Inflammatory Bowel Disease - PowerPoint Presentation

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Inflammatory Bowel Disease

Anjali Morey, M.D., Ph.D.

Digestive Specialists, Inc.

999 Brubaker Drive

• Kettering, OH 45429Slide2

Which would be considered a

high risk Crohns Disease patient?

Highly Symptomatic

Advanced age of disease onsetPrior Surgical resectionDisease limited to one section of the colon

10Slide3

Which vaccine should not be given to

an IBD patient on immunosuppressive therapy?

Influenza

PneumoniaHep B Vaccine

GardasilShinglesSlide4
Slide5

ObjectivesReview

primary care workup for chronic diarrhea when IBD is suspected

Report on current treatment recommendations forUlcerative Colitis and Crohn’s

DiseaseDiscuss clinical follow-up of patients on immunosuppressive therapy Discuss lifestyle

changes that can help maintain remissionSlide6

IBD OverviewSlide7

Overview of Crohn’s Disease (CD)

Any segment of GI tract (mouth-anus)Rectal SparingDiscontinuous “skip lesions”Perianal Diseaseskin tags

fissuresfistulae

Transmural inflammation stricturefistulaperforationabscess

Normal Crohn’s DiseaseSlide8

Overview of Crohn’s Disease (CD)

Pathologic ChangesEpithelioid non-caseating granulomasChronic inflammatory infiltrate

Crypt architectural distortionSlide9

Overview ofUlcerative Colitis (UC)

Confined to colonBegins in rectum and extends proximally in a continuous fashionConfined to mucosa and submucosa

Normal Ulcerative ColitisSlide10

Overview ofUlcerative Colitis (UC)

Pathologic changesCryptitis / crypt abscessesCrypt architectural distortionLamina

propria expansion with acute and chronic inflammatory cellsSlide11

Primary Care

Patients often present with diarrhea

> 2 weeks Slide12

CD: Signs & Symptoms

Abdominal Pain GI BleedingDiarrheaWeight Loss

FatigueFeverJoint Pain

Skin RashesSlide13

CD: Staging WorkupSlide14
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CD: Initial LabsCBCCRP / ESR

CMPTSHStrongyloides AntibodyConsider Prometheus TestingConsider Absorption LabsSlide19

CD: Absorption LabsIron Studies / Ferritin

B-12 / Folic AcidVitamin D Vitamin D Target Range (for IBD Patients):  40-60 ng/mLVitamin

A Zinc Slide20

CD: Stool Studies to Rule Out Infection / Inflammation

Stool Ova and ParasitesStool for C. difficile toxinStool giardia antigen

Stool for CryptosporidiumStool culture and sensitivityFecal CalprotectinSlide21

CT Enterography / MR Enterography

Cross-sectional imaging technologyAssess for small intestine disease activity Assess for complications AbscessFistula

obstruction< 30 y/o, MRE preferred to avoid radiation exposure

CD: ImagingSlide22

CD: High Risk PatientsSurgical

ResectionFistula / StrictureAbscessEarly onset of disease

Deep ulceration

Perianal involvement and / or severe rectal diseaseExtensive anatomic involvementSlide23

UC: Signs & Symptoms Bloody Diarrhea

Tenesmus Urgency Abdominal PainFever 

Weight LossJoint PainSkin RashFatigueSlide24

UC: LabsCBCCMPCRP / ESR

Fecal CalprotectinStool studies to rule out infectionSlide25

UC: ImagingCase-by-case based on clinical presentation and evaluationCan be used to assess disease extent

and severity in severe flareSlide26

Mayo Scoring System for Assessment of UC Activity

Used for initial evaluation and monitoring treatment responseScores range from 0 to 12

Higher scores indicate more severe disease≤

2 = Clinical remission 3-4 = Mild activity6-10 = Moderate activity11-12 = Severe activitySlide27

Mayo Scoring System for Assessment of UC Activity

Variable

0 Points

1 Points2 Points3 Points

Bowel movement (BM) frequencyNormal1-2 BM > normal3-4 BM > normal>5 BM > normalRectal bleedingNoneStreaks on stool < 50% BM’sObvious fresh blood with most BM’sBM’s with fresh bloodEndoscopyNormalMild Erythema,  vascularity,

