Download Guidelines for IBD Advances Practice Provider

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
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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
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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:
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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:
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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:
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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