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IBS/IBD lecture

Epidemiology of Crohn’s and UC: Demographics Commonly presents in persons of 15-30 YOA. Women and men equally affected, though women can have incr. risk if on BCPs. Smoking appears to reduce risk! o However, women on BCPs may have ↑ risk of IBD Smoking and appendectomy may reduce risk of UC
Epidemiology of Crohn’s and UC: Populations with increased risk Northern countries, higher socioeconomic populations, Jewish population esp Ashkenazi, and in urban populations
Epidemiology of Crohn’s and UC: Populations with decreased risk Southern countries, lower socioeconomic populations, non-Jewish Caucasians, African Americans, Hispanics, and Asians
Etiology of IBD (UC and Crohn's) Genetic factors: 30-50% if both parents have IBD; 67% in MZ twins (Crohn’s); 20% in MZ twins (UC) • Immunologic mechanism • Infectious
Pathophysiology - UC UC always involves the rectum and is always continuous. o Rectosigmoid 50% o Extends proximal to sigmoid 30% o Pan-colitis 20% (Backwash ileitis (10-20% in pan-colitis))
Pathophysiology - Crohn's Lesions can be anywhere in GI tract (mouth to anus). o SI alone 30-40% o Both SI and colon 40-55% o Colitis alone 15-25% • Most common site is the terminal ileum • Inflammation is transmural/full thickness and is characterized by skip lesions(common
SX and Disease Course in IBD (In General) Symptoms: abdominal pain and diarrhea Dz course: * characterized by acute exacerbations and remissions. * Severityusually depends on extent of GI involvement *
SX in Ulcerative Colitis (specifically) Sx are related to recosigmoidal bleeding. ** BLOODY D is hallmark of Dx and more common * may have altered bowel pattern (Fecal urgency, tenesmus, and incomplete evacuation) * abdominal pain is LESS common (usu LLQ relieved with diarrhea).
SX in Crohn's Dz (Specifically) Depend on location in GI tract. * Ileocolitis may cause RLQ crampy abdominal pain * jejunoileitis may cause malabsorption * gastroduodenal dz may cause epigastric pain* Perianal dz may cause sx related to anal fissure, perianal abscess, and fistulas.
Distinguish between UC and Crohn's in terms of clinical presentation. in UC, bloody diarrhea more common; abdominal pain less so; abd. pain in UC is usu. in the LLQ and relieved with diarrhea. In Crohn’s, diarrhea is usually NOT bloody, and pain is more common (usually RLQ but varies depending on location of inflammation.
Describe the endoscopic findings in UC. Rectum involved, continuous involvement, diffuse erythema, mucosal granularity, fistulas *NOT* seen, normal terminal ileum.
Describe the endoscopic findings in Crohn's. Rectum often spared, skip lesions are seen, 'cobblestoning' from submucosal edema, linear ulcers, fistulas, and ulceration of terminal ileum
Distinguish between UC and Crohn's in terms of radiographic findings. * UC: Loss of haustral markings* * Crohn’s:string sign and cobblestoning*
List systems affected by extraintestinal manifestations of IBD Hepatobiliary, joints, eyes, skin, and urological systems * disregulation of the immune system * these occur in up to 1/3 of IBD pts
List extraintestinal manifestations Specific to Crohn's Increased risk of colorectal cancer but less so than UC* fistulas * gall and renal stones * erythema nodosum and apthous stomatitis*
List extraintestinal manifestations Specific to UC Higher rate of colorectal cancer* pericholabgitis * pyoderma gangrenosum *
List extraintestinal manifestations of IBD in general primary sclerosing cholangitis (can progress to cirrhosis or liver CA), arthritis (often cured by colectomy), ankylosing spondylitis (more common with Crohn’s and HLA-B27 antigen), iritis, uvelitis, episcleritis
Describe lab eval of IBD (excluding specific serologic markers) CBC may show anemia or leukocytosis* CRP and ESR may be elevated * Albumin may be low with malnutrition* Stool culture/ova/parasite suggests infectious cause
Describe the serologic markers in the DiffDiag of IBD Anti-saccharomyces cerevisiae ABs useful for DX of Crohn's ** AND ** Perinuclear antineutrophil cytoplasmic ABs (pANCA) useful for dx of UC
Describe limitations of serologic markers in the DiffDiag of IBD If pANCA(+) and ASCA(-) only 57% SENSITIVE for UC (97% specific). If pANCA(-) and ASCA(+) only 49% sensitivity for Crohn's (97% specificity however)
Form a diagnostic plan for the eval. of IBD. Fam/PMI HX (thorough), appropriate Hx questions, phys exam, pANCA/ASCA/CBC/CRP/ESR/Albumin/Stool cult/ova/parasite - if indicated, endoscopy/biopsy
What HX questions are appropriate for dx of suspected IBD? * Aside from family Hx, stoll frequency, night wakening to stool, amt of rectal bleeding if any, abd. pain, fecal urgency, tenesmus
Outline non-pharmacological treatment options for IBD/UC/Crohn's ** diet and nutrition **: Limit caffeine and gas-producing veggies, Fe supplements if chronic blood loss, B12 supps if terminal ileum dz, Parenteral nutrition if severe exacerbations or evidence of growth delay in children
Outline pharmacological treatment options for active IBD Start with 5-ASA oral or enemas, add abx for perianal dz in Crohn's (cipro or flagyl), corticosterids for acute flares; if steroid dependent add immunosuppressant; for FULMINANT ibd, cyclosporine or IV steriods
