2ObjectivesRecognise the possibility of IBD in patient’s presenting with lower GI symptomsRecognise the possibility of systemic symptoms associated with IBDRecognise the differences in presentation between Crohn’s and UC – and how these relate to underlying pathologyInitiate appropriate investigations in a patient with suspected IBDInitiate appropriate management in a patient with IBDExplain to patients the nature of and the rationale for maintenance treatment of IBDSo these are the objectives for this session – which ive chosen becuase these are the IBD objectives set out in your handbook. Now who finds the objectives in the handbook useful?They are quite vague, so you have to think what is it getting at and try to simplify it..
3ObjectivesRecognise the possibility of IBD in patient’s presenting with lower GI symptoms = GI symptoms of IBDRecognise the possibility of systemic symptoms associated with IBD = Extra-intestinal symptomsRecognise the differences in presentation between Crohn’s and UC – and how these relate to underlying pathology = Differences between UC and Crohn’s: Pathology and presentationInitiate appropriate investigations in a patient with suspected IBD = InvestigationsInitiate appropriate management in a patient with IBD = Management of IBDExplain to patients the nature of and the rationale for maintenance treatment of IBD = Explain in lay terms why we give medications to prevent flare upsPoints 1-3 are basicaly asking you to know what are the differences between UC and Chron’s – eg definition for each; pathology; presentation (GI and extra-intestinal).Then you just need to know what investigations to do and how to manage them (acute and chronic)Finally there is an explaining section – which you will need to do in your examsIm going to make the session as interactive as possible so feel free to ask questions at any point. I do have some group work to do, but we will go through the objectives together first, then you can recall what youve learnt
4Crohn's verses UC Definition? Aetiology? So we will start with the definiation and aeitoogy of crohns and Ulcreative colitis: Any ideas?Crohn's verses UC
5Crohn's verses UC Definition Aeitology Chronic Relapsing and remitting Inflammatory bowel diseaseChrons: any part of GI tract - often terminal ileumUC: large bowelAeitologyUnknownGeneticEnvironmentalSo the definition is basiaclly the same for both – its chronic; relapsing and remitting; its an inflammatory bowel disease (which you should know because thats the name of this teaching session); and it affects either any part of the GI tract (crohns) or the large bowel only (UC).The cause for this is great to get in exams – because if clever scientist dont know then they cant expect you to – so the cause is ‘unknown but possibly due to a combination of genetic and environmental factors’ May be due to immune reaction to infection.
7Crohn’sSo have any of your heard the worse pneumonic (second to the 5 B’s of bone metatasis) ever given in medicine and if not can you guess it with this picture diagram.Tranny Granny skip down cobblestone street.
8Tranny Granny Skipped down Cobblestone street Crohn’sTranny Granny Skipped down Cobblestone streetStricturesFistulaeAbscessesTranny = Transmural (extends through layers of the bowel)Granny = Granulomatous (non caseating)Skipping – Skip lesions; Often with RECTAL SPARINGCobblestone appearance – ulcers seperated by areas of normal tissueBecause of the transmural pathology of Crohns patients can develop strictures, fistulae and abscesses.UC: Starts at the rectum –no rectal sparing (up the chuff); and extends proximally. Can sometimes be transmural and have granulomas but for this is uncommon so for the sake of exams it affects the mucosal lining only.
9Can see the cobble stone mucosa – the bumps are the unaffected bowel – pseudopolpys Crohn’s
10Proctosigmoiditis = rectum and sigmoid colon Left sided Colitis Ulcerative colitisStarts from rectumExtends proximallyContinuousMucosa onlyProctitis = rectumProctosigmoiditis = rectum and sigmoid colonLeft sided ColitisPancolitis – Whole of large colonUC: Starts at the rectum –no rectal sparing (up the chuff); and extends proximally. Can sometimes be transmural and have granulomas but for this is uncommon so for the sake of exams it affects the mucosal lining only.You may heard lots of different names for how far up the colon the disease effects. But basically it can affect just the rectum; the rectum and sigmoid colon; the whole left side of the large bowel; or the whole bowel, which is Pancolitis. This is important because it can affect the symptoms that the patient expereinces and also the management.
