Inflammatory Bowel Disease
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Inflammatory Bowel Disease Jonathan C Taylor, MD MAJ, MC USAFP - 2010
Transcript of Inflammatory Bowel Disease
Inflammatory Bowel Disease
Jonathan C Taylor, MDMAJ, MC
USAFP - 2010
Learning Objectives
• What is the spectrum of inflammatory bowel disease?
• What is the approach to the patient with inflammatory bowel disease?
• What are the key management aspects of IBD in the primary care setting?
Case Example
• 18 year old high school senior presents to your clinic with several weeks of constipation and profound fatigue
• She was seen in the ED over the weekend and told she was very anemic with hgb 7.7 with mcv of 63
• Iron studies confirm iron def anemia with low ferritin and serum iron
Case Example
• She denies melanotic or bloody stools• She denies history of inflammatory bowel
disease• She denies heavy menstrual bleeding• She denies other “B” symptoms other than
fatigue• She was placed on iron and stool bulking
agents and scheduled for follow up
Case Example
• She presented to the ED one week later with lower abdominal pain
• CT showed possible inflamed appendix• She was taken to the OR, appendix was
normal but a 2 cm abscess was removed• The pathology revealed tissue architecture
consistent with Crohn's
Inflammatory Bowel Disease
• Crohn’s disease• Ulcerative colitis• Infectious etiologies• Ischemic colitis and pseudomembranous• Radiation induced• Celiac disease• Irritable bowel disease?
Common Presentations of IBD
• Abdominal pain • Diarrhea – bloody or non-bloody• Fever• Weight loss• Malaise• Arthralgia• Skin manifestations
Crohn’s Disease
Crohn’s disease
• Granulomatous inflammation of the GI tract• The inflammation is transmural• Can affect any age group most common in the
second and third decade• Crohn’s is not curable• Crohn’s results in significant morbidity and
mortality
Clinical Presentation
• Can present with both GI and extra-intestinal symptoms• Chronic or nocturnal diarrhea with abdominal pain• Weight loss and fever• Rectal bleeding• Perianal fissures and fistulas• Perianal abscesses• Inflammation of the eyes skin or joints• Delayed development and children secondary to chronic
diarrhea• Toxic megacolon• Demographic: white, Jewish ancestry, smokers
Clinical Features
• Ileum and the colon are most frequently affected• Spondylo-arthritis and peripheral arthritis• Erythema nodosum and pyoderma gangrenosum• Uveitis, episcleritis, conjunctivitis• Primary sclerosing cholangitis• Anemia, cholelithiasis, nephrolithiasis, metabolic
bone disease• Mouth to anus and anywhere else!
Diagnosing Crohn’s
• Crohn’s should be considered with any of the aforementioned clinical features
• The other inflammatory bowel diseases should be considered and ruled out as well
• Early consult to gastroenterology should be considered in for patients with possible Crohn’s
Laboratory tests
• ESR, C-reactive protein• Stool culture for enteric pathogens, ova,
parasites, C. difficile• ANA• Antibody testing against S. Cerevisiae• Antibodies directed against CBir1 and OmpC • Genetic testing – NOD2/CARD15
Endoscopy
• Can be both diagnostic and therapeutic• Can be used to exclude the presence of other
pathogens• Can differentiate between Crohn’s and
ulcerative colitis• Video capsule endoscopy – may be superior in
detecting small bowel disease
Treatment
• Patients are scored using the Crohn’s disease activity index (CDAI)
• Treatment must be tailored to disease location, severity and complications
• Treatment is directed towards inducing and maintaining mucosal healing
• Monitoring requires close follow up
Mild to moderate disease
• Oral mesalamine 3.2 g-4 g daily or sulfasalazine 3 g-6 g daily
• Oral budesonide 9 mg daily even more effective
• Use of antibiotics has been debated**
Moderate to severe disease
• Prednisone 40 mg-60 mg daily until resolution of symptoms
• Azathioprine or 6-mercaptopurine are effective for maintain steroid induced remissions
