Dr Sam Gausden FY2

February 2015

Inflammatory bowel disease

Contents/aims/objectives

DefinitionPresentationInvestigationsManagementClinical scenarioExplanation station

Definition

Definition

Umbrella term

Definition

Umbrella term Chronic

Definition

Umbrella term Chronic Relapsing-remitting

Definition

Umbrella term Chronic Relapsing-remitting Acute non-infectious inflammation

Differences

Differences

Distribution

Differences

Differences

Distribution Smoking

Smoking in IBD

• 2/3 Crohn’s pts are smokers and cessation halves relapse

• 95% of UC pts are non-smokers or ex-smokers

Smoking in IBD

• YOU SEE people smoking with UC• Smoking in Crohn’s makes you want to GROAN

Differences

Distribution Smoking Histology

UC histology

UC histology

• Hyperaemic/haemorrhagic colonic mucosa

• Pseudopolyps

• Usually on affects mucosal layer

• Absence of goblet cells

Crohn’s histology

• Transmural granulomatous inflammation

• Cobblestoning

MACROSCOPICALLY:

Strictures, abscesses, fistulae, skip lesions

Systemic manifestations

Systemic manifestations

Hepatic - autoimmune hepatitis (UC), gallstones (Cr), PSC (UC)

Systemic manifestations

Hepatic Other - VTE, osteoporosis

(Cr), amyloidosis (Cr)

Systemic manifestations

Hepatic Other Rheum - arthritis, sacro-ileitis, AS

Systemic manifestations

Hepatic Other Rheum Skin – EN and PG (UC>Cr)

Systemic manifestations

Hepatic Other Rheum Skin Eyes – iritis, uveitis

Eyes

Uveal tract = iris, ciliary body and choroid

Systemic manifestations

H epatic O ther R heum S kin E yes

Symptoms - UC

Symptoms - UC

Diarrhoea + blood/mucousFaecal urgency/incontinenceTenesmusLower abdominal pain

Tiredness/malaiseWeight loss/failure to thrive or growFever

Symptoms – Crohn’s

Symptoms - Crohn’s

Diarrhoea +/- blood/mucous Malabsorption Abdominal pain (crampy) Mouth ulcers Bowel obstruction Fistulas (perianal) Abscesses (perianal/intrabdominal)

Tiredness/malaiseWeight loss/failure to thrive or growFever

Signs - UC

Signs - UC

ClubbingPallorEyesLegs

Abdominal tenderness

PR

Signs – Crohn’s

Signs – Crohn’s

ClubbingPallorEyesMouthLegs

Abdominal tendernessMass in RIF

PR – skin tags, abscesses, fistulas

Investigations

Bedside tests

Bedside tests

Faecal calprotectin

Protein common in neutrophil cytoplasmBacteriostatic and resistant to enzyme

degredation

NICE guideline:1)To differentiate IBD from IBS in pts where

cancer is NOT suspected

Also: can also be used to evaluate IBD Rx and predict flares

Blood tests

Imaging (acute)

Imaging (acute)

Special test (acute)

Special tests (acute)

Management (long-term)

Conservative

Conservative

Inducing remission in mild-mod UC1

Inducing remission in mild-mod UC1

1) Aminosalicylates

2) Steroids

3) Immunosuppression (tacrolimus)

Inducing remission in severe UC (inpatient)1

Inducing remission in severe UC (inpatient)1

1) IV steroids

2) Immunosuppression (ciclosporin)

3) Biologics (infliximab)

Assessing UC severity

Assessing UC severity

TRUELOVE AND WITTS’ CRITERIA1

Inducing remission in Crohn’s1

Inducing remission in Crohn’s1

1) Steroids (oral or IV)

2) Aminosalicylates (2nd line)

3) Immunosuppressants (aza, mercapto, methotrexate)

4) Biologics (infliximab or adalimumab)

Maintaining remission in UC

Maintaining remission in UC

1) Aminosalicylates

2) Immunosupressants (aza or mercapto)

Maintaining remission in Crohn’s

Maintaining remission in Crohn’s

1) Immunosupressants (aza, mercapto or MTX)

2) Continue biologics

3) OR nothing

Surgery

• Indications

• Incidence

Prognosis

Ca colon risk with UC approx. 15% over 20yrs with pancolitis

Colonoscopy screening (after 1-5 years depending on risk)

Scenario time

• 29 year old female

• PC: Diarrhoea• HPC: 1/12 Hx12x day nowBlood and mucous

mixed inCramping LIF painUnwell and lethargic

On examination

Temp: 38.2C

Soft Abdomen, slightly distended

Tender in LIF

PR exam very painful and reveals fresh blood and mucous on the glove

Diagnosis?

On examination

Temp: 38.2C

Soft Abdomen, slightly distended

Tender in LIF

PR exam very painful and reveals fresh blood and mucous on the glove

Diagnosis?

Acute flare of UC

Differential diagnoses?

Differential diagnoses?

InfectionInflammationNeoplasticVascularDrugs

Acute investigations?

Acute investigations?

Stool culture, pregnancy test

FBC, U&Es, LFTs, CRP, ESR, clotting, G&S

Erect CXR, AXR, CT abdomen

?flexi sigmoidoscopy

Long-term investigation?

Long-term investigation?

Colonoscopy + biopsy

Colonoscopic surveillance

Initial acute management

Initial acute management

A-E approach

NBM, IVI, transfusion depending on Hb

IV hydrocortisone +/- rectal steroids

If getting better – transfer to oral pred and 5-ASA

If getting worse – consider ciclo/infliximab/surgery

Long term management

Long term management

Aminosalicylates

Azathioprine or mercaptopurine

Comparing Crohn’s and UC

Clinical presentation

Histological findings?

Smoking?

Recap

Scoring system for UC severity?

Extra-intestional manifestations of IBD?

Explanation station

Please explain a colonoscopy to the patient

Explanation station

• Check patient’s understanding

• Think about patient’s experience

• Why we do it and risks

• No jargon

• Any questions

• Leaflet

Always remember for IBD

Ask about eyes, joints and skin

Only ever do flexi sig in an acute flare

If in doubt over diagnosis, say IBD

Know difference between ileostomy and colostomy

Test for TB before starting infliximab

Any questions?

References

1) http://www.nice.org.uk/guidance/conditions-and-diseases/digestive-tract-conditions/inflammatory-bowel-disease