11ObjectivesRecognise the differences in presentation between Crohn’s and UC – and how these relate to underlying pathologyRecognise the possibility of IBD in patient’s presenting with lower GI symptomsSo we are now well on our way to being able to check off 2 of the 5 IBD objectives from your handbook... So we will no think about how crohns and UC may present based on what we now know about the pathology of each disease, and also thinking about the area of the bowel that is being affected:
12So Crohns. We know it can affect any part of the bowel; and that its Transmural, which opens it up to more complications, so how may it present?Crohn’s
13Crohn’s Crampy abdominal pain Diarrhoea Weight loss Fever Anaemia Inflammation; fibrosis; bowel obstructionDiarrhoeaBloodSteatorrheaWeight lossFeverAnaemiaObstruction: Distension, VomitingAbscessesFistulae: Enteroenteral; Anorectal; Vesicointestinal; RectovaginalAbdominal pain is common – whether its due to inflammation or fibrosisDiarrhoea – when affecting the large bowel; but can also be present seoncdary to malabsorption when it affects the small bowelWeight loss – may be due to malabsorption; or general loss of apeptiteFever – chrons tends up present with more systemic symptoms than UC.Think about complications:Strictures= Obstruction: Small bowel – distension; vomitingAbscesses: Often perianalFistulae: (abnormal connection between 2 epithelial lined organs/vessels. May have pnuemonuria/ fecealuria;
14UC – Affects colon; involves rectum UC – Affects colon; involves rectum. Think about what symptoms she may have.Ulcerative Colitis
15Ulcerative Colitis Crampy abdominal pain Diarrhoea Urgency Tenesmus Relieved by defecationLeft iliac fossaDiarrhoeaBlood ++MucousUrgencyTenesmusWeight lossFeverAnaemiaSeverity: Truelove Witts CriteriaUC: Again have abdominal pain – but more likely due to inflammation in the large bowel and so often worse in left iliac fossa, releived by defecation. Much more blood in diarrhoea along with mucous. They may have a feeling of urgency and tenesmus – inflammation make them feel like faeces in rectum. Can also have weight loss due to feeling generally unwell and fever-more during an acute flare. Systemic symptoms are less common in UC and if present they suggest a pancolitis.In UC we can assess the severity of the disease using the truelove witts criteria: Dont need to know all about this-if your just aware of it this should be enough for your exams.Stools (<4/day = mild; >6 = severe)Temperature: None=mild; >37.8=severePulse: Normal=mild; >90= severeHb: >11= mild; <10.5= severeESR: <20=mild; >30m/hr= severe
16Recognise the possibility of systemic symptoms associated with IBD. ObjectivesRecognise the possibility of systemic symptoms associated with IBD.So what are the extra-intestinal symptoms?
17Extra-intestinal symptoms EyesIritis; uveitis; episcleritisSkinErythema nodosum; pyoderma gangrenosumJointsSeronegative spondyloarthropathyLarge joints; Spine; Sacroiliitis; Can affect small jointsOtherClubbingDVTPrimary sclerosing cholangitis (UC)Heamolytic anaemia (autoimmune) (Crohn’s)Osetoporosis (Crohn’s)Extra-intestinal symptoms – love to ask this. List is endless. They only have 5 minutes to ask you questions/ 4-5marks on written so jiust learn a few various ones. Just rememeber eyes, skin, joints.3% patients with UC have PSC % of patients with PSC have UC
20Get into 2 groupsComplete first 3 boxes on form based on what we have just done.What are your differential diagnosis to consider in a patient presenting with IBD symptoms?Abdominal painDiarrhoeaPR bleeding/ mucousWeight lossMalabsorption(Thanks to Zoe Campbell for providing the basis to this form)This is a form similar to the one I used during my revision.Look up differentialsColon ca – diarrhoea; PR bleeding, weight loss (also anaemia): Need to rule out. May feel mass; PR examinationIBS: Bloating; may also have constipation; Anxiety; stress; Gastro-intestinal reflex; Diagnosis of exclusionCoeliacs: Malabsorption; Steatorrhoea; Weight loss; Abdo pain/discomfort; Diarrhoea.Infective: acute. Recent abx? Usually resolves in 2-3 weeks. > 1 month needs investigationConstipation: overflow diarrhoea; abdo pain; unlikely in younger age groupRandom stuff: Anorexia/Bulimia: teenagers: weight loss; vomiting; abdominal pain; microscopic colitis (chronic diarrheoa, normal colonoscopy, lymphocytes in biospy); ischeamic bowel –(acute-risk factors)
21Initiate appropriate investigations in a patient with suspected IBD BedsideBloodsImagingSpecial testsWhat investigations are you going to do?
