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GP Update on Inflammatory Bowel Disease

GP Update on Inflammatory Bowel Disease. Clare Donnellan Consultant Gastroenterologist Leeds Teaching Hospitals. Overview. Key features of IBD History & examination Investigations Treatment including DMARDs Flares – what should GPs do? What’s new?. Key Features. How common?.

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GP Update on Inflammatory Bowel Disease

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  1. GP Update on Inflammatory Bowel Disease Clare Donnellan Consultant Gastroenterologist Leeds Teaching Hospitals

  2. Overview • Key features of IBD • History & examination • Investigations • Treatment including DMARDs • Flares – what should GPs do? • What’s new?

  3. Key Features

  4. How common? • Incidence UC 10 per 100,000 • Incidence CD 6-7 per 100,000 • Prevalence 400 per 100,000 (250/150) • Onset between 15 and 40 years of age • Similar in males and females

  5. UC vs. Crohn’s • Ulcerative colitis • Proctitis • Left-sided disease • Pan-colitis • Crohn’s Disease • Affects anywhere • Small bowel (80%) • Small & Large bowel (50%) • Peri-anal disease (35%) • More likely to get complications • IBD-unclassified 5%

  6. Why do they occur? • Genetics • 10-25% of patients have at least one other family member affected • No particular gene identified in UC • NOD2/CARD15 gene abnormalities in CD • Terminal ileal disease • Possibly more chance of requiring surgery

  7. Why do they occur? • Environmental factors • Smoking • Protective for UC • Worsens outcome for CD • Appendicectomy • Protective for UC • Unlikely effect for CD • Diet? • Bacteria?

  8. Extra GI manifestations • Episcleritis/scleritis • 2 to 5% of patients • Activity linked to GI tract • Anterior uveitis • 0.5-3%, but much more serious • Females:males 4:1 • 75% of patients have arthritis • Activity not linked to GI tract

  9. Extra GI manifestations • Erythema nodosum • Most common skin manifestation of IBD (up to 15%) • Typically flares at same time as GI symptoms • Pyoderma grangrenosum • Up to 5% of patients • More chronic course

  10. Summary of Extra-GI complications • Related to GI activity • Peripheral arthritis • Episcleritis/scleritis • Erythema nodosum • Not related to GI activity • Spondylitis/sacroiliitis • Anterior uveitis • Pyoderma Gangrenosum

  11. History & examination

  12. History – Is it UC? • Bloody diarrhoea or prolonged diarrhoea (-ve MC&S) • Abdominal pain • Urgency • Tenesmus • If 1st presentation • Stool frequency/day & night • Systemic features • Weight loss • Fever • Extra-GI features • Travel • DH (Abx, NSAIDs • FH • SH

  13. History – known UC with flare • ‘The professional patient’ • Is it like a ‘usual’ flare? • What are the usual strategies? • IBD Helpline 0113 206 8679 • Is it severe? • Truelove and Witts criteria • ≥6 bloody stools per day • Systemic toxicity (HR>90, T>37.8, ESR>30) or Hb<10.5 • NEEDS ADMITTING for IV steroids

  14. History – Is it Crohn’s? • Much more challenging to ΔΔ IBD vs. IBS…. • Abdominal pain • Diarrhoea (ask re: nocturnal symptoms) • Weight loss • Systemic features • Extra-GI manifestations

  15. History – known Crohn’s with flare • ‘The professional patient’ • Is it like a ‘usual’ flare? • What are the usual strategies? • IBD Helpline 0113 206 8679

  16. Examination • Systemically unwell? • Fever • Tachycardia • Dehydration • BMI/weight • Abdominal tenderness/distension/bowel sounds • Palpable mass • Peri-anal examination

  17. General principles • Follow ‘usual’ strategy • Call helpline (pt or GP) if concerned • Advice • Early access to IBD clinic • Admit if systemically unwell