Mild

friability

Marked erythema,

Lack vascular pattern, Friability,

Erosions

Severe spontaneous bleeding, Ulceration

Physician Global Assessment (PGA)

Normal

Mild

Moderate

SevereSlide28

UC: Colonoscopy Used to Assess Disease Severity

Mayo Score = 0

Mayo Score = 1

Mayo Score = 2

Mayo Score = 3

Mayo Endoscopic

SubscoreSlide29

IBD TherapiesSlide30

Goals of IBD TherapyAchieve mucosal healing and

induce remissionMaintain steroid-free remissionPrevent / treat complications of diseaseAvoid short and long term toxicity of

therapyEnhance quality of lifeSlide31

IBD TherapiesAminosalicylates (5-ASA)

CorticosteroidsImmunomodulators (6 MP / AZA / MTX)Biologics Anti-TNF

Anti-IntegrinAnti IL-12 / IL-23 Slide32
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Azathioprine/6 MP Pharmacology6 TG

(active metabolite) 235-400 Therapeutic range > 400 Higher risk for bone marrow suppression6 MMP > 5700 Higher risk for hepatotoxicitySlide34
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Biologic therapy for IBDCertolizumab

- CimziaAdalimumab - HumiraGolimumab -

SimponiInfliximab - RemicadeAnti-Integrin antibody: Natalizumab

-Tysabri (PML –Progressive Multifocal Leucoencephalopathy)Anti-Integrin antibody: Vedolizumab

- EntyvioAnti IL-12 / IL-23 antibody: Ustekinumab – Stelara - moderate to severe CD.Slide36
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Crohn’s

Disease Therapies

Therapy is

modified according to

severity at presentation or failure at prior step

Pentasa

Biologics or

Thiopurine

+

Corticosteroid

Biologics

+

Thiopurine

+

Corticosteroid

Disease Severity

at Presentation

Severe

Moderate

Mild

Biologics

or

Thiopurine

Pentasa

Biologics

Induction

MaintenanceSlide38

Sequential Therapies for UC

Therapy is stepped up according to severity at presentation or failure at prior step

Aminosalicylate

Aminosalicylate

or

Thiopurine

+

Corticosteroid

Biologics

+

Thiopurine

+

Corticosteroid

Disease Severity

at Presentation

Severe

Moderate

Mild

Aminosalicylate

or

Thiopurine

Aminosalicylate

Biologics

Induction

Maintenance

ColectomySlide39
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Guidelines for Initiating and Follow-up of Immunosuppressive TherapySlide41

Labs Prior to Start of Immunosuppressive TherapyQuantiFERON

/ Chest X-ray (TB Testing)Acute Hepatitis PanelSlide42
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For Patients on Immunosuppressive TherapyAnnual head

to toe dermatology skin exam Sun precautions Annual Pap smear Annual TB Testing (Quantiferon

/ chest x-ray)Serial labs (CBC with Diff and Hepatic Function Panel) if on Imuran, 6MP or MTXSlide44

Lifestyle ModificationsSlide45

Mediterranean DietPrimarily

plant-based foods (fruits and vegetables, whole grains, legumes and nuts)

Replace butter with healthier fats (olive oil)Herbs and spices instead of salt

Limit red meat (beef and pork) to no more than a few times a monthFish, chicken, and turkey at least twice a weekRed

wine in moderation (optional)Slide46

Other Dietary ConsiderationsEat smaller, more frequent meals

Drink plenty of fluidsConsider multivitamin once dailyTalk to a dietitianProbiotics – Kefir once daily

Dairy, gluten, excessive caffeine /carbonation can exacerbate symptomsSlide47

Lifestyle ChangesStress Management

Exercise (20 minutes / day) Relaxation and breathing exercises (yoga and meditation)Smoking Cessation / avoid second hand smoke exposureAvoid unnecessary antibiotic exposure

Utilize Patient Education Resources (CCFA)Slide48

Final ThoughtsEarly diagnosis / avoid treatment delaysTreating IBD patients is a collaborative approach

between primary care and GI and other specialistsIncrease patient satisfaction