Inflammatory Bowel Disease

Dawn Kershaw (FY1)

ObjectivesRecognise the possibility of IBD in patient’s

presenting with lower GI symptomsRecognise the possibility of systemic symptoms

associated with IBDRecognise 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

ObjectivesRecognise the possibility of IBD in patient’s presenting

with lower GI symptoms = GI symptoms of IBDRecognise the possibility of systemic symptoms

associated with IBD = Extra-intestinal symptomsRecognise 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

Crohn's verses UC

Definition?Aetiology?

Crohn's verses UCDefinition

◦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

StricturesFistulaeAbscesses

Crohn’s

Ulcerative colitis◦Starts from rectum◦Extends proximally◦Continuous◦Mucosa only

Proctitis = rectumProctosigmoiditis = rectum and sigmoid

colonLeft sided ColitisPancolitis – 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 obstructionDiarrhoea

◦Blood◦Steatorrhea

Weight lossFeverAnaemia

Obstruction: Distension, VomitingAbscessesFistulae: Enteroenteral; Anorectal;

Vesicointestinal; Rectovaginal

Ulcerative Colitis

Ulcerative ColitisCrampy abdominal pain

◦Relieved by defecation◦Left iliac fossa

Diarrhoea◦Blood ++◦Mucous

UrgencyTenesmusWeight lossFeverAnaemia

Severity: Truelove Witts Criteria

Objectives

Recognise the possibility of systemic symptoms associated with IBD.

Extra-intestinal symptomsEyes

◦Iritis; uveitis; episcleritisSkin

◦Erythema nodosum; pyoderma gangrenosumJoints

◦Seronegative spondyloarthropathy Large joints; Spine; Sacroiliitis; Can affect small

jointsOther

◦Clubbing◦DVT◦Primary sclerosing cholangitis (UC)◦Heamolytic anaemia (autoimmune) (Crohn’s)◦Osetoporosis (Crohn’s)

Erythema nodosum Pyoderma gangrenosum

Uveitis Clubbing

Get into 2 groupsComplete 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

BedsideBloodsImagingSpecial tests

InvestigationsBedside

◦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

InvestigationsImaging

◦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 Not in acute flare!!!

Initiate appropriate management in a patient with IBD

AcuteChronicLifestyleMDT

ManagementAcute

◦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: InfliximabSurgery: Resection

ManagementLifestyle

◦Diet: Elemental◦Stop smoking?

MDT◦Consultant’s: Gastroenterologist; Surgeons◦IBD specialist nurse◦Dietician◦Smoking cessation◦Stoma nurse

Medications used in IBD

5-ASAsSteroidsAzathioprine/ Mercaptopurine

(Immunosuppressant)Methotrexate (Crohn's)Infliximab (Anti-TNF)

Get back into groups

Complete the rest of the form

Objectives

Explain to patients the nature of and the rationale for maintenance treatment of IBD

Patient.co.ukOnce 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 dailyMesalazine – 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 long-term 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 awayUnderstanding 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