Clare Donnellan Consultant Gastroenterologist Leeds Teaching Hospitals.
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Transcript of Clare Donnellan Consultant Gastroenterologist Leeds Teaching Hospitals.
Clare Donnellan
Consultant Gastroenterologist Leeds Teaching Hospitals
Key features of IBD History & examination Investigations Treatment including DMARDs Flares – what should GPs do? What’s new?
Incidence UC 10 per 100,000
Incidence CD 6-7 per 100,000
Prevalence 400 per 100,000 (250/150)
Onset between 15 and 40 years of age Similar in males and females
Ulcerative colitis◦ Proctitis◦ Left-sided disease◦ Pan-colitis
Crohn’s Disease◦ Affects anywhere
Small bowel (80%) Small & Large bowel (50%) Peri-anal disease (35%) More likely to get complications
IBD-unclassified 5%
Genetics◦10-25% of patients have at least one
other family member affected◦No particular gene identified in UC
◦NOD2/CARD15 gene abnormalities in CD Terminal ileal disease Possibly more chance of requiring surgery
Environmental factors◦ Smoking
Protective for UC Worsens outcome for CD
◦ Appendicectomy Protective for UC Unlikely effect for CD
◦ Diet?◦ Bacteria?
Episcleritis/scleritis◦ 2 to 5% of patients◦ Activity linked to GI tract
Anterior uveitis◦ 0.5-3%, but much more serious◦ Females:males 4:1◦ 75% of patients have arthritis◦ Activity not linked to GI tract
Erythema nodosum◦ Most common skin
manifestation of IBD (up to 15%)
◦ Typically flares at same time as GI symptoms
Pyoderma grangrenosum◦ Up to 5% of patients◦ More chronic course
Related to GI activity◦ Peripheral arthritis◦ Episcleritis/scleritis◦ Erythema nodosum
Not related to GI activity◦ Spondylitis/sacroiliitis◦ Anterior uveitis◦ Pyoderma Gangrenosum
Bloody diarrhoea or prolonged diarrhoea (-ve MC&S)◦ Abdominal pain◦ Urgency◦ Tenesmus
If 1st presentation◦ Stool frequency/day & night◦ Systemic features◦ Weight loss◦ Fever◦ Extra-GI features
◦ Travel◦ DH (Abx, NSAIDs◦ FH◦ SH
‘The professional patient’◦ Is it like a ‘usual’ flare?◦ What are the usual strategies?◦ IBD Helpline 0113 206 8679
Is it severe?◦ Truelove and Witts criteria
≥6 bloody stools per day Systemic toxicity (HR>90, T>37.8, ESR>30) or
Hb<10.5 NEEDS ADMITTING for IV steroids
Much more challenging to ΔΔ IBD vs. IBS….◦ Abdominal pain◦ Diarrhoea (ask re: nocturnal symptoms)◦ Weight loss◦ Systemic features◦ Extra-GI manifestations
‘The professional patient’◦ Is it like a ‘usual’ flare?◦ What are the usual strategies?◦ IBD Helpline 0113 206 8679
Systemically unwell?◦ Fever◦ Tachycardia
Dehydration BMI/weight Abdominal tenderness/distension/bowel
sounds Palpable mass Peri-anal examination
Follow ‘usual’ strategy Call helpline (pt or GP) if concerned
◦ Advice◦ Early access to IBD clinic
Admit if systemically unwell
FBC, U&E, LFT, CRP Haematinics Stool MC&S Stool C diff (Stool OC&P)
Urgent referral to gastroenterology if high index of suspicion
UC◦ Bloods◦ AXR◦ Urgent stool cultures◦ Urgent flexible sigmoidoscopy within 24 hours◦ (CMV PCR and CMV on biopsies)◦ CT if risk of perforation
Crohn’s◦ Varies on symptoms/distribution
◦ Low threshold for CT abdo/pelvis
◦ Flexible sigmoidoscopy often unhelpful
◦ MR pelvic if abscess/fistulising disease
Small bowel◦ Small bowel meal if suspected CD/suspected SB
CD◦ MR enterography (enteroclysis) if known SB CD◦ OGD◦ Ultrasound◦ Wireless capsule endoscopy◦ Isotope (labelled white cell scans)
Colon◦ Colonoscopy◦ CT colonography
5-ASAs◦ Prescribe by drug name◦ But lower cost equivalents (Asacol = Mesren =
Octasa)
◦ Dose Asacol 2.4 g vs. 4.8 g Minimum 2 g for maintenance (1.2 g cancer
prevention)
◦ OD as effective and better adherence for maintenance
◦ Tablets + Local therapy often avoids steroids 5-ASA enemas better than steroid enemas
DMARDs◦ Azathioprine 2-2.5 mg/kg◦ 6-mercaptopurine 1-1.5 mg/kg
◦ Weekly bloods for 4/52◦ Then monthly◦ Then 3 monthly
◦ S/E (Raised MCV and lymphopaenia)
Other DMARDs◦ Methotrexate
Evidence not great
◦ Mycophenolate Some evidence
Optimise 5-ASAs first if sole treatment◦ Maximise dose◦ Add in local therapy (5-ASAs, not steroids)
Prednisolone 30 mg daily with Ca/Vit D cover◦ More prolonged course
If not settling (or severe UC) IV steroids
Is it severe?◦ Truelove and Witts criteria
≥6 bloody stools per day Systemic toxicity (HR>90, T>37.8, ESR>30) or
Hb<10.5 NEEDS ADMITTING for IV steroids Colectomy rate approx. 30%
Day 3 (Travis criteria)◦ If stool frequency > 8 or CRP > 45◦ 85% chance of colectomy
3 options◦ Surgery
◦ Infliximab as a bridge to Aza/6-MP◦ Cyclosporin
Ciclosporin/infliximab◦ 70 – 80% leave hospital with colon◦ 30% long-term
Infection risks
No role for 5-ASAs except if mild colitis ? Role after surgery in preventing relapse
If luminal disease◦ Oral steroids◦ IV steroids if no response
◦ Still no response? No role for ciclosporin Give infliximab +/- azathioprine for 1 year
◦ Nutrition support key
If peri-anal disease◦ Drain any sepsis◦ Antibiotics◦ Seton sutures
◦ Escalate therapy as appropriate
DMARDS◦ Azathioprine◦ Methotrexate (s/c)◦ Mycophenolate◦ Tacrolimus
Surgery◦ For complications
Biologicals◦ Infliximab◦ Adalimumab
(Humiara)
◦ NICE assessment at 1 yr
Liquid diet for Crohn’s Bone protection Endoscopic dilatation of strictures
Calprotectin◦ Diagnosis◦ Activity assessment
Azathioprine metabolite levels◦ Optimise dose◦ Minimise side-effects◦ ? Reduce number of patients needing biologicals
Leucocytapheresis
Mucosal healing
Guided self-management
More nurse-led clinics
Reduce follow-up waits…
Less ‘black and white’ in/out of service
Significant morbidity
Early, focused management
Use helpline 0113 206 8679
Admit if systemically unwell Stool cultures Appropriate steroid course