Extra GI Manifestations of IBD

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Extra GI Manifestations of IBD

• Dr. Matt W. Johnson
• BSc MBBS MRCP MD
• Consultant Gastroenterologist
• Luton Dunstable FT Hospital

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Luminology
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(No Transcript)
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To the ileum and beyond
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Extra GI Manifestations of IBD 40
Organ Complications
Mouth Glossitis / Angular stomatitis / Orofacial granulomatosis
Eyes Episcleritis / Iritis / Uveitis
Skin Erythema nodosum / Pyoderma Gangrenosum
Bones Sacroiliitis / Enteropathic Arthropathy / Ankylosing Spondylitis / Osteoporosis
Lungs Fibrosing Alveolitis (UIP)
Liver AICAH / Granulomatous Hepatitis / Amyloid
Biliary Tract Gallstones / Bile acid malabsorption / Primary Sclerosing Cholangitis / AI pancreatitis / Cholangiocarcinoma
Kidneys Stones (uric acid, oxalate)
Blood Fe B12 Folate deficiency / AV Thrombosis
Constitutional Toxic megacolon / Weight loss / Growth retardation
Post-Surgical Bile acid malabsorption / abscess / strictures / fistulae
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EGIM of IBD
CrD UC Both Activity IBD Rx
OFG /-
Gallstone sb - -
PSC - -
PBC - -
AIP - -
Epi/Scleritis
Iritis/Uveitis
EN
PG /- /-
Serositis
Sacroilitis
T1 Arthro
T2 Arthro - -
AnkSpond - -
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Mouth

1. Glossitis -
2. Angular Stomatitis
3. Orofacial granulomatosis

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Glossitis

• B12 deficiency
• Red beefy tongue
• Fe deficiency
• Atrophic smooth tongue
• Rx Supplements

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Angular Stomatitis

• Fe deficiency
• Rx Supplements

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Orofacial Granulomatosis

• Rare chronic inflammatory condition
• Characterised by lip swelling
• 64 have histological granulomas similar to CrD
• Rx Elemental or Cinnamon and benzoate free diet

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Eyes

1. Episcleritis
2. Iritis
3. Uvietis
4. Steroid Cataracts

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Episcleritis

• Incidence 5
• Superficial redness of the episclera and
  conjuctiva
• Burning itching due to dilated vessels
• Mx Self resolves /- NSAIDS

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Scleritis

• Deeper redness of sclera
• Serious inflammatory condition
• Ocular pain, photophobia, tearing, blindness
• Rx Treat the IBD Systemic steroids, NSAIDS,
  antibiotics or immunosuppressant

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Iritis / Uveitis

• Inflammation of the iris (anterior uveitis)
• 0.5-3
• Acute self resolves within weeks
• Chronic persists for months and needs Rx
• Ocular pain, photophobia, blurry vision, synechia

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Iritis

• Complications include synechia, cataracts,
  glaucoma, blindness
• Rx Steroids (PO drops, subconjuctival
  injections)

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Uveitis

• Inflammation of middle/inner eye
• 10 of blindness in USA
• Mx Urgent referral to ophthalmologist
• Treat the IBD
• Rx Steroids (PO drops, subconjuctival
  injections), dilators pressure reducing drops
  (brimonidine tartrate) /- MTX, IFX

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Skin

1. Erythema Nodosum
2. Pyoderma gangerenosum

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Erythema Nodosum

• 8-15 of UC CrD
• Usually reflects active disease
• Can precede the IBD diagnosis
• Red hot nodules on extensor surfaces
• Assoc with pauciarticular arthropathy
• Rx the IBD and you Rx the EN

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Pyoderma Gangerenosum

• 5 UC
• 2 of CrD patients
• 50 assoc with IBD activity
• Starts with a red area central pustules then
  develops into a painful necrotic ulcer
• Steroids, IFX, Cyclosporin
• Colectomy does not always help

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Airway inflammation

• UC gt CrD
• Chronic cough and mucopurulent sputum
• Progressive airways narrowing leads to Chronic
  bronchitis bronchiectasis bronchiolitis
  obliterans
• CXRs frequently normal, needs HRCT
• Rx Large airways - Inhaled steroids
• Small airways - Systemic steroids
  

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Thrombo-embolic disorders

• TE events occur in 25
• 3 fold increase above general population
• Recurrence risk is 10-15

