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Inflammatory Bowel Disease


Inflammatory Bowel Disease Michael Tuggy. MD Epidemiology and Genetics Prevalence approx. 100/100,000 Incidence 10,000 per year UC=CD, M=W Bimodal distribution, peaks ... – PowerPoint PPT presentation

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Title: Inflammatory Bowel Disease

Inflammatory Bowel Disease
  • Michael Tuggy. MD

Epidemiology and Genetics
  • Prevalence approx. 100/100,000
  • Incidence 10,000 per year
  • UCCD, MW
  • Bimodal distribution, peaks between ages 15-25
    and 55-65
  • Highest incidence in whites of North America and
    Ashkenazi Jews

  • 3 theories
  • Genetic 10 IBD pt.s with family hx
  • Infectious vs. Environmental
    L. monocytogenes, M. paratuberculosis,
    stress, smoking, NSAIDs
  • Immunologic imbalance between pro- and
    anti-inflammatory cytokines in gut lumen

A day in clinic
  • 45 y.o. AA male with painless rectal bleeding.
    Hx of anxiety and depression, on disability.
  • History of 3-4 years of hemorrhoids
  • Urgency of bowel movement
  • crampy abdominal pain
  • diffuse joint pains, no swelling or redness

Your evaluation?
  • Exam - stool guaiac, normal rectal exam
  • Small flecks of blood on anoscopy, normal mucosa
  • HEENT no injection of conjunctiva or sclera
  • MSK no joint swelling or redness, no edema
  • Labs CBC Hct 42, ESR 44
  • Colonoscopy - segment of inflamed bowel about
    25 cm up from the pectinate line (5 cm long and

Ulcerative Colitis
  • Superficial mucosal inflammation of colon only
  • Begins at rectum and spreads continuously
  • 30 proctitis, 40 L sided colitis, 30
  • Sxs bloody diarrhea, fecal urgency, tenesmus,
    abdominal cramping

Ulcerative Colitis
Crohns Disease
Crohns Disease
  • Transmural inflammation of any part of GI tract,
    presence of skip lesions and noncaseating
  • Rectum often spared
  • 30 small bowel (usually terminal ileum), 40
    ileum/colon, 25 colon, 5 stomach/duodenum
  • Sxs non-bloody diarrhea, weight loss, fever, RLQ
    pain and/or mass, perianal disease with abscess
    and/or fistulas

UC vs. CD
  • Continuous/superficial
  • Colon only w/ rectum
  • Rectal bleeding
  • Rare fistulas/strictures
  • Surgery curative
  • Skip/Deep
  • Mouth to anusrectum
  • Rectal bleeding
  • fistulas/strictures
  • Surgery palliative (high rate of recurrence, gt50)

Laboratory testing
  • CBC (high rate of anemia, due to chronic
    inflamm., blood loss, B12 malabsorption)
  • ESR, CRP often elevated
  • Albumin (often low due to chronic inflamm., blood
    loss, malabsorption)
  • Stool studies to rule out infection
  • Noncaseating granulomas on biopsy suggest CD

  • Antineutrophil cytoplasmic antibodies found in
    65 UC and 5-10 CD
  • Antibodies to yeast S. cerevisiae found in 60-70
    CD and 10-15 UC
  • 10-20 of pt.s w/ IBD, unable to distinguish btwn
    UC and CD
  • Combo of -pANCA/ASCA 50 sens and 97 spec for
  • Combo of pANCA/-ASCA 57 sens and 97 spec for

Extraintestinal Manifestations
  • Derm erythema nodosum, pyoderma gangrenosum

Extraintestinal Manifestations
  • Ocular episcleritis, anterior uveitis
  • MSK arthritis, ankylosing spondylitis,
  • Hepatobiliary steatosis, cholelithiasis, primary
    sclerosing cholangitis

Toxic Megacolon
  • Occurs in 1-3 of pt.s w/ IBD
  • Colonic dilatation gt6cm and signs of toxicity
    (fever, hypotension, tachycardia, leukocytosis)
  • High risk of perforation
  • Medical management w/ broad-spectrum antibx,
    urgent surgical consultation if no response

Colon Cancer
  • Risk for colon cancer UCCD
  • Risk factors disease duration, disease extent,
    dysplasia on bx, presence of PSC
  • 1-2 risk per year if IBD gt10 years
  • Colon cancer not preceded by adenomatous polyps
  • Colonoscopy with surveillance biopsies
    recommended q1-2 years after disease for 10 years

Treatment of IBD
  • Aminosalicylates
  • 5-ASA reduces inflammation
  • Sulfasalazine (Azulfadine) oldest/cheapest
  • Newer agents comprised of Mesalamine bound to
    carrier molecules to prevent degradation in the
    proximal small bowel (Rowasa, Asacol, Pentasa)
  • Oral, enema, and suppository forms available

Treatment of IBD
  • Corticosteroids
  • Topical tx w/ Hydrocortisone foam or enemas tried
  • Systemic tx w/ Prednisone or Methylprednisolone
    if pt fails topical tx
  • Steroids should not be used to maintain
    remission, only for acute flares
  • Significant side effects growth retardation,
    osteoporosis, HTN, hyperglycemia, cataracts
  • Budesonide recently approved in US, fewer
    systemic side effects and less adrenal suppression

Treatment of IBD
  • Immunomodulatory drugs
  • Mercaptopurine, Azathioprine, Methotrexate often
    used as long-term tx
  • 3-6 month onset of action
  • Significant side effects bone marrow
    suppression, pancreatitis, hepatic toxicity

Treatment of IBD
  • Antibiotics
  • Primarily for treatment of CD, high risk of small
    intestinal bacterial overgrowth due to enteral
  • Metronidazole and Ciprofloxacin commonly used,
    considered to have broad bactericidal activity
    with immunosuppressive properties

Treatment of IBD
  • Cyclosporine
  • Used in pt.s with severe UC refractory to
  • Often used as a bridge to surgery or onset of
    action of immunomodulatory drugs only has short
    term benefit.
  • Significant side effects nephrotoxicity,
    electrolyte or liver chemistry abnormalities,
    HTN, paresthesias, anaphylaxis, sz

Treatment of IBD
  • Biologic therapy
  • Infliximab (Remicade) a chimeric IgG anti-TNF
    antibody (about as good as steroids in UC).
  • Certolizumab may be more effective.
  • Antagonizes activity of TNF-alpha, cytotoxic to
    immune cells, induces T-cell apoptosis
  • Approved for use w/ CD and UC
  • Significant side effects risk of
    infusion-related reactions, hypersensitivity
    reactions, lupus-like syndrome, infections-sepsis.

Treatment of IBD
  • Other possible txs
  • Omega-3 FAs reduces relapses for patients in
    remission. (CD)
  • Probiotics may reduce relapses in adults (UC)
  • Lactobacillus, E. coli
  • VSL 3 (induced remission in children AND adults
  • 47 per month!

Treatment of IBD
  • Surgical tx for UC
  • Total proctocolectomy curative, eliminates risk
    of colon cancer
  • Required in 25 of pt.s
  • Indications severe hemorrhage, perforation,
    carcinoma, fulminant colitis, toxic megacolon not
    improving with medical tx

Treatment of IBD
  • Surgical tx for CD
  • gt50 of pt.s will require at least one surgery
  • Palliative, gt50 recurrence rate at surgical site
  • Indications fistulas or perianal disease
    refractory to medical management, intra-abdominal
    abscess, obstruction related to strictures,

  • Flare-ups and recurrence common
  • Increased recurrence rate with smoking
  • Quality of life an issue as many complications
    with disease
  • Crohns and Colitis Foundation of America

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