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Guidelines for IBD Advanced Provider If you suspect that your patient may have an IBD, it is important to have a standardized approach for taking history and conducting a physical exam. Chief Complaint: Patient’s main reason for visit/symptoms? Pertinent IBD History - (HPI): Some of the important questions to ask are: IBD diagnosis and date of dx: (UC, CD, Indeterminate or not known, specify location of disease i.e. ileocolitis, proctitis, perianal) Onset of symptoms (Including duration and change from baseline): • Ask about pain or discomfort: o Location? o Describe pain? o Precipitating factors? o Alleviating factors? • Fever, chills or night sweats: o When occur? o How often? o Associated with other symptoms? Pain? Change in bowel pattern? Perianal abscess or fistula draining? Joint pains? o Alleviates/Precipitates? • Ask about the patient’s bowel movements: o Frequency and consistency? What’s normal? o Urgency and tenesmus? o Nocturnal symptoms? o Rectal bleeding? o Is there abdominal pain before, during or after? o If ostomy? Type? How often empty? Consistency? Self–Management? Peristomal skin condition? • Ask about appetite: o Anorexia? o Sitophobia? o Early satiety? o Nausea? When? How often? Precipitates? Alleviates? o Vomiting? When? How often? Precipitates? Alleviates? o Dysphagia/odonophagia? 7 3 3 T hi r d A v e n u e , S u i te 5 1 0 N e w Y or k , N Y 1 0 0 1 7 T e l : 2 1 2 – 68 5 – 3 4 4 0 , Fax : 2 1 2 – 7 7 9 – 4 0 98 , E - mai l : i n fo@ c c fa. or g , In te r n e t : ww w.c c f a. or g • • • • • • • • Weight loss/gain: o How much and in what time period? o Intentional/Unintentional? Ask about extra-intestinal manifestations: o Eyes (Iritis,uveitis) o Skin (Pyoderma gangrenosum, Erythema nodosum) o Musculoskeletal (Osteoporosis, peripheral arthralgias and arthritis, spondylarthritis(ankylosing spondylitis, sacroileitis) o Hematologic (Anemia, venous thromboembolism, pulmonary embolism) o Hepatobiliary (Cholelithiasis, PSC) o Renal (Nephrolithiasis) o Perianal (abscess, fistula, skin tag) Medical history (Include IBD diagnosis, date and location of macroscopic and microscopic disease, cancer or dysplasia) o ER visits for IBD o Hospitalizations for IBD o Iron or blood transfusions o Depression o Anxiety o PSC o Blood clotting disorders Surgical history (Date/type/complications) *For CD include cm estimate of small bowel resection or remaining SB Social history o Have you traveled recently? Family history of IBD? Specify? Lifestyle o Do you smoke? Past smoker? When quit? Willing to quit? Enroll in cessation program? o Have you experienced food intolerance in the past? Special diet? o Quality of life affected? Medications (name/form & dose/duration/response/adverse events and tolerance) o What medications are you currently taking? (NSAIDs) o What about over-the-counter medications? o Corticosteroids – dose, length of use, when discontinued o Recent exposure to antibiotics o Adherence to medication regimens 7 3 3 T hi r d A v e n u e , S u i te 5 1 0 N e w Y or k , N Y 1 0 0 1 7 T e l : 2 1 2 – 68 5 – 3 4 4 0 , Fax : 2 1 2 – 7 7 9 – 4 0 98 , E - mai l : i n fo@ c c fa. or g , In te r n e t : ww w.c c f a. or g • • Vaccination history if known: o Annual flu o Pneumovax o TB o Hep B o Meningococcal Meningitis o Zoster o HPV Recent radiologic/procedure studies: date and results (CT, MRI, SBS, Colonoscpy, Flex. Sig.) Physical Examination: Remember to check/perform the following: • • • • • Vitals (blood pressure, heart rate, respiratory rate, temperature) Body height and weight with BMI (especially in pediatric patients) Abdominal examination (e.g., location, distension, tenderness, ) Digital rectal examination (perianal inspection for