Imflammatory bowel disease: Ulcerative colitis and Crohn's dz
Describe what each causes?
Ulcerative only is muscosa and occasionally submucosa (all throughout)
Crohns is tranmural (skip lesions)
Etiologic theories of IBD?
Most common in 2nd & 3rd decades, but can affect any age.
Males = females.
Pathophysiology of IBD?
–Defect in the function of the intestinal lumen
–Breakdown of the defense barrier of the gut
–Exposure of mucosa to microorganisms or their products
–Results in chronic inflammatory process mediated by T cells.
Systemic complications of IBD related to imflammatory activity:
1. Oral? 1
2. Eye? 2
3. Cutaneous? 2
4. Cardiac? 1
5. Muskuloskeletal? 1
HLA B28 presentation
Systemic complications of IBD related to small bowel pathophysiology:
1. Gallbladder? 1
2. Intestinal? 1
3. Renal? 4
1. What is Ulcerative Colitis?
2. Always includes what? Spreads where?
3. What kind of inflammation does it cause with distal colitis? 2
4. –Extensive colitis aka?
1. uInvolves the mucosal surface of colon with the formation of crypt abscesses.
2. Always includes the rectum, spreads proximally
Is uniformly continuous, NO SKIP LESIONS
1. 50% is where?
2. 30% is where?
3. 20% is where?
WHY WOULD WE DO A colonscopy and not a sigmoidoscopy?
1. –50% rectosigmoid (Proctosigmoiditis)
2. –30% to splenic flexure (Left sided colitis)
3. –20% extend proximally (Pancolitis)
THey are at much higher risk for cancer
What are the two pictures showing?
ALWAYS HAVE TO BE THINKING ABOUT COLON CANCER
Ulcerative Colitis Clinical Course?
1. –Flare-ups and remissions.
2. –More common in nonsmokers.
3. –Disease severity may be lower in active smokers and may worsen in patients who stop smoking.
4. –Higher risk for development of cancer.
1. Onset of flares occasionally appears to coincide with what?
2. What is the development of cancer in UC related to? 2
1. Onset occasionally appears to coincide with smoking cessation
-related to extent and duration of disease and
-age at diagnosis
Signs and symptoms:
–Mild to moderate disease
1. Bloody diarrhea (hallmark)***
2. Lower abdominal cramps
–Relieved with defecation
3. Fecal urgency
Signs and symptoms of severe disease UC?
1. Rectal bleeding
2. Left lower quadrant cramps
3. Severe diarrhea
4. Fever (high grade fever would be perforation)
5. Anemia (blood loss- iron deficiency)
Ulcerative Colitis: Systemic associations?5
–Central (axial) arthritis
–Erythema nodosum (raised rash on the skin that isnt itchy)
What is sclerosing cholangitis?
Sclerosing cholangitis: disease of bile ducts that causes inflammation and obstruction,
80% of these patients have UC,
Treatment: liver transplant.
2. Sed rate and CRP
4. –Perinuclear antineutrophil cytoplasmic antibodies (pANCA) - a lot of people don't have this but still have the disease.
1. What would the CBC show us? 2
2. Sed rate and CRP?
3. CMP? 3
-anemia is common due to multiple factors
2. Sed rate and CRP
-elevated sedimentation rate & C-RP reflect acute phase (only elevated while having symptoms)
-decreased serum albumin
-prolonged clotting time
Describe the following for mild, moderate and severe UC
–Weight loss: ?
–Albumin : ?
–Stools: less than 4/day
–Pulse: less than 90
–Weight loss: none
–ESR: less than 20
–Albumin : normal
–Hematocrit : 30-40
–Weight loss: 1-10%
–Albumin : 3-3.5
–Stools: >6/day (mostly bloody)
–Hematocrit : less than 30
–Weight loss: >10%
–Albumin : less than 3
What is an ulcerative colitis diagnosis based on?
Diagnosis is usually based on
1. clinical presentation,
2. sigmoidoscopic demonstration of inflammation and
3. the exclusion of bacterial and parasitic infection.
What 4 things would give us our diagnosis of UC?
(dignosis is best made at?)
1. –Bloody diarrhea (differentiates from Crohn’s)
2. –Plain abdominal xrays
4. –CT Scan – (complications)
–diagnosis is best made at Sigmoidoscopy.
Ulcerative colitis treatment?
–Reduce dietary fiber during an exacerbation.
