Inflammatory Bowel Disease, Diverticulitis, and Inflammatory Bowel Disease Eddie Needham, MD, FAAFP...

Inflammatory Bowel Disease, Inflammatory Bowel Disease,

Diverticulitis, andDiverticulitis, andInflammatory Bowel DiseaseInflammatory Bowel Disease

Eddie Needham, MD, FAAFPEddie Needham, MD, FAAFP

Assistant Professor, Emory Family MedicineAssistant Professor, Emory Family Medicine

Program Director, EFMRPProgram Director, EFMRP

Inflammatory Bowel Disease et alInflammatory Bowel Disease et alObjectivesObjectives

Discuss IBS, diverticular disease, and IBDDiscuss IBS, diverticular disease, and IBD

Compare and contrast Crohn’s disease Compare and contrast Crohn’s disease and ulcerative colitisand ulcerative colitis

Discuss medical therapy and patient Discuss medical therapy and patient compliance techniquescompliance techniques

Discuss systemic manifestations of IBDDiscuss systemic manifestations of IBD

The Pepto Bismol Milkshake

CaseCase

23 yo female (maybe even a PA student at 23 yo female (maybe even a PA student at test time) with intermittent abdominal pain, test time) with intermittent abdominal pain, bloating, and loose, nonbloody stools.bloating, and loose, nonbloody stools.

FamHx - negative for GI illnessesFamHx - negative for GI illnesses

Above sx present for at least five yearsAbove sx present for at least five years

Dx?Dx?

Irritable Bowel SyndromeIrritable Bowel Syndrome

Irritable Bowel SyndromeIrritable Bowel SyndromeDiagnosisDiagnosis

Abdominal pain associated with disturbed Abdominal pain associated with disturbed defecation and relieved with defecationdefecation and relieved with defecation

Stools looser or more frequent at pain Stools looser or more frequent at pain onsetonset

Feeling of incomplete evacuationFeeling of incomplete evacuation

Mucus per rectumMucus per rectum

Visible abdominal distention (bloating)Visible abdominal distention (bloating)

Labs and sigmoidoscopy negativeLabs and sigmoidoscopy negative


Diagnostic tests?Diagnostic tests?

There are noneThere are none - this is purely a clinical - this is purely a clinical diagnosis and a diagnosis of exclusiondiagnosis and a diagnosis of exclusion

Consider the following:Consider the following:– CBC, CMP (Chem-20), ESR, hCG, KUB, UACBC, CMP (Chem-20), ESR, hCG, KUB, UA

Celiac DiseaseCeliac Disease

With any new diagnosis of IBS, entertain With any new diagnosis of IBS, entertain the Dx of celiac disease in your Ddx.the Dx of celiac disease in your Ddx.

Tissue transglutaminase and other labs Tissue transglutaminase and other labs tests to confirmtests to confirm

Gluten free dietGluten free diet

Irritable Bowel SyndromeIrritable Bowel SyndromeTreatmentTreatment

Reassurance!Reassurance!

Identify and correct precipitating factors Identify and correct precipitating factors (lactose intolerance, anxiety disorder, etc)(lactose intolerance, anxiety disorder, etc)

Reduce stressReduce stress

Diet therapy - eat fiber!Diet therapy - eat fiber!


Diagnostic criterion*Diagnostic criterion*

Recurrent abdominal pain or discomfort** at least 3 days/month in the lastRecurrent abdominal pain or discomfort** at least 3 days/month in the last

3 months associated with 3 months associated with two or more of the following:two or more of the following:– Improvement with defecationImprovement with defecation

– Onset associated with a change in frequency of stoolOnset associated with a change in frequency of stool

– Onset associated with a change in form (appearance) of stoolOnset associated with a change in form (appearance) of stool

* Criterion fulfilled for the last 3 months with symptom onset at least 6 * Criterion fulfilled for the last 3 months with symptom onset at least 6 months prior to diagnosismonths prior to diagnosis

** “Discomfort” means an uncomfortable sensation not described as pain.** “Discomfort” means an uncomfortable sensation not described as pain.

http://www.theromefoundation.org/assets/pdf/19_RomeIII_apA_885-898.pdfhttp://www.theromefoundation.org/assets/pdf/19_RomeIII_apA_885-898.pdf