  18. Investigations

  19. GP investigations • FBC, U&E, LFT, CRP • Haematinics • Stool MC&S • Stool C diff • (Stool OC&P) • Urgent referral to gastroenterology if high index of suspicion

  20. Hospital investigations - acute • UC • Bloods • AXR • Urgent stool cultures • Urgent flexible sigmoidoscopy within 24 hours • (CMV PCR and CMV on biopsies) • CT if risk of perforation

  21. Hospital investigations - acute • Crohn’s • Varies on symptoms/distribution • Low threshold for CT abdo/pelvis • Flexible sigmoidoscopy often unhelpful • MR pelvic if abscess/fistulising disease

  22. Hospital investigations – O/P • Small bowel • Small bowel meal if suspected CD/suspected SB CD • MR enterography (enteroclysis) if known SB CD • OGD • Ultrasound • Wireless capsule endoscopy • Isotope (labelled white cell scans) • Colon • Colonoscopy • CT colonography

  23. Examples

  24. Treatment

  25. UC • 5-ASAs • Prescribe by drug name • But lower cost equivalents (Asacol = Mesren = Octasa) • Dose • Asacol 2.4 g vs. 4.8 g • Minimum 2 g for maintenance (1.2 g cancer prevention) • OD as effective and better adherence for maintenance • Tablets + Local therapy often avoids steroids • 5-ASA enemas better than steroid enemas

  26. UC • DMARDs • Azathioprine 2-2.5 mg/kg • 6-mercaptopurine 1-1.5 mg/kg • Weekly bloods for 4/52 • Then monthly • Then 3 monthly • S/E • (Raised MCV and lymphopaenia)

  27. UC • Other DMARDs • Methotrexate • Evidence not great • Mycophenolate • Some evidence

  28. UC Flares • Optimise 5-ASAs first if sole treatment • Maximise dose • Add in local therapy (5-ASAs, not steroids) • Prednisolone 30 mg daily with Ca/Vit D cover • More prolonged course • If not settling (or severe UC) IV steroids

  29. UC Flares • Is it severe? • Truelove and Witts criteria • ≥6 bloody stools per day • Systemic toxicity (HR>90, T>37.8, ESR>30) or Hb<10.5 • NEEDS ADMITTING for IV steroids • Colectomy rate approx. 30%

  30. UC Flares • Day 3 (Travis criteria) • If stool frequency > 8 or CRP > 45 • 85% chance of colectomy • 3 options • Surgery • Infliximab as a bridge to Aza/6-MP • Cyclosporin

  31. UC Outcome • Ciclosporin/infliximab • 70 – 80% leave hospital with colon • 30% long-term • Infection risks

  32. CD • No role for 5-ASAs except if mild colitis • ? Role after surgery in preventing relapse

  33. CD Flares • If luminal disease • Oral steroids • IV steroids if no response • Still no response? • No role for ciclosporin • Give infliximab +/- azathioprine for 1 year • Nutrition support key

  34. CD Flares • If peri-anal disease • Drain any sepsis • Antibiotics • Seton sutures • Escalate therapy as appropriate

  35. CD • DMARDS • Azathioprine • Methotrexate (s/c) • Mycophenolate • Tacrolimus • Surgery • For complications • Biologicals • Infliximab • Adalimumab (Humiara) • NICE assessment at 1 yr

  36. Other treatments • Liquid diet for Crohn’s • Bone protection • Endoscopic dilatation of strictures

  37. What’s new?

  38. What’s new? • Calprotectin • Diagnosis • Activity assessment • Azathioprine metabolite levels • Optimise dose • Minimise side-effects • ? Reduce number of patients needing biologicals • Leucocytapheresis • Mucosal healing

  39. What’s new? • Guided self-management • More nurse-led clinics • Reduce follow-up waits… • Less ‘black and white’ in/out of service

  40. Summary • Significant morbidity • Early, focused management • Use helpline 0113 206 8679 • Admit if systemically unwell • Stool cultures • Appropriate steroid course

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