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60 Cards in this Set
- Front
- Back
How many cases of IBD are there in the US? UC vs CD?
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> 1 million
50% UC and 50% CD |
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How many new cases of IBD are there per year? How many total cases of IBD are there / 100,000?
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- New cases: 10 / 100,000 / year
- Total cases: >200 / 100,000 in the West |
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What is the long-term outlook of IBD?
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- Chronic, lifelong disease without medical cure
- Surgery often necessary |
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Where are the highest incidences of IBD in the world?
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- US
- Canada - Europe |
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What part of the GI tract is affected by Ulcerative Colitis? Pattern?
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- Continuous inflammation
- Colon only, superficially affects mucosa, lamina propria, and submucosa - Starts at rectum and works its way proximally |
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What is the clinical presentation of Ulcerative Colitis?
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- Diarrhea (bloody w/ mucus)
- Abdominal pain and tenderness - Loss of appetite and weight - Fever - Fatigue - Urgency for BM - Children: growth and developmental failure |
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What findings are there of Ulcerative Colitis on endoscopy?
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- Erythema
- Loss of usual fine vascular pattern - Granularity of mucosa - Friability - Edema - Pseudopolyps - Erosions and ulcers - Spontaneous bleeding - Cecal patch - Backwash ileitis |
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What does this endoscopy show?
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- Mild ulcerative colitis with loss of vascular pattern
- Hard to see the blood vessels - Some whitening = accumulation of immune cells |
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What does this endoscopy show?
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Severe ulcerative colitis
- Spontaneous bleeding and friability - Occult blood leaking in from bowel - White blobs are mucus, neutrophils, macrophages, and lymphocytes leaking into lumen |
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What does this endoscopy show?
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Ulcerative Colitis
- Erythematous - Friable - Loss of vascular pattern - Also notice continuous and circumferential pattern |
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What does this endoscopy show?
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Ulcerative Colitis
- Inflammatory pseudopolyp - outpouching of inflammatory cells predominantly seen in UC - Large population of goblet cells covers the pseudopolyps with mucous |
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What does this endoscopy show?
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Ulcerative Colitis
- Lots of Pseudopolyps decreasing the size of the lumen |
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What is the remission rate of Ulcerative Colitis?
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Around 40% no matter how many years after diagnosis
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What are the potential outcomes of Ulcerative Colitis over time?
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- Colectomy (up to 20%)
- Disease activity persists (30-50%) - Remission (~40%) |
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What are the possible disease severities in Ulcerative Colitis? How common?
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- Low activity (20%)
- Moderate to Higher activity (71%) - Fulminant disease (9%) Activity = patients presenting with symptoms of their disease (diarrhea, pain, etc) |
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What is meant by Fulminant Colitis?
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Severe UC, with:
- Fever, elevated WBC count, and unstable vitals - High risk of perforation |
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How do you diagnose Fulminant Colitis?
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- Usually full colonoscopy not necessary
- Flex sig only to rule out other causes such as C. difficile and take biopsies - Otherwise based on presence of fever, elevated WBC count, and unstable vitals |
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What part of the GI tract is affected by Crohn's Disease? Pattern?
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- Patchy inflammation
- Mouth to anus involvement - Full-thickness inflammation (all layers of the bowel wall) |
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What are the characteristics that indicate Crohn's Disease?
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- Variable involvement
- "Cobblestone" appearance - Fistulae - Strictures |
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What is the most common location to be affected by Crohn's Disease?
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Ileocecal area
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How common is Crohn's Disease that only affects the small intestine? Only the large intestine? Both small and large intestine?
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- Small intestine: 30%
- Large intestine: 20-25% - Small AND Large intestine: ~50% (remember UC always only affects the large intestine) |
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What is the typical clinical presentation of Crohn's Disease?
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Usually in pediatric population (<18 years):
- Abdominal pain - Diarrhea and occasionally rectal bleeding (bleeding less common in CD) - Weight loss - Anorexia (failure to thrive) - Vomiting - Stunted growth - Fevers |
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How does Crohn's Disease that presents in an adult differ from that which presents in a pediatric patient?
