Transcript Inflammatory Bowel Disease

Internal Medicine
Lecture Series Presents:
Inflammatory Bowel
Disease
Garrett P. Clark, D.O.
Learning Objectives:
Distinguish between Inflammatory Bowel
Disease (IBD) and Irritable Bowel Syndrome
(IBS).
Describe the pathophysiology of Inflammatory
Bowel Disease.
Identify the differences between the two main
types of Inflammatory Bowel Disease: Ulcerative
Colitis (UC) and Crohn’s Disease (CD).
Differentiate the histopathological and
radiographical qualities of IBD.
Identify the current treatment options.
IBD
Inflammatory Bowel disease describes a set of
conditions which entail an idiopathic immune
reaction to the body’s own intestinal tract.
There are two main subtypes to this disease:
Ulcerative Colitis (UC) and Crohn’s Disease.
Inflammation of the intestinal mucosa paves the
way for edema, ulcerations, bleeding, and
fluid/electrolyte loss which may be characterized
in both UC and Crohn’s Disease.
Both disease states exhibit waxing and waning
of symptoms which herald periods of active
“flare-ups” or inactive states of the disease.
IBD
Inflammatory Bowel Disease is NOT Irritable Bowel
Syndrome .
Irritable Bowel Syndrome (IBS) denotes a set of
symptoms, most commonly found in women, which are
characterized by periods of abdominal pain and bloating,
small and frequent stools, intermixed with periods of
constipation. However, Inflammatory Bowel Disease
should be excluded.
This endeavourer can be met by skillful H&P, exclusion
of other disease, and implementation of the International
Classification for Irritable Bowel Syndrome commonly
referred to as the Rome Criteria:
ROME
CRITERIA for
IBS:
Abdominal pain relieved by defecation which may also be accompanied
with change in frequency and/or consistency of stools.
Disturbance of defecation at least 25% of the time with at least 2 or more
of the following:
–
–
–
–
–
Altered frequency
Altered consistency
Passage of mucus
Altered passage of stool
Abdominal distention
NO constitutional signs or symptoms. (i.e. fever, wt. loss, anorexia, or
anemia).
Hannaman RA, Kraemer F, et al: The Internal Medicine Review 2003; 1-18. Medstudy.
rome.jpg350 x 247 pixels - 25.9kB www.irbd.org/fr/2007/fr_irbd2007.html
IBS STOOL CHART
chart-stool.gif485 x 356 pixels - 19.3kB www.medscape.com/pages/.../article-diagnosis
Back to Inflammatory Bowel
Disease:
Approximately 1 million people in the U.S. are stricken with IBD.
Prevalence in Americans of African descent are about equal to
that of Americans of European descent.
However, it is lower in Americans of Hispanic and Asian descent.
Internationally, those living in colder climates seem to have
higher rates than those living in warmer climates.
eMedicine - Inflammatory Bowel Disease Article by William A Rowe, MD.htm
Dr_Evil.jpg848 x 440 pixels - 49.0kB diary.ru/~green-filin
IBD
The American Jewish population have a 4 to 5
time greater risk for IBD than that of the general
American population.
The ratio between the types of IBD among
males and females is approximately equal.
IBD is most often diagnosed in patients between
the 2nd and 3rd decades of life.
In sharp contrast to Irritable Bowel Syndrome
(IBS), patients stricken with Inflammatory Bowel
Disease (IBD) are mired by episodes of bloody
diarrhea and tenesmus, along with abdominal
pain and other systemic symptoms.
eMedicine - Inflammatory Bowel Disease Article by William A Rowe, MD.htm
Crohn Disease
Disease may present at any age, but mostly b/w
the 20’s and 30’s. There is a smaller peak
incidence b/w 70 and 80 years of age.
Patients are likely to develop inflammatory
masses, strictures, perianal fistulae, and
abscesses.
Obstruction is also more likely!
Abdominal pain,and fever are often present.
IBD: Crohn Disease
Signs of Crohn’s include occult blood loss and
low-grade fever, weight loss and anemia, growth
retardation in children, fistulae and perianal
disease.
Diagnosis is by endoscopy or radiologically with
contrast radiographs that show cobblestone and
skip lesion characteristics of the mucosa.
The disease may manifest as refractory PUD*.
Extraintestinal complications may present in
Crohn’s disease as well as in UC.
eMedicine - Inflammatory Bowel Disease Article by William A Rowe, MD.htm
IBD: Crohn Disease
+
+
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Cobblestone SKIP LESIONS !
