Dr Sam Gausden FY2 February 2015 Inflammatory bowel disease

Contents/aims/objectives Definition Presentation Investigations Management Clinical scenario Explanation station

Definition

Umbrella term

Definition Umbrella term Chronic

Definition Umbrella term Chronic Relapsing-remitting

Definition Umbrella term Chronic Relapsing-remitting Acute non-infectious inflammation

Differences

Distribution

Differences

Distribution Smoking

Smoking in IBD 2/3 Crohn’s pts are smokers and cessation halves relapse 95% of UC pts are non- smokers or ex-smokers

Smoking in IBD YOU SEE people smoking with UC Smoking in Crohn’s makes you want to GROAN

Differences Distribution Smoking Histology

UC histology

Hyperaemic/haemorrhagic colonic mucosa Pseudopolyps Usually on affects mucosal layer Absence of goblet cells

Crohn’s histology Transmural granulomatous inflammation Cobblestoning MACROSCOPICALLY: Strictures, abscesses, fistulae, skip lesions

Systemic manifestations

Hepatic - autoimmune hepatitis (UC), gallstones (Cr), PSC (UC)

Systemic manifestations Hepatic Other - VTE, osteoporosis (Cr), amyloidosis (Cr )

Systemic manifestations Hepatic Other Rheum - arthritis, sacro-ileitis, AS

Systemic manifestations Hepatic Other Rheum Skin – EN and PG (UC>Cr)

Systemic manifestations Hepatic Other Rheum Skin Eyes – iritis, uveitis

Eyes Uveal tract = iris, ciliary body and choroid

Systemic manifestations H epatic O ther R heum S kin E yes

Symptoms - UC

Diarrhoea + blood/mucous Faecal urgency/incontinence Tenesmus Lower abdominal pain Tiredness/malaise Weight loss/failure to thrive or grow Fever

Symptoms – Crohn’s

Symptoms - Crohn’s Diarrhoea +/- blood/mucous Malabsorption Abdominal pain (crampy) Mouth ulcers Bowel obstruction Fistulas (perianal) Abscesses (perianal/intrabdominal ) Tiredness/malaise Weight loss/failure to thrive or grow Fever

Signs - UC

Clubbing Pallor Eyes Legs Abdominal tenderness PR

Signs – Crohn’s

Clubbing Pallor Eyes Mouth Legs Abdominal tenderness Mass in RIF PR – skin tags, abscesses, fistulas

Investigations

Bedside tests

Faecal calprotectin Protein common in neutrophil cytoplasm Bacteriostatic and resistant to enzyme degredation NICE guideline: 1) To differentiate IBD from IBS in pts where cancer is NOT suspected Also: can also be used to evaluate IBD Rx and predict flares

Blood tests

Imaging (acute)

Special test (acute)

Special tests (acute)

Management (long-term)

Conservative

Inducing remission in mild-mod UC 1

1) Aminosalicylates 2) Steroids 3) Immunosuppression (tacrolimus)

Inducing remission in severe UC (inpatient) 1

1) IV steroids 2) Immunosuppression (ciclosporin) 3) Biologics (infliximab)

Assessing UC severity

TRUELOVE AND WITTS’ CRITERIA 1

Inducing remission in Crohn’s 1

1) Steroids (oral or IV) 2) Aminosalicylates (2 nd line) 3) Immunosuppressants (aza, mercapto, methotrexate) 4) Biologics (infliximab or adalimumab)

Maintaining remission in UC

1) Aminosalicylates 2) Immunosupressants (aza or mercapto)

Maintaining remission in Crohn’s

1) Immunosupressants (aza, mercapto or MTX) 2) Continue biologics 3) OR nothing

Surgery Indications Incidence

Prognosis Ca colon risk with UC approx. 15% over 20yrs with pancolitis Colonoscopy screening (after 1-5 years depending on risk)

Scenario time 29 year old female PC: Diarrhoea HPC: 1/12 Hx 12x day now Blood and mucous mixed in Cramping LIF pain Unwell and lethargic

On examination Temp: 38.2C Soft Abdomen, slightly distended Tender in LIF PR exam very painful and reveals fresh blood and mucous on the glove Diagnosis?

On examination Temp: 38.2C Soft Abdomen, slightly distended Tender in LIF PR exam very painful and reveals fresh blood and mucous on the glove Diagnosis? Acute flare of UC

Differential diagnoses?

Infection Inflammation Neoplastic Vascular Drugs

Acute investigations?

Stool culture, pregnancy test FBC, U&Es, LFTs, CRP, ESR, clotting, G&S Erect CXR, AXR, CT abdomen ?flexi sigmoidoscopy

Long-term investigation?

Colonoscopy + biopsy Colonoscopic surveillance

Initial acute management

A-E approach NBM, IVI, transfusion depending on Hb IV hydrocortisone +/- rectal steroids If getting better – transfer to oral pred and 5-ASA If getting worse – consider ciclo/infliximab/surgery

Long term management

Aminosalicylates Azathioprine or mercaptopurine

Comparing Crohn’s and UC Clinical presentation Histological findings? Smoking?

Recap Scoring system for UC severity? Extra-intestional manifestations of IBD?

Explanation station Please explain a colonoscopy to the patient

Explanation station Check patient’s understanding Think about patient’s experience Why we do it and risks No jargon Any questions Leaflet

Always remember for IBD Ask about eyes, joints and skin Only ever do flexi sig in an acute flare If in doubt over diagnosis, say IBD Know difference between ileostomy and colostomy Test for TB before starting infliximab Any questions?

References 1) and-diseases/digestive-tract- conditions/inflammatory-bowel-disease