1. Inflammatory Bowel Disease
Digestive Specialists, Inc.
999 Brubaker Drive • Kettering, OH 45429
Anjali Morey, M.D., Ph.D.

2. Which would be considered a high risk Crohns Disease patient?
Highly Symptomatic
Advanced age of disease onset
Prior Surgical resection
Disease limited to one section of the colon 10

3. Which vaccine should not be given to an IBD patient on immunosuppressive therapy?
Influenza
Pneumonia
Hep B Vaccine
Gardasil
Shingles

5. Objectives
Review primary care workup for chronic diarrhea when IBD is suspected
Report on current treatment recommendations for Ulcerative Colitis and Crohn’s Disease
Discuss clinical follow-up of patients on immunosuppressive therapy
Discuss lifestyle changes that can help maintain remission

6. http://ibd. cochrane. org/sites/ibd. cochrane. org/files/uploads/IBD2
IBD Overview

7. Overview of Crohn’s Disease (CD)
Any segment of GI tract (mouth-anus)
Rectal Sparing
Discontinuous “skip lesions”
Perianal Disease
skin tags
fissures
fistulae
Transmural inflammation
stricture
fistula
perforation
abscess
Normal Crohn’s Disease

8. Overview of Crohn’s Disease (CD)
Pathologic Changes
Epithelioid non-caseating granulomas
Chronic inflammatory infiltrate
Crypt architectural distortion

9. Overview of Ulcerative Colitis (UC)
Confined to colon
Begins in rectum and extends proximally in a continuous fashion
Confined to mucosa and submucosa
Normal Ulcerative Colitis

10. Overview of Ulcerative Colitis (UC)
Pathologic changes
Cryptitis / crypt abscesses
Crypt architectural distortion
Lamina propria expansion with acute and chronic inflammatory cells

11. Patients often present with diarrhea > 2 weeks
Primary Care
Patients often present with diarrhea > 2 weeks

12. CD: Signs & Symptoms Abdominal Pain GI Bleeding Diarrhea Weight Loss
Fatigue
Fever
Joint Pain
Skin Rashes

13. CD: Staging Workup If abdominal symptoms present
Initial Steps
Labs
Colonoscopy
TI exam & biopsy
If iron deficiency anemia exists and colonoscopy negative
EGD
If EGD negative in the setting of iron deficiency anemia
Small Bowel Capsule Endoscopy
Consider imaging prior if any suspicion of narrowing / stricture
If abdominal symptoms present
CTE / MRE to assess small bowel

18. CD: Initial Labs CBC CRP / ESR CMP TSH Strongyloides Antibody
Consider Prometheus Testing
Consider Absorption Labs

19. CD: Absorption Labs Iron Studies / Ferritin B-12 / Folic Acid
Vitamin D
Vitamin D Target Range (for IBD Patients):  40-60 ng/mL
Vitamin A
Zinc

20. CD: Stool Studies to Rule Out Infection / Inflammation
Stool Ova and Parasites
Stool for C. difficile toxin
Stool giardia antigen
Stool for Cryptosporidium
Stool culture and sensitivity
Fecal Calprotectin

21. CD: Imaging CT Enterography / MR Enterography
Cross-sectional imaging technology
Assess for small intestine disease activity
Assess for complications
Abscess
Fistula
obstruction
< 30 y/o, MRE preferred to avoid radiation exposure

22. CD: High Risk Patients Surgical Resection Fistula / Stricture Abscess
Early onset of disease
Deep ulceration
Perianal involvement and / or severe rectal disease
Extensive anatomic involvement

23. UC: Signs & Symptoms Bloody Diarrhea Tenesmus Urgency Abdominal Pain
Fever 
Weight Loss
Joint Pain
Skin Rash
Fatigue

24. UC: Labs CBC CMP CRP / ESR Fecal Calprotectin
Stool studies to rule out infection

25. UC: Imaging Case-by-case based on clinical presentation and evaluation
Can be used to assess disease extent and severity in severe flare
CT of toxic megacolon or significant colitis

26. Mayo Scoring System for Assessment of UC Activity
Used for initial evaluation and monitoring treatment response
Scores range from 0 to 12
Higher scores indicate more severe disease
≤ 2 = Clinical remission
3-4 = Mild activity
6-10 = Moderate activity
11-12 = Severe activity

