1. Dr Sam Gausden FY2 February 2015 Inflammatory bowel disease

2. Contents/aims/objectives Definition Presentation Investigations Management Clinical scenario Explanation station

3. Definition

4. Umbrella term

5. Definition Umbrella term Chronic

6. Definition Umbrella term Chronic Relapsing-remitting

7. Definition Umbrella term Chronic Relapsing-remitting Acute non-infectious inflammation

8. Differences

9. Distribution

10. Differences

11. Distribution Smoking

12. Smoking in IBD 2/3 Crohn’s pts are smokers and cessation halves relapse 95% of UC pts are non- smokers or ex-smokers

13. Smoking in IBD YOU SEE people smoking with UC Smoking in Crohn’s makes you want to GROAN

14. Differences Distribution Smoking Histology

15. UC histology

16. Hyperaemic/haemorrhagic colonic mucosa Pseudopolyps Usually on affects mucosal layer Absence of goblet cells

17. Crohn’s histology Transmural granulomatous inflammation Cobblestoning MACROSCOPICALLY: Strictures, abscesses, fistulae, skip lesions

18. Systemic manifestations

19. Hepatic - autoimmune hepatitis (UC), gallstones (Cr), PSC (UC)

20. Systemic manifestations Hepatic Other - VTE, osteoporosis (Cr), amyloidosis (Cr )

21. Systemic manifestations Hepatic Other Rheum - arthritis, sacro-ileitis, AS

22. Systemic manifestations Hepatic Other Rheum Skin – EN and PG (UC>Cr)

23. Systemic manifestations Hepatic Other Rheum Skin Eyes – iritis, uveitis

24. Eyes Uveal tract = iris, ciliary body and choroid

25. Systemic manifestations H epatic O ther R heum S kin E yes

26. Symptoms - UC

27. Diarrhoea + blood/mucous Faecal urgency/incontinence Tenesmus Lower abdominal pain Tiredness/malaise Weight loss/failure to thrive or grow Fever

28. Symptoms – Crohn’s

29. Symptoms - Crohn’s Diarrhoea +/- blood/mucous Malabsorption Abdominal pain (crampy) Mouth ulcers Bowel obstruction Fistulas (perianal) Abscesses (perianal/intrabdominal ) Tiredness/malaise Weight loss/failure to thrive or grow Fever

30. Signs - UC

31. Clubbing Pallor Eyes Legs Abdominal tenderness PR

32. Signs – Crohn’s

33. Clubbing Pallor Eyes Mouth Legs Abdominal tenderness Mass in RIF PR – skin tags, abscesses, fistulas

34. Investigations

35. Bedside tests

36. Faecal calprotectin Protein common in neutrophil cytoplasm Bacteriostatic and resistant to enzyme degredation NICE guideline: 1) To differentiate IBD from IBS in pts where cancer is NOT suspected Also: can also be used to evaluate IBD Rx and predict flares

37. Blood tests

38. Imaging (acute)

40. Special test (acute)

41. Special tests (acute)

42. Management (long-term)

43. Conservative

45. Inducing remission in mild-mod UC 1

46. 1) Aminosalicylates 2) Steroids 3) Immunosuppression (tacrolimus)

47. Inducing remission in severe UC (inpatient) 1

48. 1) IV steroids 2) Immunosuppression (ciclosporin) 3) Biologics (infliximab)

49. Assessing UC severity

50. TRUELOVE AND WITTS’ CRITERIA 1

51. Inducing remission in Crohn’s 1

52. 1) Steroids (oral or IV) 2) Aminosalicylates (2 nd line) 3) Immunosuppressants (aza, mercapto, methotrexate) 4) Biologics (infliximab or adalimumab)

53. Maintaining remission in UC

54. 1) Aminosalicylates 2) Immunosupressants (aza or mercapto)

55. Maintaining remission in Crohn’s

56. 1) Immunosupressants (aza, mercapto or MTX) 2) Continue biologics 3) OR nothing

57. Surgery Indications Incidence

58. Prognosis Ca colon risk with UC approx. 15% over 20yrs with pancolitis Colonoscopy screening (after 1-5 years depending on risk)

59. Scenario time 29 year old female PC: Diarrhoea HPC: 1/12 Hx 12x day now Blood and mucous mixed in Cramping LIF pain Unwell and lethargic

60. On examination Temp: 38.2C Soft Abdomen, slightly distended Tender in LIF PR exam very painful and reveals fresh blood and mucous on the glove Diagnosis?

61. On examination Temp: 38.2C Soft Abdomen, slightly distended Tender in LIF PR exam very painful and reveals fresh blood and mucous on the glove Diagnosis? Acute flare of UC

62. Differential diagnoses?

63. Infection Inflammation Neoplastic Vascular Drugs

64. Acute investigations?

65. Stool culture, pregnancy test FBC, U&Es, LFTs, CRP, ESR, clotting, G&S Erect CXR, AXR, CT abdomen ?flexi sigmoidoscopy

66. Long-term investigation?

67. Colonoscopy + biopsy Colonoscopic surveillance

68. Initial acute management

69. A-E approach NBM, IVI, transfusion depending on Hb IV hydrocortisone +/- rectal steroids If getting better – transfer to oral pred and 5-ASA If getting worse – consider ciclo/infliximab/surgery

70. Long term management

71. Aminosalicylates Azathioprine or mercaptopurine

72. Comparing Crohn’s and UC Clinical presentation Histological findings? Smoking?

73. Recap Scoring system for UC severity? Extra-intestional manifestations of IBD?

74. Explanation station Please explain a colonoscopy to the patient

75. Explanation station Check patient’s understanding Think about patient’s experience Why we do it and risks No jargon Any questions Leaflet

76. Always remember for IBD Ask about eyes, joints and skin Only ever do flexi sig in an acute flare If in doubt over diagnosis, say IBD Know difference between ileostomy and colostomy Test for TB before starting infliximab Any questions?

77. References 1) http://www.nice.org.uk/guidance/conditions- and-diseases/digestive-tract- conditions/inflammatory-bowel-disease