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- Similar symptoms
- Growth and development issues less apparent - Often had silent disease as a child / teen |
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What are the three major endoscopic findings that are specific for Crohn's Disease?
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- Aphthous ulcers (looks like a canker sore)
- Cobble-stone appearance - Discontinuous lesions |
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What does this endoscopy show?
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Crohn's Disease with linear ulcerations
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What does this endoscopy show?
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Crohn's Disease: skip lesions (areas of inflammation are adjacent to normal mucosa)
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What does this endoscopy show?
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Crohn's Disease: Cobble-stone appearance
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What findings favor a diagnosis of Crohn's Disease?
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- Rectal sparing (UC always affects the rectum)
- Normal vasculature next to affected tissue (skip lesions) - Isolated involvement of the terminal ileum (pancolitis/UC can have backwash ileitis where the lesion extends up to the ileum) - Fistulas or Strictures - Granulomas on biopsy |
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What are the extra-intestinal manifestations of IBD?
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- Acute Arthropathy (knees, spine, proximal joints of hands): 15-20%
- Erythema Nodosum (red rash on shins): 15% - Choledocholithiasis: 15-30% - Ocular complications: 5-15% - Sacroiliitis: 9-11% - Nephrolithiasis: 5-10% - Ankylosing Spondylitis: 3-5% - Pyoderma Gangrenosum: 1-2% - Primary Sclerosing Cholangitis: 1-2% - Amyloidosis: rare |
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Which extra-intestinal manifestations are more common in Crohn's Disease?
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- Ankylosing Spondylitis (3-5%)
- Nephrolithiasis (later on in CD in patients who have had surgery): 5-10% |
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Which extra-intestinal manifestations are more common in Ulcerative Colitis?
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- Pyoderma Gangrenosum: 1-2%
- Primary Sclerosing Cholangitis: 1-2% |
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What is this? What is it associated with?
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Erythema Nodosum: painful and tender extra-intestinal manifestation of IBD (15%)
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What is this? What is it associated with?
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Pyoderma Gangrenosum: violet tinge at endges of rash, extra-intestinal manifestation of IBD (more common in UC) (1-2%)
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What is this? What is it associated with?
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Ocular complications (5-15%), extra-intestinal manifestation of IBD:
- Left: Episcleritis - white part of eye is very inflamed, usually not painful, more of a cosmetic issue - Right: Uveitis - painful inflammation of the iris that hurts between light and dark rooms as the iris contracts |
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What are the goals of management of IBD?
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- Confirm accurate diagnosis
- Induce remission (absence of inflammatory symptoms and feeling "well") - Maintain remission - Avoid surgery when possible - Enhance quality of life - Avoid complications of disease and therapy |
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How common is maintenance therapy in patients in remission from IBD?
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- 95% of patients require maintenance therapies
- Transition to maintenance occurs AFTER a successful induction |
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What genetic abnormalities are associated with CD and UC? How common?
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Crohn's Disease:
- NOD2 mutations: 35-40% of patients with this mutation get the disease (incomplete penetrance) and not all patients w/ CD have this mutation - Only associated with CD (not UC) - Concordance rate for monozygotic twins is approximately 50% Ulcerative Colitis: - Concordance rate for monozygotic twins is only 16%, suggesting that genetic factors are less dominant |
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What is the function of the NOD2 gene?
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- Encodes a protein that binds to intracellular bacterial peptidoglycans and subsequently activates NF-κB
- Disease-associated NOD2 variants are less effective at recognizing and combating luminal microbes, which are then able to enter the lamina propria and trigger inflammatory reactions - Other data suggest that NOD2 may regulate immune responses to prevent excessive activation by luminal microbes |
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What is the mucosal immune response to bacteria in IBD?
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- Dendritic cells sample bacteria in lumen and present them to T cells on MHC
* Some T cells become TH1 cells, which release TNF * TNF can lead to epithelial barrier defects which can cause an influx of bacterial components * Some T cells can become TH17 cells (via IL-23) - Additionally, some T cells can become TH2 cells, which release IL-13 |
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What epithelial defects have been described in Crohn's Disease and/or Ulcerative Colitis?
