Inflammatory Bowel Disease



Inflammatory Bowel Disease Dr Alex TebbettEpidemiology Crohn’s: Slightly less common (27-106/100,000) Females 1.2:1,Younger (26)Ulcerative Colitis: Slightly more common (80-150/100,000) Males 1.2:1, Older (34)Aetiology Autoimmune, though specifics largely unknownGenetics Polygenic, HLA DRB, Familial (1 in 5)Host immunology Defective mucosal immune system, Inappropriate response to intraluminal bacteriaby T-cells and cytokinesEnvironmental Crohn’s: Good hygiene/ developed countriesl. SmokersUlcerative Colitis: No relation to hygiene. Non smokersPathology Crohn’s affects the terminal illeum most commonly. It can then extend to Ileocolonic disease where it also involves the ascending colon. It can present throughout the bowel either as skip lesions or as pancolitis. It can also affect the large bowel only!Ulcerative Colitis most commonly presents as proctitis. If it extends proximally from the rectum to involve the sigmoid and descending colon it becomes left sided colitis. If it extrends to the caecum it is pancolitis. If it also affects the distal terminal ileum it becomes backwash ileitis.Macroscopic changes Crohn’s:Bowel is thickened Lumen is narrowedDeep ulcersMucusal fissuresCobblestoneFistulaeAbscessUlcerative Colitis:Reddened mucosaShallow ulcers Inflamed and easily bleedsMicroscopic Changes Crohn’s:Chronic inflammatory cellstransmural Lymphoid hyperplasiaGranulomas Langhan’s cellsUlcerative Coltis: Chronic inflammatory cellslamina propria Goblet cell depletionCrypt abscessOther extraintestinal manifestationsAnaemiaKindney stonesFatty liverGallstonesVenous thrombosisOther autoimmune diseaseSclerosing cholangitisExtraintestinal Manifestations ConditionCrohn’sUlcerative Colitis Eyes:Uveitis5%2%Episcleritis7%6%Conjunctivitis7%6%Joints:Type 1 Arthropathy (Pauci)6%4%Type 2 Arthropathy (Poly)4%2.5%Arthralgia14%5%Ankylosing Spondylitis1.2%1%Inflammatory back pain9%3.5%Skin:Erythema Nodusum4%1%Pyoderma Gangrenosum2%1%Differential Diagnosis Each otherInfection (unlikely if >10 days)IBSIleocolonic tuberculosisLymphomas Treating IBD Induce remissionSteroids – oral or IVEnteral nutritionAzathioprine / 6MP (Crohns)Maintain remissionAminosalicylates (UC)Azathipreine/ 6MPMethorexate Biologicals generally for Crohn’s onlyInfliximab, adalimumab Test for TB first! Crohn’s Azathioprine Methotrexate Cyclosporin Humera Steroids for flaresUlcerative Colitis Aminosalicylates Mesalazie SteroidsFoam/PROralIVAzathiorprine UC Flares: Truelove-Witts Criteria: (Acronym: A STATE)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/hrSurgical Management Indications for surgery in Ulcerative ColitisAcute: Failure Rx for 3 daysToxic dilatationHaemorrhagePerforationChronicPoor Rx responseExcessive steroid useNon compliance RxRisk of cancer(Acronym: I CHOP)InfectionCarcinomaHaemorrhageObstructionPerforation Prognosis UC1/3 Single attack1/3 Relapsing attacks1/3 Progressively worsen requiring colectomy within 20 yearsCrohn’s Varied prognosis, new biological agents improvingCancerBoth 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 IBD for clinical finalsPresenting complaintCrohn’s:DiarrhoeaAbdominal painWeight lossMalaise/lethagy Nausea/vomitingLow grade feverAnorexiaUlcerative Colitis Bloody diarrhoeaLower abdominal pain+/- mucusMalaise/lethargyWeight lossApthous ulces in mouthWhat else to ask?RashesMouth ulcersJoint/back painEye problemsFamily historySmoking statusExploring their condition: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?ExaminationGeneral Exam Weight lossApthous ulcer of mouthAnaemiaClubbingAbdominal ExamColostomy bagMay be some abdominal tenderness, may not.May find a RIF massAbscessInflamed loops of bowel Anything else? Rashes on the shins“I would also like to examine…”AnusCrohn’s: Odematous tags, fissures or abscesses Ulcerative colitis: usually normalPRUlcerative colitis: bloodInvestigations BedsideStool culture: exclude infectionSigmoidoscopy BloodsFBC : anaemia and likely raised WCCHaematemics: type of anaemia Inflammartory markersLFT: hypoalbuminaemia is present in severe disease, hepatic derrangementBlood cultures (if septicaemia is suspected)Serological: pANCA (UC)ImagingPlain AXR: helpful in acute attacksThumb printing/ Lead pipe signBarium follow-through in Crohn’s CTCXR (Perforation)USSSpecial TestsFlexible sigmoidoscopy ColonoscopyBut never in severe attacks of UC due to high risk of perforationMay be painful in Crohn’s due to anal fissures Diagnostic Surveillance UC of more than 10 years duration increased risk of dysplasia and carcinomaOGDFor Crohn’s: view of terminal illeum Management Manage the patient, not just the disease!MedicationsManage extraintestinal manifestationsEg B12 deficiency anaemiaManage patient’s symptomsEg loperamide for diarrhoeaGood nutrition, hydration and vitamin supplementsPsychosocial impact of diseaseIleostomy/colostomy bagFlares and the need for a toiletExplanationPlease 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 complications of inflixmab Keep calm, remember it’s an immnuosupressent! How to do well in finals questions Have 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 you’d like to do Treat the person as well as the diseaseDon’t ever forget the MDT!What else could come up…. Coeliac disease IBSIschaemic colitisDiverticular diseaseAppendicitisPolypsHaemorrhoidsKnow 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 Questions:What are your main differential diagnoses for this lady? How would you investigate this patient acutely and long term?Initial management in acute setting and the 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? ................
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