INFLAMMATORY BOWEL DISEASES

1. INFLAMMATORY BOWEL DISEASES Dwarka G. Nath, MD Ass Prof of Medicine, UNSoM Chief, Gastroenterology Section VA Medical Center, Reno, NV

2. Q: PERTAINING TO IBD, WHICH OF THE FOLLOWING IS TRUE? • A. IBD is seen in 50% of first degree relatives • B. Strong concordance by disease category • C. More common in underdeveloped countries • D. Flares correlate with life events and/or Depression • E. Concurrent IBS is rare

3. Answer is “B” • It is “B”- Individuals with CD tend to have family members with CD and Those with UC tend to have family members with UC • Not A- IBD seen in 10-25% of 1st deg relat • Not C- More common in developed world • Not D- Not evidence based-only anecdotal • Not E- upto 30% IBS pts have overlap

4. Q: With respect to UC, Which is FALSE? • A. Majority have pancolitis at presentation • B. > 99% have rectal involvement • C. More common in non and ex smokers • D. NSAIDs can lead to relapse • E. One can manifest PSC without manifest UC symptoms

5. Answer is “ A” • It is “A”- only 20% have pancolitis at onset • Not B- it is true that Rectum is invariably involved in UC . Not C- Nicotene is protective for UC . Not D –True NSAIDs can cause relapse . Not E – True PSC can manifest without UC Symptoms

6. Q: With respect to Crohns’ disease, Which is FALSE? • A. More common in smokers • B. Clinical Post-op recurrence is 60% • C. Increased incidence of Sq Cell CA of rectum and vulva • D. GI cancers occur equally in deseased and non diseased areas of bowel • E. pANCA is found less likely than in UC

7. Answer is “ D “ • It is D- Diseases Segments have more risk • Not A- True CD-more common in smokers UC is common in non /ex smokers • Not B- recurs usually at anastamosis in 60% CD followed over 15 yrs • Not C- True incidence of anal/ vulva Sq cancer are high • Not E- pANCA is more common in UC than CD

8. Q: With regards to IBD, Which generally does not parallel disease activity? • A. Erythema Nodosum • B. Sclerosing Cholangitis • C. Episcleritis • D. Peripheral Arthritis • E. Erythrocyte Sedimentation Rate • F. CRP

9. Answer is “ B” • It is B- PSC along with Sacroilitis, Ankylosing Spondylitis, uveitis DO NOT follow disease activity • They act independ of the disease and need to be treated independantly. The onset of any of these may predate IBD by several years! • Not A,C,D,E,F- Erythema Nodosum, Peripheral arthritis, episcleritis, ESR, CRP all parallel disease activity

10. TWO DISTINCT FORMS • ULCERATIVE COLITIS • CROHNS’ DISEASE • OVERLAP IBD

13. ERYTHEMA NODOSUM • Streptococcal infections- most common cause • Sarcoidosis • Idiopathic • Tuberculosis • IBD- More association in US than in developing countries • Drugs- OCP, Erythromycin, sulfa, • Other infections: histoplasmosis, Coccidiomycosis, Brucellosis, systemic Fungal infections, Leprosy, Mycoplasma, chlamidia, Gonococcemia • Allergies • Pregnancy of OCP • Vasculitis- Behcets syndrom, SLE variants, Pancreatiits, Hodgkins T cell immunodeficincies

15. PYODERMA GANGRENOSUM • Is an Inflammatory skin disease often associated with underlying systemic disorder such as IBD, Arthritis or Lymphoproliferative disorder • The eruptions begin as an isolated pustule or scattered lesions with rapid progression into large ulcers which heals with cribriform scar • Diagnosis is made after an infectious aetiology is excluded

17. TWO DISTINCT FORMSAND A SPRECTRUM IN BETWEEN • ULCERATIVE COLITIS • CROHNS DISEASE • OVERLAP SYNDROMES • MICROSCOPIC COLITIS

18. EPIDEMIOLOGY & STATASTICS • Estimated prevalence – Active cases 100/100,000 of general population • Estimated approx 1 million cases in US split equally among CD and UC • More Prevalent in developed/ developing countries • Higher incidence in Ashkanazi Jew decent • Equal distribution among Male :Female • Peak incidence between 10-30 yrs & then a second peak between 6th/7th decade

19. AETIOLOGY • UNKNOWN • Genetics- approximately 10-15% have a family history of – eg: Ashkanazi jews • Smoking- CD -Yes, Aggrevates UC- Protective • Developed countries- extreme Hygiene may predispose (insufficient exposure and challenge of Gut immune system that makes them susceptible)

20. Clinical Manifestations- UC • UC typically involves rectum and extends proximally. • At presentation 40 % have proctitis, 40% have left sided, 20% present with Pancolitis • So Bloody diarrhea, urgency are presenting symptoms • Severe cases i.e. Toxic megacolon can present with fever, weight loss, tachycardia, failure to thrive, Growth failures and symptoms of systemic inflamation • Occasionally severe proctitis cases can present with constipation . Upto 20 % can present with extraintestinal symptoms

21. Clinical Manifestations- CD • Can involve entire GI tract and so symptoms vary depending on site of involvement • Approximately 30% have SB disease, 40% have ileo-colitis, 30% have colitis and 5% have UGI disease or Anorectal presentation • Abd pain, Diarrhea, weight loss, Failure to thrive, Growth retardation- small bowel Disease • Hematochezia, diarrhea – in Large bowel disease • Upto 20% have extraintestinal manifestations

