLA B27

Ankylosing spondylitis

Inflammation and progressive fibrosis of the intra-and extra hepatic bile ducts, which increase the patient’s risk for bile duct cancer (cholangiocarcinoma)

Sclerosing cholangitis

Why do patients with Crohn’s disease get kidney stones?

Because of poor absorption of fat, allowing for greater oxalate absorption and the formation of calcium oxalate stones

Why do patients with Crohn’s disease get gallstones?

Because of a greater frequency in ileitis as a result of poor absorption of bile acids at the terminal helium

CBC Crohn’s disease

Anemia showing blood loss and iron deficiency or male absorption of vitamin B12 or folic acid

Albumin Crohn’s disease

Hypoalbuminemia results from a loss of protein in the feces due to inflammation induced malabsorption

CMP Crohn’s disease

Fluid and electrolyte deficiencies (especially hypokalemia and hypocalcemia)

ESR and CRP Crohn’s disease

Signs of active inflammation (high WBC, ESR, CRP)

What is the Crohn’s disease activity index and what does it measure?

Evaluate the severity of the disease and response to treatment. Looks at number of bowel movements sum of abdominal pain, ratings, and general well-being during the past seven days.

What type of imaging is preferred to diagnose Crohn’s disease and why?

Colonoscopy. Can obtain mucosal biopsies of the intestine that can diagnose the disease. Observed ulcers, structures, or skip lesions.

How to differentiate between Crohn’s disease and ulcerative colitis when diagnosis is uncertain

Look at serologic tests for two types of antibody, anti-neutrophil cytoplasmic antibodies, (ANCA), and anti antibodies to the yeast saccharomyces cerevisiae (ASCA)

A negative ANCA test and a positive ASCA test have a high predictive value of what disease

Crohn’s disease

How to treat Crohn’s disease with nutritional support if they are lactose intolerant

limit dietary products or supplementation with lactase to decrease symptoms

How to treat Crohn’s disease with nutritional support if they have primarily colitis

Fiber supplementation

How to treat Crohn’s disease with nutritional support if they are anemic

Iron supplements and IM injections of vitamin B12

How to treat Crohn’s disease with nutritional support if they are a child or malnourished patient awaiting surgery

Enteral therapy

First line treatment for mild or moderate colitis in Crohn’s disease

Oral 5-aminosalicylic agents, like sulfasalazine or mesalamine

How to treat bacterial overgrowth for ileitis Crohn’s disease

Ciprofloxacin

What antibiotic do you use to treat colitis ileocolitis and anal infections from Crohn’s disease

Metronidazole

This type of drug dramatically suppresses symptoms and most patients with either ileitis or colitis from Crohn’s disease, but does not alter the course of the disease itself

CCS

What is the preferred corticosteroid for mild to moderate Crohn’s disease?

Budesonide

This drug is effective when inflammation occur occurs in the terminal ileum or ascending colon

Budesonide

What critical steroid is indicated to patients with severe Crohn’s disease when inflammation involves the distal colon, proximal small intestine, or when patient has failed treatment with budesonide

Prednisone or methylprednisolone

Adverse effects of prednisone or methylprednisolone

Osteoporosis, cataracts, DM, and HTN

This drug class is effective and treating patients for long-term Crohn’s disease and for those that are resistant to CCS therapy. Not useful for treating a cute flareups and should be given to pts with frequent recurrences and those who need chronic CCS therapy.

Immunomodulating agents like azathioprine and mercaptopurine

what do you give a pt to tx Crohn’s if they fail all other medications including the immunomodulating agents

MTX

first tx approved specifically for CD. good for pts who have moderate to severe dz and have a bad response to other immunosuppressants or in pts that get flareups when you taper steroids. Also used to quickly improve sx.

Anti TNF antibody infliximab

Side effects of infliximab

Sirius infections

When is a Crohn’s disease patient indicated for surgery.

Bad response to pharmacotherapy, development of intra abdominal abscess or stricture, perforation of the bowel, and massive bleeding, need for more bowel resections in 15 yrs due to high recurrence rate of disease.

complications of crohn’s dz

obstruction due to strictures or fibrosis, big hemorrhage, toxic megacolon, intra abdominal abscesses, bowel perforation, dehydration from loss of fluid, hypokalemia (causing life-threatening, cardiac dhsrhythmias), pneumonia, sepsis, and other life-threatening infections from immunosuppressive meds, and the development of colon cancer

If a Crohn’s disease, patient has a history of eight or more years of colitis. What screening is required?

Colonoscopy

chronic IBD of unknown etiology characterized by sx flare ups and remissions

UC

this dz causes ulcers of mucosal surface in rectum and colon but doesn’t hit any other region in the GI tract.

UC

continuous inflammation, not skipping regions of the GI tract. dz begins in rectum and spreads to colon

UC

clinical hallmark of UC

Severe bloody diarrhea

What gender is more affected by UC

Females

Age for UC prevalence

Bimodal, where highest freq is in adolescents and young adults (15-25) and a second peak at 55-65.

What race is primarily affected by UC

Caucasians, Askanazi Jews.

What race is not as affected by UC

African Americans and Asian Americans

How can microbes cause UC

initiate the inflammation that develops the dz. From pathogens like measles, protozoans, mycobacteria

How can genetic factors predispose a pt to UC

first degree relatives with chronic IBD have way higher risk for IBD.

How does smoking affect your risk of UC?

Lowers your risk. Relapses are associated with smoking cessation and nicotine transdermal patches relieve symptoms.

This surgery before the age of 20 is also associated with a reduced risk for UC

Appendectomy for acute appendicitis

How are genetic factors related to developing UC?

They can contribute to an auto immune reaction that might be triggered by a normally harmless environmental agent

What infections can develop UC?

Mycoplasma or viruses

How does the mucosal surface of the bowel wall change in the UC?

It’s infiltrated with a lymphocytes, macrophages (attracted by T cells secreted cytokines), and neutrophils

What is the cause of many of the systemic manifestations UC (arthritis and uveitis)

Immunologic

UC is usually accompanied by

Other autoimmune diseases

attacks of UC respond positively to what type of drugs

Immunosuppressive (prednisone and azathioprine)

This type of cell is excessive in patients with UC

T helper cell 2 cytokine activity (enhances the antibody mediated immune response)

What type of antibodies are found in the blood of pts with UC

Anti-colon antibodies

Inflammation pattern of UC

Begins in the rectum and spreads from the proximal to the distal colon

In approximately 1/2 of pts with UC where is the inflammation located

Confined to the rectum and sigmoid colon

In 1/3 of patients with UC where does the colitis extend?

To the splenic flexure

In 1/5 of UC cases where is the inflammation located

The entire colon

pt has continuous and superficial nature of inflammation across mucosal surface. occasionally into into submucosa. not found in deeper layers in intestinal wall. entire thickness of bowel is rarely inflamed and the adjacent messengers and regional lymph nodes are also spared.

UC

A how do ulcers form in UC

Dead tissue is sloughed off causing microscopic erosions, that then come together to form larger ulcers seen by eye. The regions of regenerating tissue resemble polyps (pseudopolyps) that are unique to this dz

When do crypt abscesses occur in the UC?

Inflammatory cells accumulate in crypts, or pouches, inside the G.I. system

Extensive mucosal injury in UC causes what symptom

Bloody diarrhea from an inability to absorb water and inflammation induced injury to capillaries