• Methotrexate 25 mg per week• Anti-TNF monoclonal antibodies
Indications for surgery
• Surgery does not cure Crohn’s• Intractable hemorrhage or perforation• Recurrent or persistent obstruction• Abscess• Dysplasia or cancer• Fulminate disease
Ulcerative Colitis
Ulcerative Colitis
• Diffuse mucosal inflammation limited to the colon
• Rectum is involved in 95% of all cases• Inflammation can be symmetrical,
circumferential and involve part or all of the large intestine
• UC is curable with surgical resection• UC results in significant morbidity and mortality
Clinical Presentation
• Bloody diarrhea • Symptoms of rectal urgency and tenesmus • Weight loss
Extra-intestinal Clinical Features
• Osteoporosis• Oral ulcerations• Arthritis• Primary sclerosing cholangitis• Uveitis• Pyoderma gangrenosum• DVT and PE
Diagnosing UC
• UC should be considered with any of the aforementioned clinical features
• The other inflammatory bowel diseases should be considered and ruled out as well
• Early consult to gastroenterology should be considered in for patients with possible UC
Laboratory tests
• ESR, C-reactive protein• Stool culture for enteric pathogens, ova,
parasites, C. difficile• pANCA and ASCA• Tuberculosis, schistosomiasis, syphilis,
Chlamydia, C. difficile, cytomegalovirus
Endoscopy
• Can be diagnostic• Can be used to exclude the presence of other
pathogens• Can differentiate between Crohn’s and
ulcerative colitis• Video endoscopy – screening tool
Characterization
• Mild: Less than 4 stools daily, no blood, no signs of toxicity, normal ESR
• Moderate: More than 4 stools a day, minimal signs of toxicity
• Severe colon 6 bloody stools a day, evidence of toxicity, fever, tachycardia, anemia, elevated ESR
• Fulminant: 10 bowel movements per day, continuous bleeding, toxicity, abdominal tenderness, blood transfusions required, colonic dilatation on abdominal films
Indications for Surgery
• Surgery can cure gastrointestinal UC• Intractable hemorrhage or perforation• Recurrent or persistent obstruction• Abscess• Dysplasia or cancer• Fulminate disease
Celiac Disease
• Estimated to affect 1% of most populations• Diagnosed only in ~15% of those affected• Huge population of undiagnosed• Immune response to gliadin (glycoprotein)• Complex heavily studied immune response
Clinical features
• More prevalent in females• Vague abdominal symptoms• Diarrhea – occasionally bloody• Vomiting and weight loss• Skin manifestations
Diagnosing Celiac Disease
• Evaluation for infectious causes• Widely available assays looking for antibody
serology• Endoscopy with biopsy useful for detection of
subtle disease • Genetic testing may be the future of diagnosis
and therapy
Treatment
• Gluten (gliadin) free diet – GFD• Mixed results– GFD greatly improved symptoms– GFD not shown to affect those in remission
• Generally, recommended to try GFD• Adherence to GFD very difficult• GFD products can be 242% more expensive
Treatment of Refractory Disease
• Refer to gastroenterology• Need surveillance for advanced lesions• Immune system modulators
Primary Care Pearls
• Diarrhea >10 days you should consider inflammatory causes
• Bloody diarrhea is inflammatory until proven otherwise• Consider inflammatory bowel disease in the presence
of systemic symptoms• Consider inflammatory bowel disease for unusual
abdominal pain symptoms• Consider the long term effects of medications –
screening for diabetes, bone loss and cancer surveillance
References
• Management of Crohn’s Disease. Doug Knutson, Greg Greenberg. AAFP 68:707-714
• Management of Crohn’s Disease in Adults. Gary Lichtenstein et al. American Journal of Gastroenterology. ACG Guidelines 2008.
• Ulcerative Colitis: Diagnosis and Treatment. Robert Langan et al. AAFP 76: 1323-1330
• Ulcerative Colitis Practice Guidelines in Adults. American Journal of Gastroenterology. ACG Guidelines 2008.
• Celiac Disease. Alberto Rubio-Tapia, Joseph Murray. Current Opinion in Gastroenterology, 25 December 2009.
