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Inflammatory Bowel Disease (Investigations: (Bloods: FBC, CRP, Faecal…
Inflammatory Bowel Disease
Chron's disease
Definition
:
Chronic relapsing inflammatory disorder of the GIT characterised by segmental areas of transmural inflammation
Characteristics:
Skip lesions
Commonly affected areas: terminal ileum and caecum (40%), perianal
Oedema --> thickened wall
Intact epithelium criscrossed by deep fissured ulcers --> cobblestone appearance
Inflammation --> adherance to adjacent abdominal structures --> adhesions, perforations and fistulas
Hallmark histology: non caseating granulomas
Clinical Features
Perianal fissures, haemorrhoids and fistulas
Non bloody, water diarrhoea
Ulcerative Colitis
Definition: Chronic inflammatory disorder of the mucosa and submucosa of the large bowel, characterised by recurrent acute exacerbation's and periods of inactivity/low grade activity.
Characteristics:
Distal to proximal spread of infection, beginning in rectum (no skip lesions)
Neutrophils accumulate in the submucosa forming crypt abscesses and the overlying mucosa sloughs off leaving small superficial ulcers
As the ulcers coalesce, they form areas of irregular ulcerations with areas that project into the lumen that are intact but oedematous, they are called pseudopolyps
During period of inactivity, the mucosa regenerates but he lamina propria remains swollen due to chronic infiltration by WBCs
Goblet cell depletion
Overtime mucosa and submucosa undergo fibrosis which leads to shortening of the colon and smoothing out of the haustrations --> lead pipe colon
Prognosis: dysplastic changes can occur --> adenocarcinoma
Clinical features:
Bloody diarrhoea
Mucus in stools
M = F
Age: <30 years, second peak in 6th decade
Pathophysiology
:
Genetic and environmental factors --> altered barrier function + abnormal inflammatory response to triggers e.g. bacteria --> M cells which usually sample antigens at the lumen translocate certain microbial products --> abnormal inflammatory response (TNF alpha, IL 12, 23, cytokines, etc) --> tissue damage and infiltration of the cell wall
Predisposing factors
Genetics: cytokines, antimicrobial peptides, autophagy
Environment: diet, infection, stress, NSAIDs, Abx, smoking
Investigations:
Bloods: FBC, CRP
Faecal calprotectin
New diagnosis: Stool MCS (electrolytes, pH, fat content), blood cultures, TFT's, serum protein
Endoscopy/Colonoscopy (not to perform in the acute phase)
Abdo X-ray
Extra-intestinal manifestations:
MSK: arthritis, ank spond
Skin and mouth: erythema nodosum, mouth ulcers, glossitis, hair and nail changes
HepatobiIiray: primary sclerosing cholangitis, autoimmine hepatits
Occular: uveitis, episcleritis
Metabolic: growth retardation
Management
:
Screening:
Consider beginning screening 10 years after onset 1-2 yearly (Most important in UC, 25% chance of ca at the 25yr mark)
Indications for surgery:
Acute: toxic megacolon, acute severe disease, perforation, abscess and severe haemorrhage
Chronic: intractable disease not responding to pharmacological Tx, growth retardation/malnutrition, cancer, fistulas
Pharmacological Tx:
Achieving remission:
Chron's: steroids (oral or IV depending on severity)
UC: 5-ASA's and/or oral immunomudulatory drugs e.g. azathioprine and/or steroids (IV)
Avoid anti-diarrheals, anti-cholinergics and opiods
Maintenance therapy:
Don't use steroids
UC: 5-ASA e.g. sulfasalazine and/or immunomodulatory agent
Chron's: immunomodulatory agent e.g. azathioprine and mecaptopurine
Diet: maximise calorie intake, iron and vitamins