Clare Donnellan

Consultant Gastroenterologist Leeds Teaching Hospitals

Key features of IBD History & examination Investigations Treatment including DMARDs Flares – what should GPs do? What’s new?

Incidence UC 10 per 100,000

Incidence CD 6-7 per 100,000

Prevalence 400 per 100,000 (250/150)

Onset between 15 and 40 years of age Similar in males and females

Ulcerative colitis◦ Proctitis◦ Left-sided disease◦ Pan-colitis

Crohn’s Disease◦ Affects anywhere

Small bowel (80%) Small & Large bowel (50%) Peri-anal disease (35%) More likely to get complications

IBD-unclassified 5%

Genetics◦10-25% of patients have at least one

other family member affected◦No particular gene identified in UC

◦NOD2/CARD15 gene abnormalities in CD Terminal ileal disease Possibly more chance of requiring surgery

Environmental factors◦ Smoking

Protective for UC Worsens outcome for CD

◦ Appendicectomy Protective for UC Unlikely effect for CD

◦ Diet?◦ Bacteria?

Episcleritis/scleritis◦ 2 to 5% of patients◦ Activity linked to GI tract

Anterior uveitis◦ 0.5-3%, but much more serious◦ Females:males 4:1◦ 75% of patients have arthritis◦ Activity not linked to GI tract

Erythema nodosum◦ Most common skin

manifestation of IBD (up to 15%)

◦ Typically flares at same time as GI symptoms

Pyoderma grangrenosum◦ Up to 5% of patients◦ More chronic course

Related to GI activity◦ Peripheral arthritis◦ Episcleritis/scleritis◦ Erythema nodosum

Not related to GI activity◦ Spondylitis/sacroiliitis◦ Anterior uveitis◦ Pyoderma Gangrenosum

Bloody diarrhoea or prolonged diarrhoea (-ve MC&S)◦ Abdominal pain◦ Urgency◦ Tenesmus

If 1st presentation◦ Stool frequency/day & night◦ Systemic features◦ Weight loss◦ Fever◦ Extra-GI features

◦ Travel◦ DH (Abx, NSAIDs◦ FH◦ SH

‘The professional patient’◦ Is it like a ‘usual’ flare?◦ What are the usual strategies?◦ IBD Helpline 0113 206 8679

Is it severe?◦ Truelove and Witts criteria

≥6 bloody stools per day Systemic toxicity (HR>90, T>37.8, ESR>30) or

Hb<10.5 NEEDS ADMITTING for IV steroids

Much more challenging to ΔΔ IBD vs. IBS….◦ Abdominal pain◦ Diarrhoea (ask re: nocturnal symptoms)◦ Weight loss◦ Systemic features◦ Extra-GI manifestations

‘The professional patient’◦ Is it like a ‘usual’ flare?◦ What are the usual strategies?◦ IBD Helpline 0113 206 8679

Systemically unwell?◦ Fever◦ Tachycardia

Dehydration BMI/weight Abdominal tenderness/distension/bowel

sounds Palpable mass Peri-anal examination

Follow ‘usual’ strategy Call helpline (pt or GP) if concerned

◦ Advice◦ Early access to IBD clinic

Admit if systemically unwell

FBC, U&E, LFT, CRP Haematinics Stool MC&S Stool C diff (Stool OC&P)

Urgent referral to gastroenterology if high index of suspicion

UC◦ Bloods◦ AXR◦ Urgent stool cultures◦ Urgent flexible sigmoidoscopy within 24 hours◦ (CMV PCR and CMV on biopsies)◦ CT if risk of perforation

Crohn’s◦ Varies on symptoms/distribution

◦ Low threshold for CT abdo/pelvis

◦ Flexible sigmoidoscopy often unhelpful

◦ MR pelvic if abscess/fistulising disease

Small bowel◦ Small bowel meal if suspected CD/suspected SB

CD◦ MR enterography (enteroclysis) if known SB CD◦ OGD◦ Ultrasound◦ Wireless capsule endoscopy◦ Isotope (labelled white cell scans)

Colon◦ Colonoscopy◦ CT colonography

5-ASAs◦ Prescribe by drug name◦ But lower cost equivalents (Asacol = Mesren =

Octasa)

◦ Dose Asacol 2.4 g vs. 4.8 g Minimum 2 g for maintenance (1.2 g cancer

prevention)

◦ OD as effective and better adherence for maintenance

◦ Tablets + Local therapy often avoids steroids 5-ASA enemas better than steroid enemas

DMARDs◦ Azathioprine 2-2.5 mg/kg◦ 6-mercaptopurine 1-1.5 mg/kg

◦ Weekly bloods for 4/52◦ Then monthly◦ Then 3 monthly

◦ S/E (Raised MCV and lymphopaenia)

Other DMARDs◦ Methotrexate

Evidence not great

◦ Mycophenolate Some evidence

Optimise 5-ASAs first if sole treatment◦ Maximise dose◦ Add in local therapy (5-ASAs, not steroids)

Prednisolone 30 mg daily with Ca/Vit D cover◦ More prolonged course

If not settling (or severe UC) IV steroids

Is it severe?◦ Truelove and Witts criteria

≥6 bloody stools per day Systemic toxicity (HR>90, T>37.8, ESR>30) or

Hb<10.5 NEEDS ADMITTING for IV steroids Colectomy rate approx. 30%

Day 3 (Travis criteria)◦ If stool frequency > 8 or CRP > 45◦ 85% chance of colectomy

3 options◦ Surgery

◦ Infliximab as a bridge to Aza/6-MP◦ Cyclosporin

Ciclosporin/infliximab◦ 70 – 80% leave hospital with colon◦ 30% long-term

Infection risks

No role for 5-ASAs except if mild colitis ? Role after surgery in preventing relapse

If luminal disease◦ Oral steroids◦ IV steroids if no response

◦ Still no response? No role for ciclosporin Give infliximab +/- azathioprine for 1 year

◦ Nutrition support key

If peri-anal disease◦ Drain any sepsis◦ Antibiotics◦ Seton sutures

◦ Escalate therapy as appropriate

DMARDS◦ Azathioprine◦ Methotrexate (s/c)◦ Mycophenolate◦ Tacrolimus

Surgery◦ For complications

Biologicals◦ Infliximab◦ Adalimumab

(Humiara)

◦ NICE assessment at 1 yr

Liquid diet for Crohn’s Bone protection Endoscopic dilatation of strictures

Calprotectin◦ Diagnosis◦ Activity assessment

Azathioprine metabolite levels◦ Optimise dose◦ Minimise side-effects◦ ? Reduce number of patients needing biologicals

Leucocytapheresis

Mucosal healing

Guided self-management

More nurse-led clinics

Reduce follow-up waits…

Less ‘black and white’ in/out of service

Significant morbidity

Early, focused management

Use helpline 0113 206 8679

Admit if systemically unwell Stool cultures Appropriate steroid course