1. Inflammatory Bowel Disease Cathy Corden GP VTS ST1

2. Mrs RS  34 year old female  Presented with 3/12 hx of lower abdominal cramps, like period pains. Bloating after eating.  No bowel or bladder problems.  Feeling a little stressed at present.  G3, P2 + 1 ectopic pregnancy (left). What are your initial thoughts?

3. Mrs RS  Pregnancy test – negative  Reassured, likely IBS  Sent for USS pelvis  Represented 3/12 later. Worsening abdominal discomfort, frequent loose stools. USS pelvis normal.  Treated as IBS but sent for bloods FBC, ESR, IP, coeliac, TFT.

4. Mrs RS  Patient returned a few days later. Started crying in reception re worsening of her pain and diarrhoea.  The duty doctor was asked to see her at the end of surgery.

5. Mrs RS  Gliadin antibody neg  WCC 16.38  Hb 10.6g/dL  Platelets 463  TFT nad  LFT nad  ESR 53

6. Mrs RS  What would you want to ask in the history?

7. History  Stool frequency and consistency  Urgency  Rectal bleeding  Abdominal pain  Malaise  Fever  Weight loss  Recent travel  Smoking  FH

8. Mrs RS  Bowels opening 4-6 times daily for last 2- 3/12. Loose motions.  Intermittent urgency to defaecate.  No blood or mucus in stool.  Abdominal pain and bloating.  Nauseous and fatigued.  Weight loss ½ stone last 4 weeks.  Non smoker.  FH father has Crohn’s Disease

9. Mrs RS  Examination  Temp. 37.8C. P86/min reg. BP normal for her.  Tender to palpation RIF. Bowel sounds normal.  What would you do now?

10. Mrs RS  Patient was admitted under the surgeons as ?appendicitis.  Underwent barium follow through which showed narrowing and mucosal ulceration of terminal ileum.  Diagnosed with Crohn’s Disease

11. Right posterior oblique spot image from SBFT in patient with Crohn disease shows ileocecal fistulas (small arrows) with narrowing of terminal ileum (large arrow) near ileocecal valve. Levine M S et al. Radiology 2008;249:445-460 ©2008 by Radiological Society of North America

12. Frontal spot image from SBFT in patient with Crohn disease shows multiple aphthoid ulcers as punctate collections of barium surrounded by radiolucent mounds of edema (arrows). Levine M S et al. Radiology 2008;249:445-460 ©2008 by Radiological Society of North America

13. Mrs RS  What would the initial inpatient treatment be for active Crohn’s Disease?

14. Mrs RS  Started on IV steroids and Asacol (mesalazine).  Converted to oral prednisolone 40mg od. To reduce by 5mg/wk over 6-8 weeks.  Referred to gastro.

15. Mrs RS  Made good improvement on steroids and was changed to pentasa. Using loperamide to control diarrhoea.  Colonoscopy – confirmed ulcers/cobblestone appearance

16. Mrs RS  Few months later returned to GP with loose bowel motions, 4 times daily. No blood. Also abdominal pain.  On pentasa 2 gram od.  How would you treat a flare of Crohn’s Disease?

17. Mrs RS  Bloods FBC, U&E, LFT, CRP  Can increase dose of prophylactic aminosalicylates mesalazine to induce remission.  Topical aminosalicylates/steroids  Oral corticosteroids 40 mg prednisolone od. Reduce slowly after 3-4 weeks to 5mg per week over several weeks. Can use budesonide 9mg daily.

18. Mrs RS  Patient returns to GP when prednisolone reduced to 20 mg. Symptoms have returned. Trial increasing back to 40 mg again & reducing more cautiously.  Well until 5 months later. Returned to GP with weight loss, fatigue, loose bowel motions 6-8 times daily. Tender to palpation RIF. Temp 38.4C.

