Transcript Inflammatory Bowel Disease

Inflammatory Bowel
Disease
Dawn Kershaw (FY1)
Objectives






Recognise the possibility of IBD in patient’s
presenting with lower GI symptoms
Recognise the possibility of systemic symptoms
associated with IBD
Recognise the differences in presentation
between Crohn’s and UC – and how these
relate to underlying pathology
Initiate appropriate investigations in a patient
with suspected IBD
Initiate appropriate management in a patient
with IBD
Explain to patients the nature of and the
rationale for maintenance treatment of IBD
Objectives






Recognise the possibility of IBD in patient’s
presenting with lower GI symptoms = GI
symptoms of IBD
Recognise the possibility of systemic symptoms
associated with IBD = Extra-intestinal symptoms
Recognise the differences in presentation between
Crohn’s and UC – and how these relate to
underlying pathology = Differences between UC
and Crohn’s: Pathology and presentation
Initiate appropriate investigations in a patient with
suspected IBD = Investigations
Initiate appropriate management in a patient with
IBD = Management of IBD
Explain to patients the nature of and the rationale
for maintenance treatment of IBD = Explain in lay
terms why we give medications to prevent flare
ups
Definition?
 Aetiology?

Crohn's verses UC
Crohn's verses UC

Definition
◦
◦
◦
◦
Chronic
Relapsing and remitting
Inflammatory bowel disease
Chrons: any part of GI tract - often terminal
ileum
◦ UC: large bowel

Aeitology
◦ Unknown
◦ Genetic
◦ Environmental

Pathology?
Crohn’s
Crohn’s

Tranny Granny Skipped down Cobblestone
street
Strictures
 Fistulae
 Abscesses

Crohn’s
Ulcerative colitis
◦
◦
◦
◦
Starts from rectum
Extends proximally
Continuous
Mucosa only
Proctitis = rectum
 Proctosigmoiditis = rectum and sigmoid
colon
 Left sided Colitis
 Pancolitis – Whole of large colon

Objectives
Recognise the differences in presentation
between Crohn’s and UC – and how these
relate to underlying pathology
 Recognise the possibility of IBD in
patient’s presenting with lower GI
symptoms

Crohn’s
Crohn’s

Crampy abdominal pain
◦ Inflammation; fibrosis; bowel obstruction

Diarrhoea
◦ Blood
◦ Steatorrhea



Weight loss
Fever
Anaemia



Obstruction: Distension, Vomiting
Abscesses
Fistulae: Enteroenteral; Anorectal;
Vesicointestinal; Rectovaginal
Ulcerative Colitis
Ulcerative Colitis

Crampy abdominal pain
◦ Relieved by defecation
◦ Left iliac fossa

Diarrhoea
◦ Blood ++
◦ Mucous





Urgency
Tenesmus
Weight loss
Fever
Anaemia

Severity: Truelove Witts Criteria
Objectives

Recognise the possibility of systemic
symptoms associated with IBD.
Extra-intestinal symptoms

Eyes
◦ Iritis; uveitis; episcleritis

Skin
◦ Erythema nodosum; pyoderma gangrenosum

Joints
◦ Seronegative spondyloarthropathy
 Large joints; Spine; Sacroiliitis; Can affect small
joints

Other
◦
◦
◦
◦
◦
Clubbing
DVT
Primary sclerosing cholangitis (UC)
Heamolytic anaemia (autoimmune) (Crohn’s)
Osetoporosis (Crohn’s)

Erythema nodosum

Pyoderma
gangrenosum

Uveitis

Clubbing
Get into 2 groups

Complete first 3 boxes on form based on what
we have just done.

What are your differential diagnosis to consider
in a patient presenting with IBD symptoms?
◦
◦
◦
◦
◦
Abdominal pain
Diarrhoea
PR bleeding/ mucous
Weight loss
Malabsorption
(Thanks to Zoe Campbell for providing the basis to this form)

Initiate appropriate investigations in a
patient with suspected IBD
Bedside
 Bloods
 Imaging
 Special tests

Investigations

Bedside
◦ Stool MC&S
◦ Faecal calprotectin

Bloods
◦
◦
◦
◦
FBC (low Hb; High WCC)
ESR; CRP (high)
LFTs: Low albumin
U&Es: Chronic diarrhoea – electrolyte
imbalance
◦ Heamatinics: ferritin, Vitamin B12, folate
◦ Amylase
◦ Cross match
Investigations

Imaging
◦ Abdominal X-ray
◦ Erect Chest X-ray
◦ Barium Meal (Crohn's)
 Fibrosis, Strictures, Ulceration (‘rose thorn’)
◦ Barium enema (UC)
 Featureless narrow colon, Loss of haustral pattern
◦ CT/MRI enterography (Crohn’s)

Special test
◦
◦
◦
◦
Flexible sigmoidoscopy
Colonoscopy
Gastroscopy
BIOPSY

Initiate appropriate management in a
patient with IBD
Acute
 Chronic
 Lifestyle
 MDT

Management

Acute
◦
◦
◦
◦

A-E; Bowel rest; Analgesia (not NSAIDs);
Steroids: IV; oral; rectal
Antibiotics
5-ASAs
Chronic
◦ 5-ASAs
◦ Per rectum steroids
◦ Immunosuppressant's
 Azathioprine
 Methotrexate (Crohn’s)
◦ Anti-TNF: Infliximab

Surgery: Resection
Management

Lifestyle
◦ Diet: Elemental
◦ Stop smoking?

MDT
◦
◦
◦
◦
◦
Consultant’s: Gastroenterologist; Surgeons
IBD specialist nurse
Dietician
Smoking cessation
Stoma nurse





5-ASAs
Steroids
Azathioprine/ Mercaptopurine
(Immunosuppressant)
Methotrexate (Crohn's)
Infliximab (Anti-TNF)
Medications used in IBD

Complete the rest of the form
Get back into groups
Objectives

Explain to patients the nature of and the
rationale for maintenance treatment of
IBD
Patient.co.uk
 Once a flare-up has settled, without
treatment, there is ~1 in 2 chance that
another flare-up will develop within a year.
 Increased likelihood of flares depends on:
◦ extent of the disease in your gut
◦ age,
◦ the extent of treatment needed to control the
initial flare-up.
If flares not frequent/mild/ respond well to
acute treatment then - may not need to
/wish to take regular meds
 For others regular meds can improve QOL
++








The treatment options that may be considered
to prevent flare-ups) include:
Immunosuppressants – take daily
Mesalazine – used daily (less common now)
Anti-TNF – selected cases where flares severe
and other treatments not worked: Have
infusion in hospital every 8 weeks.
Steroid medication is not generally used longterm to prevent flare-ups
These treatments increase the chance of
remaining free of flare-ups, but they do not
always work.
Balance between benefits and the possible
side-effects.
3 key points to take away

Understanding the pathophysiology of UC and
Crohn’s is actually useful!
◦ Symptoms
◦ Investigations
◦ Management

Communication is key- in exams AND in real
life:
◦ Patient.co.uk
◦ Easy marks in exams if you practice!

Structured answers in exams
◦ Investigations
 Bedside; Bloods; Imaging; Special tests
 Acute; chronic
◦ Management
 Acute; Chronic; lifestyle; MDT
 Conservative; Medical; Surgical