Inflammatory Bowel Disease

Inflammatory Bowel Disease

INFLAMMATORY BOWEL DISEASE Dr K Ingram OBJECTIVES Revision of pathophysiology and presentation of IBD Recall key differences between CD & UC Learn a logical, stepwise technique to enable recall of investigation and management Apply knowledge in a clinical scenario DEFINITION

Crohns Disease (CD) a chronic, relapsing, inflammatory disease characterised by transmural granulomatous inflammation Ulcerative Colitis (UC) a chronic, relapsing, inflammatory disorder of the colonic mucosa CROHNS DISEASE Epidemiology Bimodal distribution (Teens/20s & Older Adults) Exacerbated by smoking Pathophysiology Mouth

Anus (rectal sparing) Terminal Ileum > Small Bowel > Colon Areas of unaffected bowel in between (Skip lesions) CROHNS DISEASE Histologically: Transmural inflammation Aphthous ulceration Cobblestone mucosa Stricture formation (string-sign) Fistulae Entero -enteric -cutaneous -vesical

-vaginal Retroperitoneal CROHNS DISEASE Clinical Features: Symptoms Signs Diarrhoea +/- PR bleeding Colicky abdominal pain Weight loss Fever, malaise Vomiting (2o to obstruction; late) Pyrexia Anaemia Anorexia Clubbing Aphthous ulcers

Abdominal tenderness RIF mass Perianal abscess / fistulae / skin tags CLUBBING Stages: 1) Normal appearance and angle but increased fluctuancy of nail bed 2) Loss of angle between nail and nail bed 3) Increased curvature of the nail 4) Expansion of terminal phalanx Common causes: Cardiology SBE, cyanotic congenital HD Respiratory IPF, bronchial carcinoma, bronchiectasis, CF

GI IBD, coeliac disease, cirrhosis CROHNS DISEASE Extra-intestinal features Conjunctivitis / episcleritis / iritis Erythema nodosum (panniculitis) Pyoderma gangrenosum Large joint arthritis / sacroiliitis Complications Small bowel obstruction Perforation Toxic dilatation CROHNS DISEASE

Differential diagnosis: Ulcerative colitis Carcinoma Malabsorption Diverticular disease Infective Thyrotoxicosis ULCERATIVE COLITIS Epidemiology Young adults (15-30) most commonly affected Women > Men Smoking can be protective

Pathophysiology Continuous, superficial mucosal ulceration Nearly always affects rectum Rectum (Proctitis) 50% Left colon 30% Pancolitis 20% Histologically Areas of continuous mucosal inflammation ULCERATIVE COLITIS

Clinical Features: Symptoms Signs Gradual onset diarrhoea +/- blood & mucus Crampy abdominal pain Urgency Tenesmus Fever, malaise Weight loss Pyrexia Tachycardia Anorexia Clubbing Aphthous ulcers Tender, distended abdomen ULCERATIVE COLITIS

Grading severity of acute disease Truelove-Witt Criteria1: Mild Moderate Severe No stools per day <4 4-6 >6 Temperature Afebrile

Intermediate >37.8 Heart Rate Normal Intermediate >90 Haemoglobin (g/ dl) >11 10.5-11.0 <10.5 ESR <20

20-30 >30 ULCERATIVE COLITIS Extra-intestinal features As for Crohns Disease Complications Toxic megacolon >6cm of TC on AXR Fever, tachycardia, dehydration, WBC

Perforation Bleeding Colon cancer surveillance crucial Primary Sclerosing Cholangitis ULCERATIVE COLITIS Toxic Megacolon ULCERATIVE COLITIS Differential Diagnosis Crohns Disease Infective Consider C.difficile

Ischaemic colitis Carcinoma Malabsorption Diverticular disease INVESTIGATIONS Bedside Observations Stool culture (MC&S and C.Diff) Urine dip +/- bHCG Bloods FBC / U&E / LFT / ESR / CRP Haematinics

Blood cultures pANCA (UC) INVESTIGATIONS Imaging Erect CXR Abdominal X-ray CT abdomen/pelvis Special Tests Endoscopy +/- biopsy Acute Flexi-sigmoidoscopy ONLY

Chronic Sigmoid-/Colonscopy Barium Meal/Follow-through strictures in Crohns Enema drainpipe colon/loss of haustra, apple-core stricture (malignancy) INVESTIGATIONS Drainpipe Colon String Sign Apple-core stricture MANAGEMENT Conservative

Medical Acute Chronic Surgical Types of resection CONSERVATIVE MANAGEMENT Dietary advice Low fibre, elemental diet MEDICAL MANAGEMENT Acute

