Download Inflammatory Bowel Disease

Inflammatory Bowel Disease
DR ALEX TEBBETT
(WARWICK GRADUATE)
FY1 WARWICK A&E
What we’re covering
 The big two – Crohn’s and UC
 Risk factors
 Macro and microscopic changes
 Extraintestinal manifestations
 Differential diagnosis
 Treatment
 Clinical exam for IBD
 Other GI cases
 Finals hints
IBD
Crohn’s
Ulcerative Colitis
Epidemiology
Crohn’s
Ulcerative Colitis
Slightly less common
27-106/100,000
Slightly more common
80-150/100,000
Females: 1.2:1
Males: 1.2:1
Younger: 26
Older: 34
Aetiology
Largely unknown
Genetics
1.



Polygenic: 16, 12, 6, 14, 5, 19, 1, 3
HLA DRB
Familial (1 in 5)
2. Host immunology
 Defective mucosal immune system
 Inappropriate response to intraluminal bacteria
 T-cells and cytokines
Autoimmune!
Aetiology: Environmental
Crohn’s
Ulcerative Colitis
Good hygiene/
developed countries
No relation to hygiene
Appendicectomy
Appendicectomy is
protective
Smokers
Non smokers
Breast feeding is
protective
Breast feeding is
protective
Pathology
Crohn’s
Ulcerative Colitis
Mouth to anus!
Rectum and extends
proximally!
 Terminal illeum
 Proctitis
 Ileocolonic disease
 Ascending colon
 Left sided colitis
 Sigmoid and descending
 Skip lesions
 Pancolitis
 Pancolitis
 Can be large bowel only
 Backwash ileitis
 Distal terminal illem
Macroscopic
changes
o Bowel is
o
o
o
o
o
o
o
thickened
Lumen is
narrowed
Deep ulcers
Mucusal fissures
Cobblestone
Fistulae
Abscess
Apthoid
ulceration
Crohn’s
Macroscopic
changes
 Reddened
mucosa
 Shallow ulcers
 Inflamed and
easily bleeds
Ulcerative Colitis
Ulcerative Colitis
Microscopic Changes
Crohn’s
Ulcerative Coltis
Transmural!
Mucosal!
 Chronic inflammatory
cells: transmural
 Chronic inflammatory
cells: lamina propria
 Lymphoid hyperplasia
 Goblet cell depletion
 Granulomas
 Langhan’s cells
 Crypt abscess
Extraintestinal Manifestations
EYES
Crohn’s
UC
Uveitis
5%
2%
Episcleririts
7%
6%
Conjunctivitis
7%
6%
Extraintestinal Manifestations
JOINTS
Crohn’s
UC
Type 1 Arthropaty
(Pauci)
6%
4%
Type 2 Arthropathy
(Poly)
4%
2.5%
Arthralgia
14%
5%
Ankylosing Spondylitis
1.2%
1%
Inflammatory back pain
9%
3.5%
Extraintestinal Manifestations
SKIN
Crohn’s
UC
Erythema Nodosum
4%
1%
Pyoderma
Gangrenosum
2%
1%
Extraintestinal Manifestations
LIVER/BILLARY
Crohn’s
UC
Sclerosing cholangitis
1%
5%
Gall stones
Increased
Normal
Fatty liver
Common
Common
Hepatitis/ Cirrhosis
Uncommon
Uncommon
 Kidney stones in Crohn’s
 oxalate stones post resection
 Anaemia
 B12 deficiency in Crohn’s
 Venous thrombosis
 Other autoimmune diseases
Differential Diagnosis
 Each other
 Infection (unlikely if >10 days)
 IBS
 Ileocolonic tuberculosis
 Lymphomas
Treating IBD
 Induce remission
 Steroids – oral or IV
 Enteral nutrition
 Azathioprine / 6MP (Crohns)
 Maintain remission
 Aminosalicylates (UC)
 Azathipreine/ 6MP
 Methorexate
 Biologicals generally for Crohn’s only
 Infliximab, adalimumab
 Test for TB first!
Treating IBD
Ulcerative Colitis
Crohn’s
Azathioprine
2. Methotrexate
3. Cyclosporin
4. Humera
1.
1.