A classic tetrad to remember:
– Rectal sparing
–Skip lesions
– Perirectal disease
– Ileocolic disease
A classic radiological feature of Crohn
Disease is string sign. This may be seen
in the terminal ileum on small bowel
follow-through.
STRING SIGN:
www.emedicine.com/cgibin/foxweb.exe/makezoom@/em/makezoom?picture=\websites\emedicine\med\images\Large\2324_1169ROWE2.jpg&template=izoom2
IBD: Crohn Disease
Another distinct
radiographic image is
the Apple-core
lesion. This is also
narrowing of the
lumen but seen else
ware besides the
terminal ileum. This
is an ominous sign as
it is indicative of the
presence of cancer.
Name: T Colon apple-core2.jpg Details: 500 x 476 pixels - 45.1kB - JPEG
IBD: Crohn Disease
If the patient is thought to be in an acute
exacerbation of either UC or CD, barium
enema is CONTRAINDICATED!
This is due to the increased risk of Toxic
Megacolon which is a complication of both
ulcerative colitis and crohn’s disease but
often more associated with Ulcerative
Colitis.
Hannaman RA, Kraemer F, et al: The Internal Medicine Review 2003; 1-19. Medstudy.
TOXIC MEGACOLON:
surgical-tutor.org.uk/pictures/images/lower_gi/toxic_uc.jpg
IBD: Crohn Disease
There is a slight increase in risk of GI cancer
with Crohn’s disease compared to the higher risk
seen in UC patients. (0.5% up to 10% in 20
years).
Screening for GI cancer is recommended every
other year in those long term CD patients.
CD has a high rate of symptomatic recurrence –
up to 50% at 10 years.
However, endoscopic or radiographic
recurrences are thought to be MUCH higher –
up to 75% at 3 years!
Hannaman RA, Kraemer F, et al: The Internal Medicine Review 2003; 1-18. Medstudy.
IBD: Crohn Disease
Deep transmural ulcers “Crohn’s Craters”
and patchy areas of focal aphthous
ulcerations are hallmarks of the disease.
With biopsy, granulomas are
pathognomonic for Crohn’s but are rarely
seen.
Crohn’s Disease can affect any segment
of the GI tract from the mouth to the anus.
Hannaman RA, Kraemer F, et al: The Internal Medicine Review 2003; 1-10. Medstudy.
IBD: Crohn Disease
IBD: Crohn Disease
IBD: Crohn Disease
IBD: Crohn Disease
IBD: Crohn Disease
IBD: Crohn Disease*
Complications
Urinary complications are more common in
patients with Crohn’s disease than those with
UC.
Calcium oxalate stones are most commonly
associated with Crohn’s.
Inflammation of the small bowel may involve the
ureters.
This may cause obstruction and hydronephrosis.
Fistulae may occur between the bowel and
bladder or bowel and ureters.
eMedicine - Inflammatory Bowel Disease Article by William A Rowe, MD.htm
IBD: Crohn Disease
Iron deficiency anemia and anemia of chronic
disease are also often associated with CD.
Patients with Crohn’s disease involving the
proximal small intestine have difficulty absorbing
oral iron which may necessitate iron
replacement.
B-12 deficiency in patients with Crohn’s disease
may occur in those with terminal ileum disease
or resection.
Standard B-12 replacement is 1000 mcg
subcutaneously every month.
eMedicine - Inflammatory Bowel Disease Article by William A Rowe, MD.htm
CROHN DISEASE TREATMENTS:
Medical treatments for CD include:
– Sulfasalazine (Maintenance)
– 5-amino salicylates (Mild disease & remission states)
– Olsalizine (Maintenance for those intolerable to
sulfasalazine).
– Predisone (severe disease)
– Metrodidazole (delays anastomotic recurrance)
– Azathioprine and 6-mercaptopurine (for remission
states esp. if steroid dependant or refractory)
– Infliximab (severe/fulminant disease)
Tarascon Pocket Pharmacopeia
Hannaman RA, Kraemer F, et al: The Internal Medicine Review 2003; 1-18. Medstudy.
CROHN DISEASE TREATMENTS:
Up to 60% of CD patients undergo surgery for
serious complications or intractable disease
within the first 5 years.
Incidence of recurrence depends on the site of
disease and any complications (i.e. perforation,
obstruction, etc.)