Irritable Bowel SyndromeIrritable Bowel SyndromeTreatmentTreatment

Drug therapyDrug therapy

Constipation - bulking agent (psyllium), Constipation - bulking agent (psyllium), lactulose/milk of magnesialactulose/milk of magnesia

Diarrhea - bulking agent, loperamide, Diarrhea - bulking agent, loperamide, cholestyraminecholestyramine

Bloating - simethicone (OTC)Bloating - simethicone (OTC)

Pain/cramping - dicyclomine/Bentyl, Pain/cramping - dicyclomine/Bentyl, Donnatal, hyoscyamine/LevsinDonnatal, hyoscyamine/Levsin

IBS – TreatmentIBS – TreatmentInitially approved then FDA removedInitially approved then FDA removed

Zelnorm (tegaserod) – used in women with Zelnorm (tegaserod) – used in women with constipation predominant IBSconstipation predominant IBS

Lotronex (alosetron) – used in women with Lotronex (alosetron) – used in women with diarrhea predominant IBSdiarrhea predominant IBS

Sponsoredby:

The Rome Criteria IIIThe Rome Criteria III

http://www.romecriteria.org/questionnaires/


Questions on IBS?Questions on IBS?

CaseCase

64 year old male with three day h/o left 64 year old male with three day h/o left lower quadrant abdominal pain. Has had lower quadrant abdominal pain. Has had fever of 102 today. Still passing some gas.fever of 102 today. Still passing some gas.

FamHx - no colon cancerFamHx - no colon cancer

ROS - no melena, no BRBPR, no ROS - no melena, no BRBPR, no screening flex sig done to date.screening flex sig done to date.

Labs - WBC = 15, bands = 18%Labs - WBC = 15, bands = 18%

Dx?Dx?

Diverticular DiseaseDiverticular Disease


DiverticulosisDiverticulosis– Herniation of the mucosal lining of the Herniation of the mucosal lining of the

intestine through a defect in the muscular intestine through a defect in the muscular layer of the intestinelayer of the intestine

– One-third + of people aged 50 have ‘ticsOne-third + of people aged 50 have ‘tics– Two-thirds + of people aged 80 have ‘ticsTwo-thirds + of people aged 80 have ‘tics– A rough rule of thumb: incidence = ageA rough rule of thumb: incidence = age


DiverticulosisDiverticulosis– Characteristic findings on radiologic or Characteristic findings on radiologic or

endoscopic examendoscopic exam– No fever or leukocytosisNo fever or leukocytosis– Possibly some intermittent left lower quadrant Possibly some intermittent left lower quadrant

painpain– Usually asymptomaticUsually asymptomatic– Eat more fiber!!!Eat more fiber!!!

DiverticulosisDiverticulosis


DiverticulDiverticulitisitis– Acute abdominal painAcute abdominal pain– Constipation or bowel irregularityConstipation or bowel irregularity– LLQ tenderness and possible massLLQ tenderness and possible mass– Fever and leukocytosisFever and leukocytosis– Characteristic radiographic signsCharacteristic radiographic signs


DiverticulDiverticulitisitis - Treatment - Treatment– AntibioticsAntibiotics– Liquid diet or NPOLiquid diet or NPO– Can be managed as an outpatient in mild Can be managed as an outpatient in mild

casescases– NG tube if obstructedNG tube if obstructed– 10-20% of patients have a recurrence10-20% of patients have a recurrence– Surgery is an option in appropriate casesSurgery is an option in appropriate cases

DiverticulitisDiverticulitis


Questions?Questions?

CaseCase

29 year old woman with episodes of 29 year old woman with episodes of bloody diarrhea for 1 week. Has had bloody diarrhea for 1 week. Has had similar episodes in past, but they resolved similar episodes in past, but they resolved after 2 weeks on their own. No melena.after 2 weeks on their own. No melena.

FamHx - no colon cancerFamHx - no colon cancer

No ill contactsNo ill contacts

Dx?Dx?