22Investigations Bedside Bloods Stool MC&S Faecal calprotectin FBC (low Hb; High WCC)ESR; CRP (high)LFTs: Low albuminU&Es: Chronic diarrhoea – electrolyte imbalanceHeamatinics: ferritin, Vitamin B12, folateAmylaseCross matchBedside – stool sample-rule out infective cause; Calprotectin – distinguish between IBS and IBD-monitor disease severity (some people love some dont)Bloods: Inflammatory markers; signs malnutrition; rule out other caused (amylase); Cross match if blood loss severe
23Not in acute flare!!! Investigations Imaging Special test Abdominal X-rayErect Chest X-rayBarium Meal (Crohn's)Fibrosis, Strictures, Ulceration (‘rose thorn’)Barium enema (UC)Featureless narrow colon, Loss of haustral patternCT/MRI enterography (Crohn’s)Special testFlexible sigmoidoscopyColonoscopyGastroscopyBIOPSYImaging: Abdo X-ray – rule out toxic megacolon; Might see lead piping (featureless bowel) and inflammation of the bowel walls.Erect CXR: PerforationCan do barium meal (aka swallow; follow-up) – drink barium-do Xrays: done if suspect disease in uypper GI tract –so according to the pathology of Crohn and UC this is only used in Crohns. Might see strictures (apple core lesions) and ulcers.Barium enema can be used in both –but usually in UC.Can also do CT/MRI enterography to view strictures/ fistulae in crohn’sThe you can do endoscopy – again depending on site whether you do gastroscopy or colonscopy. Can differentiate UC from Chrons; and take biospys which is the diagnostic test. (if asked in writtens for diagnostic test it has to be confirmed not suspected test)Dont do colonscopy/ barium enema/meal in acute flares: risk of perforationLong term - repeat colonoscopy –risk colon ca –rule of thumb –done in patients with severe colitis for >10 years.Not in acute flare!!!
24Initiate appropriate management in a patient with IBD AcuteChronicLifestyleMDTUsing the format on the forms
25Management Acute Chronic Surgery: Resection A-E; Bowel rest; Analgesia (not NSAIDs);Steroids: IV; oral; rectalAntibiotics5-ASAsChronicPer rectum steroidsImmunosuppressant'sAzathioprineMethotrexate (Crohn’s)Anti-TNF: InfliximabSurgery: ResectionAcute: A-E: fluids. Symptoms: (always think of these two first – easy marks): Bowel rest: Parenteral feeding. Analgesia (not NSAIDs –make it worse). DVT prophylaxis. Dont give anti-diarrhoeal meds – increase risk of toxic megacolon.Steroids (hydrocortisone)– IV then oral; rectal; Antibiotics -until stool culture available- rule bacterial infection (eg Salmonella; Campylobacter); 5-ASAs (Aminosalicyclates) – sulfasalazine; mesalazine; olsalazineSurgery: In UC (curative). Done as emeragency in acute flare (toxic-risk of perf)or due to recurrent flares; interrupting with lifestyle. Total colectomy – curative.Flow diagram: 5-ASA – Steroids – Azathioprine (immunosupressant) – Methotrexate (Crohns) – Inflizimab
26Management Lifestyle MDT Diet: Elemental Stop smoking? Consultant’s: Gastroenterologist; SurgeonsIBD specialist nurseDieticianSmoking cessationStoma nurseElemental diet: given nutritional drinks- amino acids; nitorgen etc – in simplest form so body doesnt have to break it down.Stop smoking? Worsens UC; improves Crohns- but overall advice- smoking will cause more morbidity in long term. Should encourage to stop.
