Inflammatory Bowel Disease 2015

Eric M Osgard MD, FACG Consultants Reno, Nevada. IBD

• Definition – – Ulcerative – Relapsing and remitting episodes of inflam. Of the mucosal layer of the colon – invariably involved – Crohn’s Disease – Transmural inflammatory changes of any portion of the GI tract – usually term 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)

• (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 • • • Occasional in stool • Others Crohn’s Colitis Ulcerative Colitis Symptoms

• More Predictable – “Bloody Diarrhea” – Weight loss – Anemia – Tenesmus* – Fevers Diagnosis

• or FS with biopsies • Small Bowel series/CT

• Pathology – Biopsies – Crypt , 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 • Colon Cancer • Severe (uncommon)

Megacolon Complications of Crohn’s disease

• • 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

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 • – 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

• 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