Gastroenterology and Hepatology - Inflammatory Bowel Disease
Transcript of Gastroenterology and Hepatology - Inflammatory Bowel Disease
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INFLAMMATORY
BOWEL DISEASE
Steve Polyak, MD
Gastroenterology M3 Lecture Series
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Case
28 yo Caucasian female presents to clinic withabdominal pain and diarrhea for 6 months
Pain
S b/l lower quadrants
0 6 months ago
C dull to sharp
R seem to radiate to lower back
A/A improved with defecation
T dull feeling most of the time, intermittent sharp pains last until BM
E worsened with food
S persistent 2/10 and flares up to 9/10
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Case
Stooling characteristics
Loose brown runny
Small volume
Improved with fasting
Intermittent red blood
Urgency and tenesmus
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Case
Associated symptoms
No wt loss
No N/V
Knee pain, hip pain and low back pain on and offNo fever but has chills
No sick contacts, travel or camping
No PMH
Medications: NSAIDS prn for joint pain
SHx: does not drink, smoke or use drugs
FHx: Denies CRC and IBD
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Case
Vitals stable BMI 21
Exam (positive findings)Pale
Abd is nondistended,
normoactive BS, soft w/o
tympany, tender in b/l LQ, no
guarding
Rectal exam with no stool
Tests?
Blood
WBC 9.5, HCT 30.3, PLT 575
Chem 7, LFTs wnl
Stool studies
Fecal lactoferrin positive
Culture negC diff PCR neg
Giardia/Crypto antigen neg
O&P neg
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Differential
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Colonoscopy/Histology
Normal appearing Terminal Ileum Normal appearing histology of TI
Colonoscopy Inflamed mucosa to transverse colon
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Colonoscopy/Histology
Example of normal colon Transmural inflammation, crypt distortion
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Colonoscopy/Histology
Architectural distortion of the crypts
Crypt
Abscess
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Active vs Chronic Cryptitis
Crypt abscess formation
Erosions
Ulcers
Pseudomembranes(plaques of surface exudatewith fibrin, mucin,degeneratedepithelial/inflammatorycells
Crypt distortion/atrophy
Surface villiform change
Basal plasmacytosis
Basal lymphoid aggregates
Paneth cell metaplasia (intransverse and left colon)
Increased mononuclearinflammation in the laminapropria (least useful)
Histology
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Histology
CD
Transmural inflammation
Deep fissures
Cryptitis
Crypt abscess
Crypt arch distortion
Noncaseating granulomas
in 25-50%
UC
Inflammation confined to
mucosa
Cryptitis
Crypt abscess
Crypt arch distortion
Glandular drop out
Basal lymphoid aggregates
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Crohns Indeterminate Ulcerative
Disease Colitis Colitis
10-15 %
IBD Overview
IBD
1-2 million in USA
Loftus EV. Gastroenterology. 2004;126:1504-1517.
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Ulcerative Colitis Crohns Disease
*Per 100,000 population
Reprinted from Lashner BA. In: Stein SH and Rood RP, eds. Inflammatory Bowel Disease: A Guide forPatients and Their Families. Lippincott-Raven Publishers; 1999:23-29.
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Age (yrs) Age (yrs)
Age Specific Incidence
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Genetic Environment
Immunology Microbial
Immune
Dysregulation
Epithelial
Dysfunction
Pathogenesis
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Clinical Features
Feature UC CD
Abdominal pain Less frequent Frequent
Bloody diarrhea Frequent Occasional
Abdominal mass Never Frequent
Intestinal obstruction Never Frequent
Perianal disease Infrequent Frequent
Fistula Never Common
Effect of smoking Protective Detrimental
Systemic symptoms/EIMs Less common Common
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Extraintestinal Manifestations
PeripheralArthritis
I 5-10% of IBD pts
II 3-4% of IBD pts
Type I pauciarticular yes
Type II polyarticular no
SI
AS
5-20% of IBD pts
1-25% of IBD pts
NO HLA B27 + in AS
ErythemaNodosum
10-20% of IBD pts YES
PyodermaGangrenosum
2% 5% NO IBD in up to 50% of PG pts
Uveitis 1-3% of IBD pts NO Painful, blindness risk
Scleritis
Episcleritis
5% of IBD pts
10% of IBD ptsYES
SclerosingCholangitis
4% 5-20% NOUC in up to 90% of PSC pts
Cholangiocarcinoma and CRC risk
Aphthae 5-20% of IBD pts YES
IBD Preference
CD UC
Disease Activity
Correlation Special Features
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Involvement
Crohns Disease
Image adapted from CDWG
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Involvement
Pro
Proctitis
28%
Left-sided
25%
Pancolitis
47%
Image adapted from CDWG
Ulcerative Colitis
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Diagnostic Tools
Endoscopy
EGD
Colonoscopy
Capsule endoscopy
Radiology
SBFT
Enterography
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Endoscopic Features
Feature UC CD
Mucosal involvementDiffuse continuous
superficial ulcerations
Focal asymmetric
aphthoid or linear
ulcerations
Strictures Rare (neoplasm) Common
Rectal involvement
Always present at
diagnosisSparing may represent
healing
Common
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Endoscopic features of UC
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Endoscopic features of CD
Discrete ulcers and aphthae in the terminal ileum
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Endoscopic features of CD
Discrete aphthae in the colon Linear ulcerations in the colon
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Endoscopic features of CD
Severe linear ulcers in the colon Severe disease with narrowing
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Types of CD
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Perianal Disease of CD
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Enterocutaneous Fistula of CD
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Medical Treatment
Aminosalicylates 5ASAAzulfidine
Pentasa
Asacol
Colazal
Apriso
Lialda
Rowasa & Canasa
Steroids
PrednisoneEntocort (Budesonide)
AntibioticsFlagyl
Cipro
Rifaxamin
Immunomodulators6MP
Azathioprine (Imuran)
Methotrexate
Cyclosporin
Myocphenolate (CellCept)
Thalidomide
FK506
Biologic Agents
Infliximab (Remicade)Adalimumab (Humira
Certolizumab (Cimzia)
Probiotics
Elemental diet
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Surgical Therapy
CD
Resection only for
complications
Recurrence 40-70%
Post op treatment reduces
recurrence at anastomosis
UC
Potentially curative
TAC with
Ileostomy
IPAA (J pouch)
10% failure rate
30% pouchitis
Some post op cases developinto Crohns
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Surveillance of CRC
in Chronic Colitis
Colon cancer risk directly related to duration and
extent of disease
Increase 1%/yr each year after 10 years
UC and Crohns colitis similar
Begin after 8-10 yrs of disease if disease is beyond
the splenic flexure
Left sided disease begin surveillance after 15 yrs
Surveillance Q1-2yrs