dr alex tebbett (warwick graduate) fy1 warwick a&e inflammatory bowel disease
TRANSCRIPT
DR ALEX TEBBETT(WARWICK GRADUATE)
FY1 WARWICK A&E
Inflammatory Bowel Disease
What we’re covering
The big two – Crohn’s and UC Risk factors Macro and microscopic changes Extraintestinal manifestations Differential diagnosis Treatment
Clinical exam for IBDOther GI casesFinals hints
IBD
Crohn’s Ulcerative Colitis
Crohn’s Ulcerative Colitis
Epidemiology
Slightly more common80-150/100,000
Slightly less common27-106/100,000
Males: 1.2:1
Older: 34
Females: 1.2:1
Younger: 26
Aetiology
Largely unknown
1. Genetics Polygenic: 16, 12, 6, 14, 5, 19, 1, 3 HLA DRB Familial (1 in 5)
2. Host immunology Defective mucosal immune system Inappropriate response to intraluminal bacteria T-cells and cytokines
Autoimmune!
Crohn’s Ulcerative Colitis
Aetiology: Environmental
Good hygiene/ developed countries
No relation to hygiene
Non smokers
Appendicectomy is protective
Breast feeding is protective
Breast feeding is protective
Appendicectomy
Smokers
Crohn’s Ulcerative Colitis
Terminal illeumIleocolonic disease
Ascending colonSkip lesionsPancolitis
Can be large bowel only
ProctitisLeft sided colitis
Sigmoid and descending
PancolitisBackwash ileitis
Distal terminal illem
Pathology
Mouth to anus! Rectum and extends proximally!
Macroscopic changes
Crohn’s
o Bowel is thickened
o Lumen is narrowed
o Deep ulcerso Mucusal
fissureso Cobblestoneo Fistulaeo Abscesso Apthoid
ulceration
Macroscopic changes
Ulcerative ColitisReddened
mucosaShallow ulcersInflamed and
easily bleeds
Ulcerative Colitis
Crohn’s Ulcerative Coltis
Chronic inflammatory cells: transmural
Lymphoid hyperplasia
Granulomas Langhan’s cells
Chronic inflammatory cells: lamina propria
Goblet cell depletion
Crypt abscess
Microscopic Changes
Transmural! Mucosal!
Extraintestinal Manifestations
EYES Crohn’s UC
Uveitis 5% 2%
Episcleririts 7% 6%
Conjunctivitis 7% 6%
Extraintestinal Manifestations
JOINTS Crohn’s UC
Type 1 Arthropaty(Pauci)
6% 4%
Type 2 Arthropathy(Poly)
4% 2.5%
Arthralgia 14% 5%
Ankylosing Spondylitis 1.2% 1%
Inflammatory back pain 9% 3.5%
Extraintestinal Manifestations
SKIN Crohn’s UC
Erythema Nodosum 4% 1%
Pyoderma Gangrenosum
2% 1%
Extraintestinal Manifestations
LIVER/BILLARY Crohn’s UC
Sclerosing cholangitis
1% 5%
Gall stones Increased Normal
Fatty liver Common Common
Hepatitis/ Cirrhosis Uncommon Uncommon
Kidney stones in Crohn’s oxalate stones post resection
Anaemia B12 deficiency in Crohn’s
Venous thrombosisOther autoimmune diseases
Differential Diagnosis
Each otherInfection (unlikely if >10 days)IBSIleocolonic tuberculosisLymphomas
Treating IBD
Induce remission Steroids – oral or IV Enteral nutrition Azathioprine / 6MP (Crohns)
Maintain remission Aminosalicylates (UC) Azathipreine/ 6MP Methorexate
Biologicals generally for Crohn’s only Infliximab, adalimumab Test for TB first!
