Case Presentation 07

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Case Presentation 07

  1. 1. CASE PRESENTATION MAY 7 2008 DR PHYO AUNG HMO
  2. 2. 45 yo Mrs. JK on 2 nd May ,Cat 3 <ul><li>Vomiting 3 days </li></ul><ul><li>with Nausea </li></ul><ul><li>could not eat food </li></ul><ul><li>Abdomen Pain 3 days </li></ul><ul><li>Lower Abdominal Pain, Colicky Nature </li></ul><ul><li>7 out of 10 </li></ul><ul><li>Diarrhoea 3 days </li></ul><ul><li>Mucous , but NO bloody diarrhoea </li></ul>
  3. 3. Past History <ul><li>Crohn’s disease since 1998 </li></ul><ul><li>Appendicectomy 1997 </li></ul><ul><li>Bowel Resection done in 2005 </li></ul><ul><li>Attending IBD Clinic@BHH </li></ul><ul><li>Osteoporosis </li></ul><ul><li>Obesity </li></ul><ul><li>Hysterectomy </li></ul><ul><li>Social Hx- lives with family </li></ul><ul><li>Non Smoker </li></ul>
  4. 4. Medication <ul><li>Caltrate, Endep </li></ul><ul><li>Finished 1st dose Infliximab three weeks ago </li></ul><ul><li>Next Infliximab Infusion May 28 th </li></ul><ul><li>Prednisolone for ten years </li></ul><ul><li>Methotrexate+Folic Acid Rx before Sx </li></ul><ul><li>Mesalazine for short period (not response) </li></ul><ul><li>No Known drug allergy </li></ul>
  5. 5. Physical Examination <ul><li>Temp 37.6 C , BP 130/80 , Pulse 88/min </li></ul><ul><li>Chest- A/E Clear </li></ul><ul><li>Abdomen- Soft, Tenderness over lower abdomen and umbilical region </li></ul><ul><li>No Rebound Tenderness </li></ul><ul><li>Bowel Sound- Present </li></ul><ul><li>PR Examination- No Fresh Blood </li></ul><ul><li>Plus </li></ul><ul><li>Steroid Face , Striae over trunk </li></ul><ul><li>No extra intestinal complication of Crohn’s </li></ul>
  6. 6. Investigations Blood Results <ul><li>Na 132* ( 135- 145) </li></ul><ul><li>K 3.3* (3.5 – 5.0) </li></ul><ul><li>CL 90 * (95-110) </li></ul><ul><li>Urea 6.9 (2.5-8.5) </li></ul><ul><li>Cr 107* (40-90) </li></ul><ul><li>Albu 41 (34-47) </li></ul><ul><li>LFT Normal </li></ul><ul><li>CRP 8 (<5) </li></ul><ul><li>ESR T/F </li></ul>
  7. 7. Blood Results Contd <ul><li>Hb 109 ( 120-150) </li></ul><ul><li>WCC 4.7 (4.0- 10.0) </li></ul><ul><li>Plt 405 (150- 410) </li></ul><ul><li>Neutro 2.24(2 – 7) </li></ul><ul><li>B12 310 ( 156- 698) </li></ul><ul><li>Folate 34.6( 13.0-45.0) </li></ul>
  8. 8. Investigation Contd <ul><li>CXR – Normal Heart Size , No Signs of acute infection , No free gas under diaphragm </li></ul><ul><li>Abdomen X Rays( Erect & Supine) </li></ul><ul><li>No Signs of bowel obstructions, Bowel wall </li></ul><ul><li>thickness < 6 cm </li></ul><ul><li>Stool for Microscopy ,Culture & Sensitivity sent </li></ul>
  9. 9. <ul><li>Diagnosis “Acute Exacerbation Crohn’s disease with dehydration” Differential Diagnosis Infective Colitis Pseudomembranous Colitis Ischaemic Colitis Radiation Colitis </li></ul>
  10. 10. Management for Mrs. JK <ul><li>Morphine 5 mg IV </li></ul><ul><li>Maxolon 10 mg IV </li></ul><ul><li>Paracetamol 1 g Oral </li></ul><ul><li>Buscopan 20 mg IVI </li></ul><ul><li>Nil by Mouth </li></ul><ul><li>Normal Saline 1 L 6 hourly </li></ul><ul><li>Medical Referral </li></ul><ul><li>Admission under Medical Unit 1 </li></ul><ul><li>Discussed with Gastro Consultant On call for Metronidazole+Steriod >>> will decide later </li></ul>
  11. 11. What is Crohn’s Disease <ul><li>Chronic,Episodic,Inflammatory Bowel D/S </li></ul><ul><li>Affects any part of GI Tract (Mouth To Anus) </li></ul><ul><li>Described by US Gastroenterologist Dr Burrill Bernad Crohn(1884-1983) </li></ul><ul><li>Unknown Aetiology, ?? Immune Disorder </li></ul>
  12. 12. Anatomical Distribution
  13. 13. Epidemiology <ul><li>Incidence High in European/White </li></ul><ul><li>More common in Women </li></ul><ul><li>Bimodal ,Peak in 3 rd Decade& 5 th Decade </li></ul><ul><li>Genetic Predisposition exists, Increase risk in 1 st D Relative </li></ul>