27Medications used in IBD 5-ASAsSteroidsAzathioprine/ Mercaptopurine (Immunosuppressant)Methotrexate (Crohn's)Infliximab (Anti-TNF)Know you all panic about medications so heres a little bit about the main ones used in IBD, but also in other autoimmune conditions (rheumatology etc) – see SHAD lecture5-ASAs –exact mechanism unknown. Inhibits COX and 5-lipo oxygenase – decrease arachadonic acid- decreased PGs – decreased inflammation. SEs: agranulocytosis; Hepatits; Nausea; Diarrhoea; Abdo pain.Azathioprine: metabolised to 6-mercaptopurine (by thiopurine methyl transferase) –inhibits purine production- decreased leucocyte proliferation; lymphopenia. 1 in 300 deficient in TMPT so test beforehand.No clincal effect for 3 month –need to test FBC:In exam –asked how often-what you going to say?regular (weekly for a month then 3 monthly therefater):Myelosupression. Ses bone marrow suppression; hepatitits; pancreatitis;Chrons: may stop after 4 years; UC very likely to relapse on stopping. Slowly decrease dose.Methotrexate – folate antagonist (inhibits dihydrofolate reductase): essential for DNA sysnthesis. Stop 3 months prior to conception. Not if have effusions (pleural; ascitic)-drug accumuloates and stores then becomes toxic. Given weekly – give with folic acid.Infliximab: Use if severe acute crohns + immunosuppressants not effective/not tolerated + surgery inappropraiteMonoclonal antibody against TNF alpha (proinflammatory cytokine) – attached to tnf alpha recpetors on t lympocytes and blocks it- stops the cell from working = decreased inflammation.Only prescribed by consultants. Give infusion over 2 hours – have obs every 30 mins and resus equipment nearby. Ses hypersenstivity – acute or delayed; resistance; lymphoma; TB reacivation (test beforehand); Dont give live vaccines. Avoid pregnancy fpr 6 months after stopping.Medications used in IBD
28Complete the rest of the form Get back into groups
29ObjectivesExplain to patients the nature of and the rationale for maintenance treatment of IBDCommunication section of the clinical exam is easy marks and you should start practising doing this when you see a case – so pick a proceedure or management or investigation etc to explain and give it a go. THEN, look on patient.co.uk that has information for patients written in a really nice way. Its a great way to get ideas of how to explain things to patients in a way that they will understand. Rememebr to never lie – if you dont know the answer be honest and say this and say you would like to find out for them. Does anyone want to give this a go?
30Increased likelihood of flares depends on: Patient.co.ukOnce a flare-up has settled, without treatment, there is ~1 in 2 chance that another flare-up will develop within a year.Increased likelihood of flares depends on:extent of the disease in your gutage,the extent of treatment needed to control the initial flare-up.If flares not frequent/mild/ respond well to acute treatment then - may not need to /wish to take regular medsFor others regular meds can improve QOL ++This is from patient.co.uk
31Immunosuppressants – take daily The treatment options that may be considered to prevent flare-ups) include:Immunosuppressants – take dailyMesalazine – used daily (less common now)Anti-TNF – selected cases where flares severe and other treatments not worked: Have infusion in hospital every 8 weeks.Steroid medication is not generally used long- term to prevent flare-upsThese treatments increase the chance of remaining free of flare-ups, but they do not always work.Balance between benefits and the possible side-effects.Look up objectives in your handbook that have ‘explain, describe, understand etc’ and practise doing this.
323 key points to take awayUnderstanding the pathophysiology of UC and Crohn’s is actually useful!SymptomsInvestigationsManagementCommunication is key- in exams AND in real life:Patient.co.ukEasy marks in exams if you practice!Structured answers in examsBedside; Bloods; Imaging; Special testsAcute; chronicAcute; Chronic; lifestyle; MDTConservative; Medical; SurgicalUnlike lots of useless stuff you have to learn for exams, the pathology of crohns verses UC is actually more useful than you might think – it helps to understand the symptoms; interpret/ choose investigation; and choose appropraite treatment.Learning to talk to patients at their level is really important – not just for exams but also when you start working.Think of a structure to use in exams and stick to it – helps to practice so you remember it when your nervous and mind goes blank-happy you rememebr your system.