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63 Cards in this Set
- Front
- Back
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What conditions are most commonly applied to IBD?
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Ulcerative colitis
Crohn’s Disease |
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Epidemiology of IBD
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Principally in U.S. and Europe
1 million Americans - Evenly split between ulcerative colitis and Crohn’s Highest incidence of onset in ages 15-35 - Also affects those over age 70 and young children --- 10% under the age of 18 Equal distribution between females and males |
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Genetic risk factors of IBD
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Family history: 20-25% of IBD patients have close relative with IBD
- Brother or sister with IBD=10 x greater risk White (149/100,000) African Americans Hispanics and Asians American Jews of European descent 4-5 x the prevalence than the general population |
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Environmental risk factors of IBD
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Smoking: 2 x risk
Urban > Rural Developed world > Underdeveloped world Northern climates > Southern climates |
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Etiology of IBD
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Unknown
Abnormal mutation or alteration in a gene known as NOD2/CARD15 occurs twice as frequently in Crohn’s patients as the general population. Environment, antigens, bacteria, viruses, genetics, immune system |
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What is the difference between ulcerative colitis and Crohn's?
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Due to similar symptoms of the diseases, it can be difficult to establish the diagnosis definitively
10% of colitis cases can’t be pinpointed as UC or CD |
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Ulcerative colitis
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Idiopathic inflammatory condition that involves the mucosal surface of the colon.
- Invariably involves the rectum - May extend proximally in a continuous fashion to involve other portions of the colon |
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How is ulcerative colitis characterized?
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Characterized by periods of symptomatic flare-ups and remissions.
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How is ulcerative colitis involvement defined?
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Various terms can be used to describe the degree of involvement:
- Ulcerative proctitis (rectum), distal colitis, left sided colitis, extensive colitis, and pancolitis --- 1/3 proctosigmoiditis, 1/3 left sided colitis, 1/3 extensive colitis |
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What is the hallmark of ulcerative colitis?
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Bloody diarrhea
Always order additional testing to |
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S/S of mild ulcerative colitis
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- Intermittent rectal bleeding associated with the passage of mucus
- Mild diarrhea (less than 4-5 small loose stools/day) - Left lower quadrant cramps often relieved by defecation - Fecal urgency or tenesmus - Periods of constipation common |
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How is mild ulcerative colitis disease defined?
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Typically confined to rectum or rectosigmoid
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S/S of moderate ulcerative colitis
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Involvement of more than the distal colon, with the inflammatory process extending to at least the splenic flexure.
Frequent loose, bloody stools (up to 10/day) Mild anemia Abdominal pain that is not severe Low grade fever Hypoalbuminemia (above 3.5 is normal) |
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How is ulcerative colitis classified?
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Variable presentation
Useful to classify by severity of disease - mild - moderate - severe |
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How is moderate ulcerative colitis disease defined?
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Involvement of more than the distal colon, with the inflammatory process extending to at least the splenic flexure.
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Fulminant colitis
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Subset of severe disease characterized by rapidly worsening symptoms with signs of toxicity.
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Toxic megacolon
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Results from fulminant colitis.
Condition in which the inflammation extends beyond the mucosa to involve the muscle layers of the colon resulting in impaired colonic mobility, dilated colon, diminished bowel movements, and possible extension to serosa leading to colonic perforation. |
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How is severe ulcerative colitis disease defined?
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Extensive colonic involvement
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S/S of toxic megacolon
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Very ill patient
Suddenly stops having bowels movements Possible history of colitis |
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S/S of severe ulcerative colitis
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Frequent loose stools (greater than 10/day)
Abdominal pain and tenderness Severe anemia often necessitating blood transfusions Fever Poor nutritional state with hypoalbuminemia Signs of hypovolemia: rapid pulse |
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How is ulcerative colitis diagnosed?
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Sigmoidoscopy is diagnostic with acute colitis
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Ulcerative colitis imaging
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Colonoscopy may be used for disease extent and severity - if no acute flare up
- Risk of perforation with severe disease - Histological features from biopsy - grade disease activity Plain abdominal film, supine – severe attack - Margin of colon is edematous and irregular - Colon thickening and toxic dilation can be seen Single-contrast barium enema - Little utility in acute colitis - May precipitate toxic megacolon in severe disease |
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Initial presentation of ulcerative colitis
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Gradual onset of symptoms, often preceded by a self-limited episode of rectal bleeding that occurred weeks or months earlier.
Physical examination often normal - Possible evidence of weight loss, abdominal tenderness, positive fecal occult blood test |
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How should a normal sigmoid colonic mucosa appear on an endoscopy?
