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©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):
©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 MFMER | slide-10 ©2012 MFMER | slide-10 Faubion SS et al. Mayo Clinic Proceedings 2012; 87:
©2013 MFMER | slide-11 Results: Symptoms 1625 Number of patients 57% 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 /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: %
©2013 MFMER | slide-23 Biancone 2000 Pimentel 2003 Collins 2011 Chang 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:
©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 Colesevelam g/d Colestyramine4-36 g/day Colestipol5-30 g/day Loperamide, Diphenoxylate /atropine
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