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INFLAMMATORY BOWEL DISEASEAnusha Reddy
FY1 SWFT
3rd Feb 2014
OBJECTIVES
2 Case Studies: Crohn’s Vs Colitis
THINK: AETIOLOGY EPIDEMIOLOGY SIGNS AND SYMPTOMS INVESTIGATIONS MANAGEMENT
CASE STUDY 1
22 Female
PC: 6/52 of 5 x loose, non-bloody stools daily Right lower quadrant abdominal pain (especially
after eating) 8kg weight loss Bilateral knee and ankle pains
MORE INFORMATION REQUIRED
Full history Nil PMH, no hx of foreign travel No medications or allergies Current smoker- 5 pack-years
Examination Definite and moderately tender 5-cm mass in the
right lower quadrant No joint effusion or skin lesions are noted
DIFFERENTIAL DIAGNOSIS Gastroenteritis Crohn’s Disease Ulcerative Colitis Irritable Bowel Syndrome Behcet’s Disease
Bowel Cancer Tuberculosis Amyloidosis Acute Appendicitis
WHAT DO WE THINK THIS IS?
22 Female
PC: 6/52 of 5 x loose, non-bloody stools daily Right lower quadrant abdominal pain (especially
after eating) 8kg weight loss Bilateral knee and ankle pains
CROHN’S DISEASE- DEFINITION
Chronic Inflammatory Bowel Disease (IBD) Unknown Aetiology Characterised by
1. Focal 2. Asymmetrical 3. Transmural4. Occasionally granulomatous inflammation
Any part of the GI tract- mouth anus
CROHN’S DISEASE- EPIDEMIOLOGY
Incidence: 9.56 per 100,00011
Prevalence: 115,000 in the UK Age of onset: 2 peaks 1) 15-30 Y (more common) 2) 60-80 Y Female: Male 1.8:1 Children this is reversed!
Risk Factors22
Mycobacterium paratuberculosis, Pseudomonas spp. & Listeria spp.
↑TNF-alpha High-fat diets Genetic mutations
1) Steed H, Walsh S, Reynolds N; Crohn's disease incidence in NHS Tayside. Scott Med J. 2010 Aug;55(3):22-52) Rangasamy P et al; Crohn Disease, Medscape, Jun 2011
CROHN’S DISEASE- SYMPTOMS
• Abdominal pain, cramping or swelling • Anaemia • Fever • Gastrointestinal bleeding • Joint pain • Malabsorption • Persistent or recurrent diarrhoea • Stomach ulcers • Vomiting • Weight loss
CROHN’S DISEASE- ON EXAMINATION
General ill health- weight loss & dehydrated
Hypotension, tachycardia and pyrexia Abdominal tenderness or distension, palpable
masses. Anal and perianal lesions (abscesses,
fistulae) Mouth Ulcers
Extra-intestinal manifestations of Crohn’s ......
CROHN’S DISEASE- EXTRA INTESTINAL
INVESTIGATIONS
Bloods FBC, CRP, U&Es, LFTs
Stool culture and microscopy anti-S. cerevisiae antibodies Perinuclear
antineutrophil cytoplasmic antibody (p-ANCA) (UC>CD)
Abdo Xray Ileocolonscopy and biopsy from the terminal
ileum as well as the affected sites Small bowel follow through If upper GI symptoms- Upper GI endoscopy If lower GI symptoms- Flexible
sigmoidoscopy/EUA
CROHN’S DISEASE- MANAGEMENT
First presentation (NICE guidelines)1. Glucocorticoids
1. Prednisolone, Methylprednisolone IV hydrocortisone
2. Budesonide3. 5-ASA
+/- ADD ON Azathioprine or Mercaptopurine
Biologic: Infliximab and Adalimumab
CROHN’S DISEASE- MANAGEMENT
Maintaining Remission (NICE guidelines)
Offer Azathioprine or Mercaptopurine as Monotherapy
Methotrixate
Surgery- if limited to distal ileum (weighing out the risk Vs benefits) and for complications...