Inflammatory Bowel DiseaseInflammatory Bowel DiseaseIBD (not IBS)IBD (not IBS)

Inflammatory Bowel DiseaseInflammatory Bowel Disease

Two major types of IBDTwo major types of IBD

Crohn’s diseaseCrohn’s disease– Incidence - 5 per 100,000 personsIncidence - 5 per 100,000 persons– Prevalence - 90 per 100,000 personsPrevalence - 90 per 100,000 persons

Ulcerative colitisUlcerative colitis– Incidence - 10 per 100,000 personsIncidence - 10 per 100,000 persons– Prevalence - 200 per 100,000 personsPrevalence - 200 per 100,000 persons

Inflammatory Bowel DiseaseInflammatory Bowel Disease

Etiology - not clearly discernable. Etiology - not clearly discernable. Possible combination of genetic Possible combination of genetic predisposition and environmental predisposition and environmental exposures.exposures.

Crohn’s Disease - affects mouth to anus Crohn’s Disease - affects mouth to anus and has and has transmuraltransmural involvement involvement

Ulcerative colitis - strictly affects the colon Ulcerative colitis - strictly affects the colon and has and has mucosalmucosal involvement involvement

Crohn’s DiseaseCrohn’s Disease

SymptomsSymptoms– Right lower quadrant pain and diarrhea, Right lower quadrant pain and diarrhea,

usually intermittent in natureusually intermittent in nature– Hematochezia occurs in a minority of patientsHematochezia occurs in a minority of patients– Low fever and weight loss also possibleLow fever and weight loss also possible– High fever and pain may be indicative of a High fever and pain may be indicative of a

complication, e.g., perirectal abscess.complication, e.g., perirectal abscess.


SignsSigns– Abdominal TTP, especially RLQAbdominal TTP, especially RLQ– Palpable mass in RLQ is possiblePalpable mass in RLQ is possible– Rectal exam may reveal a perirectal massRectal exam may reveal a perirectal mass– Abdominal distention/SBO pictureAbdominal distention/SBO picture– Peritoneal signs in patients who have Peritoneal signs in patients who have

fistulized or ruptured.fistulized or ruptured.


Lab findings - generally nonspecificLab findings - generally nonspecific– ESR usually elevated - may be normal when ESR usually elevated - may be normal when

disease in remissiondisease in remission– Anemia - both low iron from anemia of chronic Anemia - both low iron from anemia of chronic

disease and low B12 secondary to ileal disease and low B12 secondary to ileal involvement or resectioninvolvement or resection

– Leukocytosis and thrombocytosisLeukocytosis and thrombocytosis– Hypoalbuminemia Hypoalbuminemia

Lab FindingsLab Findings

p-ANCAp-ANCA Antiglycan Antiglycan antibodiesantibodies

Crohn’s Crohn’s DiseaseDisease

Positive in 15%Positive in 15% Positive in 75%Positive in 75%

Ulcerative Ulcerative ColitisColitis

Positive in 85%Positive in 85% Positive in 5%Positive in 5%

Crohn’s DiseaseCrohn’s DiseaseImaging StudiesImaging Studies– Small bowel follow through - drink barium and Small bowel follow through - drink barium and

take pictures as it transits the small boweltake pictures as it transits the small bowel

Small Bowel ObstructionSmall Bowel Obstruction

Ultrasound with thickened bowel Ultrasound with thickened bowel wallwall


Imaging StudiesImaging Studies– Colonoscopy preferable over ACBE in Colonoscopy preferable over ACBE in

evaluating the colon evaluating the colon – ACBE can evaluate for fistulas and strictures ACBE can evaluate for fistulas and strictures – Colonoscopy may take biopsies in addition to Colonoscopy may take biopsies in addition to

direct visualization. direct visualization. – Both can provide evaluation of the terminal Both can provide evaluation of the terminal

ileum to help distinguish Crohn’s from UCileum to help distinguish Crohn’s from UC


Tablet EnteroscopyTablet Enteroscopy– Swallow a small pill that is a video recorder.Swallow a small pill that is a video recorder.– Records a video image of the small bowel.Records a video image of the small bowel.– Transmits an image to a video receiver that Transmits an image to a video receiver that

then visualizes the small bowel.then visualizes the small bowel.– Recovery of the pill is problematic Recovery of the pill is problematic


Imaging StudiesImaging Studies– Abdominal CT - not useful as an initial Abdominal CT - not useful as an initial

diagnostic study but is extremely helpful in diagnostic study but is extremely helpful in managing complications of Crohn’s disease. managing complications of Crohn’s disease. E.g., evaluating for an intra-abdominal E.g., evaluating for an intra-abdominal abscess or fistulaabscess or fistula


