PANCE Blueprint GI and Nutrition (10%)

Inflammatory bowel disease

Ulcerative colitis will present as →  A 32-year-old woman comes to your office with a 6-month history of loose bowel movements, approximately eight per day. Blood has been present in many of them. She has lost 30 pounds. For the past 6 weeks, she has had an intermittent fever. She has had no previous gastrointestinal (GI) problems, and there is no family history of GI problems. On examination, the patient looks ill. Her blood pressure is 130/ 70 mm Hg. Her pulse is 108 beats/ minute and regular. There is generalized abdominal tenderness with no rebound. A sigmoidoscopy reveals a friable rectal mucosa with multiple bleeding points.

Crohn's disease will present as → a 25-year-old man with an 18-month history of chronic abdominal pain. The patient has seen several physicians and has been diagnosed as having “nervous stomach,” irritable bowel syndrome, and “depression.” Associated with this abdominal pain for the past 3 months have been nonbloody diarrhea, anorexia, and a weight loss of 20 pounds. He has developed a painful area around the anus. On examination, the patient has diffuse abdominal tenderness. He looks thin and unwell. He has a tender, erythematous area in the right perirectal area.

Ulcerative Colitis (“colitis” = confined to colon)

  • Presents with bloody puss filled diarrhea, rectal/lower quadrant pain, fever, and urgency
  • Inflammation isolated to colon and confined to mucosa and submucosa (unlike Crohn's not transmural)
  • Most common site is rectum
  • Bimodal distribution of peak onset: age 15-25 and age 55-65
  • Labs: ↑ WBC, ESR, and anemia
  • Diagnosis by barium enema LEAD PIPE APPEARANCE and colonoscopy with biopsy both show continuous inflammation starting from rectum and extending proximally with loss of haustral markings and lumen narrowing
  • Complications: Toxic megacolon, colorectal cancer
  • Antibody test: Antineutrophil cytoplasmic antibodies (pANCA)

Crohn's Disease

  • Presents with abdominal pain, weight loss, diarrhea and oral mucosal aphthous ulcers.  Longer standing disease may have severe anemia, polyarthralgia, and fatigue.
  • Most common site is the terminal ileum
  • Distribution from mouth to anus and will commonly present with thickened bowel wall,  cobblestoning and  “skip” lesions
  • Linear fissures and cobblestone appearance.  Tends to be transmural while UC is limited to the mucosa and submucosa
  • Complications include strictures identified by a STRING SIGN on barium study
  • Presents with abdominal pain, weight loss, diarrhea and oral mucosal aphthous ulcers
  • Obstruction, abscess, fistula and sinus tracts are common
  • 1-3% cancer risk (low)
  • Antibody test: +Anti-saccharomyces cerevisiae antibodies (ASCA)

Crohn's disease

  • Barium x-rays of the stomach, small bowel, and colon
  • Abdominal CT
  • Sometimes magnetic resonance (MR) enterography, upper endoscopy, and/or colonoscopy

Ulcerative Colitis:

Sigmoidoscopy with biopsy

Laboratory tests should be done to screen for anemia, hypoalbuminemia, and electrolyte abnormalities. Liver function tests should be done; elevated alkaline phosphatase and γ–glutamyl transpeptidase levels in patients with major colonic involvement suggest possible primary sclerosing cholangitis. Leukocytosis or increased levels of acute-phase reactants (eg, ESR, C-reactive protein) are nonspecific but may be used serially to monitor disease activity. To detect nutritional deficiencies, levels of vitamin D and B 12 should be checked every 1 to 2 yr.

Treatment for UC and Crohn's disease are the same

  • Loperamide and dietary management for symptom relief
  • 5-Aminosalicylic acid (5-ASA)
  • Corticosteroids and other drugs depending on symptoms and severity
  • Anticytokine drugs
  • Sometimes surgery
Ulcerative colitis and Crohn's disease are inflammatory bowel diseases characterized by chronic inflammation of a portion of the GI tract resulting from inappropriate mucosal immune activation.
IM_NUR_CrohnsDiseaseAss_v1.3_ Crohn's disease is an inflammatory bowel disorder that can involve any segment of the GI tract from the mouth to the anus but preferentially is found in the terminal ileum. The disease is characterized by periodic remissions and exacerbations.

Crohn's Disease Assessment

Crohn's Symptoms and Associations

Crohn's Disease Characteristics

 

_DM_Ulcerative_Colitis_Characteristics_v1.7_ Ulcerative colitis is characterized by severe ulcerating inflammation of the mucosal and submucosal layers that is limited to the colon and rectum. In contrast, Crohn's disease may involve any area of the GI tract and can extend into all layers of the GI wall. Although ulcerative colitis is not considered an autoimmune disease, there are associations with autoimmunity and thought to result from a mixture of defects in host interactions with intestinal microbiota, epithelial dysfunction, and aberrant mucosal immune responses. Grossly, ulcerative colitis always involves the rectum and expands proximally in a stepwise fashion to involve all or a part of the colon. Affected areas can demonstrate broad-based ulcers and regions of regenerating mucosa can bulge into the lumen creating pseudopolyps. Histologic features include inflammatory infiltrates and crypt abscesses. Chronic inflammation can cause the colon to become thickened and stiff and can lead to shortening of the colon with atrophic mucosa and loss of haustral folds. This can give the appearance of a lead pipe in the descending and sigmoid colon when visualized with barium study. The most common symptoms include relapsing attacks of bloody diarrhea with mucous and pus and cramping lower abdominal pain. Chronic disease can lead to anorexia, weight loss, and even growth retardation.

