1 / 36

Inflammatory Bowel Disease

Inflammatory Bowel Disease. Dr Alex Tebbett (Warwick graduate) Fy1 Warwick A&E. 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 IBD Other GI cases

gabi
Download Presentation

Inflammatory Bowel Disease

An Image/Link below is provided (as is) to download presentation Download Policy: Content on the Website is provided to you AS IS for your information and personal use and may not be sold / licensed / shared on other websites without getting consent from its author. Content is provided to you AS IS for your information and personal use only. Download presentation by click this link. While downloading, if for some reason you are not able to download a presentation, the publisher may have deleted the file from their server. During download, if you can't get a presentation, the file might be deleted by the publisher.

E N D

Presentation Transcript

  1. Inflammatory Bowel Disease Dr Alex Tebbett (Warwick graduate) Fy1 Warwick A&E

  2. 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 IBD • Other GI cases • Finals hints

  3. IBD Crohn’s Ulcerative Colitis

  4. Epidemiology Crohn’s Ulcerative Colitis Slightly more common 80-150/100,000 Slightly less common 27-106/100,000 Females: 1.2:1 Males: 1.2:1 Younger: 26 Older: 34

  5. Aetiology Largely unknown • Genetics • Polygenic: 16, 12, 6, 14, 5, 19, 1, 3 • HLA DRB • Familial (1 in 5) • Host immunology • Defective mucosal immune system • Inappropriate response to intraluminal bacteria • T-cells and cytokines Autoimmune!

  6. Aetiology: Environmental Crohn’s Ulcerative Colitis Good hygiene/ developed countries No relation to hygiene Appendicectomy Appendicectomy is protective Non smokers Smokers Breast feeding is protective Breast feeding is protective

  7. Pathology Crohn’s Ulcerative Colitis Mouth to anus! Rectum and extends proximally! • Terminal illeum • Ileocolonic disease • Ascending colon • Skip lesions • Pancolitis • Can be large bowel only • Proctitis • Left sided colitis • Sigmoid and descending • Pancolitis • Backwash ileitis • Distal terminal illem

  8. Bowel is thickened • Lumen is narrowed • Deep ulcers • Mucusal fissures • Cobblestone • Fistulae • Abscess • Apthoid ulceration Macroscopic changes Crohn’s

  9. Reddened mucosa • Shallow ulcers • Inflamed and easily bleeds Ulcerative Colitis Macroscopic changes Ulcerative Colitis

  10. Microscopic Changes Crohn’s Ulcerative Coltis Transmural! Mucosal! • Chronic inflammatory cells: transmural • Lymphoid hyperplasia • Granulomas • Langhan’s cells • Chronic inflammatory cells: lamina propria • Goblet cell depletion • Crypt abscess

  11. Extraintestinal Manifestations

  12. Extraintestinal Manifestations

  13. Extraintestinal Manifestations

  14. Extraintestinal Manifestations • Kidney stones in Crohn’s • oxalate stones post resection • Anaemia • B12 deficiency in Crohn’s • Venous thrombosis • Other autoimmune diseases

  15. Differential Diagnosis • Each other • Infection (unlikely if >10 days) • IBS • Ileocolonic tuberculosis • Lymphomas

  16. 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!

  17. Treating IBD Crohn’s Ulcerative Colitis • Azathioprine • Methotrexate • Cyclosporin • Humera • Adalimumab/anti TNF • Steroids for flares • Aminosalicylates • Mesalazie • Steroids • Foam/PR • Oral • IV • Azathiorprine

  18. UC Flares • Truelove-Witts Criteria: • Anemia less than 10g/dl • Stool frequency greater than 6 stools/day with blood • Temperature greater than 37.5 • Albumin less than 30g/L • Tachycardia greater than 90bpm • 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

  19. Surgical Management • Surgery can be curative for ulcerative colitis • 80% 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 CHOP • Infection • Carcinoma • Haemorrhage • Obstruction • Perforation

  20. Prognosis • UC • 1/3 Single attack • 1/3 Relapsing attacks • 1/3 Progressively worsen requiring colectomy within 20 years • Crohn’s • Varied prognosis, new biological agents improving • Cancer • 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

  21. Clinical Finals: IBD History 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

  22. Clinical finals: IBD History • What else to ask? • Rashes • Mouth ulcers • Joint/back pain • Eye problems • Family history • Smoking status

  23. 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?

  24. 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

  25. 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

  26. Clinical finals: IBD • What is the most likely diagnosis? • Inflammatory bowel disease

  27. 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)

  28. 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

  29. Clinical finals: IBD Investigations • Flexible sigmoidoscopy • Colonoscopy • 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,

  30. 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

  31. Clinical finals: IBD Explanation • Please explain a colonoscopy to the patient • Please explain an OGD to the patient • Please 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!

  32. 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 management • Have a reason for each investigation you’d like to do • Treat the person as well as the disease • Don’t ever forget the MDT!

  33. What else could come up…. • Coeliac disease • IBS • Ischaemic colitis • Diverticular disease • Appendicitis • Polyps • Haemorrhoids Know the side effects of steroids! Know the difference between colostomy and ileostomy!

  34. 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 glove acute flare of ulcerative colitis

  35. 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

  36. Good Luck! Any questions?

More Related