We think you have liked this presentation. If you wish to download it, please recommend it to your friends in any social system. Share buttons are a little bit lower. Thank you!
Presentation is loading. Please wait.
Published byFreddie Priestly
Modified about 1 year ago
©2013 MFMER | slide-1 Management of Co-Existing Disorders That Make IBD Worse S. Kane, M.D., W. Tremaine, M.D. Rochester, MN,
©2013 MFMER | slide-2 Sunanda Kane, M.D.
©2013 MFMER | slide-3 Case 1 29 yr old woman with history of Crohn’s disease of terminal ileum, colon Presents to office with several months of worsening lower abdominal pain Has episodic diarrhea and bleeding Currently on adalimumab + azathioprine On physical exam tender in periumbilical area, no rebound guarding or mass
©2013 MFMER | slide-4 Case 1 continued Labs including CBC, CRP normal Fecal calprotectin level normal Empiric trial of anti-spasmodic no help, she returns a month later with same sx CT performed
©2013 MFMER | slide-5 CT Scan
©2013 MFMER | slide-6 Case 1 continued Endometriosis can present with cyclical symptoms that patients will describe as “intermittent” or “unpredictable” Can present with diarrhea, bleeding that correlates with menses or just pelvic pain Jess T. Gut 2012; 61(9):1279-83.
©2013 MFMER | slide-7 Case 2 28 year old Crohn’s ileocolitis for 9 years Previous 12 cm ileal plus cecal resection Maintenance treatment: Adalimumab 40 mg weekly. Blood levels therapeutic. Current symptoms: Abdominal pain, bloating, distension. Loose stools, 0-5 daily.
©2013 MFMER | slide-8 Case 2 continued Physical exam Looks well No abdominal mass, mild direct tenderness Rectal. No lesions. No perineal descent with valsalva Colonoscopy Patchy erythema and granularity in the colon, no ulcers, normal TI
©2013 MFMER | slide-9 Rectal Balloon Expulsion Test LyingMeasurementWeight Normal< 200 gm Bharucha A et al. Gastro 2013. 144: 218-38
©2013 MFMER | slide-10 ©2012 MFMER | slide-10 Faubion SS et al. Mayo Clinic Proceedings 2012; 87: 187-93
©2013 MFMER | slide-11 Results: Symptoms 1625 Number of patients 57% 46 39 UC Crohn’s 71% of N-R PFD pt. have Diarrhea 20% of N-R PFD pt. have constipation
©2013 MFMER | slide-12 Pelvic Floor Retraining 1:1 training with a physical therapist Three times daily for 5 days then 2 times daily sessions for 5 days Initially with rectal sensor and EMG monitoring; subsequently rectal balloon expulsion
©2013 MFMER | slide-13 Results: Pelvic Floor Retraining. n=19 ImprovementNo ImprovementTotal Female4610 Male639 Ulcerative colitis 033 Crohn’s Disease 066 Ileal J-pouch Pouchitis No-Pouchitis 10 8 2 010 10/19 (53%) improved
©2013 MFMER | slide-14 Case 3 41 yr old male with Crohn’s ileocolitis presents with intermittent abdominal pain No weight loss, diarrhea, bleeding More stress at work with big project due Physical exam unremarkable Labs including CBC, CRP, chemistries nl Trial of amitriptyline initiated
©2013 MFMER | slide-15 Case 3 continued Pt returns 2 months later with worse RLQ pain, still intermittent though Not related to food CT scan performed
©2013 MFMER | slide-16 Case 3
©2013 MFMER | slide-17 Case 3 continued Midgut carcinoid causes pain No diarrhea if no liver mets Surgical resection is treatment
©2013 MFMER | slide-18 Case 4 38 year old 3 jejuno-ileal resections totaling 160cm, 7 strictureplasties 280 cm of small bowel from ligament of Treitz to ileocecal valve Certolizumab plus methotrexate maintenance therapy
©2013 MFMER | slide-19 Case 4 continued Abdominal bloating, cramping, 3-8 loose to liquid stools daily 3 kg weight loss in the past 9 months Exam Mild dehydration No abdominal masses Normal rectal exam and pelvic descent
©2013 MFMER | slide-20
©2013 MFMER | slide-21 Case 4 continued Glucose hydrogen breath test Negative Upper GI endoscopy Normal, including duodenal biopsies Duodenal aspirates Multiple bacteria with >10 5 CFU/ml
©2013 MFMER | slide-22 SIBO in IBS: Aspirates vs Breath Tests Uttar Pradesh, India 80 pt with IBS, Rome 3 UGI endoscopy with small duodenal aspirates Glucose hydrogen breath test Lactulose hydrogen breath test Ghoshal UC et al. Eur J Gastro Hep 2014; 26: 753-60 %
©2013 MFMER | slide-23 Biancone 2000 Pimentel 2003 Collins 2011 Chang 2011 0.110 Overall (95% CI 2.55 Meta-analysis: antibiotics for SIBO Shah SC et al. Aliment Pharm Ther 2013; 38(8)
©2013 MFMER | slide-24 SIBO Treatment Trials AntibioticTest Rifaxamin vs placeboLHBT Rifaxamin vs MetronidazoleGHBT Metronidazole vs CiproLHBT Neomycin vs placeboLHBT Shah SC et al. Aliment Pharm Ther 2013; 38(8)
©2013 MFMER | slide-25 SIBO in Inactive Crohn’s Disease Valencia Spain 107 pt with CD in remission Immune suppressants: 57% Biologics: 20% GHBT Positive 16.8% SIBO: YES vs NOP value Immune suppressants NS BiologicsNS Dual RxNS PPINS Sánchez-Montes C et al. World J Gastro 2014; 20: 13999-14003
©2013 MFMER | slide-26 Case 5 32 yr old with history of Crohn’s ileocolitis presents with abdominal pain, bloating Patient trying to lose weight secondary to steroid course Some nausea but no vomiting, rectal bleeding or diarrhea Physical exam reveals some tympany to percussion but soft and non-tender
©2013 MFMER | slide-27 Case 5 continued Labs including CBC, CRP and chemistries all normal CT scan shows stable inactive disease Trial of amitriptyline unsuccessful Now what?
