Inflammatory Bowel Disease

Cathy CordenGP VTS ST1

Mrs RS

34 year old female Presented with 3/12 hx of lower

abdominal cramps, like period pains. Bloating after eating.

No bowel or bladder problems. Feeling a little stressed at present. G3, P2 + 1 ectopic pregnancy (left).

What are your initial thoughts?

Mrs RS

Pregnancy test – negative Reassured, likely IBS Sent for USS pelvis

Represented 3/12 later. Worsening abdominal discomfort, frequent loose stools. USS pelvis normal.

Treated as IBS but sent for bloods FBC, ESR, IP, coeliac, TFT.

Mrs RS

Patient returned a few days later. Started crying in reception re worsening of her pain and diarrhoea.

The duty doctor was asked to see her at the end of surgery.

Mrs RS

Gliadin antibody neg WCC 16.38 Hb 10.6g/dL Platelets 463 TFT nad LFT nad ESR 53

Mrs RS

What would you want to ask in the history?

History

Stool frequency and consistency Urgency Rectal bleeding Abdominal pain Malaise Fever Weight loss Recent travel Smoking FH

Mrs RS

Bowels opening 4-6 times daily for last 2-3/12. Loose motions.

Intermittent urgency to defaecate. No blood or mucus in stool. Abdominal pain and bloating. Nauseous and fatigued. Weight loss ½ stone last 4 weeks. Non smoker. FH father has Crohn’s Disease

Mrs RS

Examination Temp. 37.8C. P86/min reg. BP

normal for her. Tender to palpation RIF. Bowel

sounds normal.

What would you do now?

Mrs RS

Patient was admitted under the surgeons as ?appendicitis.

Underwent barium follow through which showed narrowing and mucosal ulceration of terminal ileum.

Diagnosed with Crohn’s Disease

Right posterior oblique spot image from SBFT in patient with Crohn disease shows ileocecal fistulas (small arrows) with narrowing of terminal ileum (large arrow) near ileocecal valve.

Levine M S et al. Radiology 2008;249:445-460©2008 by Radiological Society of North America

Frontal spot image from SBFT in patient with Crohn disease shows multiple aphthoid ulcers as punctate collections of barium surrounded by radiolucent mounds of edema (arrows).

Levine M S et al. Radiology 2008;249:445-460

©2008 by Radiological Society of North America

Mrs RS

What would the initial inpatient treatment be for active Crohn’s Disease?

Mrs RS

Started on IV steroids and Asacol (mesalazine).

Converted to oral prednisolone 40mg od. To reduce by 5mg/wk over 6-8 weeks.

Referred to gastro.

Mrs RS

Made good improvement on steroids and was changed to pentasa. Using loperamide to control diarrhoea.

Colonoscopy – confirmed ulcers/cobblestone appearance

Mrs RS

Few months later returned to GP with loose bowel motions, 4 times daily. No blood. Also abdominal pain.

On pentasa 2 gram od.

How would you treat a flare of Crohn’s Disease?

Mrs RS

Bloods FBC, U&E, LFT, CRP Can increase dose of prophylactic

aminosalicylates mesalazine to induce remission.

Topical aminosalicylates/steroids Oral corticosteroids 40 mg prednisolone

od. Reduce slowly after 3-4 weeks to 5mg per week over several weeks. Can use budesonide 9mg daily.

Mrs RS

Patient returns to GP when prednisolone reduced to 20 mg. Symptoms have returned. Trial increasing back to 40 mg again & reducing more cautiously.

Well until 5 months later. Returned to GP with weight loss, fatigue, loose bowel motions 6-8 times daily. Tender to palpation RIF. Temp 38.4C.

Mrs RS

Would you admit this patient? What are the criteria for acute

admission of a Crohn’s Disease patient?

Mrs RS

Criteria for admission Severe abdominal pain, tenderness

to palpation. Severe diarrhoea >8 per day +/-

blood. Systemically unwell, feverish Weight loss +++ Symptoms of bowel obstruction

Mrs RS

Admitted to gastro. Raised inflammatory markers, anaemic,

low albumin. Stool sample neg for infection No evidence obstruction AXR. Treated with IV methylprednisolone. Once improved converted to oral pred 40

mg reducing course. Started on azathioprine 50 mg/day.

Mrs RS

Seen in gastro clinic few weeks later.

Azathioprine increased to 125mg. Not much improvement. Pentasa 1 gram tds.

Referred to surgeons for consideration of right hemicolectomy due to recurrent need for steroids.

Mr SW

63 year old gentleman presented to GP with 2-3 weeks generalised pruritis. No other symptoms. Weight stable. Not been in contact with noticeable allergens.

Treated with loratidine. Sent for bloods.

Mr SW

LFTS abnormal Bilirubin 6 AlK phos 658 ALT 76 GGT 871 Alb 33 ESR 57 FBC, U&E

normal

What would you have done now?

Mr SW

Discussed with liver team. Agreed to rv in clinic. No jaundice. No risk factor hepatitis. Liver screen incl. coag, hepatitis

serology, CMV, autoantibodies negative.

Had raised serum globulins.

Mr SW

Endoscopic retrograde cholangiopancreatography performed showing multiple intrahepatic bile duct strictures and beading.

Mr SW

Diagnosed Primary Sclerosing Cholangitis.

Followed up appointment 9/12 later by liver team.

Noticed a change in his bowel habit last 4-5 months. Bowels opening 6-8 times daily, loose stools with dark red rectal bleeding. Also had some left sided lower abdominal pain, tenesmus and weight loss.

Concerned re sinister symptoms ? Colonic ca.

Mr SW

Bloods taken Hb 8.8 g/dL MCV 72.6 WCC 8.77 Platelets 503 ESR 44 mm/hr CRP 34 U&E normal Alk phos 173 GGT 96 Alb 29

Mr SW

A rigid sigmoidoscopy was performed. Showed colitis from rectum up to sigmoid and beyond upper limits.

Diagnosed with ulcerative colitis. Started on prednisolone 30 mg od,

reducing course 5mg weekly. Also mesalazine 800 mg tds.

Mr SW

Colonoscopy-pancolitis

www.gastrointestinalatlas.com

Mr SW

Compliance issues with this gentleman. Difficult to get Mr SW to take mesalazine. Developed diarrhoea with asacol. Diarrhoea resolved once he stopped taking. Changed to pentasa and to salofalk. Blames meds on any symptoms he develops now.

Mr SW

Insists on taking steroids long term rather than maintenance therapy.

Ongoing gastro input. Considering azathioprine/methotrexate as symptoms uncontrolled.

Inflammatory Bowel Disease

240,000 people in UK with IBDMost common age group 10 - 40 years

Ulcerative Colitis Crohn’s Disease

Diffuse mucosal inflammation

Patchy transmural inflammation. Skip lesions, cobblestones

Colon only Mouth to anus

Incidence 10-20/100000/ year Incidence 5-10/100000/year

Prevalence 100-200/100000 Prevalence 50-100/100000

Inflammatory Bowel Disease

Ulcerative Colitis Crohn’s Disease

Smoking protective Smoking increases riskGenetic component stronger

Bloody diarrhoea, colicky abdo pain often peridefecatory, urgency, tenesmus.

Pain/mass RIF, abdo pain, diarrhoea, weight loss, malaise, anorexia, fever, strictures, fistulae, abcess

Complications: undernutrition, short bowel syndrome, colorectal carcinoma, colonic perforation, obstruction

(crohn’s), toxic megacolon (UC)

Extraintestinal Associations

http://www.eyecasualty.co.uk/, http://www.dermis.net/, http://www.bmj.com/