Role of 5-ASA in IBD Treatment * Sulfasalazine, asacol, pentasa * Sulfasalazine combines an abx (sulfa) with antiinflamm (5-ASA)* Asacol and Pentasa are sulfa-free * Mesalamine enemas – good for proctitis *
Role of Corticosterids in IBD treatment (dramatically suppress sx but carry side effects)
Role of Antibiotics in IBD treatment (specifically for Crohn's - no role in UC!) ** No role in UC ** in Crohn's, 1st line for perianal dz, ileocolitis, fistulas. Usual drugs - Cipro or Flagyl
Role of immunomodulators in IBD treatment * Azathroprine or mercaptopurine reduce exacerbations/reduce need for corticosteroids ** Cyclosporine – indicated for severe/fulminant IBD not responding to 5-ASA or other immunosupp. therapy *
Role of glucocorticoids in IBD treatment * Used to treat moderate or severe exacerbations * No role in maintenance therapy * Usu need 40-60mg/day and a taper to avoid rebound * Systemic SEs limit long term use. Also require Ca and Vit D suppplements while using
What are the potential complications (intestinal) of Crohn's? * ulcers - erosions that may penetrate full thicknes * fistulas * obstruction due to inflammation and fibrosis * malnutrition due to diarrhea *
What are the potential complications (intestinal) of ulcerative colitis? * Toxic megacolon: severe inflamm. with weakness of the colon wall; risk of perforation and peritonitis * hemorrhage that may require transfusions * colectomy indicated in SEVERE bleeds * obstructions due to strictures around the rectum
Discuss the epidemiology of IBS * one of the most commonly encountered GI issues in primary practice, yet poorly understood * defined as GI disorder characterized by changed bowel habits in absence of any structure or biochem abnormalities
Discuss the differential dx for IBS * IBS has sx resembling many other conditions * Dx based on Hx (Rome criteria) and supported with limited dx workup * Complexity of workup depends on pt presentation * KEY – all tests NORMAL **
Discuss the diagnostic eval of IBS DEpends on following factors: duration of sx, change in sx over time, age and gender of pt, prior dx studies, FHx of malignancy or IBD, and degree of psychosocial dysfunction (stress level and situations)
In diagnosing IBS, list the Rome III criteria Recurrent abd pain or discomfort for >3 days per month during previous 3 months that is assoc. with 2 or more of the following * Relieved by stooling * Onset assoc. with a change in stool frequency (3) Onset assoc. with change in stool form or appearance
In diagnosing IBS, list what supports that Dx o Dx in younger pts o Sx over long period of time WITHOUT PROGRESSION o Onset of sx during stress, relieved with a BM o Absence of systemic sx
In diagnosing IBS, list what DOES NOT support that Dx o Dx at older age o Progressive course from onset o Persistent diarrhea >48h, bloody diarrhea, or noctournal diarrhea o Systemic sx (fever, weight loss)
Rome III supporting sx  Altered stool frequency  Altered stool form  Altered stool passage (straining and/or urgency)  Mucorrhea  Abdominal bloating or subjective distention
Discuss the educational/support approach to treating IBS • Develop therapeutic relationship with pt • Education, reassurance, and support • ID current stressors causing exacerbations • Explain that IBS is a chronic condition that can be controlled but not cured
Discuss the non-pharmalogical treatment of IBS o Diet: avoid triggers (caffeine, fatty foods, or gas producing veggies) o High fiber diet may benefit constipation o Avoid dairy if lactose intol. o Eat slowly, avoid gum and carbonated beverages o Eat smaller more frequent meals
Discuss the pharmacological treatment of IBS (in general terms) * anti constipation agents * antidiarrheal agents * antidepressents (TCA) * serotonin receptor antagonists or agonists (depending on whether constipation or diarrheal IBS)
Discuss the role of anticonstipation agents in IBS treatment o Anticonstipation agents  Stool bulking agents (psyllium) - add bulk and increase GI transit time  Osmotic laxatives (use VERY cautiously) – milk of magnesia may increase stool freq. and consistency and reduce straining
Discuss the role of Seratonin in the treatment of IBS Serotonin involved in GI motility and sensation
Discuss the role of antidepressants in the treatment of IBS * treat underlying depression/underlying psychological dx * TCAs have effects on motility, visceral sensitivity, and central pain perception (Nortriptyline, imipramine, desipramine)
Discuss the role of anticholinergics in the treatment of IBS Relieve intestinal spasm by relaxing intestinal smooth muscle  Dicyclomine (bentyl) 20mg QID is commonly used but therapeutic effects are variable; used to control acute exacerbations or prevent sx in times of stress
Discuss the role of antidiarrheals in treatment of IBS Antidiarrheal agents – lomotil for diarrhea variant IBS
What drug is approved for women with constipation IBS, and what does it do? Tegaserod (5-HT4 agonist) ; • Causes incr. stool frequency, improves consistency, and reduces abd. Pain and bloating
What drug is approved for women with diarrhea IBS, and what does it do? Alosetron (5HT3 antagonist)* • Causes delayed colon motility, increases pain threshold to intestinal distention
Created by: 1285601599