Inflammatory Bowel Disease - Essential GP Revision

Inflammatory bowel disease for general practice exams.

Video version: https://youtu.be/O5VCYrKeF70

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Transcript

SPEAKER_00 0:00

Hi, this is Tom and welcome to the Zero to GP Podcast. In this episode, I'm going to be going through inflammatory bowel disease, the key stuff you need to know for your GP exams. The format, as always, is I'm going to ask you questions based on cases. I want you to come up with your answer in the pause. Ideally, say it out loud or write it down to really commit to that answer, and then we'll go through explanations. So let's jump straight into this episode on inflammatory bowel disease. The first case is a 25-year-old man and he presents to you his GP with loose stools for the past two months. Says he's got diarrhea for two months. He's noticed blood mixed with the stools on occasions. He also has fecal urgency, so he says he's going about his day and then suddenly he has to go and have a loose stool. When you examine him, he's tender in the lower left quadrant of his abdomen. So my first question is, what's your suspected diagnosis in this patient? The answer here is ulcerative colitis, a type of inflammatory bowel disease. My next question is, with ulcerative colitis, what part of the bowel is affected? Ulcerative colitis causes continuous superficial inflammation in the colon and the rectum. Kind of starts at the rectum and works backwards, and some people it will just be the rectum that's involved, other people it'll go through the sigmoid colon, the descending colon, transverse colon, and so on. So how far up depends on the individual, but it's really the colon and the rectum. My next question to you is what stool tests will you consider doing in this patient? So there are two key stool tests to consider here. The first is microscopy and culture. So you send a sample to look under the microscope and try and culture bugs, and this is to look for infection. Infection is another cause of chronic diarrhea or acute bloody diarrhea, and you can send a stool sample to look for infection. The second sample is fecal calprotectin, and this looks for inflammation in the bowel. Fecal cowprotectin is the key test to remember for inflammatory bowel disease. It's the screening test for inflammatory bowel disease such as ultra colitis. So we've got a 25-year-old man, he's had diarrhea for two months, and he comes back with a positive fecal cowprotectin test. You're the GP, he's sat in front of you. What's your next steps here? So he needs an urgent referral to gastroenterology on the inflammatory bowel disease service for suspected inflammatory bowel disease. So hopefully he'll be seen and managed quickly as an outpatient. But the other thing to do is consider admission. So he's got bloody diarrhoea, which which is kind of a prompt to admit him, depending on how many times a day he's going, whether he's tachycardic, feverish, and so on, you may want to consider admission. If he's stable, wait for an urgent outpatient appointment. My next question is what would be the definitive diagnostic test to see what the diagnosis is here. The key diagnostic test is a colonoscopy with biopsies. The fecal cowprotectin test looks for inflammation, but it's not specific, so it can go up with infections, diverticulitis, other inflammatory conditions, but to get a definitive diagnosis he needs a colonoscopy and multiple intestinal biopsies. My next question is let's say he's diagnosed with ulstive colitis. What would be the treatment of flares in this condition? So if he has a flare up of symptoms in ulstive colitis, how is that treated? So there are two main treatments for flare-ups of ulcerative colitis. The first is amino salicillates, specifically mesalazine or sulfur salazine. And mesalazine or sulfasalazine, typically mesalazine, is can be given topically, so you could have a rectal foam or given topically where it affects just the rectum, or it could be given orally, so take it as tablets. The second treatment is corticosteroids, for example, bedesenide, which can be taken topically, again, for example, as a foam, a foam enema, or orally, or in severe cases, intravenous steroids. So the key treatments for ulstave colitis, amino salicylates, and corticosteroids if needed. My next question is what would be the normal maintenance treatment? So let's say his flares under control, his bowels are back to normal, and you want to maintain his remission in ulstacolitis, what treatment is used typically?

SPEAKER_01 6:10

First line.

SPEAKER_00 6:18

Remission is maintained with amino salicylates, for example, mesalazine. So he may take oral mesalazine tablets long-term or regular topical treatments to maintain remission. Okay, we have a new case. We've got a 22-year-old woman, and she's had diarrhea for six weeks with no blood. She's not noticed any blood in the diarrhea. She also has vague abdominal pain. She says there's kind of a grumbling, deep pain in there, but she can't localize it. And she also complains of mouth ulcers and general fatigue and malaise. She generally doesn't feel very well.

SPEAKER_01 7:00

What's your suspected diagnosis in this case? This is Crohn's disease as opposed to ulstive colitis.

