INFLAMMATORY BOWEL DISEASEAnusha Reddy

FY1 SWFT

3rd Feb 2014

OBJECTIVES

2 Case Studies: Crohn’s Vs Colitis

THINK: AETIOLOGY EPIDEMIOLOGY SIGNS AND SYMPTOMS INVESTIGATIONS MANAGEMENT

CASE STUDY 1

22 Female

PC: 6/52 of 5 x loose, non-bloody stools daily Right lower quadrant abdominal pain (especially

after eating) 8kg weight loss Bilateral knee and ankle pains

MORE INFORMATION REQUIRED

Full history Nil PMH, no hx of foreign travel No medications or allergies Current smoker- 5 pack-years

Examination Definite and moderately tender 5-cm mass in the

right lower quadrant No joint effusion or skin lesions are noted

DIFFERENTIAL DIAGNOSIS Gastroenteritis Crohn’s Disease Ulcerative Colitis Irritable Bowel Syndrome Behcet’s Disease

Bowel Cancer Tuberculosis Amyloidosis Acute Appendicitis

WHAT DO WE THINK THIS IS?

22 Female

PC: 6/52 of 5 x loose, non-bloody stools daily Right lower quadrant abdominal pain (especially

after eating) 8kg weight loss Bilateral knee and ankle pains

CROHN’S DISEASE- DEFINITION

Chronic Inflammatory Bowel Disease (IBD) Unknown Aetiology Characterised by

1. Focal 2. Asymmetrical 3. Transmural4. Occasionally granulomatous inflammation

Any part of the GI tract- mouth anus

CROHN’S DISEASE- EPIDEMIOLOGY

Incidence: 9.56 per 100,00011

Prevalence: 115,000 in the UK Age of onset: 2 peaks 1) 15-30 Y (more common) 2) 60-80 Y Female: Male 1.8:1 Children this is reversed!

Risk Factors22

Mycobacterium paratuberculosis, Pseudomonas spp. & Listeria spp.

↑TNF-alpha High-fat diets Genetic mutations

1) Steed H, Walsh S, Reynolds N; Crohn's disease incidence in NHS Tayside. Scott Med J. 2010 Aug;55(3):22-52) Rangasamy P et al; Crohn Disease, Medscape, Jun 2011

CROHN’S DISEASE- SYMPTOMS

• Abdominal pain, cramping or swelling • Anaemia • Fever • Gastrointestinal bleeding • Joint pain • Malabsorption • Persistent or recurrent diarrhoea • Stomach ulcers • Vomiting • Weight loss

CROHN’S DISEASE- ON EXAMINATION

General ill health- weight loss & dehydrated

Hypotension, tachycardia and pyrexia Abdominal tenderness or distension, palpable

masses. Anal and perianal lesions (abscesses,

fistulae) Mouth Ulcers

Extra-intestinal manifestations of Crohn’s ......

CROHN’S DISEASE- EXTRA INTESTINAL

INVESTIGATIONS

Bloods FBC, CRP, U&Es, LFTs

Stool culture and microscopy anti-S. cerevisiae antibodies Perinuclear

antineutrophil cytoplasmic antibody (p-ANCA) (UC>CD)

Abdo Xray Ileocolonscopy and biopsy from the terminal

ileum as well as the affected sites Small bowel follow through If upper GI symptoms- Upper GI endoscopy If lower GI symptoms- Flexible

sigmoidoscopy/EUA

CROHN’S DISEASE- MANAGEMENT

First presentation (NICE guidelines)1. Glucocorticoids

1. Prednisolone, Methylprednisolone IV hydrocortisone

2. Budesonide3. 5-ASA

+/- ADD ON Azathioprine or Mercaptopurine

Biologic: Infliximab and Adalimumab

CROHN’S DISEASE- MANAGEMENT

Maintaining Remission (NICE guidelines)

Offer Azathioprine or Mercaptopurine as Monotherapy

Methotrixate

Surgery- if limited to distal ileum (weighing out the risk Vs benefits) and for complications...