abscess, fistula, fissure, skin tag) Extra-intestinal manifestations (e.g., eyes, skin, joints) The work-up for a patient that presents with suspected IBD may include the following: • • • • Stool cultures for C Difficile, O&P, Bacterial pathogens to rule out infectious colitis Stool sample for inflammation: lactoferrin or calprotectin (discriminates between IBS and IBD) Laboratory tests o Complete blood count o C-Reactive Protein (CRP) or Erythrocyte sedimentation rate (ESR) – CRP is preferred o C-reactive protein (CRP) o Vitamin B12, folate, ferritin, iron, TSH, albumin Radiological/GI procedure studies o Flex. Sig./Colonoscopy with biopsies o Small bowel series o Barium enema o CT enterography/ Abd./pelvic CT 7 3 3 T hi r d A v e n u e , S u i te 5 1 0 N e w Y or k , N Y 1 0 0 1 7 T e l : 2 1 2 – 68 5 – 3 4 4 0 , Fax : 2 1 2 – 7 7 9 – 4 0 98 , E - mai l : i n fo@ c c fa. or g , In te r n e t : ww w.c c f a. or g Differential diagnosis for IBD to consider: As you may have noticed, the common signs and symptoms of IBD can be easily mistaken for other gastrointestinal disorders. Here is a list of some other diseases that should be considered in patients presenting with similar signs and symptoms: • • • • • • • Infectious gastroenteritis/colitis o Presentation: varies depending on the pathogen o Can be screened for by stool cultures o Always order a Clostridium difficule toxin analysis Ischemic colitis o Presentation: acute (abdominal pain, urgency, bright red blood in stool), chronic (transmural scarring, stricturing) o Should be considered in patients in a hypercoagulable state or with a severe cardiac/peripheral vascular disorder Irritable Bowel Syndrome o Presentation: change in bowel habits (diarrhea/constipation/alternating bowel patterns) o Abdominal pain relieved with bowel movement o Increased visceral sensitivity to intestinal motility o No tissue abnormality, inflammation on endoscopic evaluation Diverticulitis o Presentation: fever, abdominal pain/tenderness, leukocytosis, partial obstruction and fistulas (similar to severe CD) Radiation o Presentation: Bloody diarrhea, tenesmus, malabsorption, weight loss, obstruction, fistulas, Pain o Patients will present with gastrointestinal symptoms within 1-2 weeks of starting radiation therapy Colorectal Cancer o Presentation: Ill-defined abdominal pain, weight loss and occult bleeding if right colon. Altered bowel habits, decreased stool caliber and hematochezia if left colon o Risk is higher in older patients (>50 years), those with family history of colon cancer, family or personal history of polyps, certain genetic syndromes. Microscopic colitis o Presentation: moderate to severe watery diarrhea ± abdominal cramping and no bleeding o Rarely leads to surgery o Most cases respond readily to anti-diarrheals (Imodium, Lomotil, pepto Bismol) or budesonide 7 3 3 T hi r d A v e n u e , S u i te 5 1 0 N e w Y or k , N Y 1 0 0 1 7 T e l : 2 1 2 – 68 5 – 3 4 4 0 , Fax : 2 1 2 – 7 7 9 – 4 0 98 , E - mai l : i n fo@ c c fa. or g , In te r n e t : ww w.c c f a. or g References: Dubinsky M, Friedman S. Pocket Guide to IBD, 2nd Edition. New Jersey, Slack Inc., 2011 Sachar D. Waye J. Lewis B.Gastroenterology for the House Officer. Baltimore, Williams & Wilkins, 1989 Lichtenstein GR, et al. Am J Gastroenterol 2009:104:465-483 Murphy SJ, Kornbluth A. Advanced Therapy in Inflammatory Bowel Disease, 3rd ed. 2011:1,295-399 CCFA The Facts About IBD. 2011 Peyrin-Biroulet L, et al. Inflamm Bowel Dis. 2011 Kornbluth A, et al. Am J Gastroenterol 2010; 105:501-523 7 3 3 T hi r d A v e n u e , S u i te 5 1 0 N e w Y or k , N Y 1 0 0 1 7 T e l : 2 1 2 – 68 5 – 3 4 4 0 , Fax : 2 1 2 – 7 7 9 – 4 0 98 , E - mai l : i n fo@ c c fa. or g , In te r n e t : ww w.c c f a. or g