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INFLAMMATORY BOWEL DISEASE

INFLAMMATORY BOWEL DISEASE. Anusha Reddy FY1 SWFT 3 rd Feb 2014. objectives. 2 Case Studies: Crohn’s Vs Colitis THINK: AETIOLOGY EPIDEMIOLOGY SIGNS AND SYMPTOMS INVESTIGATIONS MANAGEMENT. Case Study 1. 22 Female PC: 6/52 of 5 x loose, non-bloody stools daily

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INFLAMMATORY BOWEL DISEASE

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  1. INFLAMMATORY BOWEL DISEASE Anusha Reddy FY1 SWFT 3rd Feb 2014

  2. objectives • 2 Case Studies: Crohn’s Vs Colitis • THINK: • AETIOLOGY • EPIDEMIOLOGY • SIGNS AND SYMPTOMS • INVESTIGATIONS • MANAGEMENT

  3. Case Study 1 • 22 Female • PC: 6/52 of 5 x loose, non-bloody stools daily • Right lower quadrant abdominal pain (especially after eating) • 8kg weight loss • Bilateral knee and ankle pains

  4. More information required • Full history • Nil PMH, no hx of foreign travel • No medications or allergies • Current smoker- 5 pack-years • Examination • Definite and moderately tender 5-cm mass in the right lower quadrant • No joint effusion or skin lesions are noted

  5. Differential diagnosis • Gastroenteritis • Crohn’s Disease • Ulcerative Colitis • Irritable Bowel Syndrome • Behcet’s Disease • Bowel Cancer • Tuberculosis • Amyloidosis • Acute Appendicitis

  6. WHAT DO WE THINK THIS IS? • 22 Female • PC: 6/52 of 5 x loose, non-bloody stools daily • Right lower quadrant abdominal pain (especially after eating) • 8kg weight loss • Bilateral knee and ankle pains

  7. Crohn’s Disease- Definition • Chronic Inflammatory Bowel Disease (IBD) • Unknown Aetiology • Characterised by • Focal • Asymmetrical • Transmural • Occasionally granulomatous inflammation • Any part of the GI tract- mouth anus

  8. Crohn’s Disease- Epidemiology • Incidence: 9.56 per 100,0001 • Prevalence: 115,000 in the UK • Age of onset: 2 peaks 1) 15-30 Y (more common) 2) 60-80 Y • Female: Male 1.8:1 Children this is reversed! • Risk Factors2 • Mycobacterium paratuberculosis, Pseudomonas spp. & Listeria spp. • ↑TNF-alpha • High-fat diets • Genetic mutations 1) Steed H, Walsh S, Reynolds N; Crohn's disease incidence in NHS Tayside. Scott Med J. 2010 Aug;55(3):22-5 2) Rangasamy P et al; Crohn Disease, Medscape, Jun 2011

  9. Crohn’s Disease- Symptoms • Abdominal pain, cramping or swelling • Anaemia • Fever • Gastrointestinal bleeding • Joint pain • Malabsorption • Persistent or recurrent diarrhoea • Stomach ulcers • Vomiting • Weight loss

  10. Crohn’s Disease- On Examination • General ill health- weight loss & dehydrated • Hypotension, tachycardia and pyrexia • Abdominal tenderness or distension, palpable masses. • Anal and perianal lesions (abscesses, fistulae) • Mouth Ulcers • Extra-intestinal manifestations of Crohn’s ......

  11. Crohn’s Disease- Extra Intestinal

  12. Investigations • Bloods • FBC, CRP, U&Es, LFTs • Stool culture and microscopy • anti-S. cerevisiae antibodies Perinuclear antineutrophil cytoplasmic antibody (p-ANCA) (UC>CD) • Abdo Xray • Ileocolonscopy and biopsy from the terminal ileum as well as the affected sites • Small bowel follow through • If upper GI symptoms- Upper GI endoscopy • If lower GI symptoms- Flexible sigmoidoscopy/EUA

  13. Crohn’s Disease- Management • First presentation (NICE guidelines) • Glucocorticoids • Prednisolone, Methylprednisolone IV hydrocortisone • Budesonide • 5-ASA • +/- ADD ON Azathioprine or Mercaptopurine • Biologic: Infliximab and Adalimumab

  14. Crohn’s Disease- Management • Maintaining Remission (NICE guidelines) • Offer Azathioprine or Mercaptopurine as Monotherapy • Methotrixate • Surgery- if limited to distal ileum (weighing out the risk Vs benefits) and for complications...

