Inflammatory Bowel Disease

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Inflammatory Bowel Disease. Dr Alex Tebbett (Warwick graduate) Fy1 Warwick A&E. What we’re covering. The big two – Crohn’s and UC Risk factors Macro and microscopic changes Extraintestinal manifestations Differential diagnosis Treatment Clinical exam for IBD Other GI cases - PowerPoint PPT Presentation

Transcript of Inflammatory Bowel Disease

Inflammatory Bowel Disease

Dr Alex Tebbett(Warwick graduate)

Fy1 Warwick A&EInflammatory Bowel DiseaseWhat were coveringThe big two Crohns and UCRisk factorsMacro and microscopic changesExtraintestinal manifestationsDifferential diagnosisTreatmentClinical exam for IBDOther GI casesFinals hintsIBDCrohnsUlcerative Colitis

CrohnsUlcerative ColitisEpidemiologySlightly more common80-150/100,000Slightly less common27-106/100,000Males: 1.2:1Older: 34Females: 1.2:1Younger: 26Mention the changes of epidemiology if you get a case in clinicals, but dont assume anything4AetiologyLargely unknown

GeneticsPolygenic: 16, 12, 6, 14, 5, 19, 1, 3HLA DRBFamilial (1 in 5)Host immunologyDefective mucosal immune systemInappropriate response to intraluminal bacteriaT-cells and cytokinesAutoimmune!5CrohnsUlcerative ColitisAetiology: EnvironmentalGood hygiene/ developed countriesNo relation to hygieneNon smokersAppendicectomy is protectiveBreast feeding is protectiveBreast feeding is protectiveAppendicectomySmokersA clean intestine makes it more likely to react to commensual bacteria in Crohns. There is no relationshop with this in UC.Flare ups of Crohns can follow a GI infection or cause the first presntationNicotine can be a successful treatment for UCAppedicectomy is related to increased incidence and increased severity of Crohns6CrohnsUlcerative ColitisTerminal illeumIleocolonic diseaseAscending colonSkip lesionsPancolitisCan be large bowel only

ProctitisLeft sided colitisSigmoid and descendingPancolitisBackwash ileitisDistal terminal illemPathologyMouth to anus!Rectum and extends proximally!7Macroscopic changesCrohnsBowel is thickened Lumen is narrowedDeep ulcersMucusal fissuresCobblestoneFistulaeAbscessApthoid ulceration

Cobblestone due to deep and shallow ulcers8Macroscopic changesUlcerative ColitisReddened mucosaShallow ulcersInflamed and easily bleeds

Ulcerative ColitisCrohnsUlcerative ColtisChronic inflammatory cells: transmural

Lymphoid hyperplasiaGranulomasLanghans cellsChronic inflammatory cells: lamina propria

Goblet cell depletionCrypt abscessMicroscopic ChangesTransmural!Mucosal!Extraintestinal ManifestationsEYESCrohnsUCUveitis5%2% Episcleririts7%6%Conjunctivitis7%6%

Uveitis, episcleritisSlightly more common in Crohns11Extraintestinal ManifestationsJOINTSCrohnsUCType 1 Arthropaty(Pauci)6%4% Type 2 Arthropathy(Poly)4%2.5%Arthralgia14%5%Ankylosing Spondylitis1.2%1%Inflammatory back pain9%3.5%

Again, generally more common in CrohnsAlways ask about joints in clinical cases for a holisit approach to patient care. If your mind goes blank and you forget about salicytates etc for treatment you can talk about treating the patient as a whole and helping them with their joint pain12Extraintestinal ManifestationsSKINCrohnsUCErythema Nodosum4%1%Pyoderma Gangrenosum2%1%

Again more common in CrohnsDDx for erythema nodosum: Infection (streptococci), ai (IBD), pregnancy, rx (sulphonamides), cancer (NHL), idopathic13Extraintestinal ManifestationsLIVER/BILLARYCrohnsUCSclerosing cholangitis1%5%Gall stonesIncreasedNormalFatty liverCommonCommonHepatitis/ CirrhosisUncommonUncommonKidney stones in Crohns oxalate stones post resectionAnaemia B12 deficiency in CrohnsVenous thrombosisOther autoimmune diseasesDifferential DiagnosisEach otherInfection (unlikely if >10 days)IBSIleocolonic tuberculosisLymphomasTreating IBDInduce remissionSteroids oral or IVEnteral nutritionAzathioprine / 6MP (Crohns)Maintain remissionAminosalicylates (UC)Azathipreine/ 6MPMethorexateBiologicals generally for Crohns onlyInfliximab, adalimumabTest for TB first!CrohnsUlcerative ColitisAzathioprineMethotrexateCyclosporinHumeraAdalimumab/anti TNF

Steroids for flares

AminosalicylatesMesalazieSteroidsFoam/PROralIVAzathiorprine

Treating IBDUC FlaresTruelove-Witts Criteria: Anemia less than 10g/dlStool frequency greater than 6 stools/day with bloodTemperature greater than 37.5Albumin less than 30g/LTachycardia greater than 90bpmESR greater than 30mm/hrUsed to classify the flare up into mild, moderate or severe