27. Mayo Scoring System for Assessment of UC Activity
Variable
0 Points
1 Points
2 Points
3 Points
Bowel movement (BM) frequency
Normal
1-2 BM > normal
3-4 BM > normal
>5 BM > normal
Rectal bleeding
None
Streaks on stool < 50% BM’s
Obvious fresh blood with most BM’s
BM’s with fresh blood
Endoscopy
Mild Erythema,  vascularity,
Mild friability
Marked erythema,
Lack vascular pattern, Friability,
Erosions
Severe spontaneous bleeding, Ulceration
Physician Global Assessment (PGA)
Mild
Moderate
Severe

28. UC: Colonoscopy Used to Assess Disease Severity
Normal / Inactive Disease
No friability or granularity
Intact vascular pattern
Mild Disease
Erythema
Decreased vascular pattern
Mild Friability
Moderate Disease
Marked erythema
Absent vascular pattern
Friability
Erosions
Severe Disease
Moderate signs plus:
Spontaneous bleeding
Ulceration
Mayo Score = 0
Mayo Score = 1
Mayo Score = 2
Mayo Score = 3
Double check score/subscore
Full Mayo score includes bowel movement frequency, rectal bleeding, endoscopy, and physician global assessment
Mayo Endoscopic Subscore

29. IBD Therapies

30. Goals of IBD Therapy Achieve mucosal healing and induce remission
Maintain steroid-free remission
Prevent / treat complications of disease
Avoid short and long term toxicity of therapy
Enhance quality of life
5-ASA Products and Corticosteroids

31. IBD Therapies Aminosalicylates (5-ASA) Corticosteroids
Immunomodulators (6 MP / AZA / MTX)
Biologics
Anti-TNF
Anti-Integrin
Anti IL-12 / IL-23

33. Azathioprine/6 MP Pharmacology
6 TG (active metabolite)
Therapeutic range
> 400 Higher risk for bone marrow suppression
6 MMP > 5700 Higher risk for hepatotoxicity

35. Biologic therapy for IBD
Certolizumab - Cimzia
Adalimumab - Humira
Golimumab -Simponi
Infliximab - Remicade
Anti-Integrin antibody: Natalizumab -Tysabri
(PML –Progressive Multifocal Leucoencephalopathy)
Anti-Integrin antibody: Vedolizumab - Entyvio
Anti IL-12 / IL-23 antibody: Ustekinumab – Stelara - moderate to severe CD.

37. Crohn’s Disease Therapies
Disease Severity
at Presentation
Biologics +
Thiopurine +
Corticosteroid
Severe
Moderate
Mild
Biologics
Biologics or
Thiopurine +
Corticosteroid
Biologics or
Thiopurine
Change How Biologics are Positioned for UC
Pentasa
Pentasa
Induction
Maintenance
Therapy is modified according to severity at presentation or failure at prior step

38. Sequential Therapies for UC
Disease Severity
at Presentation
Colectomy
Biologics +
Thiopurine +
Corticosteroid
Severe
Moderate
Mild
Biologics
Aminosalicylate
or Thiopurine +
Corticosteroid
Aminosalicylate
or Thiopurine
Change How Biologics are Positioned for UC
Aminosalicylate
Aminosalicylate
Induction
Maintenance
Therapy is stepped up according to severity at presentation or failure at prior step

40. Guidelines for Initiating and Follow-up of Immunosuppressive Therapy

41. Labs Prior to Start of Immunosuppressive Therapy
QuantiFERON / Chest X-ray (TB Testing)
Acute Hepatitis Panel
– Hep B

43. For Patients on Immunosuppressive Therapy
Annual head to toe dermatology skin exam
Sun precautions
Annual Pap smear
Annual TB Testing (Quantiferon / chest x-ray)
Serial labs (CBC with Diff and Hepatic Function Panel) if on Imuran, 6MP or MTX

44. Lifestyle Modifications

45. Mediterranean Diet
Primarily plant-based foods (fruits and vegetables, whole grains, legumes and nuts)
Replace butter with healthier fats (olive oil)
Herbs and spices instead of salt
Limit red meat (beef and pork) to no more than a few times a month
Fish, chicken, and turkey at least twice a week
Red wine in moderation (optional)

46. Other Dietary Considerations
Eat smaller, more frequent meals
Drink plenty of fluids
Consider multivitamin once daily
Talk to a dietitian
Probiotics – Kefir once daily
Dairy, gluten, excessive caffeine / carbonation can exacerbate symptoms

47. Lifestyle Changes Stress Management Exercise (20 minutes / day)
Relaxation and breathing exercises (yoga and meditation)
Smoking Cessation / avoid second hand smoke exposure
Avoid unnecessary antibiotic exposure
Utilize Patient Education Resources (CCFA)

48. Final Thoughts Early diagnosis / avoid treatment delays
Treating IBD patients is a collaborative approach between primary care and GI and other specialists
Increase patient satisfaction
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