INFLAMMATORY BOWEL

DISEASE
Anusha Reddy
FY1 SWFT
3rd Feb 2014
OBJECTIVES

 2 Case Studies: Crohn’s Vs Colitis

 THINK:
 AETIOLOGY
 EPIDEMIOLOGY
 SIGNS AND SYMPTOMS
 INVESTIGATIONS
 MANAGEMENT
CASE STUDY 1

 22 Female

 PC: 6/52 of 5 x loose, non-bloody stools daily

 Right lower quadrant abdominal pain (especially
after eating)
 8kg weight loss
 Bilateral knee and ankle pains
MORE INFORMATION REQUIRED
 Full history
 Nil PMH, no hx of foreign travel
 No medications or allergies
 Current smoker- 5 pack-years

 Examination
 Definite and moderately tender 5-cm mass in the
right lower quadrant
 No joint effusion or skin lesions are noted
DIFFERENTIAL DIAGNOSIS
 Gastroenteritis
 Crohn’s Disease
 Ulcerative Colitis
 Irritable Bowel Syndrome
 Behcet’s Disease

 Bowel Cancer
 Tuberculosis
 Amyloidosis
 Acute Appendicitis
WHAT DO WE THINK THIS IS?

 22 Female

 PC: 6/52 of 5 x loose, non-bloody stools daily

 Right lower quadrant abdominal pain (especially
after eating)
 8kg weight loss
 Bilateral knee and ankle pains
CROHN’S DISEASE- DEFINITION
 Chronic Inflammatory Bowel Disease (IBD)
 Unknown Aetiology
 Characterised by
1. Focal
2. Asymmetrical
3. Transmural
4. Occasionally granulomatous
inflammation

 Any part of the GI tract- mouth anus

CROHN’S DISEASE- EPIDEMIOLOGY
 Incidence: 9.56 per 100,0001
 Prevalence: 115,000 in the UK
 Age of onset: 2 peaks 1) 15-30 Y (more common)
2) 60-80 Y
 Female: Male 1.8:1 Children this is reversed!

 Risk Factors2
 Mycobacterium paratuberculosis, Pseudomonas spp. &
Listeria spp.
 ↑TNF-alpha

 High-fat diets

 Genetic mutations

1) Steed H, Walsh S, Reynolds N; Crohn's disease incidence in NHS Tayside. Scott Med J. 2010 Aug;55(3):22-5
2) Rangasamy P et al; Crohn Disease, Medscape, Jun 2011
CROHN’S DISEASE- SYMPTOMS
• Abdominal pain, cramping or swelling
• Anaemia
• Fever
• Gastrointestinal bleeding
• Joint pain
• Malabsorption
• Persistent or recurrent diarrhoea
• Stomach ulcers
• Vomiting
• Weight loss
CROHN’S DISEASE- ON EXAMINATION
 General ill health- weight loss & dehydrated

 Hypotension, tachycardia and pyrexia

 Abdominal tenderness or distension, palpable
masses.
 Anal and perianal lesions (abscesses, fistulae)

 Mouth Ulcers

 Extra-intestinal manifestations of Crohn’s ......

CROHN’S DISEASE- EXTRA INTESTINAL
INVESTIGATIONS
 Bloods
 FBC, CRP, U&Es, LFTs
 Stool culture and microscopy
 anti-S. cerevisiae antibodies Perinuclear
antineutrophil cytoplasmic antibody (p-ANCA)
(UC>CD)
 Abdo Xray
 Ileocolonscopy and biopsy from the terminal ileum as
well as the affected sites
 Small bowel follow through
 If upper GI symptoms- Upper GI endoscopy
 If lower GI symptoms- Flexible sigmoidoscopy/EUA
CROHN’S DISEASE- MANAGEMENT
 First presentation (NICE guidelines)
1. Glucocorticoids
1. Prednisolone, Methylprednisolone IV
hydrocortisone
2. Budesonide
3. 5-ASA

 +/- ADD ON Azathioprine or Mercaptopurine

 Biologic: Infliximab and Adalimumab

CROHN’S DISEASE- MANAGEMENT
 Maintaining Remission (NICE guidelines)