CROHN’S DISEASE- COMPLICATIONS

A

B

C C

CASE STUDY 2

32 Male Bloody diarrhoea 4/52 Bilateral lower abdominal cramping Malaise and weight loss No associated fever, visual changes,

arthralgias, or skin lesions

Previously fit and well contractor Non-smoker, 14-18 units/week drinker FHx: Diabetes Mellitus Type 1

ULCERATIVE COLITIS- DEFINITION

Chronic Inflammatory Bowel Disease Unknown aetiology

Only Large Colon Classification:

Distal Disease More extensive disease Pancolitis

ULCERATIVE COLITIS- EPIDEMIOLOGY

More common than Crohn’s Incidence: 10 per 100,000 Prevalence 240 per 100,000 in the UK Age of onset: 2 peaks 1) 15-25 Y (more

common) 2) 55-65 Y

Male:Female= 1:1 Idiopathic: ?autoimmune condition triggered by

colonic bacteria inflammation Genetic component: sibling of an individual who

has IBD 17-35 x more risk of development Risk of UC decreased in smokers

1) Ulcerative Colitis; NICE Clinical Guideline (Jun 2013)

ULCERATIVE COLITIS- SYMPTOMS

Bloody diarrhoea Abdominal Pain Tenesmus Systemic symptoms: malaise, fever,

weightless

ULCERATIVE COLITIS- ON EXAMINATION

Unwell, pale, febrile, dehydrated Abdo pain and tenderness .. + distension TOXIC MEGACOLON

Worrying signs: Tachycardia, anaemia and fever

Extra- intestinal disease...

ULCERATIVE COLITIS- EXTRA-INTESTINAL

Aphthous ulcers Ocular manifestations 5%

Episcleritis Anterior uveitis

Acute arthropathy affecting the large joints 26% Sacroiliitis Ankylosing Spondylitis 3%

Deramatology 19% Pyoderma gangrenosum Erythema nodosum

Primary Sclerosing Cholangitis

ULCERATIVE COLITIS- INVESTIGATIONS

Bloods: FBC, LFTs, U+Es, CRP Serology- pANCA Vs. ASCA Stool cultures

Imaging Abdo x-ray- acute setting Barium enema- can show mucosal structure

Flexible Sigmoidoscopy and Biopsy- for diagnosis

ULCERATIVE COLITIS- MANAGEMENT

a) Topical aminosalicylate alone (suppository or enema b) ?ADD PO aminosalicylate to a topical aminosalicylate ORc) consider an PO aminosalicylate alone

a) PO Aminosalicylate - High induction dose of an

b) ?ADD topical Aminosalicylate OR PO beclometasone dipropionate

- If no improvement 72 hrs despite IV Hydrocortisone OR-Symptoms worsen to pancolitis:

a) ADD IV Ciclosporin to IV steroids

ULCERATIVE COLITIS- MANAGEMENT

Indications for Surgery: Unresponsive to medical treatment Significantly affecting quality of life Growth retardation in Children Life-threatening complications...

Bleeding Toxic Megacolon Impending perforation Carcinoma

ANY QUESTIONS?

SUMMARY

SUMMARY: CROHN’S VS. UC (1)

Symptoms of Crohn's Disease

• Abdominal pain, cramping or swelling •Anaemia •Fever •Gastrointestinal bleeding •Joint pain •Malabsorption •Persistent or recurrent diarrhoea •Stomach ulcers •Vomiting •Weight loss

Symptoms of Ulcerative Colitis

•Bloody diarrhoea •Abdominal pain or discomfort •Anaemia caused by severe bleeding •Dehydration •Fatigue •Fever •Joint pain •Loss of appetite •Malabsorption •Rectal bleeding •Urgent bowel movements •Weight loss

SUMMARY: CROHN’S VS. UC (2)

SUMMARY- CROHN’S VS. UC (3)

SUMMARY: CROHN’S VS. UC (2)

LEARNING POINTS

RELAPSE AND REMITTING MANAGE THE PATIENT

BONE PROTECTION- IF ON LONG-TERM STROIDS

TEST FOR TB BEFORE STARTING INFLIXIMAB

RISK OF COLONIC CARCINIMA IN UC

THANK YOU!!