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Definitions

Definitions. UC. Crohn’s. Superficial ulcer to submucosa, muscularis and serosa Transmural inflammation Any portion of the alimentary tract Mouth to anus Fistulas Granulomas Only a minority of patients. Inflammation confined to mucosa Starting in rectum May involve entire colon

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Definitions

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  1. Definitions UC Crohn’s • Superficial ulcer to submucosa, muscularis and serosa • Transmural inflammation • Any portion of the alimentary tract • Mouth to anus • Fistulas • Granulomas • Only a minority of patients • Inflammation confined to mucosa • Starting in rectum • May involve entire colon • Crypt abscess • Rare • Rectal sparing • Discontinuous • Only proctitis

  2. Epidemiology & Genetics - IBD • M=F • Increased risk • Turners, Hermansky-Pudlak, GSD type 1B, Leukocyte adhesion • First degree relative • Single greatest risk factor (30 to 100 times) • Multiple genetic loci • pANCA • 70% UC • ASCA • 50-60%CD

  3. Pathogenesis Cause unknown Abnormalities in gastrointestinal immunoregulation Cytokines, arachidonic acid metabolites, reactive oxygen intermediates and growth factors

  4. Diarrhea • Factors increase electrolyte secretion • Increased fluid loss • Loss of bile salts from terminal ileum • Malabsorption • Bacterial overgrowth • CD • Exudation of serum proteins and blood • PLE • CD

  5. UC Bloody diarrhea Proctitis May have formed stool Pain with defecation Intestinal Manifestations • Both • Nausea and/or vomiting • Fever *Know the clinical manifestations and distinguish

  6. Intestinal Manifestations • Crohn’s • Diarrhea • 50% • Occasionally bloody • Abdominal pain • More severe • Perirectal inflammation • 25% • Fissure and/or fistula • Aphthous ulcers *Understand that chronic perianal lesions or recurrent aphthous ulcers can be an early sign of CD

  7. Extraintestinal Manifestations • 25-35% • Directly related to disease activity • Unrelated to disease activity • Result from the presence of diseased bowel • Arise from therapy

  8. Extraintestinal Manifestations • Growth Failure • 20-30% CD • Multifactorial • Chronic undernutrition, steroids, cytokines • 10% UC • Prolonged steroids • Don’t forget delayed puberty • *May be a presenting sign *Know the reasons for growth failure in patients with IBD *Know that pts with CD may have GF secondary to decreased caloric intake

  9. Extraintestinal Manifestations • Arthritis • Peripheral • 10% • Larger joints • Related to active colonic disease • Axial • Ankylosing spondylitis/Sacroiliitis • Rare in children *Recognize that arthritis may occur in patients with IBD

  10. Extraintestinal Manifestations • Skin • Pyoderma gangrenosum • Erythema nodosum

  11. Extraintestinal Manifestations • Liver • Steatosis • Elevated enzymes • Chronic hepatitis • Sclerosing cholangitis • Cholelithiasis • Acalculous cholecystitis • Budd-Chiari Syndrome

  12. Extraintestinal Manifestations • Pancreas • Pancreatitis • Bone • Osteopenia • Aseptic Necrosis • Eye • Uveitis • Episcleritis • Keratitis

  13. Extraintestinal Manifestations • Urologic • Nephrolithiasis • Obstructive hydronephrosis • Enterovesical fistula • Nephritis • Amyloidosis

  14. Extraintestinal Manifestations • Hematologic • Anemia • Iron • Folate • B12 • Autoimmune • Thrombocytosis • Thrombocytopenia • Hypercoaguable

  15. Diagnosis • No substitute for H&P • Labs • Anemia • Most due to iron deficiency • Thrombocytosis • ESR – 80% CD, 40% UC • CRP • Sensitive for active disease • Low albumin • Protein loss and malnutrition • Elevated liver enzymes • pANCA, ASCA

  16. Diagnosis • Radiographs • UGI with SBFT • CD • Endoscopy • Gross • Microscopic • Complications • CT • Abscess *Plan the initial evaluation of a patient with suspected IBD

  17. Admit? • Severe Colitis • Fever • Hypoalbumnemia • Anemia • >5 bloody stools/day • Bowel rest, TPN, IV steroids and careful monitoring

  18. Management • Pharmacologic • Aminosalicylates • Mesalamine, sulfasalazine • Mild colonic inflammation • Corticosteroids • Prednisone, budesonide • Moderate to severe symptoms • >5 bloody stools/day, fever, hypoalbuminemia, anemia • Goal is to decrease symptoms then change to maintenance therapy

  19. Management • Pharmacologic • Immunomodulators • Azathioprine, 6-MP, methotrexate • Steroid dependant or refractory • Maintenance • Biologics • Infliximab • Steroid dependant or refractory • Maintenance

  20. Management • Pharmacologic • Antibiotics • Metronidazole, ciprofloxacin • Perirectal fistula, abscess • Probiotics • Lactobacillus GG, Saccharomyces boulardii • Adjunctive therapy

  21. Management • Nutrition Therapy • Primary • Adjunctive • Important for • Remission • Chronic undernutrition • Growth failure

  22. Management • Surgical Therapy • Uncontrolled GI bleeding • Bowel perforation • Obstruction • Unacceptable medication toxicity • Intractability • Growth failure • Some perirectal disease • Cancer

  23. Prognosis • UC • 70% remission in 3 months • 50% remission for 1 year • 10-26% colectomy within 5 years • 70% likelihood of severe disease if proctitis present

  24. Prognosis • CD • 1% will not have at least one relapse • Ileocolitis • Responds poorly to medical therapy • Greater need for surgery • 70% will have surgery within 10-20 years of diagnosis • Cancer • Colitis >10 y and extent • Sclerosing cholangitis

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