DR ALEX TEBBETT(WARWICK GRADUATE)

FY1 WARWICK A&E

Inflammatory Bowel Disease

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 IBDOther GI casesFinals hints

IBD

Crohn’s Ulcerative Colitis

Crohn’s Ulcerative Colitis

Epidemiology

Slightly more common80-150/100,000

Slightly less common27-106/100,000

Males: 1.2:1

Older: 34

Females: 1.2:1

Younger: 26

Aetiology

Largely unknown

1. Genetics Polygenic: 16, 12, 6, 14, 5, 19, 1, 3 HLA DRB Familial (1 in 5)

2. Host immunology Defective mucosal immune system Inappropriate response to intraluminal bacteria T-cells and cytokines

Autoimmune!

Crohn’s Ulcerative Colitis

Aetiology: Environmental

Good hygiene/ developed countries

No relation to hygiene

Non smokers

Appendicectomy is protective

Breast feeding is protective

Breast feeding is protective

Appendicectomy

Smokers

Crohn’s Ulcerative Colitis

Terminal illeumIleocolonic disease

Ascending colonSkip lesionsPancolitis

Can be large bowel only

ProctitisLeft sided colitis

Sigmoid and descending

PancolitisBackwash ileitis

Distal terminal illem

Pathology

Mouth to anus! Rectum and extends proximally!

Macroscopic changes

Crohn’s

o Bowel is thickened

o Lumen is narrowed

o Deep ulcerso Mucusal

fissureso Cobblestoneo Fistulaeo Abscesso Apthoid

ulceration

Macroscopic changes

Ulcerative ColitisReddened

mucosaShallow ulcersInflamed and

easily bleeds

Ulcerative Colitis

Crohn’s Ulcerative Coltis

Chronic inflammatory cells: transmural

Lymphoid hyperplasia

Granulomas Langhan’s cells

Chronic inflammatory cells: lamina propria

Goblet cell depletion

Crypt abscess

Microscopic Changes

Transmural! Mucosal!

Extraintestinal Manifestations

EYES Crohn’s UCUveitis 5% 2%

Episcleririts 7% 6%Conjunctivitis 7% 6%

Extraintestinal Manifestations

JOINTS Crohn’s UCType 1 Arthropaty

(Pauci)6% 4%

Type 2 Arthropathy(Poly)

4% 2.5%

Arthralgia 14% 5%Ankylosing Spondylitis 1.2% 1%Inflammatory back pain 9% 3.5%

Extraintestinal Manifestations

SKIN Crohn’s UCErythema Nodosum 4% 1%

Pyoderma Gangrenosum

2% 1%

Extraintestinal Manifestations

LIVER/BILLARY Crohn’s UCSclerosing cholangitis

1% 5%

Gall stones Increased NormalFatty liver Common Common

Hepatitis/ Cirrhosis Uncommon UncommonKidney stones in Crohn’s

oxalate stones post resectionAnaemia

B12 deficiency in Crohn’sVenous thrombosisOther autoimmune diseases

Differential Diagnosis

Each otherInfection (unlikely if >10 days)IBSIleocolonic tuberculosisLymphomas

Treating IBD

Induce remission Steroids – oral or IV Enteral nutrition Azathioprine / 6MP (Crohns)

Maintain remission Aminosalicylates (UC) Azathipreine/ 6MP Methorexate

Biologicals generally for Crohn’s only Infliximab, adalimumab Test for TB first!

Crohn’s Ulcerative Colitis

1. Azathioprine2. Methotrexate3. Cyclosporin4. Humera

1. Adalimumab/anti TNF

Steroids for flares

1. Aminosalicylates1. Mesalazie

2. Steroids1. Foam/PR2. Oral3. IV

3. Azathiorprine

Treating IBD

UC Flares

Truelove-Witts Criteria: 1. Anemia less than 10g/dl2. Stool frequency greater than 6 stools/day with blood3. Temperature greater than 37.54. Albumin less than 30g/L5. Tachycardia greater than 90bpm6. ESR greater than 30mm/hr