Ulcerative Colitis Characteristics

Ulcerative Colitis Associations

Question 1
Which medication is considered the mainstay of therapy for mild to moderate inflammatory bowel disease?
A
Prednisone
Hint:
Glucocorticoids are used in moderate to severe inflammatory bowel disease.
B
Sulfasalazine
C
Metronidazole
Hint:
Metronidazole may have a role in Crohn's disease after ileal resection but has no role in the treatment of mild to moderate disease.
D
Azathioprine (Imuran)
Hint:
Azathioprine is used in severe, glucocorticoid-dependent inflammatory bowel disease.
Question 1 Explanation: 
Sulfasalazine and other 5-aminosalicylic acid drugs are the cornerstone of therapy in mild to moderate inflammatory bowel disease as they have both anti-inflammatory and antibacterial properties.
Question 2
Which of the following is not an extraintestinal manifestation of inflammatory bowel disease?
A
Uveitis
Hint:
See D for explanation
B
Erythema nodosum
Hint:
See D for explanation
C
Arthritis
Hint:
See D for explanation
D
Dermatitis herpetiformis
Question 2 Explanation: 
Dermatitis herpetiformis (A chronic, very itchy skin rash made up of bumps and blisters) is an extraintestinal manifestation of celiac disease. All other options are correct.
Question 3
Which of the following statements concerning inflammatory bowel disease is not true?
A
Ulcerative colitis is more common in non-smokers and ex-smokers.
Hint:
Smoking is protective in UC, with a lower incidence of disease in smokers and current smoking protects against UC and, after onset of the disease, improves its course, reducing the need for colectomy.
B
Appendectomy protects against ulcerative colitis.
Hint:
Appendectomy is a protective factor against UC.
C
Crohn disease causes segmental transmural inflammation of the bowel.
Hint:
Distribution from mouth to anus and will commonly present with thickened bowel wall, segmental transmural inflammation of the bowel, cobblestoning and “skip” lesions.
D
Ulcerative colitis affects the colon in a descending fashion.
Question 3 Explanation: 
Ulcerative colitis is isolated to colon and confined to mucosa and submucosa. Most common site is the rectum. Ulcerative colitis affects the colon in an ascending fashion starting from the rectum up to the ascending colon.
Question 4
Which of the following drugs has no role in the management of inflammatory bowel disease (IBD)?
A
Infliximab
Hint:
An anti-TNF antibodies. Suppress inflammation and induce apoptosis of inflammatory cells.
B
Budesonide
Hint:
Budesonide is a potent corticosteroid and has an anti-inflammatory effect.
C
Mercaptopurine
Hint:
Mercaptopurine is a Thiopurine. It is an immunomodulator which acts by inducing T-cell apoptosis.
D
Cisapride
Question 4 Explanation: 
Cisapride is a prokinetic agent. It has no role in the management of IBD.
Question 5
Crohn’s disease is associated with which of the following?
A
Inflammation limited to the superficial layer of the bowel wall
Hint:
Crohn’s disease is characterized by a transmural inflammation of the GI tract.
B
The affinity to involve the rectosigmoid junction
Hint:
It may affect any part of the GI tract but is usually associated with the terminal ileum, the colon, or both.
C
Decreased risk of colon cancer
Hint:
There is also an increased risk— five times the average— for bowel cancer.
D
Continuous mucosal areas of ulceration that affect the anus
Hint:
This is the description of ulcerative colitis
E
Fistula formation
Question 5 Explanation: 
Crohn’s disease is characterized by a transmural inflammation of the GI tract. It may affect any part of the GI tract but is usually associated with the terminal ileum, the colon, or both. On colonoscopy, areas of ulceration and submucosal thickening give the bowel a cobblestone appearance, with some skipped areas of normal bowel. In addition to the transmural inflammation, there are granulomas, abscesses, fissures, and fistula formation. Symptoms include fever, weight loss, abdominal pain (usually the right-lower quadrant), diarrhea (rarely with associated blood), and growth retardation in children. In children, Crohn’s disease is more common than ulcerative colitis. Complications include intestinal obstruction; toxic megacolon, which is usually more common in ulcerative colitis; malabsorption, particularly associated with fat-soluble vitamins and especially vitamin B12; intestinal perforation; fistula formation; and development of gall and kidney stones.
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