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Mikroskopisk colitis

Mikroskopisk colitis. Fagligt Selskab for Gastroenterologiske sygeplejerkser Landskursus, Kolding 16. November 2012. Ole Bonderup, Medicinsk afdeling, Regionshospitalet Silkeborg. Mikroskopisk colitis. Mikroskopisk colitis. Collagenous Colitis (Lindström, 1976) . Lymphocytic Colitis

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Mikroskopisk colitis

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  1. Mikroskopisk colitis Fagligt Selskab for Gastroenterologiskesygeplejerkser Landskursus, Kolding 16. November 2012 Ole Bonderup, Medicinsk afdeling, Regionshospitalet Silkeborg

  2. Mikroskopisk colitis

  3. Mikroskopisk colitis Collagenous Colitis (Lindström, 1976) Lymphocytic Colitis (Read et al.1980) (Lazenby et al., 1989) Microscopic Colitis Ole Bonderup, Medicinsk afd. Regionshospitalet Silkeborg

  4. Mikroskopisk colitis

  5. Mikroskopisk colitis

  6. Mucosal tears in collagenous colitis Allende DS et al. Am J Gastroenterol 2008

  7. Mikroskopisk colitis It´s best to know what you are looking for before you look for it Normal colon mucosa Lymphocytic colitis Collagenous colitis

  8. Mikroskopisk colitis MC versus non MC Interobserver agreement 91% (kappa = 0.90) Intraobserver agreement 95% (kappa = 0.89). Limsui D, et al Inflamm Bowel Dis. 2009

  9. Epidemiologi

  10. Mikroskopisk colitis - epidemiologi Female/male ratio

  11. Incidence of collagenous colitis. Annual incidence per 100.000 inhabitants Örebro, Sweden 1984-88 1989-93 1993-95 1996-98 Olmsted County, 1985-89 1990-93 1994-97 1997-2001

  12. Incidence of lymphocytic colitis Annual incidence per 100.000 inhabitants Örebro, Sweden 1993-95 1996-98 1999-04 Olmsted County, 1985-89 1990-93 1994-97 1998-01

  13. Symptomer

  14. Mikroskopisk colitis F Baert et al, Gut 1999

  15. Mikroskopisk colitis • Hovedsymptomet ved mikroskopisk colitis er et svært diaré-problem. • Hyppigt et meget langvarigt diaré-problem • Afføringen beskrives som vandtynd op til 10 -15 gange i døgnet. • Der er ofte pludselig indsættende og uimodståelig afføringstrang.

  16. Mikroskopisk colitis • Der er sædvanligvis ingen ”advarsels-symptomer” • Ingen blod i afføringen • Intet større vægttab • Ingen væsentlige smerter Er dette tilfældet skal andre sygdomme overvejes

  17. Mikroskopisk colitis - symptomer • Svære afføringsgener • Diaré • Natlig afføring • Imperiøs afføring • Incontinens • Lette almensymptomer • Vægttab • Mavesmerter • Meteorisme Ole Bonderup, Regionshospitalet Silkeborg

  18. Livskvalitet

  19. Mikroskopisk colitis - livskvalitet Hjertesorg er svær at bære Mavekneb det er dog værre Piet Hein

  20. Mikroskopisk colitis - livskvalitet Kronisk diaré = Dårlig livskvalitet

  21. Mikroskopisk colitis – livskvalitet Quality of life (SF-36) in patients with collagenous and lymphocytic colitis. Ole Bonderup, Medicinsk afd.Regionshospitalet Silkeborg Miehlke et al.

  22. Mikroskopisk colitis– livskvalitet H. Hjortswang, 2005

  23. Etiologi

  24. Kollagen colitis - etiologi Importance of intraluminal agencies ?

  25. Food Drugs Bile acids ? Bacte- ria

  26. Behandling

  27. Mikroskopisk colitis • Ubehandlet har sygdommen ofte et langvarigt kronisk forløb. • Almentilstanden er relativ upåvirket, men sygdommen påvirker i svær grad livskvaliteten.

