IBD

Dr Samantha ChambersFY2IBDAimsWhat is IBDDifferences between UC and CrohnsPresentationExtra-intestinal manifestationsInvestigationsManagementCase scenarioWhat is IBD? The boring bitInflammatory bowel disease: a group of idiopathic inflammatory conditions affecting the gastrointestinal tractUsually affect 15-30 age group, but any age, UC shows bimodal incidence(>60)No major sex differenceMore common in Western worldMainly Crohns disease and UCCrohns 50-100 cases/ 100,000 populationUC twice as common as CrohnsMultifactorial aetiology:Crohns NOD2 susceptibility geneNSAIDs and stress exacerbate diseaseOther typesIndeterminate colitisMicroscopic colitis which you DO NOT need to worry about!!

Crohns vs Ulcerative colitisCrohns UCDistributionWhole GI tractColon onlyContinuitySkip lesionsContinuous (proctitis spreading backwards)InflammationTransmuralSuperficialPathologyCobblestoningGoblet cell loss, crypt abcessesGranulomasYesNoSmokingWorsens diseaseProtectivePicture here

Main pathological features, risk factors, imaging differences. Pathology UC-superficial continuous inflammation, loss of goblet cells, crypt abcesses4PresentationCan be hard to distinguish the 2 from history there are a few cluesDiarrhoea (nocturnal diarrhoea is always pathological) +++ in UC +/- blood +/- mucusCrampy abdominal painWeight lossTenesmus, urgency rectal diseaseFever, malaise, anorexia active diseasePerianal disease (commoner in Crohns) fistulas, fissuresRIF mass (Crohns)Oral apthous ulcers (commoner in Crohns)Clubbing (commoner in Crohns) Extra intestinal manifestationsSkin, eyes and joints!!Erythema nodosumPyoderma gangrenosumScleritisEpiscleritisOligoarthropathySacroiliitis! Ankylosing spondylitis rate is higher in IBDPrimary Sclerosing Cholangitis UC> CrohnsProgressing stricturing and obstruction of biliary treeFluctuating obstruction LFTs (ALP>ALT)Higher risk of cholangiocarcinoma and Bowel cancer

Kantors string sign ERCP6Differential diagnosesInflammatoryUCCrohns diseaseInfective colitisAcute abdomenAppendicitisDiverticular diseaseCancerPseudomembranous colitisRadiation colitisIschaemic colitisLymphomaDont forget Gynae!Ectopic pregnancyOvarian cyst

Dont forget gynae!!!!!!7InvestigationsBedsideUrine dip, BMECG if tachycardic when presentsBloodsFBC Anaemia, WBCsU&Es - ?dehydrationLFTs - ? Obstructive picture (ALP>ALT)CRP monitoring disease response/deteriorationTFTs exclude thyroid disease (hyper diarrrhoea)Stool exclude infective causeMC&S(Faecal calprotectin)ImagingErect CXR exclude perforation in acute presentationAXR - ? Toxic megacolonCT abdo + pelvisMRI small bowel for ?small bowel Crohns MRI pelvis for perianal/rectal disease in CrohnsOlder/out of date Barium enema/ follow through shows strictures, rose thorn ulcers, cobblestoningSpecial testsEndoscopy + biopsy! (OGD, Flexi Sig, Colonoscopy (never in acute flare!!), enteroscopy)

Management Acute presentation: ABCDE!!ConservativePatient education (reduce non-complicance), diet advice (eg.low residue if strictures), smoking cessation advice (!)MDT involvement IBD nurse specialist, nutritionist, stoma nurseMedicalAcute - to induce remissionCorticosteroids inc IV hydrocortisoneInfliximab as rescue therapySymptomatic treat anaemiaChronic - to maintain remission5 ASAs (Mesalazine) cornerstone of disease management take time to workLocalised suppositories/foam enemas to treat proctitisSteroids out of fashion due to side effectsSteroid sparing agents (immunosuppressants e.g. azathioprine, methotrexate)Biologics; Infliximab anti-TNF alpha; Adalimumab (Humira)SurgicalAcute for toxic megacolon, failure of medical therapy, perforationResection/ colectomy (usually Hartmanns procedure)Panproctocolectomy is curative for UCChronic resection of Crohns stricturesLocal surgery in perianal diseaseElective panproctocolectomy for UC cancer risk

Infliximab mouse chimeric, adalimumab human. Note: indications for surgery; perforation, massive haemorrhage, toxic dilatation, failure to respond to medical therapy. Indications in UC chronic incomplete response to medical treatment, excessive steroid requirement, non-compliance with medication, risk of cancer9PrognosisCrohns may need several operations (increases adhesions)Prone to strictures and fistulasConsiderable morbidity, 15% mortality rateUC panproctocolectomy is curativeUC patients have higher risk of bowel cancer (>10yrs)Need surveillance colonoscopiesN.b. UC + PSC = even higher bowel ca risk>10yrs UC increases risk of bowel cancer 2%, 20yrs 8%, 30yrs 18%10Case scenario29 year old female, one month history of loose watery stools, increasing in frequency to 12 times 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

29 year old female, one month history of loose watery stools, increasing in frequency to 12 times 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

What are your main differential diagnoses for this lady? How would you investigate this patient acutely and long term?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 IBDPlease explain a colonoscopy to the patientTruelove and Witts criteria assessing UC severity motions/day, rectal bleeding, temp, HR, Hb, ESR mild, moderate, severe12

Questions ?

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