CROHN’S DISEASE- COMPLICATIONS
A
B
C C
CASE STUDY 2
32 Male Bloody diarrhoea 4/52 Bilateral lower abdominal cramping Malaise and weight loss No associated fever, visual changes,
arthralgias, or skin lesions
Previously fit and well contractor Non-smoker, 14-18 units/week drinker FHx: Diabetes Mellitus Type 1
ULCERATIVE COLITIS- DEFINITION
Chronic Inflammatory Bowel Disease Unknown aetiology
Only Large Colon Classification:
Distal Disease More extensive disease Pancolitis
ULCERATIVE COLITIS- EPIDEMIOLOGY
More common than Crohn’s Incidence: 10 per 100,000 Prevalence 240 per 100,000 in the UK Age of onset: 2 peaks 1) 15-25 Y (more
common) 2) 55-65 Y
Male:Female= 1:1 Idiopathic: ?autoimmune condition triggered by
colonic bacteria inflammation Genetic component: sibling of an individual who
has IBD 17-35 x more risk of development Risk of UC decreased in smokers
1) Ulcerative Colitis; NICE Clinical Guideline (Jun 2013)
ULCERATIVE COLITIS- SYMPTOMS
Bloody diarrhoea Abdominal Pain Tenesmus Systemic symptoms: malaise, fever,
weightless
ULCERATIVE COLITIS- ON EXAMINATION
Unwell, pale, febrile, dehydrated Abdo pain and tenderness .. + distension TOXIC MEGACOLON
Worrying signs: Tachycardia, anaemia and fever
Extra- intestinal disease...
ULCERATIVE COLITIS- EXTRA-INTESTINAL
Aphthous ulcers Ocular manifestations 5%
Episcleritis Anterior uveitis
Acute arthropathy affecting the large joints 26% Sacroiliitis Ankylosing Spondylitis 3%
Deramatology 19% Pyoderma gangrenosum Erythema nodosum
Primary Sclerosing Cholangitis
ULCERATIVE COLITIS- INVESTIGATIONS
Bloods: FBC, LFTs, U+Es, CRP Serology- pANCA Vs. ASCA Stool cultures
Imaging Abdo x-ray- acute setting Barium enema- can show mucosal structure
Flexible Sigmoidoscopy and Biopsy- for diagnosis
ULCERATIVE COLITIS- MANAGEMENT
a) Topical aminosalicylate alone (suppository or enema b) ?ADD PO aminosalicylate to a topical aminosalicylate ORc) consider an PO aminosalicylate alone
a) PO Aminosalicylate - High induction dose of an
b) ?ADD topical Aminosalicylate OR PO beclometasone dipropionate
- If no improvement 72 hrs despite IV Hydrocortisone OR-Symptoms worsen to pancolitis:
a) ADD IV Ciclosporin to IV steroids
ULCERATIVE COLITIS- MANAGEMENT
Indications for Surgery: Unresponsive to medical treatment Significantly affecting quality of life Growth retardation in Children Life-threatening complications...
Bleeding Toxic Megacolon Impending perforation Carcinoma
ANY QUESTIONS?
SUMMARY
SUMMARY: CROHN’S VS. UC (1)
Symptoms of Crohn's Disease
• Abdominal pain, cramping or swelling •Anaemia •Fever •Gastrointestinal bleeding •Joint pain •Malabsorption •Persistent or recurrent diarrhoea •Stomach ulcers •Vomiting •Weight loss
Symptoms of Ulcerative Colitis
•Bloody diarrhoea •Abdominal pain or discomfort •Anaemia caused by severe bleeding •Dehydration •Fatigue •Fever •Joint pain •Loss of appetite •Malabsorption •Rectal bleeding •Urgent bowel movements •Weight loss
SUMMARY: CROHN’S VS. UC (2)
SUMMARY- CROHN’S VS. UC (3)
SUMMARY: CROHN’S VS. UC (2)
LEARNING POINTS
RELAPSE AND REMITTING MANAGE THE PATIENT
BONE PROTECTION- IF ON LONG-TERM STROIDS
TEST FOR TB BEFORE STARTING INFLIXIMAB
RISK OF COLONIC CARCINIMA IN UC
THANK YOU!!
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