Classic findingsClassic findings– Skip lesions - Crohn’s does not affect the Skip lesions - Crohn’s does not affect the

intestinal mucosa in a continuous fashionintestinal mucosa in a continuous fashion– Cobblestoning owing to mucosal fissuresCobblestoning owing to mucosal fissures– Luminal narrowing/strictures - string signLuminal narrowing/strictures - string sign– FistulasFistulas– Aphthous ulcersAphthous ulcers

Angular CheilitisAngular Cheilitis

Aphthous UlcersAphthous Ulcers

Galandiuk S and Davis BR (2008) Infliximab-induced disseminated histoplasmosis in a patient with Crohn's disease

Nat Clin Pract Gastroenterol Hepatol doi:10.1038/ncpgasthep1119

Figure 1 Image of a fissure in ano suspicious for squamous cell carcinoma in a 56-year-old female patient with ileocolic Crohn's disease


“Creeping Fat”


Other names/nomenclatureOther names/nomenclature

Regional enteritis - secondary to skip Regional enteritis - secondary to skip lesionslesions

Granulomatous enteritis - secondary to Granulomatous enteritis - secondary to granulomas that may be seen on granulomas that may be seen on histologic sectionhistologic section


PatternPattern % at % at presentationpresentation

Ileocecal diseaseIleocecal disease 40-5040-50

Small bowel onlySmall bowel only 30-4030-40

Colon onlyColon only 20 20


Differential diagnosis of ileocecal small bowel Differential diagnosis of ileocecal small bowel disease:disease:

Acute appendicitis with RLQ painAcute appendicitis with RLQ pain

Ectopic pregnancy, tubo-ovarian abscess/PIDEctopic pregnancy, tubo-ovarian abscess/PID

Cecal diverticulitisCecal diverticulitis

Yersinia enterocoliticaYersinia enterocolitica

CMV in immunocompromised hostCMV in immunocompromised host

Lymphoma, cecal carcinomaLymphoma, cecal carcinoma


Differential diagnosis:Differential diagnosis:

Colonic disease - infectious Colonic disease - infectious – Bacterial colitis - Salmonella, Shigella, Bacterial colitis - Salmonella, Shigella,

CampylobacterCampylobacter– Ameba (Amoeba if you’re BritishAmeba (Amoeba if you’re British))– CMVCMV

Colonic disease - noninfectiousColonic disease - noninfectious– Ulcerative Colitis, radiation, ischemiaUlcerative Colitis, radiation, ischemia


ComplicationsComplications– Fistula formation - up to 40% of patientsFistula formation - up to 40% of patients– Enteroenteric Enteroenteric – Enterovesicular - recurrent UTIs and Enterovesicular - recurrent UTIs and

pneumaturiapneumaturia– Enterocutaneous - rectovaginal, fistula-in-ano Enterocutaneous - rectovaginal, fistula-in-ano


ComplicationsComplications– Perforation/abscess formationPerforation/abscess formation– Stricture/ small bowel obstructionStricture/ small bowel obstruction– Nutritional deficiencies - vitamin B12 is Nutritional deficiencies - vitamin B12 is

predominantly absorbed in the terminal ileum, predominantly absorbed in the terminal ileum, as are bile acids. Disease involvement or as are bile acids. Disease involvement or resection thus necessitate B12 and fat-soluble resection thus necessitate B12 and fat-soluble vitamin supplementation (ADEK).vitamin supplementation (ADEK).


ComplicationsComplications– Cancer: small bowel adenocarinomaCancer: small bowel adenocarinoma– Cancer: colon???Cancer: colon???

Ulcerative ColitisUlcerative Colitis


SymptomsSymptoms– Bloody diarrheaBloody diarrhea– Crampy abdominal painCrampy abdominal pain– Tenesmus - urgent feeling of needing to Tenesmus - urgent feeling of needing to

evacuate to the rectum.evacuate to the rectum.– Fever, weight loss also possibleFever, weight loss also possible– 15-25% have extra-intestinal manifestations15-25% have extra-intestinal manifestations


SignsSigns– LLQ pain - mild to severeLLQ pain - mild to severe– Can be very ill in patients with toxic Can be very ill in patients with toxic

megacolon: fever, tachycardia, orthostasismegacolon: fever, tachycardia, orthostasis


