Inflammatory Bowel Disease Dawn Kershaw (FY1). Objectives Recognise the possibility of IBD in...
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Transcript of Inflammatory Bowel Disease Dawn Kershaw (FY1). Objectives Recognise the possibility of IBD in...
Inflammatory Bowel Disease
Dawn Kershaw (FY1)
ObjectivesRecognise the possibility of IBD in patient’s
presenting with lower GI symptomsRecognise the possibility of systemic symptoms
associated with IBDRecognise the differences in presentation
between Crohn’s and UC – and how these relate to underlying pathology
Initiate appropriate investigations in a patient with suspected IBD
Initiate appropriate management in a patient with IBD
Explain to patients the nature of and the rationale for maintenance treatment of IBD
ObjectivesRecognise the possibility of IBD in patient’s presenting
with lower GI symptoms = GI symptoms of IBDRecognise the possibility of systemic symptoms
associated with IBD = Extra-intestinal symptomsRecognise the differences in presentation between
Crohn’s and UC – and how these relate to underlying pathology = Differences between UC and Crohn’s: Pathology and presentation
Initiate appropriate investigations in a patient with suspected IBD = Investigations
Initiate appropriate management in a patient with IBD = Management of IBD
Explain to patients the nature of and the rationale for maintenance treatment of IBD = Explain in lay terms why we give medications to prevent flare ups
Crohn's verses UC
Definition?Aetiology?
Crohn's verses UCDefinition
◦Chronic ◦Relapsing and remitting◦Inflammatory bowel disease◦Chrons: any part of GI tract - often terminal ileum◦UC: large bowel
Aeitology◦Unknown◦Genetic ◦Environmental
Pathology?
Crohn’s
Crohn’s
Tranny Granny Skipped down Cobblestone street
StricturesFistulaeAbscesses
Crohn’s
Ulcerative colitis◦Starts from rectum◦Extends proximally◦Continuous◦Mucosa only
Proctitis = rectumProctosigmoiditis = rectum and sigmoid
colonLeft sided ColitisPancolitis – Whole of large colon
Objectives
Recognise the differences in presentation between Crohn’s and UC – and how these relate to underlying pathology
Recognise the possibility of IBD in patient’s presenting with lower GI symptoms
Crohn’s
Crohn’s Crampy abdominal pain
◦ Inflammation; fibrosis; bowel obstructionDiarrhoea
◦Blood◦Steatorrhea
Weight lossFeverAnaemia
Obstruction: Distension, VomitingAbscessesFistulae: Enteroenteral; Anorectal;
Vesicointestinal; Rectovaginal
Ulcerative Colitis
Ulcerative ColitisCrampy abdominal pain
◦Relieved by defecation◦Left iliac fossa
Diarrhoea◦Blood ++◦Mucous
UrgencyTenesmusWeight lossFeverAnaemia
Severity: Truelove Witts Criteria
Objectives
Recognise the possibility of systemic symptoms associated with IBD.
Extra-intestinal symptomsEyes
◦Iritis; uveitis; episcleritisSkin
◦Erythema nodosum; pyoderma gangrenosumJoints
◦Seronegative spondyloarthropathy Large joints; Spine; Sacroiliitis; Can affect small
jointsOther
◦Clubbing◦DVT◦Primary sclerosing cholangitis (UC)◦Heamolytic anaemia (autoimmune) (Crohn’s)◦Osetoporosis (Crohn’s)
Erythema nodosum Pyoderma gangrenosum
Uveitis Clubbing
Get into 2 groupsComplete first 3 boxes on form based on what
we have just done.
What are your differential diagnosis to consider in a patient presenting with IBD symptoms?◦Abdominal pain◦Diarrhoea◦PR bleeding/ mucous◦Weight loss◦Malabsorption
(Thanks to Zoe Campbell for providing the basis to this form)
Initiate appropriate investigations in a patient with suspected IBD
BedsideBloodsImagingSpecial tests
InvestigationsBedside
◦Stool MC&S◦Faecal calprotectin
Bloods◦FBC (low Hb; High WCC)◦ESR; CRP (high)◦LFTs: Low albumin◦U&Es: Chronic diarrhoea – electrolyte imbalance◦Heamatinics: ferritin, Vitamin B12, folate◦Amylase◦Cross match
InvestigationsImaging
◦Abdominal X-ray◦Erect Chest X-ray◦Barium Meal (Crohn's)
Fibrosis, Strictures, Ulceration (‘rose thorn’)◦Barium enema (UC)
Featureless narrow colon, Loss of haustral pattern◦CT/MRI enterography (Crohn’s)
Special test◦Flexible sigmoidoscopy◦Colonoscopy◦Gastroscopy◦BIOPSY Not in acute flare!!!
Initiate appropriate management in a patient with IBD
AcuteChronicLifestyleMDT
ManagementAcute
◦A-E; Bowel rest; Analgesia (not NSAIDs); ◦Steroids: IV; oral; rectal◦Antibiotics◦5-ASAs
Chronic◦5-ASAs◦Per rectum steroids◦Immunosuppressant's
Azathioprine Methotrexate (Crohn’s)
◦Anti-TNF: InfliximabSurgery: Resection
ManagementLifestyle
◦Diet: Elemental◦Stop smoking?
MDT◦Consultant’s: Gastroenterologist; Surgeons◦IBD specialist nurse◦Dietician◦Smoking cessation◦Stoma nurse
Medications used in IBD
5-ASAsSteroidsAzathioprine/ Mercaptopurine
(Immunosuppressant)Methotrexate (Crohn's)Infliximab (Anti-TNF)
Get back into groups
Complete the rest of the form
Objectives
Explain to patients the nature of and the rationale for maintenance treatment of IBD
Patient.co.ukOnce a flare-up has settled, without
treatment, there is ~1 in 2 chance that another flare-up will develop within a year.
Increased likelihood of flares depends on:◦extent of the disease in your gut◦age,◦the extent of treatment needed to control the
initial flare-up.If flares not frequent/mild/ respond well to
acute treatment then - may not need to /wish to take regular meds
For others regular meds can improve QOL ++
The treatment options that may be considered to prevent flare-ups) include:
Immunosuppressants – take dailyMesalazine – used daily (less common now)Anti-TNF – selected cases where flares severe
and other treatments not worked: Have infusion in hospital every 8 weeks.
Steroid medication is not generally used long-term to prevent flare-ups
These treatments increase the chance of remaining free of flare-ups, but they do not always work.
Balance between benefits and the possible side-effects.
3 key points to take awayUnderstanding the pathophysiology of UC and
Crohn’s is actually useful!◦Symptoms◦ Investigations◦Management
Communication is key- in exams AND in real life:◦Patient.co.uk◦Easy marks in exams if you practice!
Structured answers in exams◦ Investigations
Bedside; Bloods; Imaging; Special tests Acute; chronic
◦Management Acute; Chronic; lifestyle; MDT Conservative; Medical; Surgical