1. DR ALEX TEBBETT (WARWICK GRADUATE) FY1 WARWICK A&E Inflammatory Bowel Disease

2. What we’re covering The big two – Crohn’s and UC  Risk factors  Macro and microscopic changes  Extraintestinal manifestations  Differential diagnosis  Treatment Clinical exam for IBD Other GI cases Finals hints

3. IBD Crohn’sUlcerative Colitis

4. Crohn’s Ulcerative Colitis Epidemiology Slightly more common 80-150/100,000 Slightly less common 27-106/100,000 Males: 1.2:1 Older: 34 Females: 1.2:1 Younger: 26

5. Aetiology Largely unknown 1. Genetics  Polygenic: 16, 12, 6, 14, 5, 19, 1, 3  HLA DRB  Familial (1 in 5) 2. Host immunology  Defective mucosal immune system  Inappropriate response to intraluminal bacteria  T-cells and cytokines Autoimmune!

6. Crohn’s Ulcerative Colitis Aetiology: Environmental Good hygiene/ developed countries No relation to hygiene Non smokers Appendicectomy is protective Breast feeding is protective Appendicectomy Smokers

7. Crohn’s Ulcerative Colitis Terminal illeum Ileocolonic disease  Ascending colon Skip lesions Pancolitis  Can be large bowel only Proctitis Left sided colitis  Sigmoid and descending Pancolitis Backwash ileitis  Distal terminal illem Pathology Mouth to anus! Rectum and extends proximally!

8. Macroscopic changes Crohn’s o Bowel is thickened o Lumen is narrowed o Deep ulcers o Mucusal fissures o Cobblestone o Fistulae o Abscess o Apthoid ulceration

9. Macroscopic changes Ulcerative Colitis Reddened mucosa Shallow ulcers Inflamed and easily bleeds Ulcerative Colitis

10. Crohn’s Ulcerative Coltis Chronic inflammatory cells: transmural Lymphoid hyperplasia Granulomas  Langhan’s cells Chronic inflammatory cells: lamina propria Goblet cell depletion Crypt abscess Microscopic Changes Transmural!Mucosal!

11. Extraintestinal Manifestations EYESCrohn’sUC Uveitis5%2% Episcleririts7%6% Conjunctivitis7%6%

12. Extraintestinal Manifestations JOINTSCrohn’sUC Type 1 Arthropaty (Pauci) 6%4% Type 2 Arthropathy (Poly) 4%2.5% Arthralgia14%5% Ankylosing Spondylitis1.2%1% Inflammatory back pain9%3.5%

13. Extraintestinal Manifestations SKINCrohn’sUC Erythema Nodosum4%1% Pyoderma Gangrenosum 2%1%

14. Extraintestinal Manifestations LIVER/BILLARYCrohn’sUC Sclerosing cholangitis1%5% Gall stonesIncreasedNormal Fatty liverCommon Hepatitis/ CirrhosisUncommon Kidney stones in Crohn’s  oxalate stones post resection Anaemia  B12 deficiency in Crohn’s Venous thrombosis Other autoimmune diseases

15. Differential Diagnosis Each other Infection (unlikely if >10 days) IBS Ileocolonic tuberculosis Lymphomas

16. Treating IBD Induce remission  Steroids – oral or IV  Enteral nutrition  Azathioprine / 6MP (Crohns) Maintain remission  Aminosalicylates (UC)  Azathipreine/ 6MP  Methorexate Biologicals generally for Crohn’s only  Infliximab, adalimumab  Test for TB first!

17. Crohn’s Ulcerative Colitis 1. Azathioprine 2. Methotrexate 3. Cyclosporin 4. Humera 1. Adalimumab/anti TNF Steroids for flares 1. Aminosalicylates 1. Mesalazie 2. Steroids 1. Foam/PR 2. Oral 3. IV 3. Azathiorprine Treating IBD

18. UC Flares Truelove-Witts Criteria: 1. Anemia less than 10g/dl 2. Stool frequency greater than 6 stools/day with blood 3. Temperature greater than 37.5 4. Albumin less than 30g/L 5. Tachycardia greater than 90bpm 6. ESR greater than 30mm/hr Used to classify the flare up into mild, moderate or severe Treatment  Admit to hospital  IV steroids and fluids  Daily monitoring of stool frequency, AXR, FBC, CRP, Albumin A STATE