–Prescribe folic acid supplements with Sulfasalazine.
–Oral iron may be needed with rectal bleeding and documented iron deficiency anemia.
–Frequent follow-up and close monitoring.
–Short course of Loperamide for troublesome diarrhea.
--Periodic colonoscopy and biopsy in patients with pancolitis lasting more than 8 years
Mild to Moderate UC Disease medical treatment? 4
1. –Sulfasalzine (suicidal thoughts and severe depression in males)
2. –Olsalazine (non sulfa)
4. –May have to add prednisone
Taper to lowest therapeutic dose needed
UC uModerate to Severe Disease treatment? 3
May need to consider immunosuppresive therapy for patients who need constant high doses of steroids
If the UC is limited to the rectosigmoid what can we do?
1. Proctocolitis (limited to rectosigmoid)
3. Oral or topical (enema, suppository)
4. Hydrocortisone (Enema, Suppositories, Foam)
Ulcerative colitis indications for surgery?
Ulcerative colitis surgical options?
What is Crohns Dz?
Transmural involvement with formation of fistulas, narrowing of lumen, obstruction.
Can involve any segment of the G.I. tract.
List them from most common to least common 5
–Ileocolitis = 45%
–Ileitis = 28%
–Colitis = 15%
–Gastroduodenitis = 7%
–Jejunoileitis = 5%
What does crohns usually spare?
How does cigarette smoking relate to crohns?
Cigarette smoking is strongly** associated with the
1. development of Crohn’s Disease,
2. resistance to medical therapy and
3. early disease relapse.
Crohn’s Disease Clinical Manifestations?
1. –Presentation depends upon site and severity.
2. –Insidious onset usually.
3. –Intermittent bouts of low-grade fever, diarrhea and RLQ pain (but all over the place depending on where it can be)
4. –Postprandial pain common.
5. –RLQ mass
6. –Perianal disease (abscess, fistula)
7. Often nocturnal B.M.’s, night sweats, weight loss.
8. Skin lesions, primarily erythema nodosum, may precede intestinal symptoms.
Patients are often chronically ill with what?\
–Patients are often chronically ill:
1. Weight loss
Children & Adolescents: presentation often insidious with what? 4
1. weight loss,
2. failure to grow or develop 2° sex characteristics,
3. arthritis, or
4. fever of unknown origin.
Distinguishing features of Crohns dz of the colon?
On PE what will Crohns show?
–abnormal bowel sounds
–tenderness in area of involvement
–perianal region problems
What kind of perianal problems will show on Crohns pts?
3. skin tag
4. anal stricture
Labs for Crohns?
2. Sed rate and CRP
What will the following show on a crohns pt:
1. CBC? 2
2. ESR and CRP? 1
3. CMP? 3
4. ASCA? 1
-anemia is common due to multiple factors (with diff and also B12 and folate)
2. Sed rate and CRP
-elevated sedimentation rate & C-RP reflect acute phase
-decreased serum albumin
-prolonged clotting time.
-serum anti-saccharomyces cerevisiae antibody (ASCA) highly specific, but sensitivity = 30%
What kind of imaging is best for Crohns dz and why?
–Barium contrast studies most commonly used for upper & lower G.I tract.
ubetter for finding complications…. strictures & fistulas.
What will we often see on imaging for crohns dz? 5
(two most common?)
1. “cobble stoning”,
2. “skip lesions”,
4. dilated bowel,
5. fistulas communicating to adjacent bowel/mesentery/bladder/vagina
What other procedure would we do for crohns and why?
–Histology: from endoscopic biopsy
Crohns Dz approach to differential diagnosis? 9
What are the two pictures showing with Crohns Dz?
2. String sign
Intestinal complications of Crohns
What are the different kinds?
Describe a typical hemorrhoid tag compared to a Crohns one?
Treatment of Crohns Dz?
1. 5-Aminosalicylic Acid Agents controversial
4. Anti-TNF therapy
5. Immunomodulating drugs
What are the three meds in –5-Aminosalicylic Acid Agents controversial?
What are the immunomodulating drugs? 3
–Anti-TNF therapy drug?
Older terms describing IBS?
–Functional bowel disease
What is the definition of IBS?