SPEAKER_00 7:17

My next question for you is what are the differentiating features of Crohn's disease from ulstive colitis? What features of Crohn's disease are not typically features of ulstive colitis? I remember the key differentiating features with the nest pneumonic. Imagine Crohn's or Crow's nest, and you don't want to uh so the nest pneumonic, the N is for no blood, so you're less likely to have bleeding in loose stools from Crohn's disease. Ulst of colitis often causes blood. Crohn's, the E is for entire gastrointestinal tract being affected. So Crohn's disease goes all the way from the mouth to the anus in terms of the X sections of the GI tract that are affected, as opposed to ultive colitis, which is usually isolated to the rectum and colon. The next one is skip lesions. So these are sections of the bowel between inflamed sections that are unaffected. So in ulcerative colitis, the inflammation is kind of continuous in one big patch. In Crohn's disease, a section of the bowel may be affected, then there'll be a skip lesion where the bowel's not affected, then another section is affected, and so on. T is for transmural inflammation. So the inflammation in the bowel is full thickness as opposed to ulstive colitis, where it's just the superficial mucosa that's affected. And the final S in nests is smoking, being a risk factor. Patients who smoke are at higher risk of Crohn's. However, interestingly, in ulstive colitis, smoking seems to be protective. So people who smoke are less likely to get ulstive colitis. It's not a good use of smoking. It's not a reason to start smoking because so many other diseases are associated with smoking, but it does seem to be protective of ulstive colitis. So my next question is: how do you induce remission in Crohn's disease? The first is using corticosteroids. So it could be oral prednis alone or intravenous corticosteroids in severe cases, and steroids are used to induce remission. The second option is enteral nutrition, which may be used in children. So this typically involves admission and giving very basic components of nutrition as opposed to whole foods. And this kind of gives the bowel a break and gives it a rest and increases the kind of nutrient density, and this can cause a remission in Crohn's disease. This is particularly used in children where you want to avoid steroids because of concerns about growth in children and bone density and so on. So that's the two options in Crohn's: corticosteroids or entral nutrition. Next, we've got a 26-year-old woman, and she's had Crohn's for two years. And we're going to go through a whole bunch of extraintestinal manifestations of Crohn's disease. So these are, or inflammatory bowel disease as a whole. So these are features of inflammatory bowel disease that aren't related to the bowel or the GI tract. So the first thing we have her presenting with this appearance to her legs, where she has red tender patches on the front of her shins. What condition is this associated with inflammatory bowel disease?

SPEAKER_01 11:47

This is erythema nodosum.

SPEAKER_00 11:50

So these are tender red nodules on the front of the shins from inflammation of the subcutaneous fat under the skin on the shins. Erithema nodosum, if you see this, think about inflammatory bowel disease, and the other thing to think about is sarcoidosis. The second extraintestinal manifestation is let's say they present with this rapidly enlarging painful ulcer on the leg.

SPEAKER_01 12:22

What condition is this?

SPEAKER_00 12:32

This is called pyoderma gangrinosum, which is a rapidly enlarging painful ulcer associated with inflammatory bowel disease. Next, we have a patient presenting with a painful, stiff, and swollen knee on the background of having inflammatory bowel disease.

SPEAKER_01 12:53

What condition are we suspecting here?

SPEAKER_00 13:07

We're suspecting entropathic arthritis, which is a type of inflammatory arthritis associated with inflammatory bowel disease. And the next one is a patient with inflammatory bowel disease presenting with a painful red eye. What condition would you suspect in this case? The cause of painful red eye most associated with inflammatory bowel disease is anterior uveitis. Okay, on to the final case in the series, which is a 38-year-old man, and he has a history of ulstive colitis, and he presents with itching and fatigue. He says his skin is really itchy, he's been moisturizing, he can't stop it from itching, he also feels particularly fatigued, which is out of the normal for him. You do some blood tests and he has a raised alkaline phosphatase or ALP. My question to you is, what's your suspected diagnosis in this scenario? The thing to suspect here is primary sclerosin changitis. So this is something key to remember in patients with ulsticalitis, they have an increased risk of this condition called primary sclerosin changitis, which is an autoimmune condition where the bile ducts become sclerotic or sclerosed and fibrosed. So the sclerosis and fibrosis of the bile ducts. And this will affect bile draining away from the liver, and it can result in liver damage, eventually fibrosis and liver cirrhosis. It's quite a significant condition. And the final question is in a patient with primary sclerosin colangitis, what's the key risk of malignancy here? What cancer should we be most worried about in this patient? In patients with primary sclerosin cholangitis, there's a risk of chalangiocarcinoma, so cancer of the bile ducts. And it happens in about 10 to 20% of patients with primary sclerosin cholangitis. So they need regular screening to detect uh bile duct cancer early. So thanks for listening to this episode on inflammatory bowel disease. Hopefully it was helpful. As always, check out the zero to GP revision resources. For example, the AKT revision book, which contains key notes on all the key topics you need for your GP exams. There's the zero to GP.com website where you can find practice questions, a fact trainer tool, notes and flashcards. And I do have an upcoming course in September in London where I'll go through everything in a single day as a really good preparation for your exams. There's a link to everything in the description, and I'll see you in the next episode.