Inflammatory Bowel Disease

1. Inflammatory Bowel Disease Dr K Ingram

2. Objectives • Revision of pathophysiology and presentation of IBD • Recall key differences between CD & UC • Learn a logical, stepwise technique to enable recall of investigation and management • Apply knowledge in a clinical scenario

3. Definition • Crohn’s Disease (CD) – a chronic, relapsing, inflammatory disease characterised by transmural granulomatous inflammation • Ulcerative Colitis (UC) – a chronic, relapsing, inflammatory disorder of the colonic mucosa

4. Crohn’s Disease • Epidemiology • Bimodal distribution (Teens/20s & Older Adults) • Exacerbated by smoking • Pathophysiology • Mouth → Anus (rectal sparing) • Terminal Ileum > Small Bowel > Colon • Areas of unaffected bowel in between (Skip lesions)

5. Crohn’s Disease • Histologically: • Transmural inflammation • Aphthous ulceration • Cobblestone mucosa • Stricture formation (string-sign) • Fistulae • Entero • -enteric • -cutaneous • -vesical • -vaginal • Retroperitoneal

6. Crohn’s Disease • Clinical Features:

7. Clubbing • Stages: • 1) Normal appearance and angle but increased fluctuancyof nail bed • 2) Loss of angle between nail and nail bed • 3) Increased curvature of the nail • 4) Expansion of terminal phalanx • Common causes: • Cardiology – SBE, cyanotic congenital HD • Respiratory – IPF, bronchial carcinoma, bronchiectasis, CF • GI – IBD, coeliac disease, cirrhosis

8. Crohn’s Disease • Extra-intestinal features • Conjunctivitis / episcleritis / iritis • Erythema nodosum (panniculitis) • Pyodermagangrenosum • Large joint arthritis / sacroiliitis • Complications • Small bowel obstruction • Perforation • Toxic dilatation

9. Crohn’s Disease • Differential diagnosis: • Ulcerative colitis • Carcinoma • Malabsorption • Diverticular disease • Infective • Thyrotoxicosis

10. Ulcerative Colitis • Epidemiology • Young adults (15-30) most commonly affected • Women > Men • Smoking can be protective • Pathophysiology • Continuous, superficial mucosal ulceration • Nearly always affects rectum • Rectum (Proctitis) 50% • Left colon 30% • Pancolitis 20% • Histologically • Areas of continuous mucosal inflammation

11. UlcerATIVE COLITIS • Clinical Features:

12. Ulcerative colitis • Grading severity of acute disease • Truelove-Witt Criteria1:

13. Ulcerative colitis • Extra-intestinal features • As for Crohn’s Disease • Complications • Toxic megacolon • >6cm of TC on AXR • Fever, tachycardia, dehydration, ↑WBC • Perforation • Bleeding • Colon cancer – surveillance crucial • Primary Sclerosing Cholangitis

14. Ulcerative colitis • Toxic Megacolon

15. Ulcerative colitis • Differential Diagnosis • Crohn’s Disease • Infective • Consider C.difficile • Ischaemic colitis • Carcinoma • Malabsorption • Diverticular disease

16. Investigations • Bedside • Observations • Stool culture (MC&S and C.Diff) • Urine dip +/- bHCG • Bloods • FBC / U&E / LFT / ESR / CRP • Haematinics • Blood cultures • pANCA (UC)

17. Investigations • Imaging • Erect CXR • Abdominal X-ray • CT abdomen/pelvis • Special Tests • Endoscopy +/- biopsy • Acute • Flexi-sigmoidoscopy ONLY • Chronic • Sigmoid-/Colonscopy • Barium • Meal/Follow-through – strictures in Crohn’s • Enema – drainpipe colon/loss of haustra, apple-core stricture (malignancy)

18. investigations Drainpipe Colon String Sign Apple-core stricture

19. Management • Conservative • Medical • Acute • Chronic • Surgical • Types of resection

20. Conservative management • Dietary advice • Low fibre, elemental diet

21. Medical management • Acute • Steroids – induce remission • Mild disease – prednisolone PO • Severe disease – hydrocortisone IV • NB – avoid long-term use due to side-effects • Chronic • 5-ASA → CCS → Immunosuppression → Biologicals