19. Surgical Management Surgery can be curative for ulcerative colitis 80% of Crohn’s have resections but generally little help Indications for surgery in Ulcerative Colitis  Acute:  Failure of medical treatment for 3 days  Toxic dilatation  Haemorrhage  Perforation  Chronic  Poor response to medical treatment  Excessive steroid use  Non compliance with medication  Risk of cancer I CHOP Infection Carcinoma Haemorrhage Obstruction Perforation

20. Prognosis UC  1/3 Single attack  1/3 Relapsing attacks  1/3 Progressively worsen requiring colectomy within 20 years Crohn’s  Varied prognosis, new biological agents improving Cancer  Both have increased risk of colon cancer, though UC>Crohn’s  Screening colonoscopy done every 2 years after 10 years disease and every year after 20 years disease

21. Crohn’s Ulcerative Colitis Presenting complaint  Diarrhoea  Abdominal pain  Weight loss  Malaise/lethagy  Nausea/vomiting  Low grade fever  Anorexia Presenting complaint  Bloody diarrhoea  Lower abdominal pain  +/- mucus  Malaise/lethargy  Weight loss  Apthous ulces in mouth Clinical Finals: IBD History

22. Clinical finals: IBD History What else to ask?  Rashes  Mouth ulcers  Joint/back pain  Eye problems  Family history  Smoking status

23. Clinical finals: IBD History What else to ask?  Previous diagnosed?  How many flares do they get?  Are they well managed?  Do they have any concerns about their treatment?  Do they see a specialist?

24. Clinical finals: IBD Exam Physical signs may be few! General Exam  Weight loss  Apthous ulcer of mouth  Anaemia  Clubbing Abdominal Exam  Colostomy bag  May be some abdominal tenderness, may not.  May find a RIF mass  Abscess  Inflamed loops of bowel

25. Clinical finals: IBD Exam Anything else?  Rashes on the shins “I would also like to examine…”  Anus  Crohn’s: Odematous tags, fissures or abscesses  Ulcerative colitis: usually normal  PR  Ulcerative colitis: blood

26. Clinical finals: IBD What is the most likely diagnosis?  Inflammatory bowel disease

27. Clinical finals: IBD Investigations Bedside  Stool culture: exclude infection  Sigmoidoscopy Bloods  FBC : anaemia and likely raised WCC  Haematemics: type of anaemia  Inflammartory markers  LFT: hypoalbuminaemia is present in severe disease, hepatic manifestations  Blood cultures: if septicaemia is suspected in the acute presentation  Serological: pANCA (UC)

28. Clinical finals: IBD Investigations Imaging  Plain AXR: helpful in acute attacks  Thumb printing  Lead pipe sign  Barium follow-through in Crohn’s  CT  CXR  Perforation  USS

29. Clinical finals: IBD Investigations Flexible sigmoidoscopy Colonoscopy  But never in severe attacks of UC due to high risk of perforation  May be painful in Crohn’s due to anal fissures  Diagnostic  Surveillance  UC of more than 10 years duration increased risk of dysplasia and carcinoma OGD  For Crohn’s: view of terminal illeum  In children both an OGD and colonoscopy are done,

30. Clinical finals: IBD Management Manage the patient, not just the disease!  Medications  Manage extraintestinal manifestations  Eg B12 deficiency anaemia  Manage patient’s symptoms  Eg loperamide for diarrhoea  Good nutrition, hydration and vitamin supplements  Psychosocial impact of disease  Ileostomy/colostomy bag  Flares and the need for a toilet

31. Clinical finals: IBD Explanation Please explain a colonoscopy to the patient Please explain an OGD to the patient Please advise the patient on the side effects of steroids  Prepare an organised list to reel off, it is a very common question! Please explain the compilcations of inflixmab  Keep calm, remember it’s an immnuosupressent!

32. How to do well in finals questions Have a plan on how to answer questions  Ix: bedside, bloods, imaging, special tests  Mx: medical, surgical, psychological, social acute and long term management Have a reason for each investigation you’d like to do Treat the person as well as the disease Don’t ever forget the MDT!

33. What else could come up…. Coeliac disease IBS Ischaemic colitis Diverticular disease Appendicitis Polyps Haemorrhoids Know the side effects of steroids! Know the difference between colostomy and ileostomy!

34. Clinical Scenario 29 year old female, one month history of loose watery stools, increasing in frequency to 12 time 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 acute flare of ulcerative colitis

35. Clinical finals: IBD questions What are your main differential diagnoses for this lady? How would you investigate this patient acutely and long term?  Eg. not full colonoscopy in acute flare 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?  Eg. skin, eyes, joints

36. ANY QUESTIONS? Good Luck!