Inflammatory Bowel Disease Katie Benner VTS 2

Crohns & UC Complex disorders & wide variation in clinical practice Chronic idiopathic inflammaotry intestinal conditions Patients may find symptoms embarassing May result in loss of education/ employment difficulties Growth failure, psych probs, sexual development probs

Often presents young Lifelong disease Disproportionately high impact on society Hospital serving 300,000 sees new cases per annum Small increase in mortality for both

Approach to care High level of training Central hospitals supporting DGHs Rapid access to clinic appts for new/ known pts Provide counselling and educational material Access to private toilet facilities Multi disciplinary team

Patient’s experience See pts as individuals not as the disease Views on “right” and “wrong” life approaches to be avoided Respect pts expertise Sympathy, compassion & interest

Diagnosis Symptoms often dismissed as “stress related” Rapid access to hospital ixs Rapid referral to gastroenterologist specialising in IBD

History Stool frequency/ consistency/ urgency/ rectal bleeding/ tenesmus/ abdo pain/ malaise/ fever/ weight loss Extraintestinal- joint/ eye/ cutaneous Travel/ smoking/ FH/ medication

Examination General wellbeing Pulse, BP and temp Signs anaemia Fluid depletion, weight loss Abdo pain/ distension/ palp. masses Perineal exam

Investigations FBC/ U&E/ LFT/ ESR/ CRP Micro testing for infectious diarrhoea Additional tests for abroad travellers Abdominal imaging r/o toxic megacolon (in hosp) Felxi sigi/ colonoscopy (disease extent/ severity) Histopathology

Drugs used Rapidly evolving field, likely to change drastically in next 10 years Usually started in secondary care, but useful to know what they do, how to monitor, what side effects to watch out for

Aminosalicylates E.g. Mesalazine/ “Pentasa” Oral tablets/ sachets/ suspension/ liquid/ foam enemas/ suppositories act on epithelial cells by a variety of mechanisms to moderate the release of lipid mediators, cytokines, and reactive oxygen species Better tolerability than sulfasalazine Higher doses to induce remission

Aminosalicylates cont… Mesalazine intolerance in 15% Diarrhoea/ headache/ nausea/ rash

Corticosteroids Oral/ IV/ topical/ suppositories/ foam enemas Potent anti-inflammatories for moderate to severe relapses of CD or UC Combination of oral & rectal better 40mg pred optimal for outpatient management Too rapid a reduction assd with relapse

Corticosteroids cont.. Decision to use must be weighed up against risks Should be weaned slowly e.g. at 5mg/ week 50% pts report no adverse effects Cosmetic e.g. moon face, sleep & psychiatric

Thiopurines E.g. “azathioprine” mechanism of immunomodulation is by inducing T cell apoptosis by modulating cell signalling Note potential hepatotoxicity Need LFT monitoring (organised thru pharmacy) Use in active disease and maintaining remission

Thiopurines cont… Role is steroid sparing Consider in pts needing 2 or more courses steroids in a year (This is also when they need secondary care input) thiopurine methyl transferase (TPMT) must be tested 1 st If TPMT deficient ^ risk myelotoxicity

Thiopurines cont… 20% intolerance Flu like symptoms 2-3 weeks after started & resolve once drug withdrawn Profound leucopenia in 3% Hepatoxicity and pancreatitis in <5% Can be continued in pregnancy if IBD felt to be refractory

Methotrexate Unlicensed in IBD Oral/ IM/ SC Mechanism unclear Useful in inducing remission 25mg/week (15mg/week in RA) Measure FBC and LFT before starting and monthly thereafter

Methotrexate cont… Nausea/ vomiting/ diarrhoea/ stomatitis Limited by co-rx folic acid Pneumonitis occurs in 2-3%

Ciclosporin Inhibitor of calcineurin, preventing clonal expansion of T-cell subsets Rapid onset of action Used in mx severe UC Can be used as IV salvage therapy in those heading for colectomy Measurement of blood pressure, full blood count, renal function, and CsA concentration at 0, 1, and 2 weeks, then monthly

Ciclosporin cont… Minor side effects in 31-51% Tremor/ paraesthesia/ malaise/ headache, abnormal LFTs/ gingival hyperplasia/ hirsutism Major s/es in up to 17% Renal impairment/ infections/ neurotoxicity May require pneumocystis cariinei jab

Infliximab Chimeric anti-TNF monoclonal antibody with potent anti-inflammatory effects Needs to be done in secondary care Need maintenance doses, intitially after 2 weeks, 8+ weekly thereafter Need pre- infliximab virology checks (with pt consent), CXR and EBV in men under 30 Further doses given on PIU in Barnsley

Infliximab cont… Use with immunomodulator as increase interval between doses Rarely infusion reactions Delayed reactions of joint pain/ myalgia/ fever Theoretical risk of lymphoproliferative disorders

Surgery Disease not responding to intensive medical therapy Manage between surgeon and gastroenterologist Pre-operative conselling and involvement of stoma nurse specialist Subtotal colectomy leaving long rectal stump

Surveillance for colonic carcinoma UC pts should get repeat colonscopy in years Extensive colitis (opting for surveillance) 3- yearly in teens, 2-yearly in 20s and yearly in 30s Pts with PSC have higher risk of cancer and should have annual colonscopies

Pt information NACC: The National Association for Colitis and Crohn’s disease, 4 Beaumont House, Sutton Road, St Albans, Herts AL1 5HH, UK. Information Line: ; website: CCFA: The Crohn’s and Colitis Foundation of America; website: CORE/DDF: Digestive Diseases Foundation, PO Box 251, Edgware, Middlesex, HA8 6HG, UK.

Who to contact? Debbie (IBD specialist nurse) on bleep 591 or Specific IBD advice line 2-3pm

References British Society of Gastroenterology Guidelines for the management of inflammatory bowel disease in adults Gut 2004

Thank you Any questions?