by Dr. Adnan But MCPS family medicine, MRCGP [international]

1. INFLAMMATORY
BOWEL DISEASE
Dr. Adnan Butt
MCPS family medicine, MRCGP [international]

2. Learning objectives

3. Learning objectives
• To differentiate between Crohn’s disease and Ulcerative colitis

4. Learning objectives
• To differentiate between Crohn’s disease and Ulcerative colitis
• To plan referral for IBD

5. Facts and figures

6. Facts and figures
• Chronic, relapsing, remitting condition

7. Facts and figures
• Chronic, relapsing, remitting condition
• Non-infectious inflammation of the gut

8. Facts and figures
• Chronic, relapsing, remitting condition
• Non-infectious inflammation of the gut
• Crohn’s Disease = from mouth to anus, with skip lesions

9. Facts and figures
• Chronic, relapsing, remitting condition
• Non-infectious inflammation of the gut
• Crohn’s Disease = from mouth to anus, with skip lesions
• Ulcerative Colitis = limited to colorectal mucosa

10. Facts and figures
• Chronic, relapsing, remitting condition
• Non-infectious inflammation of the gut
• Crohn’s Disease = from mouth to anus, with skip lesions
• Ulcerative Colitis = limited to colorectal mucosa
• Prevalence  Crohn’s = 50-100/100,000; UC = 100-200/100,000

11. Facts and figures
• Chronic, relapsing, remitting condition
• Non-infectious inflammation of the gut
• Crohn’s Disease = from mouth to anus, with skip lesions
• Ulcerative Colitis = limited to colorectal mucosa
• Prevalence  Crohn’s = 50-100/100,000; UC = 100-200/100,000
• Peak age = 40-60 y

12. Facts and figures
• Chronic, relapsing, remitting condition
• Non-infectious inflammation of the gut
• Crohn’s Disease = from mouth to anus, with skip lesions
• Ulcerative Colitis = limited to colorectal mucosa
• Prevalence  Crohn’s = 50-100/100,000; UC = 100-200/100,000
• Peak age = 40-60 y
• Gender = male : female

13. Facts and figures
• Chronic, relapsing, remitting condition
• Non-infectious inflammation of the gut
• Crohn’s Disease = from mouth to anus, with skip lesions
• Ulcerative Colitis = limited to colorectal mucosa
• Prevalence  Crohn’s = 50-100/100,000; UC = 100-200/100,000
• Peak age = 40-60 y
• Gender = male : female

14. Cause

15. Cause
• Unknown

17. Cause
• Unknown
• Smoking (for Crohn’s disease)

18. Cause
• Unknown
• Smoking (for Crohn’s disease)
• Gut infections

19. Cause
• Unknown
• Smoking (for Crohn’s disease)
• Gut infections
• Food

20. Symptoms
Crohn’s Disease Ulcerative Colitis

21. Symptoms
Crohn’s Disease Ulcerative Colitis
1. Tiredness, malaise, fever, weight reduction 1. Tiredness, malaise, fever, weight reduction

22. Symptoms
Crohn’s Disease Ulcerative Colitis
1. Tiredness, malaise, fever, weight reduction 1. Tiredness, malaise, fever, weight reduction
2. Diarrhea + blood/mucus 2. Diarrhea + blood/mucus

23. Symptoms
Crohn’s Disease Ulcerative Colitis
1. Tiredness, malaise, fever, weight reduction 1. Tiredness, malaise, fever, weight reduction
2. Diarrhea + blood/mucus 2. Diarrhea + blood/mucus
3. Abdominal pain 3. Abdominal pain (lower)

24. Symptoms
Crohn’s Disease Ulcerative Colitis
1. Tiredness, malaise, fever, weight reduction 1. Tiredness, malaise, fever, weight reduction
2. Diarrhea + blood/mucus 2. Diarrhea + blood/mucus
3. Abdominal pain 3. Abdominal pain (lower)
4. Malabsorption

25. Symptoms
Crohn’s Disease Ulcerative Colitis
1. Tiredness, malaise, fever, weight reduction 1. Tiredness, malaise, fever, weight reduction
2. Diarrhea + blood/mucus 2. Diarrhea + blood/mucus
3. Abdominal pain 3. Abdominal pain (lower)
4. Malabsorption
5. Mouth ulcers