 Offer Azathioprine or Mercaptopurine as

Monotherapy

 Methotrixate

 Surgery- if limited to distal ileum (weighing out

the risk Vs benefits) and for complications...
CROHN’S DISEASE- COMPLICATIONS

C C
CASE STUDY 2
 32 Male
 Bloody diarrhoea 4/52

 Bilateral lower abdominal cramping

 Malaise and weight loss

 No associated fever, visual changes, arthralgias,

or skin lesions

 Previously fit and well contractor

 Non-smoker, 14-18 units/week drinker

 FHx: Diabetes Mellitus Type 1

ULCERATIVE COLITIS- DEFINITION
 Chronic Inflammatory
Bowel Disease
 Unknown aetiology

 Only Large Colon

 Classification:
 Distal Disease
 More extensive disease
 Pancolitis
 ULCERATIVE COLITIS- EPIDEMIOLOGY
 More common than Crohn’s
 Incidence: 10 per 100,000

 Prevalence 240 per 100,000 in the UK

 Age of onset: 2 peaks 1) 15-25 Y (more common)

2) 55-65 Y
 Male:Female= 1:1
 Idiopathic: ?autoimmune condition triggered by
colonic bacteria  inflammation
 Genetic component: sibling of an individual who
has IBD 17-35 x more risk of development
 Risk of UC decreased in smokers

1) Ulcerative Colitis; NICE Clinical Guideline (Jun 2013)

ULCERATIVE COLITIS- SYMPTOMS
 Bloody diarrhoea
 Abdominal Pain

 Tenesmus

 Systemic symptoms: malaise, fever, weightless

ULCERATIVE COLITIS- ON EXAMINATION
 Unwell, pale, febrile, dehydrated
 Abdo pain and tenderness .. + distension

 TOXIC MEGACOLON

 Worrying signs: Tachycardia, anaemia and fever

 Extra- intestinal disease...

ULCERATIVE COLITIS- EXTRA-INTESTINAL
 Aphthous ulcers
 Ocular manifestations 5%
 Episcleritis
 Anterior uveitis

 Acute arthropathy affecting the large joints 26%

 Sacroiliitis
 Ankylosing Spondylitis 3%

 Deramatology 19%
 Pyoderma gangrenosum
 Erythema nodosum
 Primary Sclerosing Cholangitis
ULCERATIVE COLITIS- INVESTIGATIONS
 Bloods: FBC, LFTs, U+Es, CRP
 Serology- pANCA Vs. ASCA

 Stool cultures

 Imaging
 Abdo x-ray- acute setting
 Barium enema- can show mucosal structure

 Flexible Sigmoidoscopy and Biopsy- for diagnosis

ULCERATIVE COLITIS- MANAGEMENT

a) Topical aminosalicylate a) PO Aminosalicylate - If no improvement 72 hrs

alone (suppository or
enema
b) ?ADD PO
aminosalicylate to a topical
aminosalicylate OR
c) consider an PO
aminosalicylate alone
- High induction despite IV Hydrocortisone
dose of an OR
b) ?ADD topical -Symptoms worsen to
Aminosalicylate OR pancolitis:
PO beclometasone
dipropionate a) ADD IV Ciclosporin to IV
steroids
ULCERATIVE COLITIS- MANAGEMENT
 Indications for Surgery:
 Unresponsive to medical treatment
 Significantly affecting quality of life
 Growth retardation in Children
 Life-threatening complications...

 Bleeding
 Toxic Megacolon
 Impending perforation
 Carcinoma
ANY QUESTIONS?
SUMMARY
SUMMARY: CROHN’S VS. UC (1)
Symptoms of Crohn's Symptoms of Ulcerative
Disease Colitis

• Abdominal pain, cramping or •Bloody diarrhoea

swelling •Abdominal pain or discomfort
•Anaemia •Anaemia caused by severe
•Fever bleeding
•Gastrointestinal bleeding •Dehydration
•Joint pain •Fatigue
•Malabsorption •Fever
•Persistent or recurrent •Joint pain
diarrhoea •Loss of appetite
•Stomach ulcers •Malabsorption
•Vomiting •Rectal bleeding
•Weight loss •Urgent bowel movements
•Weight loss
SUMMARY: CROHN’S VS. UC (2)
SUMMARY- CROHN’S VS. UC (3)
SUMMARY: CROHN’S VS. UC (2)
LEARNING POINTS
 RELAPSE AND REMITTING
MANAGE THE PATIENT

 BONE PROTECTION- IF ON LONG-TERM

STROIDS

 TEST FOR TB BEFORE STARTING

INFLIXIMAB

 RISK OF COLONIC CARCINIMA IN UC

THANK YOU!!