Lab Findings - as in Crohn’s, nonspecificLab Findings - as in Crohn’s, nonspecific– ESR usually elevated in active diseaseESR usually elevated in active disease– Mild anemiaMild anemia– LeukocytosisLeukocytosis– Thrombocytosis (acute phase reactant)Thrombocytosis (acute phase reactant)– Stool studies negative (culture, C.diff toxin, Stool studies negative (culture, C.diff toxin,

O&P)O&P)


Imaging StudiesImaging Studies– As disease affects the rectum and extends As disease affects the rectum and extends

proximally, flexible sigmoidoscopy/endoscopy proximally, flexible sigmoidoscopy/endoscopy can be the definitive study. This allows for can be the definitive study. This allows for direct visualization and biopsy sampling.direct visualization and biopsy sampling.

– Contrast radiography/ACBE may show Contrast radiography/ACBE may show mucosal changes and distal ulcers. mucosal changes and distal ulcers.

– Classic long-standing finding is the lead pipe Classic long-standing finding is the lead pipe colon.colon.

Lead pipe colonLead pipe colon


Differential DiagnosisDifferential Diagnosis– Infection: Campylobacter, Shigella, Infection: Campylobacter, Shigella,

Salmonella, Yersinia, E. coli 0157:H7, Salmonella, Yersinia, E. coli 0157:H7, amebiasis, Clostridium difficileamebiasis, Clostridium difficile

– Noninfectious: Crohn’s disease, ischemic Noninfectious: Crohn’s disease, ischemic colitis, radiation colitiscolitis, radiation colitis

– Immunocompromised host: CMV, HSV, GC, Immunocompromised host: CMV, HSV, GC, Blastocystis hominis, ChlamydiaBlastocystis hominis, Chlamydia


ComplicationsComplications– Toxic Megacolon: 15-50% mortalityToxic Megacolon: 15-50% mortality– PerforationPerforation– Cancer: increasing risk of dysplasia with Cancer: increasing risk of dysplasia with

increased time from onset of disease.increased time from onset of disease.

Time from onset:Time from onset: 20 20 30 30

Risk of cancer 5-13% 13-34%Risk of cancer 5-13% 13-34%


CancerCancer– In “usual” colon adenocarcinoma, the cancer starts as In “usual” colon adenocarcinoma, the cancer starts as

a polyp sitting on or above the mucosal surface.a polyp sitting on or above the mucosal surface.– In UC, the dysplastic changes occur in flat epithelium. In UC, the dysplastic changes occur in flat epithelium.

Thus, cancer is not seen until it is a late finding. Thus, cancer is not seen until it is a late finding.– This is the reason that multiple biopsies are taken This is the reason that multiple biopsies are taken

during screening colonoscopy in patients with UC.during screening colonoscopy in patients with UC.


PrognosisPrognosis– Severity of disease is somewhat predictive of the Severity of disease is somewhat predictive of the

future course and the need for colectomy.future course and the need for colectomy.– In one study, the colectomy rate was 24% at 10 years In one study, the colectomy rate was 24% at 10 years

and 30% at 25 years.and 30% at 25 years.

– Rate of colectomy is much higher in patients with Rate of colectomy is much higher in patients with pancolitis. Those with isolated ulcerative proctitis pancolitis. Those with isolated ulcerative proctitis have essentially the same cancer risk as the baseline have essentially the same cancer risk as the baseline

populationpopulation..– Of note, total colectomy is 100% curative!Of note, total colectomy is 100% curative!

SummarySummary Ulcerative Colitis Crohn’sUlcerative Colitis Crohn’s

Clinical findingsClinical findings– Perianal DiseasePerianal Disease Rare Rare Common (1/3 Common (1/3

pts)pts)

– FistulasFistulas Rare Rare Common (up to 40%) Common (up to 40%)

– AbscessAbscess Rare Rare 20% 20%

– StrictureStricture Rare Rare Common Common

Colonoscopy findingsColonoscopy findings– Rectal involvement AlwaysRectal involvement Always Usually spared Usually spared

– PatternPattern Continuous from rectum Skip lesions Continuous from rectum Skip lesions

Radiologic findingsRadiologic findings– Ileal involvementIleal involvement Rare, backwash ileitis Rare, backwash ileitis 75% 75%

Histologic findingsHistologic findings– Depth of inflammation Mucosa to submucosa TransmuralDepth of inflammation Mucosa to submucosa Transmural