26. Symptoms
Crohn’s Disease Ulcerative Colitis
1. Tiredness, malaise, fever, weight reduction 1. Tiredness, malaise, fever, weight reduction
2. Diarrhea + blood/mucus 2. Diarrhea + blood/mucus
3. Abdominal pain 3. Abdominal pain (lower)
4. Malabsorption
5. Mouth ulcers
6. Bowel obstruction due to strictures

27. Symptoms
Crohn’s Disease Ulcerative Colitis
1. Tiredness, malaise, fever, weight reduction 1. Tiredness, malaise, fever, weight reduction
2. Diarrhea + blood/mucus 2. Diarrhea + blood/mucus
3. Abdominal pain 3. Abdominal pain (lower)
4. Malabsorption
5. Mouth ulcers
6. Bowel obstruction due to strictures
7. Fistulae (often perianal)

28. Symptoms
Crohn’s Disease Ulcerative Colitis
1. Tiredness, malaise, fever, weight reduction 1. Tiredness, malaise, fever, weight reduction
2. Diarrhea + blood/mucus 2. Diarrhea + blood/mucus
3. Abdominal pain 3. Abdominal pain (lower)
4. Malabsorption
5. Mouth ulcers
6. Bowel obstruction due to strictures
7. Fistulae (often perianal)
8. Abscesses (perianal and intra-abdominal)

29. Associated conditions

30. Associated conditions
• Joint diseases – arthritis, ankylosing spondylitis

31. Associated conditions
• Joint diseases – arthritis, ankylosing spondylitis
• Skin changes – erythema nodosum, pyoderma gangrenosum (UC > C)

32. Associated conditions
• Joint diseases – arthritis, ankylosing spondylitis
• Skin changes – erythema nodosum, pyoderma gangrenosum (UC > C)
• Liver diseases – autoimmune hepatitis (UC), gallstones (Crohn’s)

33. Associated conditions
• Joint diseases – arthritis, ankylosing spondylitis
• Skin changes – erythema nodosum, pyoderma gangrenosum (UC > C)
• Liver diseases – autoimmune hepatitis (UC), gallstones (Crohn’s)
• Eye diseases – iritis, uveitis

34. Associated conditions
• Joint diseases – arthritis, ankylosing spondylitis
• Skin changes – erythema nodosum, pyoderma gangrenosum (UC > C)
• Liver diseases – autoimmune hepatitis (UC), gallstones (Crohn’s)
• Eye diseases – iritis, uveitis
• Osteoporosis (Crohn’s)

35. Associated conditions
• Joint diseases – arthritis, ankylosing spondylitis
• Skin changes – erythema nodosum, pyoderma gangrenosum (UC > C)
• Liver diseases – autoimmune hepatitis (UC), gallstones (Crohn’s)
• Eye diseases – iritis, uveitis
• Osteoporosis (Crohn’s)
• Amyloidosis (Crohn’s)

36. Investigations

38. Investigations
• FBC (anemia, increased WBC), ESR (raised when disease is active)

39. Investigations
• FBC (anemia, increased WBC), ESR (raised when disease is active)
• RFT

40. Investigations
• FBC (anemia, increased WBC), ESR (raised when disease is active)
• RFT
• LFT

41. Investigations
• FBC (anemia, increased WBC), ESR (raised when disease is active)
• RFT
• LFT
• Stool M,C&S

42. Investigations
• FBC (anemia, increased WBC), ESR (raised when disease is active)
• RFT
• LFT
• Stool M,C&S
• AXR

43. Investigations
• FBC (anemia, increased WBC), ESR (raised when disease is active)
• RFT
• LFT
• Stool M,C&S
• AXR
• Endoscopy, Proctoscopy

45. Treatment – Crohn’s disease

46. Treatment – Crohn’s disease
• Medical treatment is difficult

47. Treatment – Crohn’s disease
• Medical treatment is difficult
• Aminosalicylate (mesalazine) – less effective than for UC