Adalimumab/anti TNF
Steroids for flares
Aminosalicylates
1.
1.
Mesalazie
2. Steroids
1.
Foam/PR
2.
Oral
3.
IV
3. Azathiorprine
UC Flares
 Truelove-Witts Criteria:
1.
2.
3.
4.
5.
6.
Anemia less than 10g/dl
Stool frequency greater than 6 stools/day with blood
Temperature greater than 37.5
Albumin less than 30g/L
A STATE
Tachycardia greater than 90bpm
ESR greater than 30mm/hr
Used to classify the flare up into mild, moderate or severe
Treatment




Admit to hospital
IV steroids and fluids
Daily monitoring of stool frequency, AXR, FBC, CRP, Albumin
Surgical Management
 Surgery can be curative for ulcerative colitis
 80% of Crohn’s have resections but generally little help
 Indications for surgery in Ulcerative Colitis

Acute:
Failure of medical treatment for 3 days
 Toxic dilatation
 Haemorrhage
 Perforation


Chronic
Poor response to medical treatment
 Excessive steroid use
 Non compliance with medication
 Risk of cancer

I CHOP
Infection
Carcinoma
Haemorrhage
Obstruction
Perforation
Prognosis
 UC
 1/3 Single attack
 1/3 Relapsing attacks
 1/3 Progressively worsen requiring colectomy within 20 years
 Crohn’s
 Varied prognosis, new biological agents improving
 Cancer
 Both 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
Clinical Finals: IBD History
Ulcerative Colitis
Crohn’s
 Presenting complaint
 Diarrhoea
 Abdominal pain
 Weight loss




Malaise/lethagy
Nausea/vomiting
Low grade fever
Anorexia
 Presenting complaint
 Bloody diarrhoea
 Lower abdominal pain
 +/- mucus



Malaise/lethargy
Weight loss
Apthous ulces in mouth
Clinical finals: IBD History
 What else to ask?
 Rashes
 Mouth ulcers
 Joint/back pain
 Eye problems
 Family history
 Smoking status
Clinical finals: IBD History
 What else to ask?
 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?
Clinical finals: IBD Exam
Physical signs may be few!
 General Exam




Weight loss
Apthous ulcer of mouth
Anaemia
Clubbing
 Abdominal Exam



Colostomy bag
May be some abdominal tenderness, may not.
May find a RIF mass
Abscess
 Inflamed loops of bowel

Clinical finals: IBD Exam
 Anything else?
 Rashes on the shins
 “I would also like to examine…”
 Anus
Crohn’s: Odematous tags, fissures or abscesses
 Ulcerative colitis: usually normal


PR

Ulcerative colitis: blood
Clinical finals: IBD
 What is the most likely diagnosis?
 Inflammatory bowel disease
Clinical finals: IBD Investigations
 Bedside
 Stool culture: exclude infection
 Sigmoidoscopy
 Bloods
 FBC : anaemia and likely raised WCC
 Haematemics: type of anaemia
 Inflammartory markers
 LFT: hypoalbuminaemia is present in severe disease, hepatic
manifestations
 Blood cultures: if septicaemia is suspected in the acute
presentation
 Serological: pANCA (UC)
Clinical finals: IBD Investigations
 Imaging
 Plain AXR: helpful in acute attacks
Thumb printing
 Lead pipe sign


Barium follow-through in Crohn’s
CT

CXR



Perforation
USS
Clinical finals: IBD Investigations
 Flexible sigmoidoscopy
 Colonoscopy
 But never in severe attacks of UC due to high risk of
perforation
 May be painful in Crohn’s due to anal fissures
 Diagnostic
 Surveillance

UC of more than 10 years duration increased risk of dysplasia and
carcinoma
 OGD
 For Crohn’s: view of terminal illeum
 In children both an OGD and colonoscopy are done,
Clinical finals: IBD Management
 Manage the patient, not just the disease!
 Medications
 Manage extraintestinal manifestations


Manage patient’s symptoms



Eg B12 deficiency anaemia
Eg loperamide for diarrhoea
Good nutrition, hydration and vitamin supplements
Psychosocial impact of disease
Ileostomy/colostomy bag
 Flares and the need for a toilet

Clinical finals: IBD Explanation
 Please explain a colonoscopy to the patient
 Please explain an OGD to the patient
 Please advise the patient on the side effects of
steroids

Prepare an organised list to reel off, it is a very common
question!
 Please explain the compilcations of inflixmab
 Keep calm, remember it’s an immnuosupressent!
How to do well in finals questions
 Have a plan on how to answer questions
 Ix: bedside, bloods, imaging, special tests
 Mx: medical, surgical, psychological, social
acute and long term management
 Have a reason for each investigation you’d like to do
 Treat the person as well as the disease
 Don’t ever forget the MDT!
What else could come up….







Coeliac disease
IBS
Ischaemic colitis
Diverticular disease
Appendicitis
Polyps
Haemorrhoids
Know 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 glove
acute flare of ulcerative colitis
Clinical finals: IBD questions
 What are your main differential diagnoses for this lady?
 How would you investigate this patient acutely and long
term?

Eg. not full colonoscopy in acute flare
 Initial management in acute setting?
 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?

Eg. skin, eyes, joints
Good Luck!
ANY QUESTIONS?