Inflammatory Bowel Disease

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Inflammatory Bowel Disease

  1. 1. Inflammatory Bowel Disease<br />USAFP - 2010<br />Jonathan C Taylor, MD<br />MAJ, MC<br />
  2. 2. Learning Objectives<br />What is the spectrum of inflammatory bowel disease?<br />What is the approach to the patient with inflammatory bowel disease?<br />What are the key management aspects of IBD in the primary care setting?<br />
  3. 3. Case Example<br />18 year old high school senior presents to your clinic with several weeks of constipation and profound fatigue<br />She was seen in the ED over the weekend and told she was very anemic with hgb 7.7 with mcv of 63<br />Iron studies confirm iron def anemia with low ferritin and serum iron<br />
  4. 4. Case Example<br />She denies melanotic or bloody stools<br />She denies history of inflammatory bowel disease<br />She denies heavy menstrual bleeding<br />She denies other “B” symptoms other than fatigue<br />She was placed on iron and stool bulking agents and scheduled for follow up<br />
  5. 5. Case Example<br />She presented to the ED one week later with lower abdominal pain<br />CT showed possible inflamed appendix<br />She was taken to the OR, appendix was normal but a 2 cm abscess was removed<br />The pathology revealed tissue architecture consistent with Crohn's<br />
  6. 6. Inflammatory Bowel Disease<br />Crohn’s disease<br />Ulcerative colitis<br />Infectious etiologies<br />Ischemic colitis and pseudomembranous<br />Radiation induced<br />Celiac disease<br />Irritable bowel disease?<br />
  7. 7. Common Presentations of IBD<br />Abdominal pain <br />Diarrhea – bloody or non-bloody<br />Fever<br />Weight loss<br />Malaise<br />Arthralgia<br />Skin manifestations<br />
  8. 8. Crohn’s Disease<br />
  9. 9. Crohn’s disease<br />Granulomatous inflammation of the GI tract<br />The inflammation is transmural<br />Can affect any age group most common in the second and third decade<br />Crohn’s is not curable<br />Crohn’s results in significant morbidity and mortality<br />
  10. 10. Clinical Presentation<br />Can present with both GI and extra-intestinal symptoms<br />Chronic or nocturnal diarrhea with abdominal pain<br />Weight loss and fever<br />Rectal bleeding<br />Perianal fissures and fistulas<br />Perianal abscesses<br />Inflammation of the eyes skin or joints<br />Delayed development and children secondary to chronic diarrhea<br />Toxic megacolon<br />Demographic: white, Jewish ancestry, smokers<br />
  11. 11. Clinical Features<br />Ileum and the colon are most frequently affected<br />Spondylo-arthritis and peripheral arthritis<br />Erythemanodosum and pyodermagangrenosum<br />Uveitis, episcleritis, conjunctivitis<br />Primary sclerosingcholangitis<br />Anemia, cholelithiasis, nephrolithiasis, metabolic bone disease<br />Mouth to anus and anywhere else!<br />
  12. 12. Diagnosing Crohn’s<br />Crohn’sshould be considered with any of the aforementioned clinical features<br />The other inflammatory bowel diseases should be considered and ruled out as well<br />Early consult to gastroenterology should be considered in for patients with possible Crohn’s<br />
  13. 13. Laboratory tests<br />ESR, C-reactive protein<br />Stool culture for enteric pathogens, ova, parasites, C. difficile<br />ANA<br />Antibody testing against S. Cerevisiae<br />Antibodies directed against CBir1 and OmpC<br />Genetic testing – NOD2/CARD15<br />
  14. 14. Endoscopy<br />Can be both diagnostic and therapeutic<br />Can be used to exclude the presence of other pathogens<br />Can differentiate between Crohn’s and ulcerative colitis<br />Video capsule endoscopy – may be superior in detecting small bowel disease<br />
  15. 15. Video Capsule Endoscopy<br />www.google.com/images/videocapsule<br />
  16. 16. Video Capsule Endoscopy<br />www.google.com/images/videocapsule<br />
  17. 17. Treatment<br />Patients are scored using the Crohn’s disease activity index (CDAI)<br />Treatment must be tailored to disease location, severity and complications <br />Treatment is directed towards inducing and maintaining mucosal healing<br />Monitoring requires close follow up<br />
  18. 18. Mild to moderate disease<br />Oral mesalamine3.2 g-4 g daily or sulfasalazine 3 g-6 g daily<br />Oral budesonide 9 mg daily even more effective<br />Use of antibiotics has been debated**<br />
  19. 19. Moderate to severe disease<br />Prednisone 40 mg-60 mg daily until resolution of symptoms<br />Azathioprine or 6-mercaptopurine are effective for maintain steroid induced remissions<br />Methotrexate 25 mg per week<br />Anti-TNF monoclonal antibodies<br />
  20. 20. Treatment<br />
