Dr Alex Tebbett - PowerPoint Presentation

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Dr Alex Tebbett(Warwick graduate)Fy1 Warwick A&E

Inflammatory Bowel DiseaseSlide2

What we’re coveringThe big two – Crohn’s and UCRisk factorsMacro and microscopic changesExtraintestinal manifestations

Differential diagnosis

Treatment

Clinical exam for IBD

Other GI cases

Finals hintsSlide3

IBDCrohn’s

Ulcerative ColitisSlide4

Crohn’sUlcerative Colitis

Epidemiology

Slightly more common

80-150/100,000

Slightly less common

27-106/100,000

Males: 1.2:1

Older: 34

Females: 1.2:1

Younger: 26Slide5

AetiologyLargely 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!Slide6

Crohn’sUlcerative Colitis

Aetiology: Environmental

Good hygiene/ developed countries

No relation to hygiene

Non smokers

Appendicectomy

is protective

Breast feeding is protective

Breast feeding is protective

Appendicectomy

SmokersSlide7

Crohn’sUlcerative Colitis

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

Pathology

Mouth to anus!

Rectum and extends proximally!Slide8

Macroscopic changesCrohn’s

Bowel is thickened

Lumen is narrowed

Deep ulcers

Mucusal fissures

Cobblestone

Fistulae

Abscess

Apthoid ulcerationSlide9

Macroscopic changesUlcerative Colitis

Reddened mucosa

Shallow ulcers

Inflamed and easily bleeds

Ulcerative ColitisSlide10

Crohn’sUlcerative Coltis

Chronic inflammatory cells: transmural

Lymphoid hyperplasia

Granulomas

Langhan’s cells

Chronic inflammatory cells: lamina propria

Goblet cell depletion

Crypt abscess

Microscopic Changes

Transmural

!

Mucosal!Slide11

Extraintestinal ManifestationsEYES

Crohn’s

UC

Uveitis

5%

2%

Episcleririts

7%

6%

Conjunctivitis

7%

6%Slide12

Extraintestinal ManifestationsJOINTS

Crohn’s

UC

Type 1

Arthropaty

(

Pauci

)

6%

4%

Type 2

Arthropathy

(Poly)

4%2.5%Arthralgia

14%5%Ankylosing Spondylitis

1.2%1%Inflammatory back pain

9%3.5%Slide13

Extraintestinal ManifestationsSKIN

Crohn’s

UC

Erythema

Nodosum

4%

1%

Pyoderma

Gangrenosum

2%

1%Slide14

Extraintestinal ManifestationsLIVER/BILLARY

Crohn’s

UC

Sclerosing

cholangitis

1%

5%

Gall stones

Increased

Normal

Fatty liver

Common

Common

Hepatitis/ CirrhosisUncommon

UncommonKidney stones in Crohn’s

oxalate stones post resectionAnaemia B12 deficiency in Crohn’s

Venous thrombosis

Other autoimmune diseasesSlide15

Differential DiagnosisEach otherInfection (unlikely if >10 days)IBSIleocolonic tuberculosisLymphomasSlide16

Treating IBDInduce remissionSteroids – oral or IVEnteral nutritionAzathioprine / 6MP (Crohns)Maintain remission

Aminosalicylates (UC)

Azathipreine/ 6MP

Methorexate

Biologicals generally for Crohn’s only

Infliximab, adalimumab

Test for TB first!Slide17

Crohn’sUlcerative Colitis

Azathioprine

Methotrexate

Cyclosporin

Humera

Adalimumab/anti TNF

Steroids for flares

Aminosalicylates

Mesalazie

Steroids

Foam/PR

Oral

IV

Azathiorprine

Treating IBDSlide18

UC FlaresTruelove-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 STATESlide19

Surgical ManagementSurgery 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 CHOPInfectionCarcinomaHaemorrhage

ObstructionPerforationSlide20

PrognosisUC1/3 Single attack1/3 Relapsing attacks1/3 Progressively worsen requiring colectomy within 20 yearsCrohn’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 diseaseSlide21

Crohn’sUlcerative 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/lethargyWeight lossApthous ulces in mouthClinical Finals: IBD HistorySlide22

Clinical finals: IBD HistoryWhat else to ask?RashesMouth ulcersJoint/back painEye problems

Family history

Smoking statusSlide23

Clinical finals: IBD HistoryWhat 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?Slide24

Clinical finals: IBD ExamPhysical 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 bowelSlide25

Clinical finals: IBD ExamAnything 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: bloodSlide26

Clinical finals: IBD What is the most likely diagnosis?Inflammatory bowel diseaseSlide27

Clinical finals: IBD InvestigationsBedside

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)Slide28

Clinical finals: IBD InvestigationsImagingPlain AXR: helpful in acute attacksThumb printingLead pipe signBarium follow-through in Crohn’s

CT

CXR

Perforation

USSSlide29

Clinical finals: IBD InvestigationsFlexible 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

illeumIn children both an OGD and colonoscopy are done,Slide30

Clinical finals: IBD ManagementManage the patient, not just the disease!MedicationsManage extraintestinal manifestationsEg 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 toiletSlide31

Clinical finals: IBD ExplanationPlease explain a colonoscopy to the patientPlease explain an OGD to the patientPlease advise the patient on the side effects of steroidsPrepare 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!Slide32

How to do well in finals questionsHave a plan on how to answer questionsIx: bedside, bloods, imaging, special testsMx: 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!Slide33

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

!Slide34

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 colitisSlide35

Clinical finals: IBD questionsWhat 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, jointsSlide36

Any questions?Good Luck!