What is ulcerative colitis?

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Is chronic inflammatory disease
Involving all or part of the colon
Characterized by inflammatory process confined to mucosa and always involves the rectum

What is its aetiology?

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Almost idiopathic
But maybe immunological, environmental or genetic

Commonest site?

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Rectum

What's meant by backwash ileitis?

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Involvement of terminal ileum due to longstanding UC with no skip lesions

Which treatment would you offer this lady?

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Total Proctocolectomy with end ileostomy

Why?

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The whole colon is susceptible

If there is liver mets, how will this affect TNM staging?

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M1

What is the microscopic features of ulcerative colitis? How does it differ from Crohn's?

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Ulcerative colitis
Crypt abscess formation
Inflammatory cells in the lamina propria
Crohn's
Granulomatous inflammation

What would you see on colonoscopy in UC, Crohn's?

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Ulcerative colitis
Pseudopolyps
Extensive ulceration (superficial)
Contact bleeding
Crohn's
Cobblestone appearance
Linear fissures
Aphthous ulcers
Thickened bowel wall

What is the prominent clinical features of ulcerative colitis?

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Diarrhoea
Crampy abdominal pain
Tenesmus
Bleeding per rectum
Extra intestinal manifestations

What are the complications?

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Toxic megacolon
Cancer colon
Malabsorption

Why does the patient have diarrhoea?

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Malabsorption
Increase motility
Infection

You have a patient who is a known case of Crohn's disease. The patient underwent terminal ileal resection for Crohn's disease, but still has diarrhoea, why?

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Relapse of Crohn's
Malabsorption
Short bowl syndrome

Why are patients with Crohn's are more susceptible to renal stones?

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Increased intestinal fat (due to malabsorption) → binds to calcium → leaving oxalates (hyperoxaluria)

Beside the GIT, what are the other systems affected by IBD?

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Skin: Pyoderma gangrenosum and Erythema nodosum
Eye: Iritis, conjunctivitis, episcleritis, anterior uveitis
Liver: Sclerosing cholangitis
Joints: Arthritis
Others: Clubbing, Aphthous ulcers.

What is the most common extra intestinal manifestation of IBD?

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Arthritis

How would you investigate a patient with suspected ulcerative colitis?

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Full blood count: macrocytic anaemia
Stool analysis: for Calprotectin & faecal occult blood
Barium follow-through X-ray, CT
Prothrombin concentration: to detect vit. K def.
Colonoscopy but not in acute phase.

What are the vitamin deficiencies to be expected in IBD?

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A, D, E, K deficiency and B12

Does this patient needs endoscopic surveillance? Why?

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Yes, For risk of colon cancer

How would you treat a patient with Crohn's disease?

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-Conservative treatment
Lifestyle modification
Dietary control (low residue diet)
-Medical treatment
Advice from gastroenterology
Steroids
Antibiotics according to trust policy and microbiologist
5-aminosalicylic acid (Mesalazine)
Immune modulators
-Surgery if medical treatment failed (resistant cases) or in case of some complications

What are the indications of surgery?

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Refractory disease
Intestinal obstruction
Toxic megacolon
Abscess, fistula, perforation, haemorrhage, cancer

What's TNF?

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It is a proinflammatory cytokine
Secreted from macrophages
Involved in systemic inflammation and in making up the acute phase reaction

Functions of TNF:

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Activate macrophages and neutrophils
Co-factor in activation of T cells
Mediators to body response to gram -ve septicaemia
Anti-tumour effect.
Similar to IL-1

What's its rule in inflammatory bowel disease?

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TNF direct epithelia to increase tight junctions permeability → increase the flux of luminal bacterial components → activates innate and adaptive immune responses.

Which drugs antagonize TNF?

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Infliximab
Adalimumab
Certolizumab

What's the mechanism of action of these drugs?

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They are Monoclonal IgG1 antibody to TNF-α. They block the inflammatory process responsible for the condition i.e. interrupting immune system signals involved in inflammatory processes that result in tissue damage.

When to use them?

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Used mainly in steroid refractory UC cases
For treatment of extra intestinal manifestations

The examiner may show pictures and then asks what they are.
e.g. cobble stone appearance, creeping mesenteric fat