  28. Collagenous colitis - background Retrospective evaluation of treatment in collagenous colitis. No. of pts. Effect No effect Adv. effect Sulphasalazine 108 37 26 45 Mesalazine 16 8 8 0 Olsalazine 15 4 6 5 Prednisolone 39 32 6 1 Budesonide 2 2 0 0 Metronidazole 44 24 16 4 Erythromycin 15 10 4 1 Penicillin 8 8 0 0 Cholestyramin 44 26 17 1 Loperamide 69 49 18 2 Bohr et al. Gut, 1996

  29. Kollagen colitis Dobbelt-blind undersøgelse Budesonide treatment of collagenous colitis Long-term budesonide treatment of collagenous colitis

  30. Budesonide Chemical structure of budesonide

  31. Kollagen kolitis • Budesonide • Steroid med lokal virkning • Frigøres i terminale ileum • Høj affinitet for steroid receptore • High first-pass metabolisme i leveren Ole Bonderup, Medicinsk afd. Regionshospitalet Silkeborg

  32. Kollagen colitis Budesonide treatment of collagenous colitis. Study design of the 8 week randomised, double-blind, placebo-controlled trial. Budesoniden = 10 R Placebon = 10 Double-blind treatmente phase Double-blind follow-up(off treatment) 8 weeks 8 weeks R, randomisation

  33. Budesonide treatment of collagenous colitis. Results of the 8 week randomised, double-blind, placebo-controlled trial.

  34. Kollagen colitis Budesonide Ole Bonderup, Medicinsk afd. Regionshospitalet Silkeborg

  35. Kollagen colitis Kaplan-Meier curve of the risk of relapse after 8 weeks budesonide treatment . Ole Bonderup, Medicinsk afd. Regionshospitalet Silkeborg

  36. Kollagen colitis Long-term budesonide treatment of collagenous colitis. Study design of the 54 week randomised, double-blind, placebo-controlled trial. Ole Bonderup, Medicinsk afd. Regionshospitalet Silkeborg

  37. Kollagen colitis Double-blind maintenance phase Double-blind follow-up(off treatment) 6 30 54 weeks Budesonide 6 mg once daily 4/17 (23.5%) 17 13/17 (76.5%)*** 17 Placebo 2/17 (12%) 2/17 (12%) ***p<0.001 versus placebo (Fisher’s exact test)

  38. Kollagen colitis Ole Bonderup, Medicinsk afd. Regionshospitalet Silkeborg

  39. Kollagen colitis

  40. Budesonide 10% 100% Pharmacokinetic of budesonide

  41. Ækvieffektive forhold budesonid versus prednisolon Budesonid (Entocort) Prednisolon Klinisk effekt ved aktiv Crohn’s sygdom . . . . 9 mg p.o. 40 mg p.o. Påvirkning af binyrebarkfunktionen . . . . . 9 mg p.o. 6 mg p.o.

  42. Kollagen colitis - behandling • NSAID • NSAID seponeres. • Kost • Nedsætte kaffe forbrug • Anti-diaré behandling. • HUSK • Imodium • Questran Ole Bonderup, Medicinsk afd. M1, Regionshospitalet Silkeborg

  43. Kollagen colitis -behandling • Budesonide • First-line behandling i 8-12 uger • 9 mg 1x dgl i 2 - 4 uger • 6 mg 1x dgl i 2 - 4 uger • 3 mg 1x dgl i 4 - 8 uger • Ved recidiv behandling i 24 uger • Omkring 30% har behov for langtidsbehandling Ole Bonderup, Medicinsk afd. Regionshospitalet Silkeborg

  44. EMCC Consensus Treatment of Microscopic Colitis MC established Drug-induced colitis ?Consider drug withdrawel* asymptomtatic  no Tx Dietary recommendations* quit smoking mild symptoms moderate/severe symptoms* i.e. antidiarrheals +/- cholestyramine* Budesonid 9 mg/ for 6-8 weeks failure relapse failure mild/moderate symptoms Retreatment with Budesonide*(intermittend, continous) + Calcium/Vitamin D Alternative drugs Aminosalicylates +/- Cholestyramin Bismuth Probiotics severe symptoms Immunomodulators i.e. AZT, MTX failure relapse, intolerance failure Surgery

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