The ileocolic region has the highest rates of
recurrence.
The greater the disease at time of resection, the
greater the likelihood of recurrence at the site of
surgical resection.
CROHN DISEASE TREATMENTS:
New evidence-based approaches to the
treatment of mild to moderate Crohn’s disease
has been proposed using budesonide
(ENTOCORT) at 9mg/day for patients with ileal
or right colonic disease and sulfasalizine for
those with disease limited to the colon.*
The use of steroids is suggested for more sever
disease of those who failed budesonide.
Steroids are also suggested for those with left
sided disease that are allergic or intolerant to
sulfasalizine.
Aliment Pharmacol Ther 2003; 18; 263-277
CROHN DISEASE TREATMENTS:
“Budesonide administered at 9mg daily or
4.5mg BID has been shown to be
comparable to prednisolone in the
remission of active Crohn’s disease. In
addition, it represents a safer, simpler
therapeutic approach with a considerable
reduction in side effects”.
Gut, August 1997, Vol 41, p 209-214
CROHN DISEASE TREATMENTS:
It should be noted that Infliximab
(Remicade) for moderate-severe disease
with fistulization is CONTRAINDICATED
for disease with strictures.
Also, TB must be ruled out with PPD &
CXR prior to use.
First Aid for the Internal Medicine Boards. Le, et al. McGraw Hill. P 243 2006.
Ulcerative Colitis (UC):
Diffuse colonic inflammation- limited to the
mucosa- marks this chronic, recurrent disease.
Greater than 50% of all cases are isolated to the
sigmoid and rectum.
Typical onset lies between patients 20-40 years
of age, but the disease may present in the
elderly or in those under 10 years of age.
Repeated flare-ups and remissions as in Crohn’s
Disease.
More common in Ashkenazi Jews.
First Aid for the Internal Medicine Boards. Le, et al. McGraw Hill. P 243, 2006.
UC
The typical presenting patient is one with a
family history of UC, NON-Smoker, who
presents with fecal urgency, bloody
diarrhea, abdominal pain or tenderness,
and tenesmus.
DRE often positive for red blood.
Bloody diarrhea is the most typical
manifestation of UC. Pain may occur but
is relatively uncommon.
eMedicine - Inflammatory Bowel Disease Article by William A Rowe, MD.htm
First Aid for the Internal Medicine Boards. Le, et al. McGraw Hill. P 243, 2006.
SMOKING is GOOD for YOU?
Indeed this is one
instance where
smoking cigarettes
may be of some
benefit, as it has
been found that
smoking may
actually attenuate
the disease.
First Aid for the Internal Medicine Boards. Le, et al. McGraw Hill. P 243, 2006.
UC
There is a higher correlation
with laboratory values (Hct,
albumin, ESR) and disease
severity.
Abdominal X-ray in
moderate to severe disease
may demonstrate lack of
haustra leading to lead pipe
deformity with colonic
dilatation.
First Aid for the Internal Medicine Boards. Le, et al. McGraw Hill. P 243, 2006.
UC
Ulcerative colitis. Double-contrast barium enema study
shows changes of early disease.
UC
Colonoscopy should be used to evaluate the colon and
terminal ileum looking for continuous circumferential
ulcerations and pseudopolyps.
Colonoscopy should be AVOIDED in the case of severe
UC flare-ups.
Biopsy may show acute and chronic inflammation with
crypt abscesses.
Unlike Crohn’s disease, granulomas are absent in UC.
Infectious colitis must be excluded before the diagnosis of
UC can be made.
Superimposed infection can occur in patients with
longstanding UC
Infection with Clostridium difficile is most common.
First Aid for the Internal Medicine Boards. Le, et al. McGraw Hill. P 243, 2006.
TOXIC MEGACOLON:
surgical-tutor.org.uk/pictures/images/lower_gi/toxic_uc.jpg
UC
Risk of colorectal cancer is not thought to be
significantly higher in UC patients compared to
the general population until several years after
diagnosis.
However, 8-10 years after diagnosis, the risk of
colorectal cancer increases by 0.5-1.0% per
year.
Surveillance colonoscopies with random
biopsies may reduce mortality from colorectal
cancer in patients with ulcerative colitis
This may be due to the detection of carcinoma at
an earlier Duke stage.
eMedicine - Inflammatory Bowel Disease Article by William A Rowe, MD.htm
UC
Surveillance colonoscopy is recommended
every 2 years after 8 years of disease.