Used to classify the flare up into mild, moderate or severe

Treatment Admit to hospital IV steroids and fluids Daily monitoring of stool frequency, AXR, FBC, CRP, Albumin

A STATE

Surgical Management

Surgery can be curative for ulcerative colitis80% of Crohn’s have resections but generally little help

Indications for surgery in Ulcerative Colitis Acute:

Failure of medical treatment for 3 days Toxic dilatation Haemorrhage Perforation

Chronic Poor response to medical treatment Excessive steroid use Non compliance with medication Risk of cancer

I CHOPInfectionCarcinomaHaemorrhageObstructionPerforation

Prognosis

UC 1/3 Single attack 1/3 Relapsing attacks 1/3 Progressively worsen requiring colectomy within

20 yearsCrohn’s

Varied prognosis, new biological agents improvingCancer

Both have increased risk of colon cancer, though UC>Crohn’s

Screening colonoscopy done every 2 years after 10 years disease and every year after 20 years disease

Crohn’s Ulcerative Colitis

Presenting complaint Diarrhoea Abdominal pain Weight loss

Malaise/lethagy Nausea/vomiting Low grade fever Anorexia

Presenting complaint Bloody diarrhoea Lower abdominal pain +/- mucus

Malaise/lethargy Weight loss Apthous ulces in

mouth

Clinical Finals: IBD History

Clinical finals: IBD History

What else to ask? Rashes Mouth ulcers Joint/back pain Eye problems Family history Smoking status

Clinical finals: IBD History

What 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 Exam

Physical signs may be few!General Exam

Weight loss Apthous ulcer of mouth Anaemia Clubbing

Abdominal Exam Colostomy bag May be some abdominal tenderness, may not. May find a RIF mass

Abscess Inflamed loops of bowel

Clinical finals: IBD Exam

Anything else? Rashes on the shins

“I would also like to examine…” Anus

Crohn’s: Odematous tags, fissures or abscesses Ulcerative colitis: usually normal

PR Ulcerative colitis: blood

Clinical finals: IBD

What is the most likely diagnosis? Inflammatory bowel disease

Clinical finals: IBD Investigations

Bedside Stool culture: exclude infection Sigmoidoscopy

Bloods FBC : anaemia and likely raised WCC Haematemics: type of anaemia Inflammartory markers LFT: hypoalbuminaemia is present in severe disease,

hepatic manifestations Blood cultures: if septicaemia is suspected in the

acute presentation Serological: pANCA (UC)

Clinical finals: IBD Investigations

Imaging Plain AXR: helpful in acute attacks

Thumb printing Lead pipe sign

Barium follow-through in Crohn’s CT

CXR Perforation

USS

Clinical finals: IBD Investigations

Flexible sigmoidoscopyColonoscopy

But never in severe attacks of UC due to high risk of perforation

May be painful in Crohn’s due to anal fissures Diagnostic Surveillance

UC of more than 10 years duration increased risk of dysplasia and carcinoma

OGD For Crohn’s: view of terminal illeum In children both an OGD and colonoscopy are done,

Clinical finals: IBD Management

Manage the patient, not just the disease! Medications Manage extraintestinal manifestations

Eg B12 deficiency anaemia Manage patient’s symptoms

Eg loperamide for diarrhoea Good nutrition, hydration and vitamin supplements Psychosocial impact of disease

Ileostomy/colostomy bag Flares and the need for a toilet

Clinical finals: IBD Explanation

Please explain a colonoscopy to the patientPlease explain an OGD to the patientPlease advise the patient on the side effects

of steroids Prepare an organised list to reel off, it is a very

common question!Please explain the compilcations of inflixmab

Keep calm, remember it’s an immnuosupressent!

How to do well in finals questions

Have a plan on how to answer questions Ix: bedside, bloods, imaging, special tests Mx: medical, surgical, psychological, social

acute and long term managementHave a reason for each investigation you’d

like to doTreat the person as well as the diseaseDon’t 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 questions

What are your main differential diagnoses for this lady? How would you investigate this patient acutely and long

term? Eg. not full colonoscopy in acute flare

Initial 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!