Inflammatory Bowel Disease

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Answer

Two types of IBD

Crohn's and ulcerative colitis

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Common age at diagnosis

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IBD epidemiology

CD is more common in Whites, especially Ashkenazi Jews. Low Hispanic and Asian incidence.

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IBD pathophysiology

The exact cause is unknown, but the working hypothesiss is that this is an abnormal immune response to bacteria within the gut.

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Common Symptoms of IBD

Diarrhea (often bloody), fatigue (can be from anemia, but not necessarily), weight loss, anorexia, N/V, Crampy abdominal pain

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___ is a dz that tends to skip areas of the bowel and is transmural

Crohn's Disease

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__ is a dz limited to the colon, starts in the rectum, is generally continuous and is more superficial

Ulcerative colitis

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Ulcerative Colitis Symptoms

Proctitis (inflammation of the rectum lining) often results in tenesmus and possibly lower abdominal/pelvic cramping. b/c the rectum is almost universally involved, bloody diarrhea is a hallmark sx. High risk for colon CA

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__ dz is associated with fistula, both around the anus and internally

Crohn's dz

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Fibrotic strictures are associated with

Crohn's dz, seen at ileocecal junction. Leads to blockages

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What habit must be stopped in Crohn's?

Smoking. It is strongly associated with the development of Crohn's Dz, resistance to medical therapy and early disease relapse

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Extra-intestinal manifestations of IBD

In general EIMs are limited to the eye, skin, liver, mouth, and joints – but be aware that there are rare associations with multiple organ systems.

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Most common EIM of IBD

primary biliary cirrhosis (UC>CD). Pruritis may be present. Primarily manifest as stricturing of the bile ducts so be aware of the risk for cholangitis

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Anti-mitchondrial antibody is seen in

primary biliary cirrhosis. No effective therapy, refer to a hepatologist

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Fever, RUQ pain and Jaundice

may be a stricture from primary biliary cirrhosis.

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Which arthralgia is not associated with disease flares?

Type 2 multiple joints, can be migratory, can be more chronic. (Type I - self limited, short lived, affecting 6 or fewer joints and is associated with disease flares)

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Type of Arthritis commonly seen in IBD

Spondylitis and sacroilitis. Tx: underlying dz, infliximab and methotrexate, PT

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Erythema nodosum is seen

on the extensor surfaces of extremities in IBD. Responds to IBD therapy.

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Necrotic inflammation in IBD

Pyoderma gangrenosum. Do NOT biopsy, send to dermatology. Some people get a colectomy to deal with this (then they have to have a stoma, and they may have pyoderma gangrenosum around the stoma!)

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Symptoms of Uveitis

Eye pain, blurred vision, photophobia, HA. Send to Opthalmologist IMMEDIATELY

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Superficial inflammation of the sclera

Episcleritis.

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What can distinguish between infectious diarrhea and IBD?

Chronicity. Short duration (<2-3 weeks) should be approached as infectious, but be sure to have follow up. Tenesmus is suggestive of proctitis

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Differential for IBD

Infectious diarrhea, Ischemia of bowel, Medication related (NSAIDs, Penicillins, mycophenolate), Diverticular dz, Perianal fistula are more commonly idiopathis, but do raise suspicion for Crohn's

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Diagnostic Evaluation for IBD

Diagnosis relies on a combination of endoscopy, histology, radiography, laboratory, and clinical dataColonoscopy with ileal intubation & biopsy (should see chronic colitis/enteritis),Small bowel follow-through, enteroclysis (+/- CT), MR enterography

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What is important to see in a colonscopy eval for IBD?

ileal intubation

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Labs in IBD patient

Often anemia (iron deficiency and chronic dz), leukocytosis, elevated CRP with CD

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What labs should you not order in IBD evaluation?

Serologies

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Number one risk factor for IBD

Family history. But only 10% have a positive history in first degree relative

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UC tx

5-ASA (work differently than aspirin), Corticosteroids, 6-MP/azathioprine, Infliximab (remicade - anti-TNF antibody

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CD tx

5-ASA, corticosteroids, 6-MP/azathioprine, Methotrexate, Infliximab (remicade), adalimumab (humira) - anti -TNF, Natalizumab (Tysabri)

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Budesonide (entocort) is used for

ileal Crohn's disease. Fairly benign

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5-ASA

effective and benign. Mesalamine has specific location formulations

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AE's of corticosteroids

cataracts, hyperglycemia, weight gain, loss of bone density, easy bruising, striae

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6-MP AE's

Cytopenias (any of the blood cell lines), liver toxicity, pancreatitis (usually an allergic rxn that occurs within the first 6 weeks of initiation)

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Which tx option has a risk of granulomatous disease?

Anti-TNF antibodies. Associated with TB. Get a Quantiferon test (b/c PPD may be false negative) prior to initiation

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TNF and steroids are

immunosuppressants

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Surgery in IBD

Avoid if possible, b/c dz tends to reoccur, plus there are often adhesions (thus risk for fistulas). Generally try to avoid surgery in CD unless absolutely necessary

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Strictures are often seen in

Crohn's Dz

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Colon cancer surveillance

q 1-2 year colonoscopy after 8-10 years of UC or colonic CD (regardless of age)

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N/V can be a sign of

obstruction

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high fever/abdominal mass may suggset

abscess, liver abscess

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Frequent UTIs/pneumoaturia may suggest

fistula to bladder

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What should be monitored in pts taking steroids?

bone density, blood glucose, eye exams

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Alkaline phosphatase levels may be off b/c of

Primary biliary cirrhosis in someone with UC

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What should you rule out in IBD flares?

infection. C. diff, SSYC (salmonella, shigella, yersinia, campylobacter)

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Left Lower Quadrant pain is associated with

Ulcerative Colitis

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When should colonoscopy be avoided in UC?

in patients with severe disease b/c of risk of perforation

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Absolute indications for surgery in UC

Severe hemorrhage, perforation or documented carcinoma.

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Right lower quadrant mass and tenderness is associated with

Crohn's Dz

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Fecal urgency is associated with

Ulcerative Colitis

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Perianal disease with abscess, fistulas is associated with

Crohn's Disease

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Granulomas on biopsy are highly suggestive of

Crohn's Disease

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Test to differentiate between Crohn's and Ulcerative Colitis

when diagnosis remains uncertain, a panel of 7 tests that measures autoantibodies to P-ANCA as well as other bacteria

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Presence of a tender abdominal mass with fever and leukocytosis suggests

an abscess. Emergent CT of the abdomen is necessary to confirm diagnosis

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Severe hemorrhage is more likely in Crohn's or Ulcerative Colitis?

Ulcerative Colitis

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Indications for surgery with Crohn's

Intractability to medical therapy, intra-abdominal abscess, massive bleeding, symptomatic refractory internal or perianal fistulas, and intestinal obstruction

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Bloody Diarrhea is more commonly seen in

Ulcerative Colitis

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___ is associated with strictures of the intestines which can lead to blockages

Crohn's Disease

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Elevated C-Reactive Protein is seen in CD or UC?

Crohn's Disease

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Tx for UC and CD

Is identical. Except that Methotrexate can be given in CD

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Mild UC Definition

No more than 4BMs/day, no signs of systemic toxicity (fever, tachycardia, anemia), and normal ESR

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Severe UC

greater than 6 BM/d adn evidence of systemic toxicity

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Which medication tx is associated with Cytopenias?

6-MP/Azathioprine

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