©2013 MFMER | slide-28 Case 5 continued Next visit significant other comes along Complains that “special diet” is expensive and disruptive to household Patient has researched “IBD diets” and is on a regimen that is supposed to boost the immune system and “cleanse the body as well as the soul” Contains nothing but high residue and high FODMAP ingredients
©2013 MFMER | slide-29 Case 6 39 year old. Crohn’s since age 14. Two ileal resections totaling 73 cm. Last surgery 5 y ago. No recurrence seen at Colonoscopy, MRE each twice in past 3 years. Negative WCE one year ago. Normal CRP, Vitamin D, A, E, Ferritin. On B12 shots. Watery stools, 8-10 daily. Abdominal pain. Stable weight No improvement with colesevelam tablets. Hydromorphone 8 mg each 4 hours
©2013 MFMER | slide-30 Case 6 continued Working diagnoses BAM bile acid malabsorption BAD bile acid diarrhea Narcotic Bowel Syndrome
©2013 MFMER | slide-31 BAM: frequency in chronic diarrhea Sheffield, UK 92 consecutive pt with chronic diarrhea Full work-up Endoscopies Capsule CT GHBT, LHBT SEHCAT Scan Diagnosis% * IBD, Functional79 IBD9 BAD6 Lactose intolerance4 Celiac disease3 Lymphocytic colitis2 Pancreatic insufficiency1 SIBO1 * Some had 2 diagnoses Kurien M et al. Alimen Pharm & Ther 2014; 40: 215
©2013 MFMER | slide-32 Bile Acid Malabsorption Type 1: Post-ileal resection Type 2: Primary, idiopathic Type 3: Other causes cholecystectomy gastric surgery radiation
©2013 MFMER | slide-33 BAM: diagnosis SeHCAT Scan 7 alphaC4 blood test 24 hr stool collection for bile acids
©2013 MFMER | slide-34 BAD: treatment TreatmentDose Colesevelam3.75-4.375 g/d Colestyramine4-36 g/day Colestipol5-30 g/day Loperamide, Diphenoxylate /atropine
IBD Patient Update Case Vignettes 12 November 2011.
Colitis in the Very Young. Case 8 month old presented with bloody bowel movements and diarrhea Maternal history of UC Endoscopy – pan colitis Infectious.
The only end-points of therapy that matter are mucosal healing, normal blood work, and negative radiologic studies. Robert N. Baldassano, MD Colman Family.
Gastroenterology Grand Rounds May 1, 2014 Fellow: David Tang, M.D. Faculty: Milena Gould, M.D.
An interesting case of a 42 year old woman with diarrhea Christie Seibert, MD July 28, 2004.
Management of Inflammatory bowel disease 8/12/10.
January 2007 Clinical Cases. BACKGROUND A 57-year-old man presents to a local emergency department with severe abdominal pain after being evacuated from.
Inflammatory Bowel Disease. Inflammatory Bowel Disease (IBD) Ulcerative colitis and Crohn's disease Chronic inflammatory diseases of the gastrointestinal.
A Case of Crohn’s Disease Rich Rames, M3 May/June 2013 Dr. Joy Sclamberg, Dr. James Cameron, Dr. Aditi Gulabani.
Ulcerative Colitis. Ulcerative colitis is a chronic inflammation of the large intestine (colon).It is a form of inflammatory bowel disease (IBD), which.
Lower Gastrointestinal Bleeding Kirk Bernadino, M.D. St. Mary’s / Duluth Clinic Section of Gastroenterology.
Digestive System. A pt present to the ER c/o pain in RUQ that radiates to his right shoulder. He has had a weight loss of 15 pounds over the last month.
NYU Medical Grand Rounds Clinical Vignette Andy Levy, MD PGY-2 March 26, 2013 U NITED S TATES D EPARTMENT OF V ETERANS A FFAIRS.
Lower GI Bleed T R Wilson Doncaster Royal Infirmary.
CROHN’S DISEASE ALLIE ABRAHAM. WHAT IS IT? An inflammatory bowel disease that causes inflammation of the digestive tract. It is an unpredictable disease.
