Inflammatory bowel disease


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INFLAMMATORY BOWEL DISEASE

  • Anusha Reddy
  • FY1 SWFT
  • 3rd Feb 2014

OBJECTIVES

  • 2 Case Studies: Crohn’s Vs Colitis
  • THINK:
    • AETIOLOGY
    • EPIDEMIOLOGY
    • SIGNS AND SYMPTOMS
    • INVESTIGATIONS
    • MANAGEMENT

CASE STUDY 1

  • 22 Female
  • PC: 6/52 of 5 x loose, non-bloody stools daily
    • Right lower quadrant abdominal pain (especially after eating)
    • 8kg weight loss
    • Bilateral knee and ankle pains

MORE INFORMATION REQUIRED

  • Full history
    • Nil PMH, no hx of foreign travel
    • No medications or allergies
    • Current smoker- 5 pack-years
  • Examination
    • Definite and moderately tender 5-cm mass in the right lower quadrant
    • No joint effusion or skin lesions are noted

DIFFERENTIAL DIAGNOSIS

  • Gastroenteritis
  • Crohn’s Disease
  • Ulcerative Colitis
  • Irritable Bowel Syndrome
  • Behcet’s Disease
  • Bowel Cancer
  • Tuberculosis
  • Amyloidosis
  • Acute Appendicitis

WHAT DO WE THINK THIS IS?

  • 22 Female
  • PC: 6/52 of 5 x loose, non-bloody stools daily
    • Right lower quadrant abdominal pain (especially after eating)
    • 8kg weight loss
    • Bilateral knee and ankle pains

CROHN’S DISEASE- DEFINITION

    • Chronic Inflammatory Bowel Disease (IBD)
    • Unknown Aetiology
    • Characterised by
      • Focal
      • Asymmetrical
      • Transmural
      • Occasionally granulomatous
      • inflammation
    • Any part of the GI tract- mouth anus

CROHN’S DISEASE- EPIDEMIOLOGY

    • Incidence: 9.56 per 100,0001
    • Prevalence: 115,000 in the UK
    • Age of onset: 2 peaks 1) 15-30 Y (more common)
    • 2) 60-80 Y
    • Female: Male 1.8:1 Children this is reversed!
    • Risk Factors2
      • Mycobacterium paratuberculosis, Pseudomonas spp. & Listeria spp.
      • ↑TNF-alpha
      • High-fat diets
      • Genetic mutations
  • 1) Steed H, Walsh S, Reynolds N; Crohn's disease incidence in NHS Tayside. Scott Med J. 2010 Aug;55(3):22-5
  • 2) Rangasamy P et al; Crohn Disease, Medscape, Jun 2011

CROHN’S DISEASE- SYMPTOMS

  • Abdominal pain, cramping or swelling
  • Anaemia
  • Fever
  • Gastrointestinal bleeding
  • Joint pain
  • Malabsorption
  • Persistent or recurrent diarrhoea
  • Stomach ulcers
  • Vomiting
  • Weight loss

CROHN’S DISEASE- ON EXAMINATION

  • General ill health- weight loss & dehydrated
  • Hypotension, tachycardia and pyrexia
  • Abdominal tenderness or distension, palpable masses.
  • Anal and perianal lesions (abscesses, fistulae)
  • Mouth Ulcers
  • Extra-intestinal manifestations of Crohn’s ......

CROHN’S DISEASE- EXTRA INTESTINAL

INVESTIGATIONS

  • Bloods
    • FBC, CRP, U&Es, LFTs
  • Stool culture and microscopy
  • anti-S. cerevisiae antibodies Perinuclear antineutrophil cytoplasmic antibody (p-ANCA) (UC>CD)
  • Abdo Xray
  • Ileocolonscopy and biopsy from the terminal ileum as well as the affected sites
  • Small bowel follow through
  • If upper GI symptoms- Upper GI endoscopy
  • If lower GI symptoms- Flexible sigmoidoscopy/EUA

CROHN’S DISEASE- MANAGEMENT

  • First presentation (NICE guidelines)
  • Glucocorticoids
    • Prednisolone, Methylprednisolone IV hydrocortisone
  • Budesonide
  • 5-ASA
  • +/- ADD ON Azathioprine or Mercaptopurine
  • Biologic: Infliximab and Adalimumab

CROHN’S DISEASE- MANAGEMENT

  • Maintaining Remission (NICE guidelines)
  • Offer Azathioprine or Mercaptopurine as Monotherapy
  • Methotrixate
  • Surgery- if limited to distal ileum (weighing out the risk Vs benefits) and for complications...