– GranulomasGranulomas Uncommon Uncommon 20% of biopsies 20% of biopsies

IBD - TreatmentIBD - Treatment

Medications used in treatmentMedications used in treatment– 5-aminosalicylic acid (5-ASA)/mesalamine5-aminosalicylic acid (5-ASA)/mesalamine– Different preparations of 5-ASA include:Different preparations of 5-ASA include:– Asacol, Rowasa, Pentasa (tradenames)Asacol, Rowasa, Pentasa (tradenames)– 5-ASA is a topically active anti-inflammatory 5-ASA is a topically active anti-inflammatory

agent for inflamed intestinal mucosa. Tummy agent for inflamed intestinal mucosa. Tummy Motrin, so-to-speak.Motrin, so-to-speak.

– Chronic 5-ASA requires folate therapy.Chronic 5-ASA requires folate therapy.

IBD - RxIBD - Rx

Sulfasalazine/Azulfidine - composed of Sulfasalazine/Azulfidine - composed of sulfapyridine and 5-ASA molecules. Bacteria in sulfapyridine and 5-ASA molecules. Bacteria in the terminal ileum cleave the drug into these the terminal ileum cleave the drug into these respective components. Because of where in respective components. Because of where in the intestinal tract the drug becomes active, the intestinal tract the drug becomes active, sulfasalazine is usually used to Rx UC and sulfasalazine is usually used to Rx UC and active ileitis in Crohn’s. Sulfapyridine is active ileitis in Crohn’s. Sulfapyridine is responsible for the sulfa-related adverse drug responsible for the sulfa-related adverse drug reactions of this drug.reactions of this drug.

IBD - RxIBD - Rx

Olsalazine/Dipentum - two 5-ASA Olsalazine/Dipentum - two 5-ASA molecules bound by a diazo bond. molecules bound by a diazo bond. Delivered intact to the terminal ileum and Delivered intact to the terminal ileum and there it is cleaved by bacteria. there it is cleaved by bacteria.

Useful in treating UC.Useful in treating UC.

Side effect of note - ileal secretory Side effect of note - ileal secretory diarrhea secondary to the diazo bond. diarrhea secondary to the diazo bond. Occurs in 5-10% of treated patients.Occurs in 5-10% of treated patients.

IBD - RxIBD - Rx

MesalamineMesalamine– Pentasa: 5-ASA packaged in ethylcellulose Pentasa: 5-ASA packaged in ethylcellulose

granules that are slowly released from the granules that are slowly released from the jejunum to the colon. jejunum to the colon.

– Used to Rx Crohn’s disease.Used to Rx Crohn’s disease.– 4 gm per day most helpful in Crohn’s, but 4 gm per day most helpful in Crohn’s, but

requires taking 16 tablets.requires taking 16 tablets.– 2-3 gm/d for active UC, 1-2 gm/d for 2-3 gm/d for active UC, 1-2 gm/d for

maintenance of UCmaintenance of UC

IBD - RxIBD - Rx

MesalamineMesalamine– Asacol - enveloped in a pH-sensitive coating Asacol - enveloped in a pH-sensitive coating

which delivers drug to the distal ileum and which delivers drug to the distal ileum and colon.colon.

– 2.4 - 4.6 gm/d for UC.2.4 - 4.6 gm/d for UC.– Can be used to maintain remission in Crohn’s Can be used to maintain remission in Crohn’s

disease in Crohn’s of the terminal ileum.disease in Crohn’s of the terminal ileum.

IBD - RxIBD - Rx

MesalamineMesalamine– Rowasa - enema or suppository form of Rowasa - enema or suppository form of

mesalamine.mesalamine.– Useful for distal proctosigmoiditis/UC. Not Useful for distal proctosigmoiditis/UC. Not

helpful in treating perirectal Crohn’s disease.helpful in treating perirectal Crohn’s disease.– Little systemic absorption, few side effects.Little systemic absorption, few side effects.– Rowasa works best if given HS and retained Rowasa works best if given HS and retained

overnight.overnight.

Oral sulfa drugs for IBDOral sulfa drugs for IBD

IBD - RxIBD - Rx

Corticosteroids - extremely useful for Corticosteroids - extremely useful for treating acute flares and in maintaining treating acute flares and in maintaining remission in moderate to severe disease.remission in moderate to severe disease.