48. Treatment – Crohn’s disease
• Medical treatment is difficult
• Aminosalicylate (mesalazine) – less effective than for UC
• Steroid – increased risk of sepsis and mortality

49. Treatment – Crohn’s disease
• Medical treatment is difficult
• Aminosalicylate (mesalazine) – less effective than for UC
• Steroid – increased risk of sepsis and mortality
• NSAIDs – can precipitate relapse

50. Treatment – Crohn’s disease
• Medical treatment is difficult
• Aminosalicylate (mesalazine) – less effective than for UC
• Steroid – increased risk of sepsis and mortality
• NSAIDs – can precipitate relapse
• Elemental or polymeric diets for 4-6 weeks

51. Treatment – Crohn’s disease
• Medical treatment is difficult
• Aminosalicylate (mesalazine) – less effective than for UC
• Steroid – increased risk of sepsis and mortality
• NSAIDs – can precipitate relapse
• Elemental or polymeric diets for 4-6 weeks
• Antibiotics, immunosuppressants, cytokines

52. Treatment – Crohn’s disease
• Medical treatment is difficult
• Aminosalicylate (mesalazine) – less effective than for UC
• Steroid – increased risk of sepsis and mortality
• NSAIDs – can precipitate relapse
• Elemental or polymeric diets for 4-6 weeks
• Antibiotics, immunosuppressants, cytokines
• Surgery (not curative)

53. Treatment – Crohn’s disease
• Medical treatment is difficult
• Aminosalicylate (mesalazine) – less effective than for UC
• Steroid – increased risk of sepsis and mortality
• NSAIDs – can precipitate relapse
• Elemental or polymeric diets for 4-6 weeks
• Antibiotics, immunosuppressants, cytokines
• Surgery (not curative)
• STOP SMOKING !! (halves the relapse rate)

54. Treatment – UC

55. Treatment – UC
• Aminosalicylate (long-term rectal preparation decreases the risk of colonic cancer
by 75%)

56. Treatment – UC
• Aminosalicylate (long-term rectal preparation decreases the risk of colonic cancer
by 75%)
• Steroid

57. Treatment – UC
• Aminosalicylate (long-term rectal preparation decreases the risk of colonic cancer
by 75%)
• Steroid
• Immunosuppressants, cytokines

58. Treatment – UC
• Aminosalicylate (long-term rectal preparation decreases the risk of colonic cancer
by 75%)
• Steroid
• Immunosuppressants, cytokines
• Surgery

59. Complications

60. Complications
Crohn’s Disease Ulcerative Colitis
1. intra-abdominal abscesses 1. Toxic megacolon
2. Intestinal strictures 2. Colonic cancer
3. Bowel obstruction 3. Slcerosing cholangitis
4. Fistula formation 4. Depression
5. Perianal disease
6. Osteoporosis
7. Depression
8. Malignancy (5%)
9. Toxic megacolon (rare)

61. Complications
Crohn’s Disease Ulcerative Colitis
1. intra-abdominal abscesses 1. Toxic megacolon
2. Intestinal strictures 2. Colonic cancer
3. Bowel obstruction 3. Slcerosing cholangitis
4. Fistula formation 4. Depression
5. Perianal disease
6. Osteoporosis
7. Depression
8. Malignancy (5%)
9. Toxic megacolon (rare)

62. Case study
• A 45 year old know patient of UC came to your GP clinic with acute severe
abdominal pain. He is febrile, tachycardic, but normotensive. Examination shows
generalized abdominal tenderness and guarding. What would be the best step for
him at that point?

63. Case study
• A 45 year old know patient of UC came to your GP clinic with acute severe
abdominal pain. He is febrile, tachycardic, but normotensive. Examination shows
generalized abdominal tenderness and guarding. What would be the best step for
him at that point?
• A = pain killers and observation at clinic
• B = steroids and observation at clinic
• C = AXR
• D = referral for admission

64. Case study
• Correct answer = D (referral for admission)

65. Take home message
•Danger signs of IBD should be picked up
for prompt referral
•NSAIDs can precipitate relapse in IBD

67. References
• Oxford Handbook of GP (4th edition)
• Current MDT (2017)