Transcript Recent developments in coeliac disease

Extra GI Manifestations
of IBD
Dr. Matt W. Johnson
BSc MBBS MRCP MD
Consultant Gastroenterologist
Luton & Dunstable FT Hospital
Luminology
To the ileum …and beyond
Extra GI Manifestations of IBD =40%
Organ
Complications
Mouth
Glossitis / Angular stomatitis / Orofacial granulomatosis
Eyes
Episcleritis / Iritis / Uveitis
Skin
Erythema nodosum / Pyoderma Gangrenosum
Bones
Sacroiliitis / Enteropathic Arthropathy / Ankylosing
Spondylitis / Osteoporosis
Lungs
Fibrosing Alveolitis (UIP)
Liver
AICAH / Granulomatous Hepatitis / Amyloid
Biliary Tract
Gallstones / Bile acid malabsorption / Primary Sclerosing
Cholangitis / AI pancreatitis / Cholangiocarcinoma
Kidneys
Stones (uric acid, oxalate)
Blood
Fe + B12 + Folate deficiency / A+V Thrombosis
Constitutional
Toxic megacolon / Weight loss / Growth retardation
Post-Surgical
Bile acid malabsorption / abscess / strictures / fistulae
EGIM of IBD
CrD
OFG
Gallstone
UC
Both
Activity
IBD Rx
+
+
+/-
+ sb
-
-
PSC
+
-
-
PBC
+
-
-
AIP
+
-
-
Epi/Scleritis
+
+
+
Iritis/Uveitis
+
+
+
EN
+
+
+
PG
+
+/-
+/-
Serositis
+
+
+
Sacroilitis
+
+
+
T1 Arthro
+
+
+
T2 Arthro
+
-
-
AnkSpond
+
-
-
Mouth
1) Glossitis 2) Angular Stomatitis
3) Orofacial granulomatosis
Glossitis
• B12 deficiency
– Red “beefy” tongue
• Fe deficiency
– Atrophic smooth
tongue
Rx = Supplements
Angular Stomatitis
• Fe deficiency
Rx = Supplements
Orofacial Granulomatosis
• Rare chronic inflammatory
•
•
condition
Characterised by lip swelling
64% have histological
granulomas similar to CrD
• Rx = Elemental or
Cinnamon and benzoate
free diet
Eyes
1) Episcleritis
2) Iritis
3) Uvietis
4) Steroid Cataracts
Episcleritis

Incidence = 5%

Superficial redness of
the episclera and
conjuctiva

Burning + itching due
to dilated vessels

Mx = Self resolves +/NSAIDS
Scleritis

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

Deeper redness of
sclera
Serious inflammatory
condition
Ocular pain,
photophobia, tearing,
blindness
Rx = Treat the IBD +
Systemic steroids,
NSAIDS, antibiotics or
immunosuppressant
Iritis / Uveitis

Inflammation of the iris
(anterior uveitis)

0.5-3%

Acute self resolves
within weeks

Chronic persists for
months and needs Rx

Ocular pain,
photophobia, blurry
vision, synechia
Iritis
 Complications
include; synechia,
cataracts,
glaucoma,
blindness
 Rx = Steroids
(PO + drops,
subconjuctival
injections)
Uveitis