Steroids induce remission Mild disease prednisolone PO Severe disease hydrocortisone IV NB avoid long-term use due to side-effects Chronic 5-ASA CCS Immunosuppression Biologicals MEDICAL MANAGEMENT 5-ASAs e.g. mesalazine 1st line therapy in IBD

Good for acute disease (remission) & maintenance Anti-inflammatory Steroids e.g. prednisolone Good for acute disease and inducing remission NOT for long-term use Immunosuppression e.g. azathioprine, MTX Steroid-sparing agents MEDICAL MANAGEMENT Biologicals e.g. infliximab Monoclonal

Ab against TNF Used predominantly for CD (esp. fistulae) NICE guidelines: Severe, active Crohns disease AND Refractory immunomodulatory drugs / cannot tolerate side-effects / experienced toxicity AND Surgery inappropriate Can also be used in acute UC unresponsive to IV steroids MEDICAL MANAGEMENT Contraindications to infliximab Sepsis

Deranged LFTs Active TB Pregnancy / Breastfeeding Side effects of infliximab Hypersensitivity reactions Reactivation of TB ALWAYS test for TB before commencing (Monospot) Increased risk infections e.g. VZV, candida Increased risk of malignancy e.g. lymphoma

SURGICAL RESECTION Crohns (~65%): Acute, severe bleeding Strictures Fistulisation Obstruction, Perforation Non-resolving inflammatory mass UC (<15%): Perforation Toxic megacolon TYPES OF RESECTION Crohns Disease:

Small Stricturoplasty Localised rections Large bowel bowel Panproctocolectomy + ileostomy Subtotal colectomy + ileorectal anastomosis Ulcerative Colitis: Total colectomy + ileostomy + oversewing of

rectal stump Creation of J-pouch (or completion proctectomy) Ileostomy reversal CROHNS VS UC Crohns Disease Ulcerative Colitis Mouth Anus (rectal-sparing) Colon only Transmural Mucosa only Skip lesions Continuous area of inflammation Fistulae No Fistulae Bimodal distribution

Older age groups Smoking exacerbates Smoking protective PR bleeding less common PR bleeding common String sign Drainpipe colon Granulomas seen at biopsy Granulomata rare CLINICAL SCENARIO 29 year old female

History: 1/12 loose, watery stools of frequency Occasional blood and slime mixed in Crampy LIF pain Lethargy Examination: Pyrexial (38.2) Abdomen soft but mild distension & tender LIF PR painful ++, fresh blood & mucus CLINICAL SCENARIO Differentials Ulcerative colitis (acute flare)

Crohns Disease Infective diarrhoea Diverticulitis Carcinoma must always be excluded Investigation Acute: Bedside obs, urine, stool Bloods FBC / U&Es / LFTs / CRP / ESR / haematinics /cultures Imaging Erect CXR, AXR, CT abdo/pelvis Special tests flexi-sigmoidoscopy ONLY CLINICAL SCENARIO Investigations (cont.)

Long-term Immunology bloods e.g. p-ANCA Colonoscopy +/- biopsy when acute flare resolved Consider barium investigations Initial management Analgesia / anti-pyretics IV fluids IV steroids Long-term management Conservative

Medical Surgical CLINICAL SCENARIO Compare Crohns & UC: Crohns Disease Ulcerative Colitis Mouth Anus (rectal-sparing) Colon only Transmural Mucosa only Skip lesions Continuous area of inflammation Fistulae

No Fistulae Bimodal distribution Older age groups Smoking exacerbates Smoking protective PR bleeding less common PR bleeding common String sign Drainpipe colon Granulomas seen at biopsy Granulomata rare CLINICAL SCENARIO

Scoring system for acute UC: Mild Moderate Severe No stools per day <4 4-6 >6 Temperature Afebrile Intermediate >37.8

Heart Rate Normal Intermediate >90 Haemoglobin (g/ dl) >11 10.5-11.0 <10.5 ESR <20 20-30 >30

CLINICAL SCENARIO Extra-intestinal features of IBD: Conjunctivitis / episcleritis / iritis Erythema nodosum (panniculitis) Pyoderma gangrenosum Large joint arthritis / sacroiliitis Explain a colonoscopy: Check initial knowledge Avoid jargon Basic description of procedure Few risks/benefits Check understanding Offer literature / opportunity for questions KEY POINTS

Key differences between Crohns & UC Extra-intestinal manifestations Eyes, joints, skin Investigations only flexi-sig in acute flare Medical management acute & chronic Always test for TB for commencing infliximab Surgical management types of

resection Explain a colonoscopy Explain a stoma REFERENCES 1) Truelove SC, Witts LJ. Cortisone in ulcerative colitis: final report on a therapeutic trial. Br Med J 1955;ii:1041 8. 2) Goldberg A, Stansby G. Surgical Talk (2nd Ed.), Imperial College Press, 2005, pp 136-140.

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