GOOD MORNING

July 5th, 2013

Semantic Qualifiers

Problem Characteristics

Ill-appearing/Toxic

Well-appearing/Non-toxic

Localized problem

Systemic problem

Acquired Congenital

New problem Recurrence of old problem

Symptoms

Acute /subacute Chronic

Localized Diffuse

Single Multiple

Static Progressive

Constant Intermittent

Single Episode Recurrent

Abrupt Gradual

Severe Mild

Painful Nonpainful

Bilious Nonbilious

Sharp/Stabbing Dull/Vague

Acute Colitis DDx**

Infectious enterocolitis Pseudomembranous colitis (C. diff) Lymphocytic colitis Eosinophilic enterocolitis HSP HUS IBD Intestinal malignancies (Non-Hodgkin

lymphoma)

Colonoscopy

Illness Script

Predisposing Conditions Age, gender, preceding

events (trauma, viral illness, etc), medication use, past medical history (diagnoses, surgeries, etc)

Pathophysiological Insult What is physically happening

in the body, organisms involved, etc.

Clinical Manifestations Signs and symptoms Labs and imaging

IBD Epidemiology

Mean age at diagnosis: 12.5 years <20% diagnosed before 10y <5% diagnosed before 5 years

Male: more likely pediatric Crohn’s disease Family history of IBD

Up to 25% of children who develop IBD w/ + family hx

1st degree relative with CD or UC = 10-13x higher risk!

European or African descent Jewish ancestry Industrialized world Tobacco use: 2x increased risk

Crohn Disease Epidemiology

3-5 per 100,000 30% of patients diagnosed before age 20

Pathophysiology

Precise cause of IBD remains unknown

Genetic predisposition PLUS

Dysregulation between the immune system and the antigenic environment of the GI tract…which leads to GI inflammation and damage

Clinical Manifestations

What complaints would you expect a patient with UC to present with?** Cardinal symptoms: diarrhea, rectal bleeding, and

abdominal pain Most present without systemic symptoms (fever,

wt loss) More severe presentation

Abdominal cramping associated with fecal urgency Malaise Low-grade/intermittent fevers Anorexia with weight loss Reflux or dyspepsia associated with upper GI

inflammation

Clinical Manifestations

What complaints would you expect a patient with CD to present with?** Classic presentation

Abdominal pain Crampy, diffuse or RLQ

Diarrhea Non-bloody, melanotic, or frank blood

Weight loss Very important to plot height and weight in

patients Poor appetite, fevers, recurrent ulcers

Growth and IBD**

Growth failure may be the ONLY sign of IBD in 5% of patients. What are some causes of growth failure both before and after treatment is started?** Occurs in 15-40% of children with IBD (CD > UC)

Reasons are multifactorial** Food avoidance secondary to abdo pain/diarrhea Increased cytokines anorexia and growth hormone

resistance In Crohn Disease

Active inflammation of the small intestine Decreases the intestinal surface absorption area Causes protein-losing enteropathy + fat soluble vitamin

deficiencies Steroid treatment

Clinical Manifestations

Other than the abdomen, what important physical exam component MUST be assessed for disease? Abdominal exam

Diffuse tenderness Possibly RLQ tenderness or mass Distension with more severe disease

Rectal exam…what might you see in a patient with CD versus UC? CD: higher likelihood of fissures, skin tags, fistulas,

and abscesses; can be an early indicator of disease**

UC: often normal

Clinical Manifestations**

Oral exam for aphthous ulcers, as recurrent aphthous-stomatitis also occurs in Crohn’s Disease.**

Clinical Manifestations

The following can also be seen on PE: Pallor Digital clubbing A benign abdomen Small for age

Work-Up**

What abnormal labs might you expect in a patient with IBD? CMP: albumin, possible in transaminases, Ca++ CBC: anemia of iron deficiency, B12/folate

deficiency, or anemia of chronic disease Elevated ESR and CRP Fecal calprotectin and lactoferrin

Released by neutrophils that have migrated to the intestinal wall

Non-invasive markers of gut inflammation and can be elevated in other diagnoses

Abnormal IBD serologic panel

Serology

IBD 7 tests for 7 markers of IBD Used to differentiate UC vs. CD ASCA and Anti-Omp C – specific for CD

Work-Up**

An infectious cause should be eliminated before diagnosing IBD Stool studies: Salmonella, Shigella, E. coli,

Campylobacter, Yersinia, Giardia, Cryptosporidium

C. difficile toxin PPD and Hepatitis test…should also be done

before initiation of treatment with immunosuppressive Remicade

Upper GI, CT for complications, MRI What is the “gold standard” for IBD diagnosis?

