Inflammatory Bowel Disease

Dr Alex Tebbett

Epidemiology

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

Aetiology

Autoimmune, though specifics largely unknown

  1. GeneticsPolygenic, HLA DRB, Familial (1 in 5)
  2. Host immunologyDefective mucosal immune system, Inappropriate response to intraluminal bacteriaby T-cells and cytokines
  3. Environmental

Crohn’s: Good hygiene/ developed countriesl.Smokers

Ulcerative Colitis: No relation to hygiene. Non smokers

Pathology

Crohn’saffects the terminal illeum most commonly. It can then extend to Ileocolonic disease where it also involves the ascending colon. It can present throughout the bowel either as skip lesions or as pancolitis. It can also affect the large bowel only!

Ulcerative Colitismost commonly presents as proctitis. If it extends proximally from the rectum to involve the sigmoid and descending colon it becomes left sided colitis. If it extrends to the caecum it is pancolitis. If it also affects the distal terminal ileum it becomes backwash ileitis.

Macroscopic changes

Crohn’s:

  • Bowel is thickened
  • Lumen is narrowed
  • Deep ulcers
  • Mucusal fissures
  • Cobblestone
  • Fistulae
  • Abscess

Ulcerative Colitis:

  • Reddened mucosa
  • Shallow ulcers
  • Inflamed and easily bleeds

Microscopic Changes

Crohn’s:

  • Chronic inflammatory cells
  • transmural
  • Lymphoid hyperplasia
  • Granulomas
  • Langhan’s cells

Ulcerative Coltis:

  • Chronic inflammatory cells
  • lamina propria
  • Goblet cell depletion
  • Crypt abscess

Extraintestinal Manifestations

Condition / Crohn’s / Ulcerative Colitis
Eyes: / Uveitis / 5% / 2%
Episcleritis / 7% / 6%
Conjunctivitis / 7% / 6%
Joints: / Type 1 Arthropathy (Pauci) / 6% / 4%
Type 2 Arthropathy (Poly) / 4% / 2.5%
Arthralgia / 14% / 5%
Ankylosing Spondylitis / 1.2% / 1%
Inflammatory back pain / 9% / 3.5%
Skin: / Erythema Nodusum / 4% / 1%
Pyoderma Gangrenosum / 2% / 1%

Differential Diagnosis

  • Each other
  • Infection (unlikely if >10 days)
  • IBS
  • Ileocolonic tuberculosis
  • Lymphomas

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!

Crohn’s

  1. Azathioprine
  2. Methotrexate
  3. Cyclosporin
  4. Humera

Steroids for flares

Ulcerative Colitis

  1. Aminosalicylates
  2. Mesalazie
  3. Steroids
  4. Foam/PR
  5. Oral
  6. IV
  7. Azathiorprine

UC Flares: Truelove-Witts Criteria: (Acronym: A STATE)

  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

Surgical Management

Indications for surgery in Ulcerative Colitis

  • Acute:
  • Failure Rx for 3 days
  • Toxic dilatation
  • Haemorrhage
  • Perforation
  • Chronic
  • Poor Rxresponse
  • Excessive steroid use
  • Non compliance Rx
  • Risk of cancer

(Acronym: I CHOP)

  • Infection
  • Carcinoma
  • Haemorrhage
  • Obstruction
  • Perforation

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

IBD for clinical finals

Presenting complaint

Crohn’s:

  • Diarrhoea
  • Abdominal pain
  • Weight loss
  • Malaise/lethagy
  • Nausea/vomiting
  • Low grade fever
  • Anorexia

Ulcerative Colitis

  • Bloody diarrhoea
  • Lower abdominal pain
  • +/- mucus
  • Malaise/lethargy
  • Weight loss
  • Apthous ulces in mouth

What else to ask?

  • Rashes
  • Mouth ulcers
  • Joint/back pain
  • Eye problems
  • Family history
  • Smoking status

Exploring their condition:

  • 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?

Examination

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

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

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 derrangement
  • Blood cultures (if septicaemia is suspected)
  • Serological: pANCA (UC)

Imaging

  • Plain AXR: helpful in acute attacks
  • Thumb printing/ Lead pipe sign
  • Barium follow-through in Crohn’s
  • CT
  • CXR (Perforation)
  • USS

Special Tests

  • 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

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

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 complications of inflixmab
  • Keep calm, remember it’s an immnuosupressent!

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!

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!

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

Questions:

  • What are your main differential diagnoses for this lady?
  • How would you investigate this patient acutely and long term?
  • Initial management in acute setting and the 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?