22. Medical management • 5-ASAs e.g. mesalazine • 1st line therapy in IBD • Good for acute disease (remission) & maintenance • Anti-inflammatory • Steroids e.g. prednisolone • Good for acute disease and inducing remission • NOT for long-term use • Immunosuppression e.g. azathioprine, MTX • Steroid-sparing agents • NB – methotrexate used in Crohn’s ONLY

23. Medical management • Biologicals e.g. infliximab • Monoclonal Ab against TNFα • Used predominantly for CD (esp. fistulae) • NICE guidelines: • Severe, active Crohn’s disease AND • Refractory immunomodulatory drugs / cannot tolerate side-effects / experienced toxicity AND • Surgery inappropriate • Can also be used in acute UC unresponsive to IV steroids

24. Medical management • Contraindications to infliximab • Sepsis • Deranged LFTs • Active TB • Pregnancy / Breastfeeding • Side effects of infliximab • Hypersensitivity reactions • Reactivation of TB • ALWAYS test for TB before commencing (Monospot) • Increased risk infections e.g. VZV, candida • Increased risk of malignancy e.g. lymphoma

25. Surgical resection • Crohn’s (~65%): • Acute, severe bleeding • Strictures • Fistulisation • Obstruction, Perforation • Non-resolving inflammatory mass • UC (<15%): • Perforation • Toxic megacolon

26. Types of Resection • Crohn’s Disease: • Small bowel • Stricturoplasty • Localised rections • Large bowel • Panproctocolectomy + ileostomy • Subtotal colectomy + ileorectal anastomosis • Ulcerative Colitis: • Total colectomy + ileostomy + oversewing of rectal stump • Creation of J-pouch (or completion proctectomy) • Ileostomy reversal

27. Crohn’sVs UC

28. Clinical scenario • 29 year old female • History: • 1/12 loose, watery stools of ↑ frequency • Occasional blood and ‘slime’ mixed in • Crampy LIF pain • Lethargy • Examination: • Pyrexial (38.2) • Abdomen soft but mild distension & tender LIF • PR – painful ++, fresh blood & mucus

29. Clinical scenario • Differentials • Ulcerative colitis (acute flare) • Crohn’s Disease • Infective diarrhoea • Diverticulitis • Carcinoma – must always be excluded • Investigation • Acute: • Bedside – obs, urine, stool • Bloods – FBC / U&Es / LFTs / CRP / ESR / haematinics /cultures • Imaging – Erect CXR, AXR, CT abdo/pelvis • Special tests – flexi-sigmoidoscopy ONLY

30. Clinical scenario • Investigations (cont.) • Long-term • Immunology bloods e.g. p-ANCA • Colonoscopy +/- biopsy when acute flare resolved • Consider barium investigations • Initial management • Analgesia / anti-pyretics • IV fluids • IV steroids • Long-term management • Conservative • Medical • Surgical

31. Clinical scenario • Compare Crohn’s & UC:

32. Clinical scenario • Scoring system for acute UC:

33. Clinical scenario • Extra-intestinal features of IBD: • Conjunctivitis / episcleritis / iritis • Erythema nodosum (panniculitis) • Pyodermagangrenosum • Large joint arthritis / sacroiliitis • Explain a colonoscopy: • Check initial knowledge • Avoid jargon • Basic description of procedure • Few risks/benefits • Check understanding • Offer literature / opportunity for questions

34. Key Points • Key differences between Crohn’s & UC • Extra-intestinal manifestations • Eyes, joints, skin • Investigations – only flexi-sig in acute flare • Medical management – acute & chronic • Always test for TB for commencing infliximab • Surgical management – types of resection • Explain a colonoscopy • Explain a stoma

35. References • 1) Truelove SC, Witts LJ. Cortisone in ulcerative colitis: final report on a therapeutic trial. Br Med J 1955;ii:1041–8. • 2) Goldberg A, Stansby G. Surgical Talk (2nd Ed.), Imperial College Press, 2005, pp 136-140.