  14. 14. Crohn’s Vs Ulcerative Colitis <ul><li>Pattern (Skip Lesions) </li></ul><ul><li>Presentation </li></ul><ul><li>Abdominal Pain+++ </li></ul><ul><li>Malnutrition ++ </li></ul><ul><li>Weight loss ++ Rectal Bleeding + </li></ul><ul><li>Urgency/Tenesmus + </li></ul><ul><li>Site </li></ul><ul><li>Any part of GI Tract </li></ul><ul><li>Complications </li></ul><ul><li>Strictures  Obstruction </li></ul><ul><li>Pattern (Continuous) </li></ul><ul><li>Abdominal Pain + </li></ul><ul><li>Malnutrition + </li></ul><ul><li>Weight loss + </li></ul><ul><li>Rectal Bleeding +++ </li></ul><ul><li>Urgency/Tenesmus +++ </li></ul><ul><li>Mostly Colon&Rectum </li></ul><ul><li>Bowel Cancer </li></ul>
  15. 15. Endoscopic Appearance
  16. 16. Different Types Of Presentation <ul><li>Mild To Moderate </li></ul><ul><li>Can take Oral </li></ul><ul><li>No dehydration </li></ul><ul><li>Slight or No Fever </li></ul><ul><li>Mild abdominal pain </li></ul><ul><li>Treatments </li></ul><ul><li>Oral Prednisolone </li></ul><ul><li>Severe Fulminat </li></ul><ul><li>Continuous Vomiting </li></ul><ul><li>Dehydration-> ARF </li></ul><ul><li>High Fever </li></ul><ul><li>Severe Abdominal pain </li></ul><ul><li>Rebound Tenderness </li></ul><ul><li>Intestinal Obstruction </li></ul><ul><li>Treatments </li></ul><ul><li>Hydrocortisone Inj & Rx of complications </li></ul>
  17. 17. Extra Intestinal Complications
  18. 18. Toxic Mega colon <ul><li>More common in UC </li></ul><ul><li>Any Colitis with High Temp,Tachycardia, </li></ul><ul><li>Increased WCC,dehydration,Abd pain,Anaemia </li></ul><ul><li>Radiological Criteria </li></ul><ul><li>Dilated Colon (>6 cm Int Diameter TC) </li></ul><ul><li>Intraluminal Soft T/S Masses(Pseudopolyp) </li></ul><ul><li>Early Surgical Intervention Required </li></ul>
  19. 19. Toxic Mega Colon X ray
  20. 20. Therapeutic Guidelines 2006 <ul><li>Mild to Moderate </li></ul><ul><li>> Oral Prednisolone </li></ul><ul><li>Daily Dose reducing over 8 to 12 weeks after clinical response </li></ul><ul><li>With or Without </li></ul><ul><li>Metronidazole 20mg/kg Daily Divided Dose </li></ul><ul><li>Doubtful benefits of Aminosilicylate in Crohn’s </li></ul><ul><li>Severe </li></ul><ul><li>Hydrocortisone 100mg 6 hourly IV followed by oral Prednisolone </li></ul><ul><li>Infliximab 5mg/kg IV infusion every 8 weeks </li></ul>
  21. 21. Maintenance Therapy <ul><li>Immunomodulating Agents </li></ul><ul><li>Azathioprine or Metcaptopurine </li></ul><ul><li>Daily Oral Doses </li></ul><ul><li>OR </li></ul><ul><li>Methotrexate Weekly+Folic Acid </li></ul><ul><li>OR </li></ul><ul><li>Infliximab IV Infusion Every 8 weeks </li></ul><ul><li>UK NICE Guidelines & AGIA Guidelines Similar </li></ul>
  22. 22. Infliximab <ul><li>Monoclonal Antibody </li></ul><ul><li>Can block Tumor Necrosis Factor Alpha which induces inflammatory cytokines+produces acute phase </li></ul><ul><li>I V Infusion 5 mg/kg over Two hours every 8 weeks </li></ul><ul><li>Side Effects </li></ul><ul><li>Serum Sickness </li></ul><ul><li>TB,Pneumonia </li></ul><ul><li>Septicemia </li></ul><ul><li>Risk of Lymphoma </li></ul><ul><li>High Cost </li></ul>
  23. 23. Evidences <ul><li>RCT in the UK showed Infliximab increase remission period, increase QOL,decrease Steroid dependency (BMJ Clinical Evidence) </li></ul><ul><li>Other RCTs reviewed by Cochrane Library showed regular infusion can introduce remission (65%) ( The Cochrane Library) </li></ul>
  24. 24. Summary <ul><li>Vomiting&Diarrhoea may be 1 st presentation of IBD </li></ul><ul><li>Important NOT to miss Surgical Emergencies such as toxic </li></ul><ul><li>mega colon , bowel obstruction etc in IBD </li></ul><ul><li>Extra Intestinal Complications should be looked </li></ul><ul><li>Severe exacerbation of IBD needs admission </li></ul><ul><li>Patient on Immunosuppressant can present with other complications such as pneumonia, sepsis. </li></ul>
  25. 25. References <ul><li>Therapeutic Guide Lines 2006 Clinician Health Channel, Victoria </li></ul><ul><li>American Family Physician Mgt of Crohn’s Disease </li></ul><ul><li>NHS NICE Guidelines for IBD </li></ul><ul><li>Evidence Base Medicine,BMJ Clinical Evidence,Cochrane </li></ul><ul><li>The John Hopkins Digestive Disease Library </li></ul><ul><li>Oxford Handbook of Acute Medicine </li></ul><ul><li>Calkins BM,Epidemiology of inflammatory bowel disease </li></ul><ul><li>Harrison’s Textbook of Internal Medicine,14 th Edition </li></ul>

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