inflammatory bowel disease

A beginner‟s guide to Inflammatory Bowel Disease Dr PJ Hamlin PhD MRCP Consultant Gastroenterologist Leeds General Infirmary Basic: from a GP perspective Key points from history / examination / investigation Basic idea about UC / CD and differences How to manage a flare How to contact us History stool frequency/consistency/blood or mucus Weight loss diet Urgency / pain / bloating / nocturnal diarrhoea Associated symptoms (fatigue, joint/eye/skin problems,mouth ulcers) duration disease medication (Abx/NSAIDs) Travel Family history Smoking / alcohol Examination fever, tachycardia, abdo findings (tender/peritonitic), hydration status EIM‟s Weight / BMI Investigation FBC, CRP, U&E, LFTs, anti TTG, glucose, TFT stool cultures Differential diagnoses Infective – Bacterial: salmonella, shigella, campylobacter, E coli (O157), Gonococcal proctitis, C difficile – Viral: HS (or chlamydial) proctitis, CMV – Protozoal: amoebiasis Differential diagnoses Non-infective Vascular: ischaemic colitis Idiopathic: microscopic colitis Drugs (eg) NSAIDs Neoplasia Radiation Behcet‟s Diverticulitis IBD Incidence / prevalence Pathogenesis Clinical Features UC and CD Differential diagnosis Investigation What to do on take Incidence / prevalence Incidence UC 10: 100,000 Incidence CD 6-7: 100,000 (increasing) Prevalence about 150:100,000 for each Therefore IBD in Leeds = 2-3000 (without tertiary referrals) Clinical Features UC and CD How may UC present? How may CD present? What are the fundamental differences? Clinical Features UC and CD: complications Toxic dilatation Haemorrhage Perforation Fistulae (Crohn‟s disease) Cancer Investigation of IBD Bloods Stool culture Endoscopy: flex siggy / colonoscopy Barium imaging Cross sectional imaging White cell scan Known UC when to worry / refer „Flare‟ suggested by increased stool frequency, pain, urgency, blood, mucus, weight loss, constitutional symptoms Fever, tachycardia What is current Rx? How were previous flares managed? Aims of treatment for IBD Achieve remission Maintain remission Prevent complications Improve quality of life The management of ulcerative colitis proctitis Left sided / distal Distribution of UC Pancolitis Algorithm for managing ulcerative colitis MILD PROCTITIS 5 ASA / steroid (topical:supp/enema) MODERATE SEVERE LEFT SIDED 5 ASA / steroid (topical:enema +/-systemic) PANCOLITIS 5 ASA (systemic+/-topical) 5 ASA / steroid (topical:supp/enema) +/Systemic steroids +/Immunomodulator (azathioprine/6MP/ Mycophenolate) +/surgery Parenteral Steroids +/Ciclosporin +/surgery Definitions Severe colitis (Truelove and Witts Br Med J 1955) 6 or more bloody stools per day Temp > 37.5 tachycardia > 90 Hb < 10.5 ESR >30 Toxic / ‘fulminant’ fever, abrupt onset, abdo tenderness, colicky pain, anorexia. Considered toxic if „severe‟ colitis + 2 or more of fever >38.6, tachy >100, WCC >10.5 and low albumin Toxic megacolon First recognised in 1950 (Marshak et al., Gastroenterology 1950;16768) ‘Segmental or total colonic distension of > 6cm in the presence of acute colitis and signs of toxicity’ The medical management of Crohn‟s disease On Take: “exacerbation Crohn‟s” History: unwell? pain, extra-intestinal features, stool frequency/consistency, vomiting Past Crohn‟s history: think anatomy and implications of any surgery (eg) ileostomy / colostomy / length SB left / could there be a stricture or adhesions or fistula Examination: TPR, abdo, PR, hydration, extra-intestinal features Ix: bloods, AXR?, rest depends on disease distribution and history 5 ASAs Crohn’s disease diagnosis Elemental diet antibiotics steroids azathioprine methotrexate Antituberculous chemotherapy Stop smoking mycophenolate infliximab Anti-TNF α strategies Tacrolimus Leucocytophoresis natalizumab worms Stem cell Tx surgery adalimumab thalidomide etanercept DRUG UC CD SIDE EFFECTS Renal LFT etc Numerous PREGNANCY BLOODS COMMENTS ROUTE ADMIN PO/PR 5 ASAs √ √ √ ? √ √ √ √ √ X Ok U&E LFT DOSES STEROIDS Not ideal CaD3 DEXA 1/12 FBC 3/12 LFT As above How long PO/PR IV PO AZATHIO 6MP MTX BM, liver, Pancreatitis, N&V Ok BM, liver, Pulmonary BM, drug induced colitis Fits, HT, Renal Infection Infusion reaction, lymphoma X How long PO/ SC IM PO MMF √ √ √ X As above CyA X U&E FBC FBC Acute severe UC How How long IV / PO IFX √ X IV ADALIMUMAB ? √ x How long SC Miscellaneous Give Ca / vit D with prednisolone Long term steroids are not an answer Get smokers with CD to stop Where are bloods monitored? IBD nurse specialist Chapel Allerton How to refer Colitis clinic every Wednesday Flares – open access On call registrar IBD nurse specialist