  15. Crohn’s Disease- Complications B A C C

  16. Case Study 2 • 32 Male • Bloody diarrhoea 4/52 • Bilateral lower abdominal cramping • Malaise and weight loss • No associated fever, visual changes, arthralgias, or skin lesions • Previously fit and well contractor • Non-smoker, 14-18 units/week drinker • FHx: Diabetes Mellitus Type 1

  17. Ulcerative Colitis- Definition • Chronic Inflammatory Bowel Disease • Unknown aetiology • Only Large Colon • Classification: • Distal Disease • More extensive disease • Pancolitis

  18. Ulcerative Colitis- Epidemiology • More common than Crohn’s • Incidence: 10 per 100,000 • Prevalence 240 per 100,000 in the UK • Age of onset: 2 peaks 1) 15-25 Y (more common) 2) 55-65 Y • Male:Female= 1:1 • Idiopathic: ?autoimmune condition triggered by colonic bacteria  inflammation • Genetic component: sibling of an individual who has IBD 17-35 x more risk of development • Risk of UC decreased in smokers 1) Ulcerative Colitis; NICE Clinical Guideline (Jun 2013)

  19. Ulcerative Colitis- Symptoms • Bloody diarrhoea • Abdominal Pain • Tenesmus • Systemic symptoms: malaise, fever, weightless

  20. Ulcerative Colitis- On examination • Unwell, pale, febrile, dehydrated • Abdo pain and tenderness .. + distension • TOXIC MEGACOLON • Worrying signs: Tachycardia, anaemia and fever • Extra- intestinal disease...

  21. Ulcerative Colitis- Extra-intestinal • Aphthous ulcers • Ocular manifestations 5% • Episcleritis • Anterior uveitis • Acute arthropathy affecting the large joints 26% • Sacroiliitis • Ankylosing Spondylitis 3% • Deramatology 19% • Pyoderma gangrenosum • Erythema nodosum • Primary Sclerosing Cholangitis

  22. Ulcerative Colitis- Investigations • Bloods: FBC, LFTs, U+Es, CRP • Serology- pANCA Vs. ASCA • Stool cultures • Imaging • Abdo x-ray- acute setting • Barium enema- can show mucosal structure • Flexible Sigmoidoscopy and Biopsy- for diagnosis

  23. Ulcerative Colitis- Management a) Topical aminosalicylate alone (suppository or enema b) ?ADD PO aminosalicylate to a topical aminosalicylate OR c) consider an PO aminosalicylate alone a) PO Aminosalicylate - High induction dose of an b) ?ADD topical Aminosalicylate ORPO beclometasone dipropionate • If no improvement 72 hrs despite IV Hydrocortisone OR • Symptoms worsen to pancolitis: • a) ADD IV Ciclosporin to IV steroids

  24. Ulcerative Colitis- Management • Indications for Surgery: • Unresponsive to medical treatment • Significantly affecting quality of life • Growth retardation in Children • Life-threatening complications... • Bleeding • Toxic Megacolon • Impending perforation • Carcinoma

  25. Any Questions?

  26. SUMMARY

  27. Summary: Crohn’s Vs. UC (1)

  28. SUMMARY: Crohn’s Vs. UC (2)

  29. SUMMARY- Crohn’s Vs. UC (3)

  30. SUMMARY: Crohn’s Vs. UC (2)

  31. LEARNING POINTS • RELAPSE AND REMITTING MANAGE THE PATIENT • BONE PROTECTION- IF ON LONG-TERM STROIDS • TEST FOR TB BEFORE STARTING INFLIXIMAB • RISK OF COLONIC CARCINIMA IN UC

  32. THANK YOU!!

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