Good Morning
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Transcript of Good Morning
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GOOD MORNINGJuly 5th, 2013
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Semantic Qualifiers
Problem CharacteristicsIll-appearing/
ToxicWell-appearing/
Non-toxicLocalized problem
Systemic problem
Acquired Congenital
New problem Recurrence of old problem
SymptomsAcute /subacute Chronic
Localized DiffuseSingle MultipleStatic Progressive
Constant IntermittentSingle Episode Recurrent
Abrupt GradualSevere MildPainful NonpainfulBilious Nonbilious
Sharp/Stabbing Dull/Vague
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Acute Colitis DDx**
Infectious enterocolitis Pseudomembranous colitis (C. diff) Lymphocytic colitis Eosinophilic enterocolitis HSP HUS IBD Intestinal malignancies (Non-Hodgkin
lymphoma)
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Colonoscopy
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Illness Script Predisposing Conditions
Age, gender, preceding events (trauma, viral illness, etc), medication use, past medical history (diagnoses, surgeries, etc)
Pathophysiological Insult What is physically happening
in the body, organisms involved, etc.
Clinical Manifestations Signs and symptoms Labs and imaging
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IBD Epidemiology Mean age at diagnosis: 12.5 years
<20% diagnosed before 10y <5% diagnosed before 5 years
Male: more likely pediatric Crohn’s disease Family history of IBD
Up to 25% of children who develop IBD w/ + family hx 1st degree relative with CD or UC = 10-13x higher risk!
European or African descent Jewish ancestry Industrialized world Tobacco use: 2x increased risk
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Crohn Disease Epidemiology
3-5 per 100,000 30% of patients diagnosed before age 20
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Pathophysiology Precise cause of IBD remains unknown
Genetic predisposition PLUS
Dysregulation between the immune system and the antigenic environment of the GI tract…which leads to GI inflammation and damage
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Clinical Manifestations What complaints would you expect a patient
with UC to present with?** Cardinal symptoms: diarrhea, rectal bleeding, and
abdominal pain Most present without systemic symptoms (fever, wt
loss) More severe presentation
Abdominal cramping associated with fecal urgency Malaise Low-grade/intermittent fevers Anorexia with weight loss Reflux or dyspepsia associated with upper GI
inflammation
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Clinical Manifestations What complaints would you expect a patient with
CD to present with?** Classic presentation
Abdominal pain Crampy, diffuse or RLQ
Diarrhea Non-bloody, melanotic, or frank blood
Weight loss Very important to plot height and weight in
patients Poor appetite, fevers, recurrent ulcers
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Growth and IBD** Growth failure may be the ONLY sign of IBD in 5% of
patients. What are some causes of growth failure both before and after treatment is started?** Occurs in 15-40% of children with IBD (CD > UC)
Reasons are multifactorial** Food avoidance secondary to abdo pain/diarrhea Increased cytokines anorexia and growth hormone
resistance In Crohn Disease
Active inflammation of the small intestine Decreases the intestinal surface absorption area Causes protein-losing enteropathy + fat soluble vitamin
deficiencies Steroid treatment
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Clinical Manifestations
Other than the abdomen, what important physical exam component MUST be assessed for disease? Abdominal exam
Diffuse tenderness Possibly RLQ tenderness or mass Distension with more severe disease
Rectal exam…what might you see in a patient with CD versus UC? CD: higher likelihood of fissures, skin tags, fistulas,
and abscesses; can be an early indicator of disease**
UC: often normal
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Clinical Manifestations**
Oral exam for aphthous ulcers, as recurrent aphthous-stomatitis also occurs in Crohn’s Disease.**
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Clinical Manifestations The following can also be seen on PE:
Pallor Digital clubbing A benign abdomen Small for age
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Work-Up** What abnormal labs might you expect in a
patient with IBD? CMP: albumin, possible in transaminases, Ca++ CBC: anemia of iron deficiency, B12/folate
deficiency, or anemia of chronic disease Elevated ESR and CRP Fecal calprotectin and lactoferrin
Released by neutrophils that have migrated to the intestinal wall
Non-invasive markers of gut inflammation and can be elevated in other diagnoses
Abnormal IBD serologic panel
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Serology IBD 7
tests for 7 markers of IBD Used to differentiate UC vs. CD ASCA and Anti-Omp C – specific for CD
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Work-Up** An infectious cause should be eliminated
before diagnosing IBD Stool studies: Salmonella, Shigella, E. coli,
Campylobacter, Yersinia, Giardia, Cryptosporidium C. difficile toxin PPD and Hepatitis test…should also be done
before initiation of treatment with immunosuppressive Remicade
Upper GI, CT for complications, MRI What is the “gold standard” for IBD diagnosis?
