Inflammatory Bowel Disease 2015 Eric M Osgard MD, FACG Gastroenterology Consultants Reno, Nevada. IBD • Definition – – Ulcerative Colitis – Relapsing and remitting episodes of inflam. Of the mucosal layer of the colon – rectum invariably involved – Crohn’s Disease – Transmural inflammatory changes of any portion of the GI tract – usually term ileum involved Ulcerative Colitis Crohns Disease History • Burrill B. Crohn – Published first account of chronic disease in JAMA – 1932 • Johne’s disease – Similar disease in cattle – M. Paratuberculosis Crohn, JAMA, 1932; 99: 1923-32 Inflammatory Bowel Disease (IBD) • Ulcerative Colitis (UC) • Crohn’s Disease (CD) – Colonic only – Whole GI tract can be • Rectum always involved involved • Often extends proximally • Most often Terminal ileum – Involves mucosa only • Anal, colonic – More predictable – Transmural presentation • Strictures, fistulae – Varied Symptomatology Indeterminate Colitis Epidemiology Epidemiology • Men + Women affected equally* • Higher socioeconomic groups • Northern latitudes • Caucasians > other races • Bimodal distribution of age of onset. – 2nd to 3rd decade of life – 5th to 7th decade of life Ileal Crohn’s Disease Pathophysiology Genetics Autoimmune Reaction Environment Pathophysiology Diet • Surprisingly little data • Western style diet – High in refined sugars, processed foods, and fried foods • High in animal fat, mild protein • Low in vegetables • Overall minimal dietary interventions have proven to be effective Crohn’s Disease Symptoms • Variable!!! – Depends on location – Subtypes – Fistulizing, inflammatory, stricturing • Abdominal pain • Weight loss • Anemia • Diarrhea • Occasional Blood in stool • Others Crohn’s Colitis Ulcerative Colitis Symptoms • More Predictable – “Bloody Diarrhea” – Weight loss – Anemia – Tenesmus* – Fevers Diagnosis • Colonoscopy or FS with biopsies • Small Bowel series/CT • Pathology – Biopsies – Crypt abscesses, crypt architectural distortion, Mild UC granulomas (CD only), basal plasmacytosis Serologies • Ulcerative Colitis • Crohn’s Disease – Anti Saccharomyces – Anti Saccharomyces Cerevisiea (ASCA) Cerevisiea (ASCA) (+) in <5% (+) in 60% – p-ANCA (+) in 75% – P-ANCA (+) in <10% Complications of UC • Perforation • Severe Inflammation • Toxic Megacolon • Colon Cancer • Severe Bleeding (uncommon) Megacolon Complications of Crohn’s disease • Fistulas • Abscesses • Obstruction • Malnutrition • Colon cancer • Lymphoma Fistula (luminal side) Extra intestinal Manifestations of IBD • Arthritis – Peripheral vs. Axial • Osteoporosis • Dermatologic – Pyoderma Gangrenosum and Erythema Nodosum • Thromboembolic • Eye • Associated with Primary Sclerosing Cholangitis – 90% PSC pt’s have IBD Pyoderma Gangrenosum Colon Cancer • Greatly increased risk – 2-8x relative Risk vs. normal population • Gi societies vary in their recommendations for surveillance • Between 8-15 years from onset risk greatly increases Ulcerative Colitis and Risk of Colorectal Cancer Eaden,et al, GUT. 2001;48:526 Crohn’s Treatment • Options depend on location of disease! • 5-ASA – controversial! – No role for sulfalsalazine with ileal disease! – Pentasa vs. Asacols etc – Location! • Steroids – Budesonide vs. Prednisone • Antibiotics – Flagyl • Biologics – Anti-TNF vs. others • Combination Biologics/immunomodulators Crohn’s Treatment • Surgery – Avoid if possible – Frequently needed – Disease will return at anastamosis – Preventative therapy standard! • No smoking! UC Treatment – Mild-Mod • Medications – 5-ASA – Topical vs. Oral • For distal disease – suppositories vs. enemas for initial therapy and maintenance • Oral for more extensive colitis. – Sulfasalazine ok – high risk of reaction – Mesalamine 3.6g + per day – Still consider added topical treatment – Tx rectal sx’s! UC Treatment – Mild-Mod • Steroids – Prednisone for mesalamine failures • Works within 10 days • Significant side effects. • Minimal role for long term remission • Budesonide – minimal role • 6MP/Imuran – Role in maintenance • Anti-TNF – Some role here – rarely needed UC Treatment - Severe • Acute – Steroids and mesalamine as initial therapy – Consider Immunomodulators early – Cyclosporine for hospitalized steroid refrac patients – Anti-TNF’s – Surgery for severe refractory patients!! UC Treatment • Total Colectomy with Ileopouch anal anastamosis (IPAA) • Often have cuff of rectal tissue remaining • Pouchitis IBD • Pearls – – Avoid NSAIDS – Bimodal peak – 20’s and 50’s – UC associated with PSC** – Men and women affected equally – Both CD and UC increase Colo. Ca risk if colon involved • Annual surveilance Colonoscopy with random biopsies starting 8-15 years from onset of dx. • High grade dysplasia on any sample (if confirmed) = Colectomy. LGD controversial. Question #1 • A patient of yours with UC in remission is doing well with normal bowel movements at this time. You need to be sure to ask about which symptom/issue in a ROS? – A - Skin Nodules – B - Peripheral arthropathy – C - Eye Pain – D - Unilateral Leg swelling – E - Lower back pain Question #2 • A patient diagnosed with UC is about to be initiated on mesalamine. What should you check prior to starting therapy? – A - Ask about allergies to sulfa – B – Check a Baseline Creatinine – C – Check a baseline WBC count – D – Check a TPMT enzyme level Question #3 • You are working inpatient at Renown and a patient with refractory UC has been admitted and has failed 5 days of IV Solumedrol. Refusing surgery. Decision has been made to start Cyclosporine. What do you need to check first? – A – Serum Cholesterol level – B – Serum albumin – C – PPD – D - Serum Magnesium Question #4 • A patient with UC undergoes a Total colectomy with IPAA. He wants to avoid pouchitis. What should you tell him? – A – Start antibiotics immediately after surgery – B – Start probiotics immediately after surgery – C – Do nothing as pouchitis is rare .