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- Defects in intestinal EPITHELIAL TIGHT JUNCTION barriers seen in CD and some of their healthy 1st-degree relatives
- Barrier dysfunction can activate innate and adaptive mucosal immunity and sensitize subjects to disease |
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How does the microbiota relate to IBD pathogenesis?
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- Some antibiotics, such as metronidazole, can be helpful in maintenance of remission in Crohn disease by controlling the microbiota
- Ill-defined mixtures containing probiotic bacteria may combat disease in experimental models, as well as in some patients with IBD - The mechanisms responsible are not well understood |
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What is the most predominant, non-genetic factor in IBD?
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Colonizing bacteria:
- IBD is characterized by an amplified response to the intestinal microbiota - Differences in microbiota composition and diversity may also contribute to IBD |
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What are the types of disease behavior in Crohn's Disease? How common are they at DIAGNOSIS of CD?
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* Inflammatory: 85% (eg, erythema, ulcerations)
- Stricturing: ~0% (eg, blockage) - Penetrating: 15% (eg, fistulas) |
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What are the types of disease behavior in Crohn's Disease? How common are they 20 years after diagnosis of CD? Implications?
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* Penetrating: 70%
* Stricturing: ~20% - Inflammatory: ~10% Most patients end up requiring surgery d/t penetrating disease (fistulas) or stricturing disease |
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What does this image represent? Which type of IBD is it associated with?
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- Fistula (can be between two loops of small intestine, or with the vagina, skin, peritoneum, etc)
- Sign of Crohn's Disease |
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What are the new classes of drugs for treating IBD?
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Biologics: antibodies against TNF
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What are the Biologics used to treat IBD? Mechanism?
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Anti-TNF monoclonal antibodies:
- Infliximab - Certolizumab pegol - Adalimumab |
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What are the benefits of anti-TNF therapy for IBD?
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- Induces and maintains remission of IBD
- Steroid sparing - Heals perianal fistulizing disease |
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What is the efficacy of anti-TNF therapy based on how long a patient has been diagnosed with IBD?
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The patients who have had a shorter disease time course were more likely to induce remission than those who had the disease for a longer period of time
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What are the side effects of anti-TNF therapy?
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Slight increase in incidence of lymphoma (however, the risk of lymphoma is very low compared to the risk that you will need surgery if you remain untreated)
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Why is there decreased rates of infection in patients with IBD?
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- Fewer patients on steroids now d/t anti-TNF therapy, therefore fewer opportunistic infections
- Improved mucosal healing - Fewer fistulas, strictures, and abscesses |
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What are the types of Microscopic Colitis?
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- Collagenous Colitis
- Lymphocytic Colitis |
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What are the symptoms of Collagenous Colitis and Lymphocytic Colitis (types of microscopic colitis)?
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- Chronic, non-bloody, watery diarrhea without weight loss
- Findings on radiologic and endoscopic studies are normal |
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What are the characteristics of Collagenous Colitis?
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- Type of microscopic colitis
- Presence of dense sub-epithelial collagen layer - Increased numbers of intra-epithelial lymphocytes - Mixed inflammatory infiltrate within lamina propria |
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What are the characteristics of Lymphocytic Colitis?
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- Type of microscopic colitis
- Histologically similar to collagenous colitis - Sub-epithelial collagen layer is of normal thickness and the increase in intra-epithelial lymphocytes may be greater - Associated with celiac and auto-immune diseases |
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Which type of microscopic colitis is associated with celiac and auto-immune diseases?
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Lymphocytic Colitis
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How do you treat Microscopic Colitis (both collagenous and lymphocytic)?
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Budesonide
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Why is the small intestine relatively sterile compared to the colon?
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- Protected by gastric acid
- Protected from bacteria in colon by ileocecal valve - Relatively fast transit time |
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What can cause increased bacterial contact with unabsorbed carbohydrates? Implications?
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- Surgery (eg, gastric bypass disrupts pH)
- Antacid - Slow motility - Can lead to small intestinal bacterial overgrowth |
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How do you diagnose Small Intestinal Bacterial Overgrowth?
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- Duodenal aspirate
- Hydrogen breath test |