Dr Sam Gausden FY2 February 2015 Inflammatory bowel disease
Dec 15, 2015
Contents/aims/objectives
DefinitionPresentationInvestigationsManagementClinical scenarioExplanation station
Smoking in IBD
• 2/3 Crohn’s pts are smokers and cessation halves relapse
• 95% of UC pts are non-smokers or ex-smokers
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
Symptoms - UC
Diarrhoea + blood/mucousFaecal urgency/incontinenceTenesmusLower abdominal pain
Tiredness/malaiseWeight loss/failure to thrive or growFever
Symptoms - Crohn’s
Diarrhoea +/- blood/mucous Malabsorption Abdominal pain (crampy) Mouth ulcers Bowel obstruction Fistulas (perianal) Abscesses (perianal/intrabdominal)
Tiredness/malaiseWeight loss/failure to thrive or growFever
Signs – Crohn’s
ClubbingPallorEyesMouthLegs
Abdominal tendernessMass in RIF
PR – skin tags, abscesses, fistulas
Faecal calprotectin
Protein common in neutrophil cytoplasmBacteriostatic 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
Inducing remission in mild-mod UC1
1) Aminosalicylates
2) Steroids
3) Immunosuppression (tacrolimus)
Inducing remission in severe UC (inpatient)1
1) IV steroids
2) Immunosuppression (ciclosporin)
3) Biologics (infliximab)
Inducing remission in Crohn’s1
1) Steroids (oral or IV)
2) Aminosalicylates (2nd line)
3) Immunosuppressants (aza, mercapto, methotrexate)
4) Biologics (infliximab or adalimumab)
Maintaining remission in Crohn’s
1) Immunosupressants (aza, mercapto or MTX)
2) Continue biologics
3) OR nothing
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 Hx12x day nowBlood and mucous
mixed inCramping LIF painUnwell 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
Acute investigations?
Stool culture, pregnancy test
FBC, U&Es, LFTs, CRP, ESR, clotting, G&S
Erect CXR, AXR, CT abdomen
?flexi sigmoidoscopy
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
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?