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The fine vasculature is easily visible and the surface is shiny and smooth. The folds are of normal thickness.
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Abnormal endoscopic imaging
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Extensive ulceration of the mucosa is the most common endoscopic finding. The surface is irregular, friable, and erythematous, with loss of normal vascular markings (A). Pseudopolyps may form as a reaction to inflammation (B) and can become quite extensive (C).
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Barium enema
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Double contrast barium enema demonstrates extensive mucosal ulceration and inflammation throughout the colon.
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Differential diagnosis of ulcerative colitis
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Exclude other known causes of colitis
Infectious colitis Stool specimen for: - Routine bacterial cultures: Salmonella, Shigella, and Campylobacter, E Coli - Ova and parasites - Stool toxin assay for C difficile (antibiotics) Sexually transmitted disease with proctitis - Gonorrhea, chlamydia, herpes, syphilis Ischemic (mesenteric) colitis - older patient Radiation colitis Crohn’s disease |
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Complications of UC
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Massive hemorrhage: in up to 3% of patients
- May necessitate urgent colectomy Fulminant colitis: 15% of patients - 20% of those progress to toxic megacolon with associated risk of perforation and death Benign stricture - Surgery indicated for strictures that cause continued symptoms of obstruction Colon cancer: related to both the duration and extent of the disease - Colonoscopy recommended every 1-2 years 8 years after diagnosis. |
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Extraintestinal complications of UC
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Uveitis (vision changes) and scleritis
Erythema nodosum and pyoderma gangrenosum Peripheral arthritis Ankylosing spondylitis Lung disease Venous and arterial thromboembolism |
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Maintenance of UC
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Natural course of the disease consists of intermittent exacerbations alternating with complete symptomatic remission.
Very small percentage of patients never achieve relapse. 75% of patients who go into remission will experience a symptomatic relapse within 1 year without long-term medical therapy. Relapse rates reduced to 35% with long-term maintenance therapy. Sulfasalazine 1-1.5 g bid, mesalamine 800 mg 2-3 times daily or 500 mg qid |
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What is the curative treatment of UC?
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Surgical resection
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Prognosis of UC
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Lifelong disease
- Characterized by exacerbations and remissions Most never require surgery or hospitalization Surgery is curative With management, majority of patients lead close to normal productive lives |
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Crohn's disease
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Characterized by transmural inflammation of the gastrointestinal tract.
As opposed to the mucosal lining of UC. |
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What areas of the GI tract may be involved with Crohn's?
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May involve the entire GI tract from mouth to anus
50% small bowel involvement only 50% ileocolitis: involvement of both ileum and colon 20% disease limited to the colon - ½ have sparing of the rectum (as opposed to UC) Small percentage have predominant involvement of the mouth or upper GI 1/3 perianal disease |
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What is the main difference in areas that are affected by UC and Crohn's?
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½ of Crohn's patients have sparing of the rectum (distinguishes from UC)
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Pathophysiology of Crohn's
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Transmural inflammation often leads to fibrosis and to obstructive clinical presentations not typically seen in ulcerative colitis.
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S/S of Crohn's
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Presentation varies depending on extent of disease
Most common - Low-grade fever, malaise, weight loss, decreased energy - Ileitis or ileocolitis: diarrhea, typically non-bloody Colitis: may be bloody diarrhea and fecal urgency |
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Physical exam findings of Crohn's
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Focal tenderness in right lower quadrant
Palpable tender mass representing inflamed intestine. |
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Intestinal obstructions related to Crohn's
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Narrowing of the small bowel
Results from inflammation, spasm, or fibrotic stenosis. Patients present with postprandial bloating, cramping, and borborygmi. |
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Sinus tracts related to Crohn's
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Penetrate through the bowel and may be contained or form fistulas
- Mass palpable on PE with fever and pain |
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Fistulas related to Crohn's
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Connects (opens up) to epithelial lined organs
Ileocecal fistulae common |
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Perianal disease related to Crohn's
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1/3 of patients
Skin tags, anal fissures, abscesses, and fistulas |
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Extraintestinal Crohn's disease
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Arthralgias, arthritis, uveitis, aphthous ulcers (canker sores), gallstones, nephrolithiasis
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Lab findings of Crohn's
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CBC
- Anemia may reflect mucosal blood loss, chronic inflammation, iron deficiency, vitamin B12 malabsorption - Leukocytosis may reflect inflammation, abscess formation, corticosteroid therapy Hypoalbuminemia Elevated sed rate or C-reactive protein Stool specimens |
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What is the dominant feature of Crohn's?