Celiac disease is an immune reaction to eating gluten, a protein found in wheat, barley and rye. If you have celiac disease, eating gluten triggers.
Crohn’s Disease Kyra Alexander. What is it? An inflammatory bowel disease that causes inflammation of the digestive tract. It is an unpredictable disease.
HPI A 25 year old Caucasian male presents to your clinic with two month history of crampy abdominal pain and diarrhea. What else would you like to know?
IBS In The Elderly Monica J. Cox ARNP-BC, MSN, MPH Geriatric Nurse Practitioner G.I. Nurse Practitioner Borland-Groover Clinic Jacksonville, Florida.
Raneen Omary. Contents Definition Pathogenesis Epidemiology Acute Radiation Enteritis Chronic Radiation Enteritis Risk Factors Diagnosis DD Medical Management.
Case Presentation. Female Patient AB Aged 20 First seen by me in August 2009 Had been diagnosed with Crohn’s Disease in March 2009.
By: Leon Richardson Period 2. Crohn’s Disease Affects Crohn's disease is a form of inflammatory bowel disease (IBD). It usually affects the intestines,
Inflammatory Bowel Disease Crohn’s Disease And Ulcerative Colitis.
David J. Hass, MD Assistant Clinical Professor of Medicine Yale University School of Medicine Gastroenterology Center of Connecticut, P.C.
Diagnostic Work-up. There is no specific laboratory or imaging test to diagnose irritable bowel syndrome. Currently the diagnosis of IBS relies on meeting.
An Autoimmune Disorder Crohn’s disease is inflammation of the digestive system that results from an abnormal immune response. A cure has not yet.
Case Presentation 34 y/o male34 y/o male 5 years Crohn’s disease of ileum and Rt. colon5 years Crohn’s disease of ileum and Rt. colon 10 days – Fever,
Case 1 21 year old male office worker GP referral, “IBS not responding to Rx 3 month history of abdominal discomfort, worse after eating, can keep him.
IMAGE CHALLENGE. A 51-year-old woman with a history of hypertension and chronic constipation presented with abdominal pain of 2 weeks' duration. The.
Marked by a group of GI symptoms often related to stress. Symptoms often benign, sometimes showing no physical or inflammatory condition More.
NYU Medical Grand Rounds Clinical Vignette Rennie Rhee MD, PGY-2 January 13, 2010 U NITED S TATES D EPARTMENT OF V ETERANS A FFAIRS.
Is the capsule a guiding star ? Dr. Niv Eva Department of Gastroenterology Tel-Aviv Sourasky Medical Center.
What are we talking about? Functional gastrointestinal disorders (FGIDs) are deﬁned as a variable combination of chronic or recurrent gastrointestinal.
Clinical Vignette: Medical Grand Rounds Joshua L. Denson MD Internal Medicine PGY2 January 7, 2013 U NITED S TATES D EPARTMENT OF V ETERANS A FFAIRS.
Copyright HD Scientific All Rights Reserved 1 When Is Intestinal Gas Dangerous? Dangerous?
CASE HISTORY #1 AIBD Breakout Session Douglas C. Wolf, M.D.
Bile Acids: The Good, the BAD and the Ugly Dr Matthew Kurien Academic Clinical Lecturer in Gastroenterology, University of Sheffield.
26 year old female from Texas presenting with loose stools and bloating for 2.5 weeks. She noticed that she also has intermittent dull abdominal pain.
Upper Gastrointestinal Disease Bradley J. Phillips, MD Burn-Trauma-ICU Adults & Pediatrics.
Vomiting, Diarrhea & Constipation Mark J. Koruda, MD Professor of Surgery.
A Novel Presentation of 6-Mercaptopurine Toxicity in a Patient with IBD Zachary C. Junga, MD, Nisha A. Shah, MD, and John D. Betteridge,
An Introduction To. Outline What is the Disease? Epidemiology Pathophysiology Ulcerative Colitis Crohn’s Disease.
Crohn’s Disease Presenting as Intestinal Parasites “I got worms…” Poster by Jared Halterman, Kade Rasmussen DO, and Joseph Dougherty DO A 14 year-old male.
Chronic Diarrheal Diseases Mohammed al-matrafi. Diarrhea more than 2 weeks.
Should we Screen for Celiac Disease in IBS? Brennan Spiegel, MD, MSHS.
Inflammatory Bowel Disease NPN 200 Medical Surgical I.
Irritable Bowel Syndrome 1481 Nadeem Khan March 2, 2015.
This lecture was conducted during the Nephrology Unit Grand Ground by Medical Student rotated under Nephrology Division under the supervision and administration.
Kim Eastman RN,MSN, CNS. INFLAMMATORY BOWEL DISEASE OVERVIEW IMMUNOLOGIC DISEASE THAT RESULTS IN INTESTINAL INFLAMMATION ULCERATIVE COLITIS CROHN’S.
Primary Impression. Active Pulmonary TB and Gastrointestinal tuberculosis previous history of TB – No sputum AFB smear was done to see if the patient.
© 2017 SlidePlayer.com Inc. All rights reserved.