23. CROHNS DISEASE

25. FEATURES UC vs CD Feature UC CD Depth of inflamation Mucosal Transmural Pattern of disease Contiguous Skip areas Location Colorectal Mouth-Anus Rectal involvement Usual less common Ileal disease Backwash 10-15% Common Fistulas Rare Common Perianal Disease Rare Common Granulomas Unlikely 10-30% pts Overt Bleeding Usual less common Malnutrition Unlikely more common Cancer Risk CRC, Cholangio CRC,Sm Bwl Tobacco use Protective Harmful

26. Extraintestinal Manifestations & IBD disease Activity • RELATED to DISEASE ACTIVITY Erythema Nodosum Peripheral arthritis Ophtholmologic manifestations • UNRELATED to DISEASE ACTIVITY Ankylosing Spondylitis/ Axial Arthritis Primary Sclerosing Cholangitis Gallstones • RELATION to DISEASE ACTIVITY LESS CLEAR Pyoderma Gangrenosum Metabolic Bone Disease Kidney stones

27. LAB FINDINGS • In mild cases Lab findings are NORMAL • Anemia is a common finding from Iron deficiency of Blood loss or B12/ Folate malabsorption in CD • Hypoalbuminemia, metabolic bone disease from malabsorption are common in CD • Hypokalemia , Metabolic acidosis from severe diarrhea • Acute Phase reactants- ESR, CRP • UC p ANCA +/ ASCA -  PPV 63% • CD  p ANCA -/ ASCA +  PPV 80%

28. ENDOSCOPIC HALLMARKS • Disease Invariably of RECTUM—UC • Disease in Perineum- fistula/ inflammation- CD • Ileal disease- CD • “Skip lesions” Vs “Continuous” disease • Oral involvement- more common in CD • UGI involvement - CD

29. CROHNS vs PM COLITIS

30. ULCERATIVE COLITISCONTINUOUS INVOLVEMENT

31. Ch Ulc COLITISPSEUDOPOLYPS,

33. Differential Diagnosis of IBD • Acute Self Limiting Colitis Bacterial- Toxigenic E Coli, Salmonella Shigella,Campylobacter, Yersinia, Mycobacterium,N. Gonorrhea,C.Diff Parasites—Amoebiasis, Chlamydia Viral----CMV, H. Simplex • Collagenous/Lymphocytic colitis • Diverticular Dis Associated Colitis • Medication related Colitis--- NSAIDs , Gold • Ischemic Colitis • Radiation Colitis • Appendicitis • Diverticulitis • Neutropenic Enterocolitis/ Typhilitis • Solitary Rectal Ulcer syndrome • Malignancies- Carcinoma/ lymphoma/ leukemia

34. Microscopic Colitis • Ch Diarrhea with abd pain, mild weight loss • Elderly (70 or >) are more affected • Women have a greater incidence • Association with NSAIDs use suggested • Colonoscopy shows normal mucosa • Biopsy shows inflammatory infiltrates • Unlike UC/ CD crypt distortion is NOT present • Co-existing Celiac sprue should be considered • Treat with Loperamide, Diphenoxylate or Bismuth alone or in combination • Rarely Cholestyramine, 5 ASA and even steroids may be considered ( < 5 %patients)

35. Histopathology features • Crypt Abscess, crypt distortion in UC • Crypt abscess- depth of involvement in CD • Granulomas are found in 30% of CD • Inflamatory infiltrates in MC- NO crypt distortion noted in MC

36. Treatment of IBD- UC • Active Disease Topical therapy for distal disease ie enemas/ suppositories- ASA / Steroid Mild disease treated with oral mesalamine Steroids for severe disease 6 MP /Azathiprine may be used to minimize steroid need In severe fulminant colitis we may have to use IV steroids, cyclosporin or infliximab for controll Surgery will have to be considered if toxic megacolon is suspeced

37. Treatment of IBD- UC • Maintenance of Remission Mild distal disease may not need maintenance Severe disease will do better with a low dose maintenance with ASA or with AZA/6MP Steroids do not have a roll in maitenance

38. Treatment of IBD- CD • Similar to UC with following exceptions Smokers should be counselled to stop 5ASA is less effective than in UC Metronidazole in an option in induction Steroids for acute flares Infliximab/ Adalimumab for induction/ maintenance AZA/ 6MP for maintenance Surgery fo complications of disease

39. QUESTION? • If you donot have any here are some of your MKSAP questions

40. Case: 69 yo man has a 6 wk h/o loose bowels with urgency, mucous and BRBPR • He underwent resection of rectosig cancer 14 months ago. • 2/14 LN positive, no distant mets • Chemo and XRT given post op • 2weeks ago he received Levofloxin for a comm aq pneumonia – which resolved • PE- unremarkable, PR-blood tinged mucous • Flex Sig- Friable granular mucosa with a few telangiectasia in distal rectum

41. Q:Which of the following is the most likely diagnosis? • A. Recurrent Rectal Cancer • B. Radiation Colitis • C. Ischemic colitis • D. Ulcerative colitis • E. C. Diff colitis

42. Answer is B: Radiation Colitis • It is B- flex sig findings of telangiectasia • Not A- Atypical for endoscopy to be neg • Not C- ischemic colitis is usually acute here we have a 6 weeks history • Not D-age of onset, no ulcerations makes it less likely • Not E- symptoms started prior to ABx therapy