TreatmentAdmit to hospitalIV steroids and fluidsDaily monitoring of stool frequency, AXR, FBC, CRP, AlbuminA STATESurgical ManagementSurgery can be curative for ulcerative colitis80% of Crohns have resections but generally little help

Indications for surgery in Ulcerative ColitisAcute: Failure of medical treatment for 3 daysToxic dilatationHaemorrhagePerforationChronicPoor response to medical treatmentExcessive steroid useNon compliance with medicationRisk of cancerI CHOPInfectionCarcinomaHaemorrhageObstructionPerforationPrognosisUC1/3 Single attack1/3 Relapsing attacks1/3 Progressively worsen requiring colectomy within 20 yearsCrohnsVaried prognosis, new biological agents improvingCancerBoth have increased risk of colon cancer, though UC>CrohnsScreening colonoscopy done every 2 years after 10 years disease and every year after 20 years diseaseCrohnsUlcerative ColitisPresenting complaintDiarrhoeaAbdominal painWeight loss

Malaise/lethagyNausea/vomitingLow grade feverAnorexiaPresenting complaintBloody diarrhoeaLower abdominal pain+/- mucus

Malaise/lethargyWeight lossApthous ulces in mouth

Clinical Finals: IBD HistoryClinical finals: IBD HistoryWhat else to ask?RashesMouth ulcersJoint/back painEye problemsFamily historySmoking status

Clinical finals: IBD HistoryWhat else to ask?Previous diagnosed?How many flares do they get?Are they well managed?Do they have any concerns about their treatment?Do they see a specialist?

Clinical finals: IBD ExamPhysical signs may be few!General ExamWeight lossApthous ulcer of mouthAnaemiaClubbing

Abdominal ExamColostomy bagMay be some abdominal tenderness, may not.May find a RIF massAbscessInflamed loops of bowelClinical finals: IBD ExamAnything else?Rashes on the shins

I would also like to examineAnusCrohns: Odematous tags, fissures or abscesses Ulcerative colitis: usually normalPRUlcerative colitis: blood

Clinical finals: IBD What is the most likely diagnosis?Inflammatory bowel disease

Clinical finals: IBD InvestigationsBedsideStool culture: exclude infectionSigmoidoscopyBloodsFBC : anaemia and likely raised WCCHaematemics: type of anaemia Inflammartory markersLFT: hypoalbuminaemia is present in severe disease, hepatic manifestationsBlood cultures: if septicaemia is suspected in the acute presentationSerological: pANCA (UC)Clinical finals: IBD InvestigationsImagingPlain AXR: helpful in acute attacksThumb printingLead pipe signBarium follow-through in CrohnsCT

CXRPerforationUSS

Clinical finals: IBD InvestigationsFlexible sigmoidoscopyColonoscopyBut never in severe attacks of UC due to high risk of perforationMay be painful in Crohns due to anal fissures Diagnostic SurveillanceUC of more than 10 years duration increased risk of dysplasia and carcinomaOGDFor Crohns: view of terminal illeumIn children both an OGD and colonoscopy are done,

Clinical finals: IBD ManagementManage the patient, not just the disease!MedicationsManage extraintestinal manifestationsEg B12 deficiency anaemiaManage patients symptomsEg loperamide for diarrhoeaGood nutrition, hydration and vitamin supplementsPsychosocial impact of diseaseIleostomy/colostomy bagFlares and the need for a toilet

Clinical finals: IBD ExplanationPlease explain a colonoscopy to the patientPlease explain an OGD to the patientPlease advise the patient on the side effects of steroidsPrepare an organised list to reel off, it is a very common question!Please explain the compilcations of inflixmabKeep calm, remember its an immnuosupressent!How to do well in finals questionsHave a plan on how to answer questionsIx: bedside, bloods, imaging, special testsMx: medical, surgical, psychological, social acute and long term managementHave a reason for each investigation youd like to doTreat the person as well as the diseaseDont ever forget the MDT!

What else could come up.Coeliac diseaseIBSIschaemic colitisDiverticular diseaseAppendicitisPolypsHaemorrhoids

Know the side effects of steroids!Know the difference between colostomy and ileostomy!

Clinical Scenario 29 year old female, one month history of loose watery stools, increasing in frequency to 12 time per day now. Occasionally stools have blood and slime mixed in with them. Cramping left iliac fossa pain. Feels unwell and lethargic. On examination, febrile at 38.2. Has a soft abdomen but slightly distended and tender in the left iliac fossa. PR examination is very painful and reveals fresh blood and mucus on the gloveacute flare of ulcerative colitis

Clinical finals: IBD questionsWhat are your main differential diagnoses for this lady? How would you investigate this patient acutely and long term? Eg. not full colonoscopy in acute flareInitial management in acute setting?Long-term management?Can you compare the clinical presentation and pathological findings for Crohns and UC?Can you tell me the effect of smoking on UC and Crohns? What scoring system is used for acute UC? What are the extra-intestinal manifestations of IBD?Eg. skin, eyes, joints

Any questions?Good Luck!