It is recommended more frequently if
areas of pathologic concern are evident.
eMedicine - Inflammatory Bowel Disease Article by William A Rowe, MD.htm
UC
UC
UC
As in Crohn’s disease, colonic strictures
are of significant concern.
In patients with UC, strictures should be
presumed to be malignant unless proven
otherwise.
Needs colonic resection.
eMedicine - Inflammatory Bowel Disease Article by William A Rowe, MD.htm
UC
Sigmoidoscopy & colonoscopy show that the
rectum is almost always involved.
Disease can be limited to the rectum, as is this
case in proctitis - but the rectum, sigmoid, and
rest of the colon are often also involved (leftsided colitis & pancolitis).
UC by definition does not involve any other
segment of the gastrointestinal tract.
Colectomy is curative.
eMedicine - Inflammatory Bowel Disease Article by William A Rowe, MD.htm
UC Extraintestinal Complications:
Eye: Episcleritis and uveitis. Vision loss
may result if left untreated.
Skin: Erythema nodosum & pyoderma
gangrenosum & lesions related to immune
suppression (eg, herpetic lesions)
Liver: Sclerosing cholangitis (fatigue
jaundice, abnormal LFT results in a
cholestatic pattern).
Blood: Anemia and hypercoaguable state
UC TREATMENT:
For distal Dz: oral or rectal corticosteroids or
aminosalicylates
For extensive colonic involvement: Oral
aminosalicylates
For fulminant Dz: IV corticosteroids OR IV
cyclosporine if resistant to steroids
In remission states: may use aminosalicylates,
oral azathioprine OR mercaptopurine if steroid
dependant or refractory.
WRAP-UP
CROHN’S
UC
Lesions
Focal, skip, deep
Shallow, continuous
Clinical Course
Indolent
More Acute
Prednisone
Less Responsive
Very Responsive
Granulomas
Present
Absent
Rectal Involvement
Rectal Sparing 50%
Rectum ALWAYS
involved
Perianal Disease
Abscesses & fistulas
NONE
Small Bowel
Involvement
> 50%
< 10%
TEST QUESTIONS:
1. Approximately how many patients in the
United States are afflicted with IBD:
A)
B)
C)
D)
E)
5 million
4 million
3 million
2 million
1 million
TEST QUESTIONS:
1. Approximately how many patients in the
United States are afflicted with IBD:
A)
B)
C)
D)
E)
5 million
4 million
3 million
2 million
1 million
TEST QUESTIONS:
2. All of the following are characteristics of
A)
B)
C)
D)
E)
Crohn’s Disease EXCEPT:
Transmural ulcerations
Ulcerations limited to the mucosa
Rectal Sparing
Abscesses and fistulas
The presence of granulomata
TEST QUESTIONS:
2. All of the following are characteristics of
A)
B)
C)
D)
E)
Crohn’s Disease EXCEPT:
Transmural ulcerations
Ulcerations limited to the mucosa
Rectal Sparing
Abscesses and fistulas
The presence of granulomata
TEST QUESTIONS
3.
A)
B)
C)
D)
E)
Current evidence-based approaches to the
treatment of Crohn’s disease involves the
implementation of which of the following drugs
for the treatment of patients with ileal or right
colonic disease:
Budesonide
Predisone
Metrodidazole
Azathioprine
Infliximab
TEST QUESTIONS
3.
A)
B)
C)
D)
E)
Current evidence-based approaches to the
treatment of Crohn’s disease involves the
implementation of which of the following drugs
for the treatment of patients with ileal or right
colonic disease:
Budesonide
Predisone
Metrodidazole
Azathioprine
Infliximab
References:
ulcerative_colitis4.jpg450 x 339 pixels - 152.6kB
www.surgical-tutor.org.uk/.../
inflam_bowel.htm
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4. www.your-doctor.net/GIT/UC_info.htm
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6. wwwartsci.clarion.edu/.../
aalarge_intest.htm lead pipe colon...is.jpg338 x 427
pixels - 30.3kB
7. www.ddfindia.org/3rcdhruu/3rcdhruu.htm
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9. www.iecdesmoines.com/crohn's_disease.htm
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index.asp?id=1751
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Aliment Pharmacol Ther 2003; 18; 263-277
Gut, August 1997, Vol 41, p 209-214
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