1. 2012 Physicians Assistance WINTER CONFERENCE March 10, 2012

2. Jannine Purcell, CNP Rapid City Medical Center Division of Gastroenterology and Hepatology

3. IBS is a gastrointestional syndrome characterized by chronic abdominal pain and altered bowel habits in the absence of any organic cause

4. THIS IS THE MOST COMMONLY DIAGNOSED GI CONDITION

5. IBS affects men, women, young patients and the elderly There is a 2:1 female predominance in North American females

6. IBS comprises 25-50% of all referrals to GI

7. IBS accounts for a significant number of visits to primary care and is the second highest cause of work absenteeism after the common cold

8. IBS has been associated with increased health care cost with studies suggesting annual direct and indirect costs up to $30 billion ANNUALLY

9. Altered bowel habits ranging from diarrhea, constipation, alternating diarrhea and constipation

25. INFLAMMATORY BOWEL DISEASE

26. Chronic inflammatory bowel disease (IBD) include: Ulcerative Colitis Crohn’s Disease

27. Ulcerative Colitis A disorder in which inflammation affects the mucosa and submucosa of the colon

28. Crohn’s Disease A disorder in which inflammation is transmural and may involve any or all segments of the gastrointestional tract

29. Ulcerative colitis 1.Disease in continuity 2.Rectum almost always involved 3.Terminal ileum involved infrequently 4. Granular and ulcerated mucosa diffusely 5. Often intensely vascular 6. Normal serosa 7. Muscular shortening of colon: fibrous strictures very rare 8. Spontaneous fistulae not typical

30. 9. Inflammatory polyposis common and extensive 10. Malignant change is well recognized 11. Anal lesions uncommon

31. Crohn’s Disease 1.Disease discontinuous 2.Rectum frequently spared 3.Terminal ileum frequently involved 4. Discretely ulcerated mucosa; with fissuring 5. Vascularity seldom pronounced 6. Serositis common 7. Shortening due to fibrosis; fibrous strictures common

32. 9. Inflammatory polyposis less prominent and less extensive 10. Malignant change 11. Anal lesions more common

33. Ulcerative Colitis 1. Diffuse mucosal and submucosal inflammation 2. Width of submucosal normal or reduced 3. Often intense vascularity, little edema 4. Focal lymphoid hyperplasia restricted to the mucosa and superficial submucosa 5. “Crypt abscesses” very common with diffuse inflammation 6. Anal lesions- non-specific if present

34. Crohn’s Disease 1. Transmural inflammation with fistulae formation 2. Width of submucosa normal or increased 3. Vascularity seldom prominent, edema marked 4. Lymphoid aggregates in mucosa, submucosa, serosa and pericolic tissues 5. Sarcoid-type granulomas, characteristic with focal patchy inflammation 6. Anal lesions; granulomatous foci often present

37. Incidence and prevalence of ulcerative colitis are: 2 – 10 and 35 -100, respectively per 100,000 population in the US

38. Incidence and prevalence of Crohn’s disease are 1-6 and 10 – 100 respectively per 100,000 population in the US

39. There is an increased incidence of IBD in relatives of patients with IBD indicating a genetic disposition

40. Both conditions are more prevalent in Jews and less common in African Americans

41. The peak age of onset of both diseases is between 15- 25 yrs and then a second peak is observed between 55 -65 yrs

42. Incidence equal between men and women

43. Ulcerative colitis is more common than Crohn’s disease in children younger then ten years old

44. Viruses and bacteria- there is little data but suspect  Measles Mycobacterium paratuberculosis

46. Dietary antigen activates abnormal immune response

47. Auto antigen expressed on patients intestional epithelium

48.  Patient mounts an initial immune response against a lumenal antigen, which persists and may be amplified

49.  Dominant symptom in the US is often bloody, frequent low volume bowel movements  Abdominal pain, usually in the lower quadrant and rectum

50.  Localized rectal involvement may be characterized by:  bloody diarrhea, with or without urgency,  tenesmus,  pain or  fecal incontinence

51. Mild disease: Diarrhea, rectal bleeding and usually normal physical exam

52. Most patients with ulcerative proctitis have mild disease

53. Moderate disease: Occurs in 27% of patients 5 -6 bloody stools, abdominal pain, tenderness, low grade fever, fatigue

54. Severe disease 19 % patients have severe ulcerative colitis Frequent bloody stools, profound weakness, weight loss, fever, tachycardia

55. Hypotension, abdominal tenderness, anemia as well as hypoalbuminemia Abdominal distention with severe disease may mean toxic megacolon

56. Usually ulcerative colitis will begin indolently and gradually worsen Initial presentation- colitis extending to the cecum in 20% patients

57. 75% patients have no disease proximal to the sigmoid 15% patients with initial proctitis will extend their disease more proximally

58. Patients with mild disease More than 90% will go into remission after first attack

59. Patients who present initially with severe disease often require colectomies Usually 50% of those patients within the first 1 -2 yrs

60. The usual pattern of chronic disease is long quiescent periods interspersed with acute attacks

61. Non compliance with medications NSAID use Antibiotics Colonic infections (c-diff) Smoking cessation

62. Temp greater then 38.6 C HR > 120 Neutrophil count > 10,500 Dehydration Mental status changes Electrolyte imbalances

63. Hypotension Abdominal distention Tenderness

70. Involvement of the ileum and cecum: 40% of patients Small bowel: 30% of patients Colon only: 25% of patients Pancolic: 2/3 Segemental: 1/3

71. Early changes  Aphthous ulcers-> deep ulcerations-> confluent ulcerations  “cobblestone” appearance  Thickened mucosal folds  Asymmetric involvement  Inflammatory pseudopolyps  Segmental distribution  Skip lesions

72. Symptoms Diarrhea Weight loss Abdominal pain

73.  Stool frequency  Abdominal pain  Sense of well being  Systemic manifestations  Use of antidiarrhea agents  Abdominal mass  Hematocrit  Body weight

74. Crohns disease is a relapsing and remitting disease that will spontaneously improve without treatment in 30% of cases

75. Patients in remission can expect to remain in remission for 2 yrs in 50% of cases

76. However, 60% of patients require surgery within 10 years of diagnosis

77. Of those patients who require surgical resection, 45% will eventually require reoperation

78. Crohns disease can produce significant disability, and 50% of patients make major changes in employment to accommodate decreased working hours and leaves of absence

79. Abscesses and fistulas result from extension of a mucosal break through the intestional wall into the extra intestional tissue

80. Abscesses occur in 15 -20% of patients usually arising from the terminal ileum Abscesses present with fever, localized tenderness and palpable mass

81. Infection is usually polymicrobial E coli, bacteroides fragilis, enterococcus, and alpha hemolytic streptococcus

82. 20-40% of Crohn’s patients have fistulizing disease Fistula may be enteroenteric, Enterocutaneous, enteovesical, or enteovaginal

83. Large enteroenteric fistulae produce diarrhea, malabsorption, and weight loss

84. Enterocutaneous fistulae produce persistent drainage that usually is refractory to medical therapy

85. Rectovaginal fistulae lead to foul-smelling vaginal discharge

86. Enterovesical fistulae produce pneumaturia and recurrent urinary tract infections

87. Obstruction, especially of the small intestine, is a common complication caused by mucosal thickening, muscular hyperplasia and scarring from prior inflammation or adhesions

88. Perianal disease, including anal ulcers, abscesses and fistulae can affect the groin, vulva or scrotum