Endoscopy with biopsies

Clinical Manifestations

Label the picture as either Crohn Disease or Ulcerative Colitis

Crohn Disease Ulcerative Colitis

Ulcerative Colitis vs. Crohn** UC Crohn

Rectal bleed Usual Sometimes

Abdominal pain

Common Common

Malaise, fever, weight loss

Common Common

Perianal disease

Rare Common

Ileum involved None Common

Strictures Rare Common

Fistulas Rare Common

Skip lesions - +

Transmural - +

Granulomas Rare Common

Crypt Abscesses

Usual Variable

Risk of cancer ↑↑↑ ↑

Ulcerative Colitis vs. Crohn

Crohn Disease can have eosinophila non-specific: h. pylori, EE, parasitic

infections

UC Crohn

Cobblestoning - +

Ulceration of IC valve

- +

Rectal sparing +/- +

Extra-intestinal Findings

1/3 develop extra-intestinal manifestations, may occur before intestinal symptoms.

Your patient, who you suspect has IBD, also complains of stiffness and pain in his lower back. What do you suspect?

Ankylosing spondylitis Is this more often associated with UC or

CD? Ulcerative colitis Which serum marker may be seen in this

diagnosis? HLA-B27 Arthalgias and arthritis are common

Pauciarticular arthritis disease course correlates with intestinal disease activity.

Extra-intestinal Findings

Name 2 skin findings associated with IBD and tell which dx (CD or UC) it is more often associated with. Erythema nodosum

More common in Crohn disease Tender, warm, red nodules or plaques

localized to the extensor surfaces Pyoderma gangrenosum

More common in UC…up to 5% of pts Associated w/ extensive colonic

involvement Lesions: discrete pustules with

surrounding erythema deep ulceration with well-defined border and deep color

Extra-intestinal Findings

Why would you want to consult ophthalmology upon diagnosis of IBD? Risk of uveitis, episcleritis, corneal

ulceration, and retinal vascular damage

Bone findings Osteopenia Osteoporosis

Decreased BMD seen in 25% of patients before steroids started

Aseptic necrosis

Extra-intestinal Findings

You are caring for a patient with known UC. His LFTs are elevated. He also complains of fatigue and anorexia. Mom feels like his eyes look yellow, and you notice him scratching throughout your exam. What is the most likely diagnosis? Primary sclerosing cholangitis (PSC)

More common in UC patients Increased GGT and Alkaline Phosphatase Cholangiography and liver biopsy help confirm

diagnosis Increases risk of cancer

Nutritional Deficiencies

Crohn’s Disease Anemia (folic acid and B12 deficiency) Vitamin D deficiency Hypocalcemia (related to low Vit, low

albumin) Zinc deficiency

Due to Inadequate nutrition +/- poor absorption Corticosteroid use

Admission

Severe Colitis Fever Hypoalbumnemia Anemia >5 bloody stools/day

Toxic megacolon Occurs in up to 5% of adults with UC Perforation may occur… very

dangerous Treatment upon admission

Bowel rest TPN IV steroids Careful monitoring

Treatment Proper nutrition

Low residue diets or special formulas TPN if severe disease and malnourishment

Mediations guided by GI specialists Corticosteroids (budesonide) 5-ASA (UC) Immunomodulators (AZA, 6-MP, MTX) biologic therapy, monoclonal Ab (Infliximab -

Remicade) Antibiotics (metronidazole, cipro for fistulas)

Surgery For Crohn’s disease complications For UC…total colectomy can be curative

Treatment

Other medications Rifaximin - PO Antibiotic not absorbed Probiotics

Check TMPT (thiopurine methyltransferase enzyme) Prior to starting 6-MP

Alternative Therapy Helminth Marijuana

Famous People with CD

Noon conference:

Thanks!!!

Noon Conference!