Start Solu-medrol at 125mg IV q6hr, then Start Solu-medrol at 125mg IV q6hr, then switch to po Prednisone at 40-60mg qD. switch to po Prednisone at 40-60mg qD.

Taper over 8-12 weeks if possible. Taper over 8-12 weeks if possible.

CorticosteroidsCorticosteroidsSide EffectsSide Effects

Cushingoid Cushingoid appearanceappearance

OsteoporosisOsteoporosis

HypertensionHypertension

DiabetesDiabetes

Peptic ulcerPeptic ulcer

PsychosisPsychosis

Aseptic necrosis of Aseptic necrosis of bone/hipbone/hip

NeuropathyNeuropathy

MyopathyMyopathy

IBD - RxIBD - Rx

Immunosuppressive drugsImmunosuppressive drugs– Azathioprine and 6-MercaptopurineAzathioprine and 6-Mercaptopurine

Purine analogs that may inhibit T cell functionPurine analogs that may inhibit T cell function

– Infliximab (Remicade ®)and other TNF inhibitors Infliximab (Remicade ®)and other TNF inhibitors Tumor Necrosis Factor (TNF)Tumor Necrosis Factor (TNF)

Antibiotics - acute treatmentAntibiotics - acute treatment– metronidazole/Flagyl - covers anaerobic metronidazole/Flagyl - covers anaerobic

bacteria. Especially useful in perirectal disease.bacteria. Especially useful in perirectal disease.

IBD - Rx IBD - Rx

EducationEducation

Support groupsSupport groups

Psychologic therapy as indicatedPsychologic therapy as indicated

Don’t lose sight of the fact that we are Don’t lose sight of the fact that we are treating patients, not diseases.treating patients, not diseases.

Holding a hand and hugging a shoulder Holding a hand and hugging a shoulder are often more effective than any medicine are often more effective than any medicine we can offerwe can offer. .

ProbioticsProbiotics

No evidence supports the use of probiotics No evidence supports the use of probiotics to induce clinical improvementto induce clinical improvement

Probiotics are not an FDA approved class Probiotics are not an FDA approved class of drugsof drugs

Many different probiotics will play…few will Many different probiotics will play…few will win…win…

Meaning we don’t yet know the utility of Meaning we don’t yet know the utility of probioticsprobiotics

Probiotics?Probiotics?

-Biotics-Biotics

Antibiotics – drugs to kill bacteriaAntibiotics – drugs to kill bacteria

Prebiotics – substances which induce the Prebiotics – substances which induce the growth of beneficial bacteriagrowth of beneficial bacteria

Probiotics – introduction of bacteria Probiotics – introduction of bacteria themselves (“Pleased to meet you”)themselves (“Pleased to meet you”)

Robiotics – introduction of Robiotics – introduction of nanobots to destroy all harmful nanobots to destroy all harmful

bacteriabacteria

Transformobiotics – Optimus Transformobiotics – Optimus Prime meets Pseudomonas Prime meets Pseudomonas

MaximusMaximus

Extra-intestinal Manifestations Extra-intestinal Manifestations of IBDof IBD

Reactive arthropathy - present with active Reactive arthropathy - present with active diseasedisease

Episcleritis - seen more commonly in Episcleritis - seen more commonly in Crohn’s diseaseCrohn’s disease

Erythema Nodosum - Crohn’s > UCErythema Nodosum - Crohn’s > UC

Pyoderma Gangrenosum - UC > Crohn’sPyoderma Gangrenosum - UC > Crohn’s

Extra-intestinal Manifestations Extra-intestinal Manifestations of IBDof IBD

Sacroiliitis - 10% patients with IBD. Sacroiliitis - 10% patients with IBD. Association with HLA-B27Association with HLA-B27

Scleritis and uveitisScleritis and uveitis

Primary sclerosing cholangitis - usually Primary sclerosing cholangitis - usually with UCwith UC

Erythema Erythema NodosumNodosum

Pyoderma GangrenosumPyoderma Gangrenosum

FineFine

Questions?Questions?

Inflammatory Bowel Disease, Diverticulitis, and Inflammatory Bowel Disease Eddie Needham, MD, FAAFP...

Documents

Transcript of Inflammatory Bowel Disease, Diverticulitis, and Inflammatory Bowel Disease Eddie Needham, MD, FAAFP...