Inflammatory Bowel Disease

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