Inflammatory Bowel Disease DR ALEX TEBBETT WARWICK GRADUATE

Inflammatory Bowel Disease DR ALEX TEBBETT (WARWICK GRADUATE) FY 1 WARWICK A&E

What we’re covering The big two – Crohn’s and UC Risk factors Macro and microscopic changes Extraintestinal manifestations Differential diagnosis Treatment Clinical exam for IBD Other GI cases Finals hints

IBD Crohn’s Ulcerative Colitis

Epidemiology Crohn’s Ulcerative Colitis Slightly less common 27 -106/100, 000 Slightly more common 80 -150/100, 000 Females: 1. 2: 1 Males: 1. 2: 1 Younger: 26 Older: 34

Aetiology Largely unknown Genetics 1. Polygenic: 16, 12, 6, 14, 5, 19, 1, 3 HLA DRB Familial (1 in 5) 2. Host immunology Defective mucosal immune system Inappropriate response to intraluminal bacteria T-cells and cytokines Autoimmune!

Aetiology: Environmental Crohn’s Ulcerative Colitis Good hygiene/ developed countries No relation to hygiene Appendicectomy is protective Smokers Non smokers Breast feeding is protective

Pathology Crohn’s Ulcerative Colitis Mouth to anus! Rectum and extends proximally! Terminal illeum Proctitis Ileocolonic disease Left sided colitis Ascending colon Sigmoid and descending Skip lesions Pancolitis Backwash ileitis Can be large bowel only Distal terminal illem

Macroscopic changes o Bowel is o o o o thickened Lumen is narrowed Deep ulcers Mucusal fissures Cobblestone Fistulae Abscess Apthoid ulceration Crohn’s

Macroscopic changes Reddened mucosa Shallow ulcers Inflamed and easily bleeds Ulcerative Colitis

Microscopic Changes Crohn’s Ulcerative Coltis Transmural! Mucosal! Chronic inflammatory cells: transmural Chronic inflammatory cells: lamina propria Lymphoid hyperplasia Goblet cell depletion Granulomas Crypt abscess Langhan’s cells

Extraintestinal Manifestations EYES Crohn’s UC Uveitis 5% 2% Episcleririts 7% 6% Conjunctivitis 7% 6%

Extraintestinal Manifestations JOINTS 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%

Extraintestinal Manifestations SKIN Crohn’s UC Erythema Nodosum 4% 1% Pyoderma Gangrenosum 2% 1%

Extraintestinal Manifestations LIVER/BILLARY Crohn’s UC Sclerosing cholangitis 1% 5% Gall stones Increased Normal Fatty liver Common Hepatitis/ Cirrhosis Uncommon Kidney stones in Crohn’s oxalate stones post resection Anaemia B 12 deficiency in Crohn’s Venous thrombosis Other autoimmune diseases

Differential Diagnosis Each other Infection (unlikely if >10 days) IBS Ileocolonic tuberculosis Lymphomas

Treating IBD Induce remission Steroids – oral or IV Enteral nutrition Azathioprine / 6 MP (Crohns) Maintain remission Aminosalicylates (UC) Azathipreine/ 6 MP Methorexate Biologicals generally for Crohn’s only Infliximab, adalimumab Test for TB first!

Treating IBD Ulcerative Colitis Crohn’s Azathioprine 2. Methotrexate 3. Cyclosporin 4. Humera 1. Adalimumab/anti TNF Steroids for flares Aminosalicylates 1. 1. Mesalazie 2. Steroids 1. 2. 3. Foam/PR Oral IV 3. Azathiorprine

UC Flares �Truelove-Witts Criteria: 1. 2. 3. 4. 5. 6. Anemia less than 10 g/dl Stool frequency greater than 6 stools/day with blood Temperature greater than 37. 5 Albumin less than 30 g/L A STATE Tachycardia greater than 90 bpm ESR greater than 30 mm/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

Surgical Management �Surgery 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 CHOP Infection Carcinoma Haemorrhage Obstruction Perforation

Prognosis UC 1/3 Single attack 1/3 Relapsing attacks 1/3 Progressively worsen requiring colectomy within 20 years Crohn’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 disease

Clinical Finals: IBD History Ulcerative Colitis Crohn’s Presenting complaint Diarrhoea Abdominal pain Weight loss Malaise/lethagy Nausea/vomiting Low grade fever Anorexia Bloody diarrhoea Lower abdominal pain +/- mucus Malaise/lethargy Weight loss Apthous ulces in mouth

Clinical finals: IBD History What else to ask? Rashes Mouth ulcers Joint/back pain Eye problems Family history Smoking status

Clinical finals: IBD History What 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?

Clinical finals: IBD Exam Physical 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 bowel

Clinical finals: IBD Exam Anything 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: blood

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

Clinical finals: IBD Investigations �Bedside 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: p. ANCA (UC)

Clinical finals: IBD Investigations Imaging Plain AXR: helpful in acute attacks Thumb printing Lead pipe sign Barium follow-through in Crohn’s CT CXR Perforation USS

Clinical finals: IBD Investigations �Flexible 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 illeum In children both an OGD and colonoscopy are done,

Clinical finals: IBD Management Manage the patient, not just the disease! Medications Manage extraintestinal manifestations Manage patient’s symptoms Eg B 12 deficiency anaemia Eg loperamide for diarrhoea Good nutrition, hydration and vitamin supplements Psychosocial impact of disease Ileostomy/colostomy bag Flares and the need for a toilet

Clinical finals: IBD Explanation Please explain a colonoscopy to the patient Please explain an OGD to the patient Please advise the patient on the side effects of steroids Prepare 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!

How to do well in finals questions Have a plan on how to answer questions Ix: bedside, bloods, imaging, special tests Mx: 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!

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!

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 colitis

Clinical finals: IBD questions �What 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, joints

Good Luck! ANY QUESTIONS?