1. Dr Samantha Chambers FY2 IBD

2. Aims What is IBD Differences between UC and Crohn’s Presentation Extra-intestinal manifestations Investigations Management Case scenario

3. What is IBD? The boring bit Inflammatory bowel disease: a group of idiopathic inflammatory conditions affecting the gastrointestinal tract Usually affect 15-30 age group, but any age, UC shows bimodal incidence(>60) No major sex difference More common in Western world Mainly Crohn’s disease and UC Crohn’s 50-100 cases/ 100,000 population UC twice as common as Crohn’s Multifactorial aetiology: Crohn’s – NOD2 susceptibility gene NSAIDs and stress exacerbate disease Other types Indeterminate colitis Microscopic colitis which you DO NOT need to worry about!!

4. Crohn’s vs Ulcerative colitis Crohn’sUC DistributionWhole GI tractColon only ContinuitySkip lesionsContinuous (proctitis spreading backwards) InflammationTransmuralSuperficial PathologyCobblestoningGoblet cell loss, crypt abcesses GranulomasYesNo SmokingWorsens diseaseProtective Picture here

5. Presentation Can be hard to distinguish the 2 from history – there are a few clues Diarrhoea (nocturnal diarrhoea is always pathological) +++ in UC +/- blood +/- mucus Crampy abdominal pain Weight loss Tenesmus, urgency – rectal disease Fever, malaise, anorexia – active disease Perianal disease (commoner in Crohn’s) – fistulas, fissures RIF mass (Crohn’s) Oral apthous ulcers (commoner in Crohn’s) Clubbing (commoner in Crohn’s)

6. Extra intestinal manifestations Skin, eyes and joints!! Erythema nodosum Pyoderma gangrenosum Scleritis Episcleritis Oligoarthropathy Sacroiliitis! Ankylosing spondylitis rate is higher in IBD Primary Sclerosing Cholangitis UC> Crohns Progressing stricturing and obstruction of biliary tree Fluctuating obstruction LFTs (ALP>ALT) Higher risk of cholangiocarcinoma and Bowel cancer

7. Differential diagnoses Inflammatory UC Crohn’s disease Infective colitis Acute abdomen Appendicitis Diverticular disease Cancer Pseudomembranous colitis Radiation colitis Ischaemic colitis Lymphoma Don’t forget Gynae! Ectopic pregnancy Ovarian cyst

8. Investigations Bedside Urine dip, BM ECG if tachycardic when presents Bloods FBC – Anaemia, WBCs U&Es - ?dehydration LFTs - ? Obstructive picture (ALP>ALT) CRP – monitoring disease response/deterioration TFTs – exclude thyroid disease (hyper – diarrrhoea) Stool – exclude infective cause MC&S (Faecal calprotectin) Imaging Erect CXR – exclude perforation in acute presentation AXR - ? Toxic megacolon CT abdo + pelvis MRI small bowel for ?small bowel Crohn’s MRI pelvis for perianal/rectal disease in Crohn’s Older/out of date – Barium enema/ follow through – shows stricture’s, rose thorn ulcers, cobblestoning Special tests Endoscopy + biopsy! (OGD, Flexi Sig, Colonoscopy (never in acute flare!!), enteroscopy)

9. Management Acute presentation: ABCDE!! Conservative Patient education (reduce non-complicance), diet advice (eg.low residue if strictures), smoking cessation advice (!) MDT involvement – IBD nurse specialist, nutritionist, stoma nurse Medical Acute - to induce remission Corticosteroids inc IV hydrocortisone Infliximab as rescue therapy Symptomatic – treat anaemia Chronic - to maintain remission 5 ASAs (Mesalazine) – cornerstone of disease management – take time to work Localised – suppositories/foam enemas to treat proctitis Steroids – out of fashion due to side effects Steroid sparing agents (immunosuppressants e.g. azathioprine, methotrexate) Biologics; Infliximab – anti-TNF alpha; Adalimumab (Humira) Surgical Acute – for toxic megacolon, failure of medical therapy, perforation Resection/ colectomy (usually Hartmann’s procedure) Panproctocolectomy is curative for UC Chronic – resection of Crohn’s strictures Local surgery in perianal disease Elective panproctocolectomy for UC – cancer risk

10. Prognosis Crohn’s may need several operations (increases adhesions) Prone to strictures and fistulas Considerable morbidity, 15% mortality rate UC – panproctocolectomy is curative UC patients have higher risk of bowel cancer (>10yrs) Need surveillance colonoscopies N.b. UC + PSC = even higher bowel ca risk

11. Case scenario 29 year old female, one month history of loose watery stools, increasing in frequency to 12 times per day now. Occasionally stools have blood and slime mixed in with them. Cramping left iliac fossa pain. Feels unwell and lethargic. On examination, febrile at 38.2. Has a soft abdomen but slightly distended and tender in the left iliac fossa. PR examination is very painful and reveals fresh blood and mucus on the glove

12. What are your main differential diagnoses for this lady? How would you investigate this patient acutely and long term? Initial management in acute setting? Long-term management? Can you compare the clinical presentation and pathological findings for Crohns and UC? Can you tell me the effect of smoking on UC and Crohns? What scoring system is used for acute UC? What are the extra-intestinal manifestations of IBD Please explain a colonoscopy to the patient

13. Questions ?