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34 Cards in this Set

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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
**
Differential Dx for bloody Diarrhea in a young healthy person
Infectious colitis
Inflammatory Bowel Disease
Unlikely: ischemic colitis or malignancy
Evaluational tests/labs
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
IBD includes
Ulcerative colitis
confined to colon
confined to mucosa and submucosa
Crohn’s disease
may be anywhere in GI tract
may be transmural
Indeterminate colitis
Epidemiology of IBD
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
Etiology of IBD
genetic, environmental/infectious, immunologic
Genetic Succeptibility in IBD
some genetic predisposition in Crohns. Less genetic predisposition in UC
Dx of IBD
Clinical Hx, physical, Labs, endososcopic, radiographic, histological studies
Presentation of Ulcerative Colitis
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.
UC location and Extent
30% proctitis, 40% Left sided colitis, 30%extensive pancolitis
Crohn's Disease
diarrhea, chronic abd pain and tenderness, weight loss, feverm perianal disease, sx vary with location of disease, extraintestinal manifestations
CD location and extent
40% ileocolitis, 25%colitis, 30%ileitis, jejunoilitis, 5% gastro
Appearance of UC-moderate
no folds, no blood vessels
Appearance of sever UC
mucus, no folds edematous, no blood vessels
Sever Crohn's Colitis Appearance
cobblestone, ulcers
Natural course of UC
relapsing and remitting disease
complications in UC
toxic or fulminant severe colitis, toxic dilation, bleeding, surgery
Surgical intervention in Crohns
usu end up doing surgery
20% may have a mild course--generally the minority
surgery does not cure crohns disease.
Perianal disease with Crohns disease
anal fistula and abcess
Extraintestinal Manifestations of IBD
Skin disorders-erythema nodosum, pyoderma gangrenosum
Joint Diseorders-peripheral arthritis, sacroilitis, ankylosing spondilitis, ocular disorders, hepatobiliary disorders, renal disorders, apthous stomatitis
Skin manifestations in UC
erythema nodosum (red tender nodules on shins. Pyoderma Gangrenosum
Peripheral arthritis in UC
monoarticular, asymmetrical, large>small joints, no synovial destruction, no subcutaneous nodules, seronegative
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
Dx: UC
Management goals in treating IBD
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
Aminosalicylates: 5ASA
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.
Steroids
prednisone or budesinide. se's almost everyone. works topically on ileum and right colon- preferred for crohns (bud)
Immunomodulators
Azathioprine/6-MP, methotrexate. Azo is pro drug of 6-MP.
Biologics
Anti TNF therapy. Infliximab, adalimumab, certolizumab. Crohns and UC. May be incr risk for lymphoma for pts on both biologics and immunomods
Tx for UC
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
Management of Fulmoinant Colitis
IV steroids
IV infliximab
IV cyclosporine
Surgery
Mild to moderate Crohns disease
oral 5ASA, budesonide
Moderate to Severe Crohns
Prednisone: short course only
Immunomodulators
Azathioprine/6-MP
Methotrexate
Anti-TNF Therapy
Infliximab
Certolizumab
adalimumab
Indications for surgery in UC
exsanguinating Hemorrhage, toxicity or perf, cancer, dyplasia, growth retardation, systemic complications, intractability-most common reason.
Indications for surgery in CD
failure to respond to surgery, mgmt of complications: strictures, fistulae, perfs, perianal disease, cancer or precursors.