inflammatory bowel disease

ulcerative colitis
*who is it seen in and the mechanism
*bowel mucose-idiopathic and diffuse
*pathogenesis -? primary immune mechanism
*typically begins in adolescence or young adulthood
*more prevalent in whites, Jews of eastern european descent
*genetic tendency

what is the clinical presentation of UC
*bloody diarrhea
*abd pain relieved be BM
*fever, anorexia, weight loss and anemia
*”extracolonic” manifestations
–>arthritis
–>uveitis
–>jaundice
–>skin lesion

where do you see UC
*almost always involves the distal colon and rectum
*chronic, recurrent, and unpredictable

describe the disease course of UC
*nearly 90% go into complete remission
*chronic cases-75% have disease limited to distal bowel
*mortality rates no different than general population (except in extensive disease)

what are the three disease severity states for UC and describe them
Mild- fewer than 4 BM’s qd, intermittent bleeding, nl. hematocrit and ESR
Moderate- 4 to 6 BM’s qd, frequent bleeding, HCT drop and ESR 20-30 mm/h
Severe- more than 6 BM’s, HCT drop, weight loss greater than 10% ESR greater than 30 mm/h

what is ulcerative proctitis
*a variant of UC
*distinguished by limited extent of inflammation, good prognosis and lack of serious complications
*relapses are more common
*less than 15% can progress to generalized UC

what’s crohn’s disease
*chronic, relapsing inflammatory disorder
*affecting alimentary tract
*appears to have autoimmune pahtophysiology
*inflammation- “discontinuous” -diseased segments separated by normal bowel
*may extend through all layers of bowel wall

what is the clinical presentation of Crohn’s disease
*peak incidence 20’s through 40’s
*often distal ileum and right colon can involve small bowel frequently (80%)
*bottom line -can happen anywhere from buccal mucosa to anus!

Crohn’s
what are the symptoms
*abdominal pain (often RLQ and sometimes relieved by BM)
*diarrhea -50% (may be bloody)
*weight loss/anorexia
*vomiting
*fever
*preianal discomfort/bleeding
*constipation may be early obstruction

what are the various disease severities for Crohn’s
Mild to moderate – weight loss less than 10 %, no dehydration
Moderate to severe- fever, anemia, wt loss greater than 10%
Severe-fever, obstruction, abscess

what are the physical findings for Crohn’s
*may reveal RLQ abdominal mass
*may see perianal fistulous tracts (<10%) *"extraintestinal"-joint, (inflammed joints, spina deformities, )skin(erythema nodosum, pyoderma), eye(uveitis), mouth (aphthous ulcers), GU (nephrolithiasis, obstruction), bone (osteoporosis/penia)

what tests are done for dx of UC
*based on clinical presentation
*sigmoindoscopy/colonoscopy and rectal biopsy
*serology- may have elevated C-reactive protein, Leuk’s, ESR, platelet count and decreased in Hgb and albumin
*pt hx, clinical symptoms, negative stool for bacteria, toxins, O&P

what tests are done for dx of crohn’s
*clinical presentation, radiologic contrast studies (UGI series, air contrast BE) and endoscopic measures
*serology-same as UC
*endoscopic-rectal sparing, apthous ulcers, fistulization, and skip lesions

what things UC
*sulfasalazine (azulfidine)
*sylfapyridine-free 5-Aminosalicylate agents
*oral corticosteroids
*immunospurressives
*opiates
*psychologial support
*surgery
*screening for cancer

UC
sulfasalazine
*initial treatment for mild to moderate symptoms
*given as 4g/day max for 2-4 weeks
*usually 80% pt response
*may combine with steroids for more sere cases
*maintenance dose 2g/day

UC ADR for sulfasalazine
*adverse effects-mostly due to sulfapyridine
*GI upset (n/v, anorexia, heartburn)
*mild hypersensitivity (rash, fever)
*serious -agranulocytosis, hepatocellular injury, lupus-like phenomena
*anemia
*?sperm count decrease

UC tx
sulfapyridine-free-5-animosalycylates
*can deliver 5-asa without many side effects associated sulfasalizine
*mesalamine (pentesas)-especiall coated for delayed release
*much more expensive than sulfasalazine

UC tx
topical 5-asa enemas
*also an alternate to sulfasalazine
*offers good option for those with distal colitis
*can be used for maintenance
*excellent safety profile
*no concern about systemic steroid absorption as with hydrocortisone enemas

UC tx
glucocoticosteroids
*for moderatley severe to severe cases
*prednisone-start with 40 qd
*hospitalization may be required for those too ill for oral therapy
*can gradually taper once symptoms lessen

UC tx
immunomodulator agents
*for those who require chronic high dose steroid therapy and inadequate response to conventional therapies
*natalizumab (tysabri)
*given as infusion
*potentially serious side effects (infection, hepatotoxicity, bone marrow suppression
*monitor blood work

UC tx
opiates/opiods
*provides symptomatic relief of diarrhea
*codeine, tincture of opium, paregoric, loperamide, diphenozylate (lomotil)
*watch for addiction