Endoscopy with biopsies
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Clinical Manifestations Label the picture as either Crohn Disease or
Ulcerative Colitis
Crohn Disease Ulcerative Colitis
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Ulcerative Colitis vs. Crohn** UC Crohn
Rectal bleed Usual SometimesAbdominal
painCommon Common
Malaise, fever, weight loss
Common Common
Perianal disease
Rare Common
Ileum involved None CommonStrictures Rare CommonFistulas Rare Common
Skip lesions - +Transmural - +Granulomas Rare Common
Crypt Abscesses
Usual Variable
Risk of cancer ↑↑↑ ↑
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Ulcerative Colitis vs. Crohn
Crohn Disease can have eosinophila non-specific: h. pylori, EE, parasitic
infections
UC CrohnCobblestoning - +Ulceration of IC
valve- +
Rectal sparing +/- +
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Extra-intestinal Findings 1/3 develop extra-intestinal
manifestations, may occur before intestinal symptoms.
Your patient, who you suspect has IBD, also complains of stiffness and pain in his lower back. What do you suspect?
Ankylosing spondylitis Is this more often associated with UC or
CD? Ulcerative colitis Which serum marker may be seen in this
diagnosis? HLA-B27 Arthalgias and arthritis are common
Pauciarticular arthritis disease course correlates with intestinal disease activity.
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Extra-intestinal Findings Name 2 skin findings associated
with IBD and tell which dx (CD or UC) it is more often associated with. Erythema nodosum
More common in Crohn disease Tender, warm, red nodules or plaques
localized to the extensor surfaces Pyoderma gangrenosum
More common in UC…up to 5% of pts Associated w/ extensive colonic
involvement Lesions: discrete pustules with
surrounding erythema deep ulceration with well-defined border and deep color
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Extra-intestinal Findings Why would you want to consult
ophthalmology upon diagnosis of IBD? Risk of uveitis, episcleritis, corneal
ulceration, and retinal vascular damage
Bone findings Osteopenia Osteoporosis
Decreased BMD seen in 25% of patients before steroids started
Aseptic necrosis
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Extra-intestinal Findings You are caring for a patient with known UC.
His LFTs are elevated. He also complains of fatigue and anorexia. Mom feels like his eyes look yellow, and you notice him scratching throughout your exam. What is the most likely diagnosis? Primary sclerosing cholangitis (PSC)
More common in UC patients Increased GGT and Alkaline Phosphatase Cholangiography and liver biopsy help confirm
diagnosis Increases risk of cancer
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Nutritional Deficiencies Crohn’s Disease
Anemia (folic acid and B12 deficiency) Vitamin D deficiency Hypocalcemia (related to low Vit, low
albumin) Zinc deficiency
Due to Inadequate nutrition +/- poor absorption Corticosteroid use
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Admission Severe Colitis
Fever Hypoalbumnemia Anemia >5 bloody stools/day
Toxic megacolon Occurs in up to 5% of adults with UC Perforation may occur… very
dangerous Treatment upon admission
Bowel rest TPN IV steroids Careful monitoring
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Treatment Proper nutrition
Low residue diets or special formulas TPN if severe disease and malnourishment
Mediations guided by GI specialists Corticosteroids (budesonide) 5-ASA (UC) Immunomodulators (AZA, 6-MP, MTX) biologic therapy, monoclonal Ab (Infliximab -
Remicade) Antibiotics (metronidazole, cipro for fistulas)
Surgery For Crohn’s disease complications For UC…total colectomy can be curative
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Treatment Other medications
Rifaximin - PO Antibiotic not absorbed Probiotics
Check TMPT (thiopurine methyltransferase enzyme) Prior to starting 6-MP
Alternative Therapy Helminth Marijuana
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Famous People with CD
Noon conference:
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Thanks!!!
Noon Conference!