A functional gastrointestinal disorder that is a variable combination of chronic or recurrent gastrointestinal symptoms not explained by structural or biochemical abnormalities (NCCP, NUD, IBS)
Characteristic symptoms of IBS
8 (these are diagnostic)
Continuous or recurrent symptoms for at least 3
1. abdominal pain or discomfort
2. pain relieved by defecation
3. pain with a change in frequency or form of stools
and a varying pattern of defecation with 3 or more of the following:
4. Altered stool frequency
5. Altered stool form
6. Altered stool passage (straining, urgency, incomplete evacuation/ sensation of rectal fullness)
7. Abdominal distension and bloating
8. Passage of mucus
Associated symptoms of IBS in order of prevalence?
Back ache 75%
Early satiety 73%
Irritable bladder 56%
Functional dyspepsia 51%
Describe the Rome II criteria for IBS?
–. Rome II Criteria: (most commonly used)
1. Abdominal discomfort/pain with 2 of the following 3 features for at least 12 weeks, not necessarily consecutive, for the past 12 months:
2. Relief with defecation.
3. Onset associated with change in stool frequency.
4. Onset associated with change in stool formation
Describe the manning criteria for IBS?
1. Pain relieved by defecation.
2. More frequent stools associated with pain onset.
3. Looser stools assoc with onset of pain.
4. Abdominal distention.
5. Passage of mucus.
6. Feeling of incomplete evacuation.
DDX for IBS:
Dietary factors? 5
Inflammatory Bowel? 4
Patient assessment: History for IBS?
1. dietary habits (sorbitol sweetener, caffeine, cruciferous vegetables) carb malabsoption
2. travel history
3. medication use
4. recent gastro-enteritis or food-born illness
5. lactose intolerance
6. gender, age
7. family history
8. night time defecation
PE for IBS?
A full physical examination is necessary to exclude organic disease
Patient will not usually have abdominal guarding
(should have guarding considering the pain the patient is having)
Labs for IBS?
3. serum electrolytes
4. liver enzymes
5. stool occult blood X 3
6. stool cultures X 3
7. stool O & P
Imaging for IBS?
–upper GI series with small bowel follow through
–plain abdominal radiograph
–air contrast barium enema
Warning Signs & Red Flags for IBS?
–Any abnormality on physical exam
–Clinical or biochemical evidence of malnutrition
–Family history of GI cancer, inflammatory bowel disease, or sprue
–Onset of symptoms after age 50
Alarm symptoms for IBS?
1. Constant abdominal pain
2. Constant diarrhea
3. Constant abdominal distension
4. Nocturnal disturbance
5. Passage of blood with stool
6. Weight loss
How do we make a positive diagnosis without costing the patient tons of money?
–Use Rome and Manning Guidelines
–American College of Gastroenterologists
Patients without alarm features. How should we procede?
–Flex sig, barium enema, colonoscopy, FOBT, stool for O & P or culture or thyroid tests cannot be recommended.
Management of IBS?
1. Make a positive dx
2. Consider patients agenda
3. Make a management classification
4. Plan a management strategy
Make a positive Dx:
1. Usually possible from hx alone. What will the hx describe? 3
2. –In younger patients, a normal what (2) may help to reassure patient.
3. In patients >45 with long history and no recent change, what might help reassure the pt? 2
1. Usually possible from history alone
-symptoms usually begin in the late teens to twenties
-Pain is intermittent and crampy
-Pain does not occur at night or interfere with sleep
2. ESR and Hgb
3. –a sigmoidoscopy and/or barium enema may help to reassure.
Consider patients agenda: What questions should we ask?
A full psychological, social and family history inquiry is necessary.
-Try to get an answer to the question”
“Why has this patient presented at this time”?
Make a management classification:
–To which category does this patient belong? 5
1. Bloating and pain predominant
2. Constipation predominant
3. Diarrhea predominant
4, Anxiety associated
5. Depression associated
Plan a management strategy
–Establish a therapeutic provider-patient relationship.
1. Focus should be on?
2. Who should be responsible for treatment decisions?
3. Demonstrate a commitment to what?
1. Focus should be on symptom relief and in addressing the patient’s concern.
2. Shift responsibility for treatment decisions to the patient by providing therapeutic options
3, Demonstrate a commitment to the patient well being rather than to the treatment of the disease
IBS patient education? 5
1. Validates the patient’s illness and sets the basis for therapeutic interventions.
2. Set realistic goals rather than cure
3. Teach symptoms monitoring
4. Reassure the benign nature of IBS
5. Address psychosocial issues