CROHN’S DISEASE- COMPLICATIONS

  • A
  • B
  • C
  • C

CASE STUDY 2

  • 32 Male
  • Bloody diarrhoea 4/52
  • Bilateral lower abdominal cramping
  • Malaise and weight loss
  • No associated fever, visual changes, arthralgias, or skin lesions
  • Previously fit and well contractor
  • Non-smoker, 14-18 units/week drinker
  • FHx: Diabetes Mellitus Type 1

ULCERATIVE COLITIS- DEFINITION

  • Chronic Inflammatory
  • Bowel Disease
  • Unknown aetiology
  • Only Large Colon
  • Classification:
    • Distal Disease
    • More extensive disease
    • Pancolitis

ULCERATIVE COLITIS- EPIDEMIOLOGY

  • More common than Crohn’s
  • Incidence: 10 per 100,000
  • Prevalence 240 per 100,000 in the UK
  • Age of onset: 2 peaks 1) 15-25 Y (more common)
    • 2) 55-65 Y
  • Male:Female= 1:1
  • Idiopathic: ?autoimmune condition triggered by colonic bacteria  inflammation
  • Genetic component: sibling of an individual who has IBD 17-35 x more risk of development
  • Risk of UC decreased in smokers
  • 1) Ulcerative Colitis; NICE Clinical Guideline (Jun 2013)

ULCERATIVE COLITIS- SYMPTOMS

  • Bloody diarrhoea
  • Abdominal Pain
  • Tenesmus
  • Systemic symptoms: malaise, fever, weightless

ULCERATIVE COLITIS- ON EXAMINATION

  • Unwell, pale, febrile, dehydrated
  • Abdo pain and tenderness .. + distension
  • TOXIC MEGACOLON
  • Worrying signs: Tachycardia, anaemia and fever
  • Extra- intestinal disease...

ULCERATIVE COLITIS- EXTRA-INTESTINAL

  • Aphthous ulcers
  • Ocular manifestations 5%
    • Episcleritis
    • Anterior uveitis
  • Acute arthropathy affecting the large joints 26%
    • Sacroiliitis
    • Ankylosing Spondylitis 3%
  • Deramatology 19%
    • Pyoderma gangrenosum
    • Erythema nodosum
  • Primary Sclerosing Cholangitis

ULCERATIVE COLITIS- INVESTIGATIONS

  • Bloods: FBC, LFTs, U+Es, CRP
  • Serology- pANCA Vs. ASCA
  • Stool cultures
  • Imaging
    • Abdo x-ray- acute setting
    • Barium enema- can show mucosal structure
    • Flexible Sigmoidoscopy and Biopsy- for diagnosis

ULCERATIVE COLITIS- MANAGEMENT

  • a) Topical aminosalicylate alone (suppository or enema
  • b) ?ADD PO aminosalicylate to a topical aminosalicylate OR
  • c) consider an PO aminosalicylate alone
  • a) PO Aminosalicylate - High induction dose of an
  • b) ?ADD topical Aminosalicylate OR PO beclometasone dipropionate
  • If no improvement 72 hrs despite IV Hydrocortisone OR
  • Symptoms worsen to pancolitis:
  • a) ADD IV Ciclosporin to IV steroids

ULCERATIVE COLITIS- MANAGEMENT

  • Indications for Surgery:
    • Unresponsive to medical treatment
    • Significantly affecting quality of life
    • Growth retardation in Children
    • Life-threatening complications...
    • Bleeding
    • Toxic Megacolon
    • Impending perforation
    • Carcinoma

ANY QUESTIONS?

SUMMARY

SUMMARY: CROHN’S VS. UC (1)

  • Symptoms of Crohn's Disease
  • Abdominal pain, cramping or swelling
  • Anaemia
  • Fever
  • Gastrointestinal bleeding
  • Joint pain
  • Malabsorption
  • Persistent or recurrent diarrhoea
  • Stomach ulcers
  • Vomiting
  • Weight loss
  • Symptoms of Ulcerative Colitis
  • Bloody diarrhoea
  • Abdominal pain or discomfort
  • Anaemia caused by severe bleeding
  • Dehydration
  • Fatigue
  • Fever
  • Joint pain
  • Loss of appetite
  • Malabsorption
  • Rectal bleeding
  • Urgent bowel movements
  • Weight loss

SUMMARY: CROHN’S VS. UC (2)

SUMMARY- CROHN’S VS. UC (3)

SUMMARY: CROHN’S VS. UC (2)

LEARNING POINTS

  • RELAPSE AND REMITTING MANAGE THE PATIENT
  • BONE PROTECTION- IF ON LONG-TERM STROIDS
  • TEST FOR TB BEFORE STARTING INFLIXIMAB
  • RISK OF COLONIC CARCINIMA IN UC

THANK YOU!!



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