Download Ambulatory Care Lecture: Inflammatory Bowel Disease

Inflammatory Bowel Disease
Kimberly Persley, MD
Digestive Disease Associates of
Dallas
Presbyterian Hospital of Dallas
What is IBD?
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Chronic
Inflammation of the bowel
Idiopathic
Relapsing course
IBD Spectrum
Ulcerative colitis
Crohn’s Disease
Indeterminant colitis
Epidemiology
IBD Facts
• Approx 1,000,000 Americans have IBD
• men and women affected equally
• first peak occurs between the ages of 15-30
a later peak occurs in the 7th decade
Normal Intestine Vs. IBD
Environmental
triggers (infection,
bacterial products)
Failure to downregulate
Chronic uncontrolled
inflammation = IBD
Moderately
inflamed
Normal gut
controlled inflammation
Down-regulate
Normal gut
controlled inflammation
Proportion of Patients with
Family History of IBD by Age of
Diagnosis
% Patients with Positive
Family History of IBD
30%
25%
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20%
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15%
10%
<20
20-39
>40
5%
0%
Age at Diagnosis
*p<0.005
Polito JM et al. Gastro.1996;111:580
Diagnosis
Diagnosis
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Clinical history
Physical examination
Laboratory tests
Endoscopic findings
Radiographic findings
Histology
Differential Diagnosis
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Lymphoma
Infectious etiologies
Appendicitis
Diverticulitis
Carcinoma
Celiac Disease
Ischemic colitis
Irritable Bowel Syndrome
Crohn’s Disease
History
• In 1932, Drs. Crohn, Oppenheimer and
Ginzburg at Mount Sinai Medical Center
described a subacute inflammatory process
affecting the distal ileum
– “terminal ileitis”
– “granulomatous ileitis”
• In 1952, Dr. Wells reported colonic
involvement
What is Crohn’s Disease?
• Crohn’s disease (CD)
is an inflammatory
bowel disorder that
Esophagus
may affect any part of
the gastro-intestinal
(GI) tract
Small
Intestine
Large
Intestine
(Colon)
Appendix
• The inflammation
Stomach
penetrates the lining
of the GI tract and
Rectum
often causes ulcers
Crohn’s Disease: Fistula
Fibrostenotic Crohn’s Disease
Crohn’s Disease Histology
Crohn’s Disease Histology
Ulcerative Colitis
History
• 1859, Samuel Wilks described “simple
idiopathic colitis”
• 1909
– Hawkins described the natural history of UC
– Hurst describe the sigmoidoscopic appearance
Disease Distribution at Presentation
n=1116
37%
46%
17%
Farmer RG. Dig Dis Sci;38:1137-1146
Ulcerative Colitis Histology
Medical Treatment
Goals of Therapy
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Relieve symptoms
Prevent recurrence of symptoms
Prevent or cure complications
Control inflammation of the GI tract
Improve quality of life
Steroid sparing
Reduce the need for surgery
Disease Activity
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Number of bowel movements a day
presence of blood in stool
abdominal exam (tenderness)
Weight loss
Extraintestinal manifestation
Overall well-being
Vitals: fever, tachycardia
Labs: anemia,
Medications for Mild-Moderate
Disease
• Aminosalicylates
– Sulfasalazine
– Mesalamine (Pentasa, Asacol, Colazal, Rowasa
enema and Canasa Suppositories)
• Antibiotics
– Metronidazole (Flagyl)
– Quinolones (Cipro)
Medications for Moderate-Severe
Disease
• Steroids
– Prednisone
– Solumedrol
– Budesonide (Entocort)
• Immunosuppressives
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Azathioprine (Imuran)
6-mercaptopurine (Purinethol)
Methotrexate
Cyclosporin
Medications for Moderate-Severe
Disease
• Biologics
– Infliximab (Remicade)
Side Effects of Sulfasalazine
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Fever
Headache
Rash
Nausea/vomiting
Diarrhea
Loss of appetite
Oral 5-ASA Release Sites
Pentasa®
Asacol®
Olsalazine
Sulfasalazine
COLAZAL™
Stomach
Small
Intestine
Large
Intestine
Mesalamine in
microgranules
Mesalamine
w/ eudragit-S
Azo bond
Mesalamine Side Effects
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Nausea/vomiting
Heartburn
Diarrhea
Headache
Allergic Reaction
Antibiotic Side Effects
• Flagyl
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metallic taste
headache
nausea/vomiting
dizziness
diarrhea
peripheral neuropathy
• Cipro
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headache
rash
nausea/vomiting
dizziness
Achilles tendon rupture
Steroid Side Effects
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GI upset
Acne
Moon face
Fluid Retention
Diabetes
HTN
Striae
Weight gain
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Cataracts
Glaucoma
Depression
Osteoporosis
Infection
Growth retardation
Outcome of Steroid Therapy for
Patients with CD
1-Month
Outcomes
(n=109)
12-Month
Outcomes
(n=87)
Remission
48%
Remission
54%
Improved
32%
Relapse
46%
Summary Steroid Dependent
Outcomes
36%
(n=39)
(n=109)
Improved
57%
Prolonged Response
44%
(n=48)
No
response
20%
Relapse
43%
Steroid Resistant
20%
(n=22)
Munkholm P et al. Gut 1994;35:360
Purine Metabolism
6Methyl Mercaptopurine
TPMT
AZA
HPRT
6MP
Xanthine oxidase
6Thiouric Acid
6TGN
Immunosuppressant Side Effects
• AZA/6MP
– Bone marrow
suppression
– pancreatitis
– hepatitis
– allergic reaction
– lymphoma
– infections
• MTX
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hepatotoxicity
pneumonitis
teratogenic
alopecia
allergic reaction
Infliximab
Infliximab Side Effects
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Reactivation of TB
Headache
Nausea
Upper respiratory tract infection
Other serious infections
Fatigue
Fever
Referral to Surgeon
• Symptoms not relieved by medications
• Serious complications
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abscesses
fistula
intestinal blockage
uncontrolled bleeding
Conclusion
• Crohn’s Disease and Ulcerative Colitis are
the two major types of IBD
• The inflammatory bowel diseases are
chronic diseases the are caused by genetic,
environmental factors and immunologic
abnormalities
• Medical treatment options should be
tailored based of disease type, distribution
and pattern
Conclusion
• Medical treatment will usually relieve
symptoms but relapse is common and
therefore treatment is lifelong