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IBD common sx Diarrhea (often bloody); Fatigue (poss rel to anemia, not nec); wt loss; anorexia; N/V; crampy abdominal pain (d/t obstructive sx?)
Features of CD Any part of GI tract (most commonly terminal ileum); skip lesions; transmural
Features of UC Limited to colon; starts in rectum; usually continuous; superficial; resulting in erosions, friability, bleeding
Specific clinical features of UC Proctitis: tenesmus; bloody diarrhea more common; high risk of CRC
Specific clinical features of CD fistula: abscesses; more common at anus; strictures of the intestine; CRC risk increased if > 1/3 colon involved; smoking & CD: bad
Extra intestinal manifestations of IBD: may involve any area; usu eye, skin, liver, and joints (arthralgias, AS)
EIM: arthralgia Type 1: self limited, short lived, affecting 6 or fewer joints. Associated with disease flares
EIM: arthralgia Type 2: multiple joints, can be migratory, can be more chronic; NOT associated with disease flares.
Primary sclerosing cholangitis (PSC) UC>CD; stricture of biliary ducts; Dx high alk phos; LFT, anti-mito Ab; ERCP/MRCP; risk for CRC; refer to hepatologist
Erythema nodosum raised tender red-purplish nodules; most commonly on extensor surfaces of extremities; parallels IBD activity/tx; may req steroids
Pyoderma gangrenosum wide spectrum of necrotic inflam; IBD tx, topical tx, or poss colectomy; DO NOT BX
IBD eye complications episcleritis; uveitis: refer to Ophtho (blindness risk)
IBD: DDx includes: infxs diarrhea; ischemia (elderly, PVD, thrombosis); meds (PCN, NSAID, CellCept); diverticular dz; perianal fistula
IBD dx/ eval: Combo of endoscopy, histology, radiography, labs & clinical data; Colonoscopy with ileal intubation & bx (should see chronic colitis/enteritis); Small bowel follow-through, enteroclysis (+/- CT), MR enterography
IBD labs often anemic (Fe def & chronic dz), leukocytosis, elevated CRP (CD); DO NOT ORDER serologies (ASCA, Cbir, OmpC & Crohns; p-ANCA & UC)
Genl principles of tx of IBD Tx affected area (enema/supp: mild-mod proctitis; budesonide: ileal CD); use as little steroid as poss; not everyone needs tx or responds to same tx
Defn Mild UC: ≤5 BM/day; no sx systemic toxicity; normal ESR
Defn Moderate UC: >5 BM/day and <10lb wt loss; no sx systemic toxicity
IBD tx options 5-ASA; corticosteroids; 6MP/AZA; anti-TNF Ab
6MP/AZA MOA: impair T cell fn; slow onset of action; AE pancreatitis, liver tox, cytopenia;
IBD colon ca risk/surveillance CD/UC colitis >1/3 colon: colonoscopies starting 8 yrs from sx onset; q1-3 years; if comorbid PSC: immed start annual colonoscopy; FH also inc CRC risk
Dysplasia, cancer, or toxic colitis may: necessitate colectomy.
Fibrotic strictures, obstruction, fistulae may: necessitate segmental resection in CD (try to avoid surg if poss in CD)
IBD: Worrisome signs frequent UTIs/pneumaturia (fistula to bladder); High fever/abd mass (abscess, liver abscess); severe abd pain (perf); N/V (obstruction); severe rectal pain (perirectal abscess)
Managing IBD flares Similar to previous flares? Worrisome features; R/O infxn; labs (WBC, H/H); 5ASA (UC) or budesonide (ileal CD)
Granulomas on bx are highly suggestive of: CD
CT scan for CD may show: thickened, matted bowel loops, intra-abdominal abscess
Defn Severe UC: Hourly BMs; toxic appearance, fever, tachy, Hct <25; 10-20lb wt loss
Test of choice for UC sigmoidoscopy
Contraindicated in eval of acute UC: Barium enema: may -> toxic megacolon
UC treatment Distal: topical mesalamine; systemic steroids if tx failure. Acute dz above sigmoid: PO sulfasalazine & mesalamine
UC tx if intractable: C-steroid enema trial; cyclosporine IV 4mg/kg/day; inflixamab
Created by: Abarnard