Inflammation of
middle/inner eye

10% of blindness in USA

Mx = Urgent referral to
ophthalmologist

Treat the IBD

Rx = Steroids (PO + drops,
subconjuctival injections),
dilators + pressure reducing
drops (brimonidine tartrate)
+/- MTX, IFX
Skin
1) Erythema Nodosum
2) Pyoderma gangerenosum
Erythema Nodosum
• 8-15% of UC + CrD
• Usually reflects active disease
• Can precede the IBD diagnosis
• Red hot nodules on extensor
surfaces
• Assoc with pauciarticular
arthropathy
• Rx the IBD and you Rx the EN
Pyoderma Gangerenosum
• 5% UC
• 2% of CrD patients
• 50% assoc with IBD activity
• Starts with a red area +
central pustules then
develops into a painful
necrotic ulcer
• Steroids, IFX, Cyclosporin
• Colectomy does not always
help
Airway inflammation
 UC > CrD
 Chronic cough and mucopurulent sputum
 Progressive airways narrowing leads to
Chronic bronchitis + bronchiectasis +
bronchiolitis obliterans
 CXRs frequently normal, needs HRCT
 Rx = Large airways - Inhaled steroids
Small airways - Systemic steroids
Thrombo-embolic disorders
• TE events occur in 25%
• 3 fold increase above general population
• Recurrence risk is 10-15%
UC
CrD
Incidence per 10,000
50
40
Increase risk of DVT
2.8
2.9
Increase risk of PE
3.6
4.7
Liver + Pancreas
1) Abnormal LFTs = 30% eg. AZA
2) Gallstones = 13-34% of sb Crohn’s
3) PSC
4) PBC
5) AI Pancreatitis
Primary Sclerosing Cholangitis
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5% of UC and 1-2% CrD
Can precede colitis by years
Symptoms = Pruritis, fatigue,
RUQ pain, jaundice, cholangitis
Bedding and stricturing of IHDs
Associated with
cholangiocarcinoma 6-20%
Increased risk of U+L GI cancer
x6 and ampullary cancer
Colonoscopy every year, with
OGD every 2 years
Survival if symptomatic = 1518y
Primary Biliary Cirrhosis
 More commonly
seen with UC
 High cholesterol
 Deficiencies in the
fat soluble vitamins
DEAK
 Leads to cholestasis
Bones
1) Osteoporosis
2) Sacroileitis
3) Arthropathies (RhA, AnkSpond)
Osteopenia / Osteoporosis
Peak bone mass reached in our 20-30s
Then 0.5-1% per year thereafter
15% BMD lost in first 5y post
menopause
Osteopenia occurs in 40-50%
Osteoporosis occurs in 2-30%
Lifetime risk of fractures in IBD = 41%
CrD women have 2.5 fold increase
fracture risk
Osteoporosis
Prevention
1)
2)
3)
4)
5)
6)
Weight bearing exercise
Stop smoking
Reduce weight
Moderate Xol intake
Ca intake (1000-1500mg/d) = 1 pint of semi skimmed is 700mg
Stop steroids ASAP
1) Bone loss starts rapidly
2) Occurs even with low doses
3) Fracture risk improves on cessation
7) Ca + Vit D = All patients on steroids
8) Bisphosphonates = steroids >3m, those >65y or low impact
(fragility) fractures
9) HRT eg testosterone in steroid induced hypogonadism
BSG Mx of Osteoporosis
 Calcium + Vit D
 PO Bisphosphonates (eg alendronate, residronate)
 IV Bisphosphonates (eg. pamidronate)


 In those with difficult side effects eg. oesophagitis
 Poor mucosal absorption
 Avoids the problems
HRT (in PMP women) - risk of clots / breast+gynae cancer
Raloxifene - modulator of OR, without increased of breast Ca
Sacroilitis
 Prevalence = 47%
 Sacro-iliac pain
 Hazziness of sacro
iliac joint
Can be one sided
 Rx = COX II



inhibitors
Try to avoid NSAIDS
Steroids / IFX
Mx = Treat the IBD
IBD Arthropathy


10-20% of IBD patients (esp in Colonic disease, EN, Eyes)
Not to be confused with arthralgia secondary to steroid

1) Type 1 (Large Joint) Arthropathy = 5%
withdrawal, AZA or steroid induced myopathy.
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 6 joints, (typically 1 large joint eg. knee)
Attacks assoc with active inflammatory relapses, EN + Iritis
Usually self limiting, no role for NSAIDS
Treat the IBD = 5ASAs, Steroids, MTX, AZA, Colectomy
2) Type 2 (Small Joint) Arthropathy = 3-4%
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
Affects >5 joints, (typically small joints of hands and feet)
No direct assoc with IBD activity or Rx
Rx Algorithm for IBD Arthropathy
1st Line Physical exercises
Simple analgesia
Intra-articular injections
Steroids + Lignocaine
2nd
Line
Sulfasalazine or Pentasa (sb) Bonner G.F. AmJG. 2002
NSAIDS!!! / Codeine !!!
Thompson GT. JRheum 2000
MTX (esp. Crohns)
(No evidence for AZA/Cyclo)
3rd
Line
IFX (Type 1)
Thalidomide (80% AnkSpon)
Bisphosphonates
EGIM of IBD
CrD
OFG
Gallstone
UC
Both
Activity
IBD Rx
+
+
+/-
+ sb
-
-
PSC
+
-
-
PBC
+
-
-
AIP
+
-
-
Epi/Scleritis
+
+
+
Iritis/Uveitis
+
+
+
EN
+
+
+
PG
+
+/-
+/-
Serositis
+
+
+
Sacroilitis
+
+
+
T1 Arthro
+
+
+
T2 Arthro
+
-
-
AnkSpond
+
-
-