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Ulcers are the dominant endoscopic feature
Linear and discontinuous - “skip lesions” Early changes may be patchy erythema or aphthoid ulcers (resembles canker sores). |
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Barium enema findings of Crohn's
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“Cobblestone” on barium enema
- Diffuse thickening of the small bowel mucosa in a patient with Crohn’s . - Cobblestone appearance is produced by barium being dispersed between the edematous inflamed mucosa |
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CT findings of Crohn's
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Useful in identifying ulcerations, fistulas, and strictures
Bowel wall thickening Barium upper GI series with small bowel follow-through. |
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Complications of Crohn's
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Abscess
- Tender abdominal mass, fever, leukocytosis - Emergent CT - Surgery needed to clear abscess Obstruction - IV fluids with NG suction Fistulas - Frequently require surgical therapy Colon carcinoma: routine colonoscopy |
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How should the diet of an urgent Crohn's patient be managed?
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Always have patient NPO immediately
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Prognosis
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Lifelong illness that can have profound emotional and social impacts.
Few die as result. Most cope with disease and complications. Can lead productive lives. |
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5-ASA treatment of Crohn's
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5-Aminosalicylic Acid (5-ASA): Potent anti-inflammatory effects
Used for active treatment and during disease inactivity to maintain remission - Mesalamine ---Topical form in suppositories and enemas (UC) --- used for disease in distal colon - Azo compounds: sulfasalazine, balsalazide - must supplement with folate |
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Corticosteroid treatment of Crohn's
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Induce remission in patients unresponsive to 5-ASA agents.
Short-term utility Side effects with short-term use - mood changes, insomnia, dyspepsia, weight gain, edema, elevated serum glucose, acne |
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Corticosteroid treatment of Crohn's
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Corticosteroid dependent patients in an attempt to maintain remission upon withdrawal of corticosteroid
Mercaptopurine and azathioprine: immunosuppressant of leukocytes Inhibits the immune response and allows 2/3 of UC and CD pts to wean from corticosteroids Cyclosporine Potent immune suppressant used in transplant patients Alters immune response by inhibiting T cell responses Helps maintain remission with azathioprine and mercaptopurine Methotrexate: - Potent anti-folate drug, used for CA tx, 2˚ effect on immune system - Effectively induces remission and reduces glucocorticoid dosage |
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Side effects of long-term corticosteroid use
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Potentially serious side effects with long-term use
Effects can be seen when patient uses steroid for more than 3 months cumulatively over lifetime. - osteoporosis, osteonecrosis of the femoral head, myopathy, cataracts, susceptibility to infections |
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Biologic therapies
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Narrowly target various components of the immune system.
Highly effective for patients with corticosteroid-dependent or refractory disease. - High cost, potentially life-threatening side effects Anti-TNF Therapies - Infliximab, adalimumab, and certolizumab Side effects: antibody development, urticaria, diaphoresis, chest tightness, serious infections |
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Anitbiotics
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Used after surgery to treat complications of UC surgery
Used with active inflammatory, fistulous, and perianal CD, and may prevent recurrence after surgery |
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Nutritional therapies
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Bowel rest and TPN can induce remission of active CD but does not maintain well – has complications.
Not as effective for UC. |
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Treatment of distal colitis
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Drug of choice: topical mesalamine
1000 mg suppository once daily at bedtime 4 g enema Topical corticosteroids and oral 5-ASA second choice |
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Treatment of mild-moderate colitis
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5-ASA, Corticosteroids, Immunomodulating agents
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Treatment of severe colitis
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Hospitalization
- Due to risk of toxic megacolon or fulminant colitis D/C oral intake 24-48 hrs. IV Corticosteroids - Anti-TNF infusion or cyclosporine if no improvement in a week Surgery - If 7-10 days of IV pharmacotherapy fails. |
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Surgery for UC
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Nearly ½ of pts undergo surgery within the first 10 years of illness
Morbidity is 20% elective, 30% urgent, 40% emergent Risks: hemorrhage, contamination, sepsis |
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Surgery for Crohn's
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Most pts require at least one operation in their lifetime
Need for surgery related to duration of disease and site of involvement Small bowel disease - 80% chance of requiring surgery Colon disease – 50% chance of requiring surgery |
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Key differences between UC and colitis
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Ulcerative Colitis
- Colon only - Mucosal layer - Continuous lesions - More association with rectal bleeding Crohn’s Disease - Can include entire GI (mouth to anus) - Transmural - Patchy “skips” - Perianal disease |