  21. 21. Indications for surgery<br />Surgery does not cure Crohn’s<br />Intractable hemorrhage or perforation<br />Recurrent or persistent obstruction<br />Abscess<br />Dysplasia or cancer<br />Fulminate disease<br />
  22. 22. Ulcerative Colitis<br />
  23. 23. Ulcerative Colitis<br />Diffuse mucosal inflammation limited to the colon<br />Rectum is involved in 95% of all cases<br />Inflammation can be symmetrical, circumferential and involve part or all of the large intestine<br />UC is curable with surgical resection<br />UC results in significant morbidity and mortality<br />
  24. 24. Clinical Presentation<br />Bloody diarrhea <br />Symptoms of rectal urgency and tenesmus<br />Weight loss<br />
  25. 25. Extra-intestinal Clinical Features<br />Osteoporosis<br />Oral ulcerations<br />Arthritis<br />Primary sclerosingcholangitis<br />Uveitis<br />Pyodermagangrenosum<br />DVT and PE<br />
  26. 26. Diagnosing UC<br />UC should be considered with any of the aforementioned clinical features<br />The other inflammatory bowel diseases should be considered and ruled out as well<br />Early consult to gastroenterology should be considered in for patients with possible UC<br />
  27. 27. Laboratory tests<br />ESR, C-reactive protein<br />Stool culture for enteric pathogens, ova, parasites, C. difficile<br />pANCA and ASCA<br />Tuberculosis, schistosomiasis, syphilis, Chlamydia, C. difficile, cytomegalovirus<br />
  28. 28. Endoscopy<br />Can be diagnostic<br />Can be used to exclude the presence of other pathogens<br />Can differentiate between Crohn’s and ulcerative colitis<br />Video endoscopy – screening tool<br />
  29. 29. Characterization<br />Mild: Less than 4 stools daily, no blood, no signs of toxicity, normal ESR<br />Moderate: More than 4 stools a day, minimal signs of toxicity<br />Severe colon 6 bloody stools a day, evidence of toxicity, fever, tachycardia, anemia, elevated ESR<br />Fulminant: 10 bowel movements per day, continuous bleeding, toxicity, abdominal tenderness, blood transfusions required, colonic dilatation on abdominal films<br />
  30. 30. Treatment<br />Ulcerative Colitis: Diagnosis and Treatment. Robert Langan et al. AAFP 76: 1323-1330<br />
  31. 31. Indications for Surgery<br />Surgery can cure gastrointestinal UC<br />Intractable hemorrhage or perforation<br />Recurrent or persistent obstruction<br />Abscess<br />Dysplasia or cancer<br />Fulminate disease<br />
  32. 32. Comparison<br />Ulcerative Colitis: Diagnosis and Treatment. Robert Langan et al. AAFP 76: 1323-1330<br />
  33. 33. Celiac Disease<br />Estimated to affect 1% of most populations<br />Diagnosed only in ~15% of those affected<br />Huge population of undiagnosed<br />Immune response to gliadin (glycoprotein)<br />Complex heavily studied immune response<br />
  34. 34. Clinical features<br />More prevalent in females<br />Vague abdominal symptoms<br />Diarrhea – occasionally bloody<br />Vomiting and weight loss<br />Skin manifestations<br />
  35. 35. Diagnosing Celiac Disease<br />Evaluation for infectious causes<br />Widely available assays looking for antibody serology<br />Endoscopy with biopsy useful for detection of subtle disease <br />Genetic testing may be the future of diagnosis and therapy<br />
  36. 36. Treatment<br />Gluten (gliadin) free diet – GFD<br />Mixed results<br />GFD greatly improved symptoms<br />GFD not shown to affect those in remission<br />Generally, recommended to try GFD<br />Adherence to GFD very difficult<br />GFD products can be 242% more expensive<br />
  37. 37. Treatment of Refractory Disease<br />Refer to gastroenterology<br />Need surveillance for advanced lesions<br />Immune system modulators <br />
  38. 38. Primary Care Pearls<br />Diarrhea >10 days you should consider inflammatory causes<br />Bloody diarrhea is inflammatory until proven otherwise<br />Consider inflammatory bowel disease inthe presence of systemic symptoms<br />Consider inflammatory bowel disease for unusual abdominal pain symptoms<br />Consider the long term effects of medications – screening for diabetes, bone loss and cancer surveillance<br />
  39. 39. References<br />Management of Crohn’s Disease. Doug Knutson, Greg Greenberg. AAFP 68:707-714<br />Management of Crohn’s Disease in Adults. Gary Lichtenstein et al. American Journal of Gastroenterology. ACG Guidelines 2008.<br />Ulcerative Colitis: Diagnosis and Treatment. Robert Langan et al. AAFP 76: 1323-1330<br />Ulcerative Colitis Practice Guidelines in Adults. American Journal of Gastroenterology. ACG Guidelines 2008.<br />Celiac Disease. Alberto Rubio-Tapia, Joseph Murray. Current Opinion in Gastroenterology, 25 December 2009.<br />

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