Inflammatory Bowel Disease

1. Inflammatory Bowel Disease Katie Benner VTS 2

2. Crohns & UC • Complex disorders & wide variation in clinical practice • Chronic idiopathic inflammaotry intestinal conditions • Patients may find symptoms embarassing • May result in loss of education/ employment difficulties • Growth failure, psych probs, sexual development probs

3. Often presents young • Lifelong disease • Disproportionately high impact on society • Hospital serving 300,000 sees 45-90 new cases per annum • Small increase in mortality for both

4. Approach to care • High level of training • Central hospitals supporting DGHs • Rapid access to clinic appts for new/ known pts • Provide counselling and educational material • Access to private toilet facilities • Multi disciplinary team

5. Patient’s experience • See pts as individuals not as the disease • Views on “right” and “wrong” life approaches to be avoided • Respect pts expertise • Sympathy, compassion & interest

6. Diagnosis • Symptoms often dismissed as “stress related” • Rapid access to hospital ixs • Rapid referral to gastroenterologist specialising in IBD

7. History • Stool frequency/ consistency/ urgency/ rectal bleeding/ tenesmus/ abdo pain/ malaise/ fever/ weight loss • Extraintestinal- joint/ eye/ cutaneous • Travel/ smoking/ FH/ medication

8. Examination • General wellbeing • Pulse, BP and temp • Signs anaemia • Fluid depletion, weight loss • Abdo pain/ distension/ palp. masses • Perineal exam

9. Investigations • FBC/ U&E/ LFT/ ESR/ CRP • Micro testing for infectious diarrhoea • Additional tests for abroad travellers • Abdominal imaging r/o toxic megacolon (in hosp) • Felxi sigi/ colonoscopy (disease extent/ severity) • Histopathology

10. Drugs used • Rapidly evolving field, likely to change drastically in next 10 years • Usually started in secondary care, but useful to know what they do, how to monitor, what side effects to watch out for

11. Aminosalicylates • E.g. Mesalazine/ “Pentasa” • Oral tablets/ sachets/ suspension/ liquid/ foam enemas/ suppositories • act on epithelial cells by a variety of mechanisms to moderate the release of lipid mediators, cytokines, and reactive oxygen species • Better tolerability than sulfasalazine • Higher doses to induce remission

12. Aminosalicylates cont… • Mesalazine intolerance in 15% • Diarrhoea/ headache/ nausea/ rash

13. Corticosteroids • Oral/ IV/ topical/ suppositories/ foam enemas • Potent anti-inflammatories for moderate to severe relapses of CD or UC • Combination of oral & rectal better • 40mg pred optimal for outpatient management • Too rapid a reduction assd with relapse

14. Corticosteroids cont.. • Decision to use must be weighed up against risks • Should be weaned slowly e.g. at 5mg/ week • 50% pts report no adverse effects • Cosmetic e.g. moon face, sleep & psychiatric

15. Thiopurines • E.g. “azathioprine” • mechanism of immunomodulation is by inducing T cell apoptosis by modulating cell signalling • Note potential hepatotoxicity • Need LFT monitoring (organised thru pharmacy) • Use in active disease and maintaining remission

16. Thiopurines cont… • Role is steroid sparing • Consider in pts needing 2 or more courses steroids in a year • (This is also when they need secondary care input) • thiopurine methyl transferase (TPMT) must be tested 1st • If TPMT deficient ^ risk myelotoxicity

17. Thiopurines cont… • 20% intolerance • Flu like symptoms 2-3 weeks after started & resolve once drug withdrawn • Profound leucopenia in 3% • Hepatoxicity and pancreatitis in <5% • Can be continued in pregnancy if IBD felt to be refractory

18. Methotrexate • Unlicensed in IBD • Oral/ IM/ SC • Mechanism unclear • Useful in inducing remission • 25mg/week (15mg/week in RA) • Measure FBC and LFT before starting and monthly thereafter

19. Methotrexate cont… • Nausea/ vomiting/ diarrhoea/ stomatitis • Limited by co-rx folic acid • Pneumonitis occurs in 2-3%

20. Ciclosporin • Inhibitor of calcineurin, preventing clonal expansion of T-cell subsets • Rapid onset of action • Used in mx severe UC • Can be used as IV salvage therapy in those heading for colectomy • Measurement of blood pressure, full blood count, renal function, and CsA concentration at 0, 1, and 2 weeks, then monthly

21. Ciclosporin cont… • Minor side effects in 31-51% • Tremor/ paraesthesia/ malaise/ headache, abnormal LFTs/ gingival hyperplasia/ hirsutism • Major s/es in up to 17% • Renal impairment/ infections/ neurotoxicity • May require pneumocystis cariinei jab

22. Infliximab • Chimeric anti-TNF monoclonal antibody with potent anti-inflammatory effects • Needs to be done in secondary care • Need maintenance doses, intitially after 2 weeks, 8+ weekly thereafter • Need pre- infliximab virology checks (with pt consent), CXR and EBV in men under 30 • Further doses given on PIU in Barnsley

23. Infliximab cont… • Use with immunomodulator as increase interval between doses • Rarely infusion reactions • Delayed reactions of joint pain/ myalgia/ fever • Theoretical risk of lymphoproliferative disorders

24. Surgery • Disease not responding to intensive medical therapy • Manage between surgeon and gastroenterologist • Pre-operative conselling and involvement of stoma nurse specialist • Subtotal colectomy leaving long rectal stump

25. Surveillance for colonic carcinoma • UC pts should get repeat colonscopy in 8-10 years • Extensive colitis (opting for surveillance) 3-yearly in teens, 2-yearly in 20s and yearly in 30s • Pts with PSC have higher risk of cancer and should have annual colonscopies

26. Pt information • NACC: The National Association for Colitis and Crohn’s disease, 4 Beaumont House, Sutton Road, St Albans, Herts AL1 5HH, UK. Information Line: 01727 844296; website: www.nacc.org.uk • CCFA: The Crohn’s and Colitis Foundation of America; website: www.ccfa.org • CORE/DDF: Digestive Diseases Foundation, PO Box 251, Edgware, Middlesex, HA8 6HG, UK.

27. Who to contact? • Debbie (IBD specialist nurse) on bleep 591 or 01226 436371 • Specific IBD advice line 2-3pm

28. References • British Society of Gastroenterology • Guidelines for the management of inflammatory bowel disease in adults • Gut 2004

29. Thank you • Any questions?