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Ulcerative Colitis Update

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					Ulcerative Colitis & Extraintestinal Manifestations
Kimberly Persley, MD April 20, 2005

Case Presentation
• 36 yo WP transfer from OSH with severe, steriod refractory UC
– 11/2004 – Bloody diarrhea and abdominal pain
• Treated with Colazol 6.75 gm/d • Prednisone 60 mg /d

– 12/2004 – Imuran started secondary to refractory symptoms but developed ITP and the Imuran stopped

Case Presentation
– 2/26/2005 – underwent colonoscopy that showed “mild to moderately active colitis in the left colon – 2/28/2005 – admitted to OSH with fevers, increased bloody diarrhea and abdominal pain
• Negative ID workup

– 3/6/2005 – transfer to PHD for further management
• 10-12 bloody bowel movements daily, abdominal pain, persistent fever, anorexia • No joint pain, oral ulcers or rashes

Case Presentation
• PMH
– ITP – first diagnosed 11/2004
• Bone marrow biopsy – megakaryocytic hyperplasia • Treated with steroids, WinRho and IVIG

– Patent foramen ovale

• Meds
– Flagyl, Cipro, Solumedrol, Morphine and Phenergan

• Family History
– Paternal Grandfather with colon cancer

Case Presentation
• Physical Exam
– – – – BP 124/69, Pulse 96, Temp 98.4 No skin lesions CV – RRR with systolic murmur Abdomen – NABS, tenderness in the lower abdomen, no masses, no splenectomy – Ext – no edema

Case Presentation
• Labs
– – – – – – WBC 15.3 (45% segs, 38% bands) Hgb 12 g/dl, ferritin 150, vit B12 1163 pg/ml Platelet 137k, ESR 67 K 3.1, chol 123 Creat 0.9 Stool and blood cultures - neg

Case Presentation
• Hospital Course
– Repeated stool and blood cultures – Solumedrol 60 mg IV continuous infusion – Platelet count decrease
• Treated with IVIG

– IV Cyclosporine (2mg/kg) started without significant improvement (received 13 days)
• Flex sig – grade 4 colitis (severe)

Flexible Sigmoidoscopy
Ulcers

Laboratory Data
Mar 6 Mar 9 Mar 22 Mar 29

Platelets WBC
HgB (g/dl)

95k 17.7
13.0

10k 10.6
10.0

46k 7.9
8.8

144k 16.4
11.8

Case Presentation
3/23/2005- underwent lap assisted colectomy with ileostomy

3/27/2005- discharged home

Spectrum of IBD

Ulcerative colitis

Crohn’s Disease

Indeterminant colitis

Normal Intestine Vs. IBD
Environmental triggers (infection, bacterial products) Failure to downregulate

Chronic uncontrolled inflammation = IBD

Moderately inflamed Normal gut controlled inflammation

Down-regulate

Normal gut controlled inflammation

Disease Distribution at Presentation
n=1116

37% 46% 17%

Farmer RG. Dig Dis Sci;38:1137-1146

IBD Treatment Pyramid
s e v e r i t y Biologics
Remicade (not approved for UC

Immunomodulators
Steroids Antibiotics 5-ASA

Imuram MTX Cyclosporine

Asacol Colazol sulfasalazine

IBD: Systemic Complications
Eye inflammation* Lower bone density*
Liver and bile duct inflammation Growth failure in children

Kidney stones
Subfertility*

Ovaries
Uterus Arthritis and joint pains

Gallstones

Skin lesions

*Higher incidence in women.

EIMs and Response to Treatment
• Responds to treatment of underlying bowel disease
– Peripheral arthritis – Erythema nodosum – Episcleritis

• Independent of treatment of underlying bowel disease
– Axial arthritis – Pyoderma gangrenosum – Uveitis – PSC

IBD and Hematology
• Anemia is common in patients with IBD
– – – – – Iron loss Defective iron transport Impaired Vitamin B12 and Folate absorption Insufficient erythropoietin production Autoimmune Hemolytic Anemia

ITP and IBD
• Not a frequent association • Usually associated with Ulcerative Colitis • Decrease in platelet counts observed during flares • Various treatment modalities used to induce remission

ITP and IBD
• 24 cases of IBD in ITP reported
– 21 Ulcerative Colitis – 3 Crohn’s Colitis

• IBD usually preceeded ITP be several months to years • No standardized approach to therapy • No other cases reported with colectomy only

Molecular Mimicry
Zlatanic et al. AJG 92,1997

antibodies platelet

Spleen APC bacteria

colon

Platelet destruction

ITP and IBD
• Treatment
– Short course of steroids – IVIG – Splenectomy may be required to maintain platelet count
• + colectomy if active colitis

– Colectomy should be considered if colitis remains active despite medical therapy

Case Presentation (follow up)
• Platelet count 275k on March 31, 2005

• On prednisone taper
• Will return in next 2-3 months for a Ileal pouch anal anastomosis


				
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