19. Mrs RS  Would you admit this patient?  What are the criteria for acute admission of a Crohn’s Disease patient?

20. Mrs RS  Criteria for admission  Severe abdominal pain, tenderness to palpation.  Severe diarrhoea >8 per day +/- blood.  Systemically unwell, feverish  Weight loss +++  Symptoms of bowel obstruction

21. Mrs RS  Admitted to gastro.  Raised inflammatory markers, anaemic, low albumin.  Stool sample neg for infection  No evidence obstruction AXR.  Treated with IV methylprednisolone.  Once improved converted to oral pred 40 mg reducing course.  Started on azathioprine 50 mg/day.

22. Mrs RS  Seen in gastro clinic few weeks later.  Azathioprine increased to 125mg. Not much improvement. Pentasa 1 gram tds.  Referred to surgeons for consideration of right hemicolectomy due to recurrent need for steroids.

23. Mr SW  63 year old gentleman presented to GP with 2-3 weeks generalised pruritis. No other symptoms. Weight stable. Not been in contact with noticeable allergens.  Treated with loratidine.  Sent for bloods.

24. Mr SW  LFTS abnormal  Bilirubin 6  AlK phos 658ALT 76  GGT 871Alb 33  ESR 57FBC, U&E normal  What would you have done now?

25. Mr SW  Discussed with liver team.  Agreed to rv in clinic.  No jaundice.  No risk factor hepatitis.  Liver screen incl. coag, hepatitis serology, CMV, autoantibodies negative.  Had raised serum globulins.

26. Mr SW  Endoscopic retrograde cholangiopancreatography performed showing multiple intrahepatic bile duct strictures and beading.

27. Mr SW  Diagnosed Primary Sclerosing Cholangitis.  Followed up appointment 9/12 later by liver team.  Noticed a change in his bowel habit last 4-5 months. Bowels opening 6-8 times daily, loose stools with dark red rectal bleeding. Also had some left sided lower abdominal pain, tenesmus and weight loss.  Concerned re sinister symptoms ? Colonic ca.

28. Mr SW  Bloods taken  Hb 8.8 g/dL MCV 72.6  WCC 8.77  Platelets 503  ESR 44 mm/hrCRP 34  U&E normal  Alk phos 173 GGT 96 Alb 29

29. Mr SW  A rigid sigmoidoscopy was performed. Showed colitis from rectum up to sigmoid and beyond upper limits.  Diagnosed with ulcerative colitis.  Started on prednisolone 30 mg od, reducing course 5mg weekly.  Also mesalazine 800 mg tds.

30. Mr SW  Colonoscopy-pancolitis www.gastrointestinalatlas.com

31. Mr SW  Compliance issues with this gentleman. Difficult to get Mr SW to take mesalazine. Developed diarrhoea with asacol. Diarrhoea resolved once he stopped taking. Changed to pentasa and to salofalk. Blames meds on any symptoms he develops now.

32. Mr SW  Insists on taking steroids long term rather than maintenance therapy.  Ongoing gastro input. Considering azathioprine/methotrexate as symptoms uncontrolled.

33. Inflammatory Bowel Disease 240,000 people in UK with IBD Most common age group 10 - 40 years Ulcerative ColitisCrohn’s Disease Diffuse mucosal inflammation Patchy transmural inflammation. Skip lesions, cobblestones Colon onlyMouth to anus Incidence 10-20/100000/ year Incidence 5-10/100000/year Prevalence 100-200/100000Prevalence 50-100/100000

34. Inflammatory Bowel Disease Ulcerative ColitisCrohn’s Disease Smoking protectiveSmoking increases risk Genetic component stronger Bloody diarrhoea, colicky abdo pain often peridefecatory, urgency, tenesmus. Pain/mass RIF, abdo pain, diarrhoea, weight loss, malaise, anorexia, fever, strictures, fistulae, abcess Complications: undernutrition, short bowel syndrome, colorectal carcinoma, colonic perforation, obstruction (crohn’s), toxic megacolon (UC)

35. Extraintestinal Associations http://www.eyecasualty.co.uk/http://www.eyecasualty.co.uk/, http://www.dermis.net/, http://www.bmj.com/http://www.dermis.net/http://www.bmj.com/