Inflammatory Bowel Disease

Front 1

23 year old woman reports 3 weeks of progressive bloody diarrhea
10 BM/day
Urgency and nocturnal stools
Some abdominal cramping
Low grade fevers
Fatigue
Joint aches

No recent travel, no sick exposures, previously healthy, on no meds, works in a office (missed 3 days of work this week).
Lost about 5 lbs.
WDWN in NAD
T 99.4, P 100, BP 100/65
Physical exam is normal

Back 1

**

Front 2

Differential Dx for bloody Diarrhea in a young healthy person

Back 2

Infectious colitis
Inflammatory Bowel Disease
Unlikely: ischemic colitis or malignancy

Front 3

Evaluational tests/labs

Back 3

Blood tests
CBC, CMP
Consider: ESR/CRP-nonspecific markers of inflammation, IBD serology-can actually help with Dx
Stool tests
Consider: fecal leukocytes, FOBT
Fecal culture: salmonella, shigella, campylobacter, yersinia, E. coli 0157
O+P exam
Consider: C. diff toxin
Endoscopy: colonoscopy or flex sig

Front 4

IBD includes

Back 4

Ulcerative colitis
confined to colon
confined to mucosa and submucosa
Crohn’s disease
may be anywhere in GI tract
may be transmural
Indeterminate colitis

Front 5

Epidemiology of IBD

Back 5

higher incidence in more developed and industrialized nations
most common in jews, then non jewish caucasians, then blacks
age of onset mostly in 20s, Females more than males

Front 6

Etiology of IBD

Back 6

genetic, environmental/infectious, immunologic

Front 7

Genetic Succeptibility in IBD

Back 7

some genetic predisposition in Crohns. Less genetic predisposition in UC

Front 8

Dx of IBD

Back 8

Clinical Hx, physical, Labs, endososcopic, radiographic, histological studies

Front 9

Presentation of Ulcerative Colitis

Back 9

Bloody diarrhea, abd cramping, tenesmus, weight loss, systemic sx, extraintestinal manifestations, sx depend of extent and severity of inflammation. Usu starts distally and progesses up.

Front 10

UC location and Extent

Back 10

30% proctitis, 40% Left sided colitis, 30%extensive pancolitis

Front 11

Crohn's Disease

Back 11

diarrhea, chronic abd pain and tenderness, weight loss, feverm perianal disease, sx vary with location of disease, extraintestinal manifestations

Front 12

CD location and extent

Back 12

40% ileocolitis, 25%colitis, 30%ileitis, jejunoilitis, 5% gastro

Front 13

Appearance of UC-moderate

Back 13

no folds, no blood vessels

Front 14

Appearance of sever UC

Back 14

mucus, no folds edematous, no blood vessels

Front 15

Sever Crohn's Colitis Appearance

Back 15

cobblestone, ulcers

Front 16

Natural course of UC

Back 16

relapsing and remitting disease

Front 17

complications in UC

Back 17

toxic or fulminant severe colitis, toxic dilation, bleeding, surgery

Front 18

Surgical intervention in Crohns

Back 18

usu end up doing surgery
20% may have a mild course--generally the minority
surgery does not cure crohns disease.

Front 19

Perianal disease with Crohns disease

Back 19

anal fistula and abcess

Front 20

Extraintestinal Manifestations of IBD

Back 20

Skin disorders-erythema nodosum, pyoderma gangrenosum
Joint Diseorders-peripheral arthritis, sacroilitis, ankylosing spondilitis, ocular disorders, hepatobiliary disorders, renal disorders, apthous stomatitis

Front 21

Skin manifestations in UC

Back 21

erythema nodosum (red tender nodules on shins. Pyoderma Gangrenosum

Front 22

Peripheral arthritis in UC

Back 22

monoarticular, asymmetrical, large>small joints, no synovial destruction, no subcutaneous nodules, seronegative

Front 23

WBC 10K, HGB 10, PLT 500
Stool cultures negative
Colonoscopy: pancolitis with mild diffuse inflammation throughout, terminal ileum normal
Biopsies: mucosal ulceration, crypt abscesses, crypt architectural changes

Back 23

Dx: UC

Front 24

Management goals in treating IBD

Back 24

dx and prompt therapeutic response, induction of complete remission, low side effect profile to enhance compliance, education and improvement of quality of life, maintenance of remission, steroid sparing

Front 25

Aminosalicylates: 5ASA

Back 25

first line, work on lining of intestine and pass thru, only small amts absorbed so they are safe, proven to work on UC, not proven to work in Crohns, but we still try them bc they are safe.

Front 26

Steroids

Back 26

prednisone or budesinide. se's almost everyone. works topically on ileum and right colon- preferred for crohns (bud)

Front 27

Immunomodulators

Back 27

Azathioprine/6-MP, methotrexate. Azo is pro drug of 6-MP.

Front 28

Biologics

Back 28

Anti TNF therapy. Infliximab, adalimumab, certolizumab. Crohns and UC. May be incr risk for lymphoma for pts on both biologics and immunomods

Front 29

Tx for UC

Back 29

First line therapy is 5-ASA
Oral and or rectal
Steroids
Short course for bad flares
Immunomodulators
Use for steroid-dependent UC
Biologics
Failure of standard therapy

Front 30

Management of Fulmoinant Colitis

Back 30

IV steroids
IV infliximab
IV cyclosporine
Surgery

Front 31

Mild to moderate Crohns disease

Back 31

oral 5ASA, budesonide

Front 32

Moderate to Severe Crohns

Back 32

Prednisone: short course only
Immunomodulators
Azathioprine/6-MP
Methotrexate
Anti-TNF Therapy
Infliximab
Certolizumab
adalimumab

Front 33

Indications for surgery in UC

Back 33

exsanguinating Hemorrhage, toxicity or perf, cancer, dyplasia, growth retardation, systemic complications, intractability-most common reason.

Front 34

Indications for surgery in CD

Back 34

failure to respond to surgery, mgmt of complications: strictures, fistulae, perfs, perianal disease, cancer or precursors.