2012 Physicians Assistance WINTER CONFERENCE March 10, 2012

Jannine Purcell, CNP Rapid City Medical Center Division of Gastroenterology and Hepatology

IBS is a gastrointestional syndrome characterized by chronic abdominal pain and altered bowel habits in the absence of any organic cause

THIS IS THE MOST COMMONLY DIAGNOSED GI CONDITION

IBS affects men, women, young patients and the elderly There is a 2:1 female predominance in North American females

IBS comprises 25-50% of all referrals to GI

IBS accounts for a significant number of visits to primary care and is the second highest cause of work absenteeism after the common cold

IBS has been associated with increased health care cost with studies suggesting annual direct and indirect costs up to $30 billion ANNUALLY

Altered bowel habits ranging from diarrhea, constipation, alternating diarrhea and constipation

INFLAMMATORY BOWEL DISEASE

Chronic inflammatory bowel disease (IBD) include: Ulcerative Colitis Crohn’s Disease

Ulcerative Colitis A disorder in which inflammation affects the mucosa and submucosa of the colon

Crohn’s Disease A disorder in which inflammation is transmural and may involve any or all segments of the gastrointestional tract

Ulcerative colitis 1.Disease in continuity 2.Rectum almost always involved 3.Terminal ileum involved infrequently 4. Granular and ulcerated mucosa diffusely 5. Often intensely vascular 6. Normal serosa 7. Muscular shortening of colon: fibrous strictures very rare 8. Spontaneous fistulae not typical

9. Inflammatory polyposis common and extensive 10. Malignant change is well recognized 11. Anal lesions uncommon

Crohn’s Disease 1.Disease discontinuous 2.Rectum frequently spared 3.Terminal ileum frequently involved 4. Discretely ulcerated mucosa; with fissuring 5. Vascularity seldom pronounced 6. Serositis common 7. Shortening due to fibrosis; fibrous strictures common

9. Inflammatory polyposis less prominent and less extensive 10. Malignant change 11. Anal lesions more common

Ulcerative Colitis 1. Diffuse mucosal and submucosal inflammation 2. Width of submucosal normal or reduced 3. Often intense vascularity, little edema 4. Focal lymphoid hyperplasia restricted to the mucosa and superficial submucosa 5. “Crypt abscesses” very common with diffuse inflammation 6. Anal lesions- non-specific if present

Crohn’s Disease 1. Transmural inflammation with fistulae formation 2. Width of submucosa normal or increased 3. Vascularity seldom prominent, edema marked 4. Lymphoid aggregates in mucosa, submucosa, serosa and pericolic tissues 5. Sarcoid-type granulomas, characteristic with focal patchy inflammation 6. Anal lesions; granulomatous foci often present

Incidence and prevalence of ulcerative colitis are: 2 – 10 and , respectively per 100,000 population in the US

Incidence and prevalence of Crohn’s disease are 1-6 and 10 – 100 respectively per 100,000 population in the US

There is an increased incidence of IBD in relatives of patients with IBD indicating a genetic disposition

Both conditions are more prevalent in Jews and less common in African Americans

The peak age of onset of both diseases is between yrs and then a second peak is observed between yrs

Incidence equal between men and women

Ulcerative colitis is more common than Crohn’s disease in children younger then ten years old

Viruses and bacteria- there is little data but suspect  Measles Mycobacterium paratuberculosis

Dietary antigen activates abnormal immune response

Auto antigen expressed on patients intestional epithelium

 Patient mounts an initial immune response against a lumenal antigen, which persists and may be amplified

 Dominant symptom in the US is often bloody, frequent low volume bowel movements  Abdominal pain, usually in the lower quadrant and rectum

 Localized rectal involvement may be characterized by:  bloody diarrhea, with or without urgency,  tenesmus,  pain or  fecal incontinence

Mild disease: Diarrhea, rectal bleeding and usually normal physical exam

Most patients with ulcerative proctitis have mild disease

Moderate disease: Occurs in 27% of patients 5 -6 bloody stools, abdominal pain, tenderness, low grade fever, fatigue

Severe disease 19 % patients have severe ulcerative colitis Frequent bloody stools, profound weakness, weight loss, fever, tachycardia

Hypotension, abdominal tenderness, anemia as well as hypoalbuminemia Abdominal distention with severe disease may mean toxic megacolon

Usually ulcerative colitis will begin indolently and gradually worsen Initial presentation- colitis extending to the cecum in 20% patients

75% patients have no disease proximal to the sigmoid 15% patients with initial proctitis will extend their disease more proximally

Patients with mild disease More than 90% will go into remission after first attack

Patients who present initially with severe disease often require colectomies Usually 50% of those patients within the first 1 -2 yrs

The usual pattern of chronic disease is long quiescent periods interspersed with acute attacks

Non compliance with medications NSAID use Antibiotics Colonic infections (c-diff) Smoking cessation

Temp greater then 38.6 C HR > 120 Neutrophil count > 10,500 Dehydration Mental status changes Electrolyte imbalances

Hypotension Abdominal distention Tenderness

Involvement of the ileum and cecum: 40% of patients Small bowel: 30% of patients Colon only: 25% of patients Pancolic: 2/3 Segemental: 1/3

Early changes  Aphthous ulcers-> deep ulcerations-> confluent ulcerations  “cobblestone” appearance  Thickened mucosal folds  Asymmetric involvement  Inflammatory pseudopolyps  Segmental distribution  Skip lesions

Symptoms Diarrhea Weight loss Abdominal pain

 Stool frequency  Abdominal pain  Sense of well being  Systemic manifestations  Use of antidiarrhea agents  Abdominal mass  Hematocrit  Body weight

Crohns disease is a relapsing and remitting disease that will spontaneously improve without treatment in 30% of cases

Patients in remission can expect to remain in remission for 2 yrs in 50% of cases

However, 60% of patients require surgery within 10 years of diagnosis

Of those patients who require surgical resection, 45% will eventually require reoperation

Crohns disease can produce significant disability, and 50% of patients make major changes in employment to accommodate decreased working hours and leaves of absence

Abscesses and fistulas result from extension of a mucosal break through the intestional wall into the extra intestional tissue

Abscesses occur in % of patients usually arising from the terminal ileum Abscesses present with fever, localized tenderness and palpable mass

Infection is usually polymicrobial E coli, bacteroides fragilis, enterococcus, and alpha hemolytic streptococcus

20-40% of Crohn’s patients have fistulizing disease Fistula may be enteroenteric, Enterocutaneous, enteovesical, or enteovaginal

Large enteroenteric fistulae produce diarrhea, malabsorption, and weight loss

Enterocutaneous fistulae produce persistent drainage that usually is refractory to medical therapy

Rectovaginal fistulae lead to foul-smelling vaginal discharge

Enterovesical fistulae produce pneumaturia and recurrent urinary tract infections

Obstruction, especially of the small intestine, is a common complication caused by mucosal thickening, muscular hyperplasia and scarring from prior inflammation or adhesions

Perianal disease, including anal ulcers, abscesses and fistulae can affect the groin, vulva or scrotum