UC tx
surgery
*last resort!
*total colectomy – complete cure of bowel disease and remission of most peripheral manifestations

what are the indications for surgery for UC
high grade dysplasia
toxic megacolon
hemorrhage
obstruction
unresponsiveness to maximal medical management

for pt’s with UC what should cancer screening look like
*all pt’s with pan colitis of 7 years of more
*best method-colonoscopy with multiple biopsies
*every 2 to 3 years until 20 yr hx and then annual
*more often with worrisome findings (dysplasia and strictures)

crohn’s disease tx
*diet *antidiarrheal agents
*sulfasalazine and other 5-asa preps
*metronidazole *ciprofloxin
*PPI (gastro/duodenal)
*glucocorticosteroids
*6-mercaptopurine, azathioprine
*other immunomodulating and antiinflammatories
*surgery

crohn’s disease tx
diet
*adequate protein and calories
*reduce fiber content with flare-ups-cramping and diarrhea
*decrease fat intake (steatorrhea)<80g/day *restricting milk products *partial bowel rest *elemental diet preps (ensure, sustacal) *TPN *vitamin supplements

crohn’s disease tx
metronidazole
*second step with failure to sulfasalazine
*15 to 20 mg/kg/day
*can be used as low dose maintenance therapy
*side effects-GI upset, metallic taste, parasthesias
*(can consider using fluoroquinolones)

crohn’s disease tx
other immunomodulators
*methotrexate-folic acid antagonist with anti-inflammatory effects
*monoclonal antibody cA2 (infliximab-remicade)
*tumor necrosis factor blockers (ie Humira)
*omega 3 fatty acids
*newer immunosuppressives- tacrolimus (similar to cyclosporin)-extensive small bowel involvement and Tysabri

what are indications for admission for Crohn’s disease
*toxic, bleeding heavily. in severe pain or too ill to obtain adequate nutrition orally
*bowel rest, nasogastric feeding of elemental diets, parenteral steroids and surgical consult is reqired

IBS, what is it
*altered bowel movements and pain
*absence of structural abnormalities
*diagnosis based on clinical presentation

what its he rome criteria for dx of IBS
*ABD pain/discomfort relieved with BM and 2 or more of the following at least 3 days/month x 3 months
–>change in stool frequency
–>change in stool consistency
–>difficult stool passage
–>sense of incomplete evacuation
–>presence of mucus in stool

what are the clinical features of IBS
*more common in “young” (under age 45)
*women more commonly affected (80% of IBS population)
*abd pain/discomfort
*altered bowel habits
*flatulance
*upper GI symptoms
*symtoms almost always during waking hours

abd pain in IBS
*location variable
*frequently episodic and cramp but may be constant ache in some pt’s
*intensity variable
*pain can be exacerbated by eating, stress
*relieved by BM passage of flatulence

IBS – altered bowel habits
*most common pattern is constipations alternating with diarrhea
*consitpation may become intractable and resistant to laxatives
*due to sense of incomplete evacuation may have smaller, frequent BM’s
*shape of stool can change (due to spasm)
*stool may be accompanied by mucus

what are the upper GI symptoms for pt’s with IBS
25-50% complain of dyspepsia, heartburn, N/V
*appears to affect motor patterns in small bowel during waking hours
*this is exacerbated by food intake

how can dx of IBS be made
*thorough H&P-dx of exclusion
*workup depends on onset and severity of symptoms and age
*most-CBC, flex sig, stool for O&P
*consider dietary causes (lactose)
*UGI work up for UGI symptoms
*US of gallbladder if postpradial RUQ pain

what is the treatment for IBS
*pt counseling/dietary alterations
*stool bulking agents/high fiber diets
*antispasmodics – bentyl (dicyclomine) or levsin (hyoscyamine)
*antidiarrheal agents-lomotil or loperamine (imodium)
*antidepressants
*antiflatulance
*GI motility enhancers (lubiprostone) for constipation -dominant in women

what is antibiotic associated colitis
*diarrhea occurs either during or within 4 weeks of impacted AB-most mild and non-specific
*clostridium difficile (spore-forming, gram + bacillus) about 20% of cases
*cephalosporins, PCN’s clindamycin, any

what are the varying degrees of severity in antibiotic associated colitis
*very mild- nl coloin mucose
*mild- mild erythema with some edema
*moderate-granular, friable or hemorrhagic
*severe -psuedomembrane formation (PMC)

Pseudomembranous Colitis
*most have positive stool toxin assays
*exudative, punctate, raised plaques with skip areas
*diarrhea-KEY!, watery, voluminous, usually no blood or mucus
*most have cramping, tenderness, fever, leukocytosis but can vary

what is the treatment for pseudomembranous colitis
*discontinue agent
*diarrhea-metronidazole (flagyl) or may try Vanco (both can cause PMC)
*avoid anti peristaltic agents (some antidiarrheals)
*pt may relapse- may repeat tx or try taper

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