UC CrD
Incidence per 10,000 50 40
Increase risk of DVT 2.8 2.9
Increase risk of PE 3.6 4.7
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Liver Pancreas

• Abnormal LFTs 30 eg. AZA
• Gallstones 13-34 of sb Crohns
• PSC
• PBC
• AI Pancreatitis

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Primary Sclerosing Cholangitis

• 5 of UC and 1-2 CrD
• Can precede colitis by years
• Symptoms Pruritis, fatigue, RUQ pain, jaundice,
  cholangitis
• Bedding and stricturing of IHDs
• Associated with cholangiocarcinoma 6-20
• Increased risk of UL GI cancer x6 and ampullary
  cancer
• Colonoscopy every year, with OGD every 2 years
• Survival if symptomatic 15-18y

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Primary Biliary Cirrhosis

• More commonly seen with UC
• High cholesterol
• Deficiencies in the fat soluble vitamins DEAK
• Leads to cholestasis

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Bones

1. Osteoporosis
2. Sacroileitis
3. Arthropathies (RhA, AnkSpond)

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Osteopenia / Osteoporosis

• Peak bone mass reached in our 20-30s
• Then 0.5-1 per year thereafter
• 15 BMD lost in first 5y post menopause
• Osteopenia occurs in 40-50
• Osteoporosis occurs in 2-30
• Lifetime risk of fractures in IBD 41
• CrD women have 2.5 fold increase fracture risk

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Osteoporosis

• Prevention
• Weight bearing exercise
• Stop smoking
• Reduce weight
• Moderate Xol intake
• Ca intake (1000-1500mg/d) 1 pint of semi
  skimmed is 700mg
• Stop steroids ASAP
• Bone loss starts rapidly
• Occurs even with low doses
• Fracture risk improves on cessation
• Ca Vit D All patients on steroids
• Bisphosphonates steroids gt3m, those gt65y or low
  impact (fragility) fractures
• HRT eg testosterone in steroid induced
  hypogonadism

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BSG Mx of Osteoporosis

• Calcium Vit D
• PO Bisphosphonates (eg alendronate, residronate)
• IV Bisphosphonates (eg. pamidronate)
• In those with difficult side effects eg.
  oesophagitis
• Poor mucosal absorption
• Avoids the problems
• HRT (in PMP women) - risk of clots / breastgynae
  cancer
• Raloxifene - modulator of OR, without increased
  of breast Ca

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Sacroilitis

• Prevalence 47
• Sacro-iliac pain
• Hazziness of sacro-iliac joint
• Can be one sided
• Rx COX II inhibitors
• Try to avoid NSAIDS
• Steroids / IFX
• Mx Treat the IBD

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IBD Arthropathy

• 10-20 of IBD patients (esp in Colonic disease,
  EN, Eyes)
• Not to be confused with arthralgia secondary to
  steroid withdrawal, AZA or steroid induced
  myopathy.
• 1) Type 1 (Large Joint) Arthropathy 5
• ? 6 joints, (typically 1 large joint eg. knee)
• Attacks assoc with active inflammatory relapses,
  EN Iritis
• Usually self limiting, no role for NSAIDS
• Treat the IBD 5ASAs, Steroids, MTX, AZA,
  Colectomy
• 2) Type 2 (Small Joint) Arthropathy 3-4
• Affects gt5 joints, (typically small joints of
  hands and feet)
• No direct assoc with IBD activity or Rx

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Rx Algorithm for IBD Arthropathy
1st Line Physical exercises Simple analgesia Intra-articular injections Steroids Lignocaine

2nd Line Sulfasalazine or Pentasa (sb) NSAIDS!!! / Codeine !!! MTX (esp. Crohns) (No evidence for AZA/Cyclo) Bonner G.F. AmJG. 2002 Thompson GT. JRheum 2000

3rd Line IFX (Type 1) Thalidomide (80 AnkSpon) Bisphosphonates
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EGIM of IBD
CrD UC Both Activity IBD Rx
OFG /-
Gallstone sb - -
PSC - -
PBC - -
AIP - -
Epi/Scleritis
Iritis/Uveitis
EN
PG /- /-
Serositis
Sacroilitis
T1 Arthro
T2 Arthro - -
AnkSpond - -