Crohn’s Ulcerative Colitis
1. Azathioprine2. Methotrexate3. Cyclosporin4. Humera
1. Adalimumab/anti TNF
Steroids for flares
1. Aminosalicylates1. Mesalazie
2. Steroids1. Foam/PR2. Oral3. IV
3. Azathiorprine
Treating IBD
UC Flares
Truelove-Witts Criteria: 1. Anemia less than 10g/dl2. Stool frequency greater than 6 stools/day with blood3. Temperature greater than 37.54. Albumin less than 30g/L5. Tachycardia greater than 90bpm6. ESR greater than 30mm/hr
Used to classify the flare up into mild, moderate or severe
Treatment Admit to hospital IV steroids and fluids Daily monitoring of stool frequency, AXR, FBC, CRP, Albumin
A STATE
Surgical Management
Surgery can be curative for ulcerative colitis80% of Crohn’s have resections but generally little help
Indications for surgery in Ulcerative Colitis Acute:
Failure of medical treatment for 3 days Toxic dilatation Haemorrhage Perforation
Chronic Poor response to medical treatment Excessive steroid use Non compliance with medication Risk of cancer
I CHOPInfectionCarcinomaHaemorrhageObstructionPerforation
Prognosis
UC 1/3 Single attack 1/3 Relapsing attacks 1/3 Progressively worsen requiring colectomy within
20 yearsCrohn’s
Varied prognosis, new biological agents improvingCancer
Both have increased risk of colon cancer, though UC>Crohn’s
Screening colonoscopy done every 2 years after 10 years disease and every year after 20 years disease
Crohn’s Ulcerative Colitis
Presenting complaint Diarrhoea Abdominal pain Weight loss
Malaise/lethagy Nausea/vomiting Low grade fever Anorexia
Presenting complaint Bloody diarrhoea Lower abdominal pain +/- mucus
Malaise/lethargy Weight loss Apthous ulces in
mouth
Clinical Finals: IBD History
Clinical finals: IBD History
What else to ask? Rashes Mouth ulcers Joint/back pain Eye problems Family history Smoking status
Clinical finals: IBD History
What else to ask? Previous diagnosed?
How many flares do they get? Are they well managed? Do they have any concerns about their treatment?
Do they see a specialist?
Clinical finals: IBD Exam
Physical signs may be few!General Exam
Weight loss Apthous ulcer of mouth Anaemia Clubbing
Abdominal Exam Colostomy bag May be some abdominal tenderness, may not. May find a RIF mass
Abscess Inflamed loops of bowel
Clinical finals: IBD Exam
Anything else? Rashes on the shins
“I would also like to examine…” Anus
Crohn’s: Odematous tags, fissures or abscesses Ulcerative colitis: usually normal
PR Ulcerative colitis: blood
Clinical finals: IBD
What is the most likely diagnosis? Inflammatory bowel disease
Clinical finals: IBD Investigations
Bedside Stool culture: exclude infection Sigmoidoscopy
Bloods FBC : anaemia and likely raised WCC Haematemics: type of anaemia Inflammartory markers LFT: hypoalbuminaemia is present in severe disease,
hepatic manifestations Blood cultures: if septicaemia is suspected in the
acute presentation Serological: pANCA (UC)
Clinical finals: IBD Investigations
Imaging Plain AXR: helpful in acute attacks
Thumb printing Lead pipe sign
Barium follow-through in Crohn’s CT
CXR Perforation
USS
Clinical finals: IBD Investigations
Flexible sigmoidoscopyColonoscopy
But never in severe attacks of UC due to high risk of perforation
May be painful in Crohn’s due to anal fissures Diagnostic Surveillance
UC of more than 10 years duration increased risk of dysplasia and carcinoma
OGD For Crohn’s: view of terminal illeum In children both an OGD and colonoscopy are done,
Clinical finals: IBD Management
Manage the patient, not just the disease! Medications Manage extraintestinal manifestations
Eg B12 deficiency anaemia Manage patient’s symptoms
Eg loperamide for diarrhoea Good nutrition, hydration and vitamin supplements Psychosocial impact of disease
Ileostomy/colostomy bag Flares and the need for a toilet
Clinical finals: IBD Explanation
Please explain a colonoscopy to the patientPlease explain an OGD to the patientPlease advise the patient on the side effects
of steroids Prepare an organised list to reel off, it is a very
common question!Please explain the compilcations of inflixmab
Keep calm, remember it’s an immnuosupressent!
How to do well in finals questions
Have a plan on how to answer questions Ix: bedside, bloods, imaging, special tests Mx: medical, surgical, psychological, social
acute and long term managementHave a reason for each investigation you’d
like to doTreat the person as well as the diseaseDon’t ever forget the MDT!
What else could come up….
Coeliac diseaseIBSIschaemic colitisDiverticular diseaseAppendicitisPolypsHaemorrhoids
Know the side effects of steroids!Know the difference between colostomy and ileostomy!
Clinical Scenario
29 year old female, one month history of loose watery stools, increasing in frequency to 12 time 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 gloveacute flare of ulcerative colitis
Clinical finals: IBD questions
What are your main differential diagnoses for this lady? How would you investigate this patient acutely and long
term? Eg. not full colonoscopy in acute flare
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 IBD?
Eg. skin, eyes, joints
ANY QUESTIONS?
Good Luck!