Extra GI Manifestations of IBD

1. Extra GI Manifestations of IBD Dr. Matt W. Johnson BSc MBBS MRCP MD Consultant Gastroenterologist Luton & Dunstable FT Hospital

2. Luminology

4. To the ileum …and beyond

5. Extra GI Manifestations of IBD =40%

6. EGIM of IBD

7. Mouth Glossitis - Angular Stomatitis Orofacial granulomatosis

8. Glossitis • B12 deficiency • Red “beefy” tongue • Fe deficiency • Atrophic smooth tongue Rx = Supplements

9. Angular Stomatitis • Fe deficiency Rx = Supplements

10. Orofacial Granulomatosis • Rare chronic inflammatory condition • Characterised by lip swelling • 64% have histological granulomas similar to CrD • Rx = Elemental or Cinnamon and benzoate free diet

11. Eyes Episcleritis Iritis Uvietis Steroid Cataracts

12. Episcleritis • Incidence = 5% • Superficial redness of the episclera and conjuctiva • Burning + itching due to dilated vessels • Mx = Self resolves +/- NSAIDS

13. Scleritis • Deeper redness of sclera • Serious inflammatory condition • Ocular pain, photophobia, tearing, blindness • Rx = Treat the IBD + Systemic steroids, NSAIDS, antibiotics or immunosuppressant

14. Iritis / Uveitis • Inflammation of the iris (anterior uveitis) • 0.5-3% • Acute self resolves within weeks • Chronic persists for months and needs Rx • Ocular pain, photophobia, blurry vision, synechia

15. Iritis • Complications include; synechia, cataracts, glaucoma, blindness • Rx = Steroids (PO + drops, subconjuctival injections)

16. Uveitis • Inflammation of middle/inner eye • 10% of blindness in USA • Mx = Urgent referral to ophthalmologist • Treat the IBD • Rx = Steroids (PO + drops, subconjuctival injections), dilators + pressure reducing drops (brimonidine tartrate) +/- MTX, IFX

17. Skin Erythema Nodosum Pyoderma gangerenosum

18. Erythema Nodosum • 8-15% of UC + CrD • Usually reflects active disease • Can precede the IBD diagnosis • Red hot nodules on extensor surfaces • Assoc with pauciarticular arthropathy • Rx the IBD and you Rx the EN

19. Pyoderma Gangerenosum • 5% UC • 2% of CrD patients • 50% assoc with IBD activity • Starts with a red area + central pustules then develops into a painful necrotic ulcer • Steroids, IFX, Cyclosporin • Colectomy does not always help

20. Airway inflammation UC > CrD Chronic cough and mucopurulent sputum Progressive airways narrowing leads to Chronic bronchitis + bronchiectasis + bronchiolitis obliterans CXRs frequently normal, needs HRCT Rx = Large airways - Inhaled steroids Small airways - Systemic steroids

21. Thrombo-embolic disorders • TE events occur in 25% • 3 fold increase above general population • Recurrence risk is 10-15%

22. Liver + Pancreas Abnormal LFTs = 30% eg. AZA Gallstones = 13-34% of sb Crohn’s PSC PBC AI Pancreatitis

23. Primary Sclerosing Cholangitis • 5% of UC and 1-2% CrD • Can precede colitis by years • Symptoms = Pruritis, fatigue, RUQ pain, jaundice, cholangitis • Bedding and stricturing of IHDs • Associated with cholangiocarcinoma 6-20% • Increased risk of U+L GI cancer x6 and ampullary cancer • Colonoscopy every year, with OGD every 2 years • Survival if symptomatic = 15-18y

24. Primary Biliary Cirrhosis • More commonly seen with UC • High cholesterol • Deficiencies in the fat soluble vitamins DEAK • Leads to cholestasis

25. Bones Osteoporosis Sacroileitis Arthropathies (RhA, AnkSpond)

26. Osteopenia / Osteoporosis Peak bone mass reached in our 20-30s Then 0.5-1% per year thereafter 15% BMD lost in first 5y post menopause Osteopenia occurs in 40-50% Osteoporosis occurs in 2-30% Lifetime risk of fractures in IBD = 41% CrD women have 2.5 fold increase fracture risk

27. Osteoporosis Prevention • Weight bearing exercise • Stop smoking • Reduce weight • Moderate Xol intake • Ca intake (1000-1500mg/d) = 1 pint of semi skimmed is 700mg • Stop steroids ASAP • Bone loss starts rapidly • Occurs even with low doses • Fracture risk improves on cessation • Ca + Vit D = All patients on steroids • Bisphosphonates = steroids >3m, those >65y or low impact (fragility) fractures • HRT eg testosterone in steroid induced hypogonadism

28. BSG Mx of Osteoporosis • Calcium + Vit D • PO Bisphosphonates (eg alendronate, residronate) • IV Bisphosphonates (eg. pamidronate) • In those with difficult side effects eg. oesophagitis • Poor mucosal absorption • Avoids the problems • HRT (in PMP women) - risk of clots / breast+gynae cancer • Raloxifene - modulator of OR, without increased of breast Ca

29. Sacroilitis • Prevalence = 47% • Sacro-iliac pain • Hazziness of sacro-iliac joint • Can be one sided • Rx = COX II inhibitors • Try to avoid NSAIDS • Steroids / IFX • Mx = Treat the IBD

30. IBD Arthropathy • 10-20% of IBD patients (esp in Colonic disease, EN, Eyes) • Not to be confused with arthralgia secondary to steroid withdrawal, AZA or steroid induced myopathy. • 1) Type 1 (Large Joint) Arthropathy = 5% •  6 joints, (typically 1 large joint eg. knee) • Attacks assoc with active inflammatory relapses, EN + Iritis • Usually self limiting, no role for NSAIDS • Treat the IBD = 5ASAs, Steroids, MTX, AZA, Colectomy • 2) Type 2 (Small Joint) Arthropathy = 3-4% • Affects >5 joints, (typically small joints of hands and feet) • No direct assoc with IBD activity or Rx

31. Rx Algorithm for IBD Arthropathy

32. EGIM of IBD