1. GP Update on Inflammatory Bowel Disease
Clare Donnellan
Consultant Gastroenterologist Leeds Teaching Hospitals

2. Overview Key features of IBD History & examination Investigations
Treatment including DMARDs
Flares – what should GPs do?
What’s new?

3. Key Features

4. How common? Incidence UC 10 per 100,000 Incidence CD 6-7 per 100,000
Prevalence per 100, (250/150)
Onset between 15 and 40 years of age
Similar in males and females

5. UC vs. Crohn’s Ulcerative colitis Crohn’s Disease IBD-unclassified 5%
Proctitis
Left-sided disease
Pan-colitis
Crohn’s Disease
Affects anywhere
Small bowel (80%)
Small & Large bowel (50%)
Peri-anal disease (35%)
More likely to get complications
IBD-unclassified 5%

6. Why do they occur? Genetics
10-25% of patients have at least one other family member affected
No particular gene identified in UC
NOD2/CARD15 gene abnormalities in CD
Terminal ileal disease
Possibly more chance of requiring surgery

7. Why do they occur? Environmental factors Smoking Appendicectomy Diet?
Protective for UC
Worsens outcome for CD
Appendicectomy
Unlikely effect for CD
Diet?
Bacteria?
Bacteria: innate immune system (NOD2) – pathogen recognition receptors (NOD = intracellular) (TOLL = extracellular/membrane bound) – cascade of perpetual immune response to commensal bacteria.

8. Extra GI manifestations
Episcleritis/scleritis
2 to 5% of patients
Activity linked to GI tract
Anterior uveitis
0.5-3%, but much more serious
Females:males 4:1
75% of patients have arthritis
Activity not linked to GI tract

9. Extra GI manifestations
Erythema nodosum
Most common skin manifestation of IBD (up to 15%)
Typically flares at same time as GI symptoms
Pyoderma grangrenosum
Up to 5% of patients
More chronic course

10. Summary of Extra-GI complications
Related to GI activity
Peripheral arthritis
Episcleritis/scleritis
Erythema nodosum
Not related to GI activity
Spondylitis/sacroiliitis
Anterior uveitis
Pyoderma Gangrenosum

11. History & examination

12. History – Is it UC? Bloody diarrhoea or prolonged diarrhoea (-ve MC&S)
Abdominal pain
Urgency
Tenesmus
If 1st presentation
Stool frequency/day & night
Systemic features
Weight loss
Fever
Extra-GI features
Travel
DH (Abx, NSAIDs FH SH

13. History – known UC with flare
‘The professional patient’
Is it like a ‘usual’ flare?
What are the usual strategies?
IBD Helpline
Is it severe?
Truelove and Witts criteria
≥6 bloody stools per day
Systemic toxicity (HR>90, T>37.8, ESR>30) or Hb<10.5
NEEDS ADMITTING for IV steroids

14. History – Is it Crohn’s? Much more challenging to ΔΔ IBD vs. IBS….
Abdominal pain
Diarrhoea (ask re: nocturnal symptoms)
Weight loss
Systemic features
Extra-GI manifestations

15. History – known Crohn’s with flare
‘The professional patient’
Is it like a ‘usual’ flare?
What are the usual strategies?
IBD Helpline

16. Examination Systemically unwell? Dehydration BMI/weight
Fever
Tachycardia
Dehydration
BMI/weight
Abdominal tenderness/distension/bowel sounds
Palpable mass
Peri-anal examination

17. General principles Follow ‘usual’ strategy
Call helpline (pt or GP) if concerned
Advice
Early access to IBD clinic
Admit if systemically unwell

18. Investigations

19. GP investigations FBC, U&E, LFT, CRP Haematinics Stool MC&S
Stool C diff
(Stool OC&P)
Urgent referral to gastroenterology if high index of suspicion

20. Hospital investigations - acuteUC
Bloods
AXR
Urgent stool cultures
Urgent flexible sigmoidoscopy within 24 hours
(CMV PCR and CMV on biopsies)
CT if risk of perforation

21. Hospital investigations - acute
Crohn’s
Varies on symptoms/distribution
Low threshold for CT abdo/pelvis
Flexible sigmoidoscopy often unhelpful
MR pelvic if abscess/fistulising disease

22. Hospital investigations – O/P
Small bowel
Small bowel meal if suspected CD/suspected SB CD
MR enterography (enteroclysis) if known SB CD
OGD
Ultrasound
Wireless capsule endoscopy
Isotope (labelled white cell scans)
Colon
Colonoscopy
CT colonography

23. Examples

24. Treatment

25. UC 5-ASAs Prescribe by drug name
But lower cost equivalents (Asacol = Mesren = Octasa)
Dose
Asacol 2.4 g vs. 4.8 g
Minimum 2 g for maintenance (1.2 g cancer prevention)
OD as effective and better adherence for maintenance
Tablets + Local therapy often avoids steroids
5-ASA enemas better than steroid enemas

26. UC DMARDs Azathioprine 2-2.5 mg/kg 6-mercaptopurine 1-1.5 mg/kg
Weekly bloods for 4/52
Then monthly
Then 3 monthly
S/E
(Raised MCV and lymphopaenia)

27. UC Other DMARDs Methotrexate Mycophenolate Evidence not great
Some evidence

28. UC Flares Prednisolone 30 mg daily with Ca/Vit D cover
Optimise 5-ASAs first if sole treatment
Maximise dose
Add in local therapy (5-ASAs, not steroids)
Prednisolone 30 mg daily with Ca/Vit D cover
More prolonged course
If not settling (or severe UC) IV steroids

29. UC Flares Is it severe? Truelove and Witts criteria
≥6 bloody stools per day
Systemic toxicity (HR>90, T>37.8, ESR>30) or Hb<10.5
NEEDS ADMITTING for IV steroids
Colectomy rate approx. 30%

30. UC Flares Day 3 (Travis criteria) 3 options
If stool frequency > 8 or CRP > 45
85% chance of colectomy
3 options
Surgery
Infliximab as a bridge to Aza/6-MP
Cyclosporin

31. UC Outcome Ciclosporin/infliximab Infection risks
70 – 80% leave hospital with colon
30% long-term
Infection risks

32. CD No role for 5-ASAs except if mild colitis
? Role after surgery in preventing relapse

33. CD Flares If luminal disease Oral steroids IV steroids if no response
Still no response?
No role for ciclosporin
Give infliximab +/- azathioprine for 1 year
Nutrition support key

34. CD Flares If peri-anal disease Drain any sepsis Antibiotics
Seton sutures
Escalate therapy as appropriate

35. CD DMARDS Biologicals Surgery Azathioprine Infliximab
Methotrexate (s/c)
Mycophenolate
Tacrolimus
Surgery
For complications
Biologicals
Infliximab
Adalimumab (Humiara)
NICE assessment at 1 yr

36. Other treatments Liquid diet for Crohn’s Bone protection
Endoscopic dilatation of strictures

37. What’s new?

38. What’s new? Calprotectin Azathioprine metabolite levels
Diagnosis
Activity assessment
Azathioprine metabolite levels
Optimise dose
Minimise side-effects
? Reduce number of patients needing biologicals
Leucocytapheresis
Mucosal healing

39. What’s new? Guided self-management More nurse-led clinics
Reduce follow-up waits…
Less ‘black and white’ in/out of service

40. Summary Significant morbidity Early, focused management
Use helpline
Admit if systemically unwell
Stool cultures
Appropriate steroid course