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When is IBD not necessarily the IBD you thought it was

When is IBD not necessarily the IBD you thought it was. by Dr Matt W. Johnson. Topics of Discussion. Proctitis Sigmoiditis. Proctitis. Definition = Inflammation of the lower 15cm of rectum = E1 Symptoms can vary greatly, but include;- Painful defaecation

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When is IBD not necessarily the IBD you thought it was

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  1. When is IBD not necessarily the IBD you thought it was • by • Dr Matt W. Johnson

  2. Topics of Discussion • Proctitis • Sigmoiditis

  3. Proctitis • Definition = Inflammation of the lower 15cm of rectum = E1 • Symptoms can vary greatly, but include;- • Painful defaecation • Soreness in the ano-rectal region • Sense of incomplete evacuation + Tenesmus • Involuntary spasms and cramping during bowel movements • Bleeding, and possibly a discharge. • Involuntary straining • Proximal constipation

  4. Physical Assessment • Anal + Rectal erythema + oedematous mucosa • Injected mucosa • Ano-Rectal erosions or ulcers • Blood or Mucus on stools • Mucopurulent or blood-stained rectal discharge

  5. BSG - Treatment • 1st Line = Topical 5ASA • 2nd Line = Topical Steroids • 3rd Line = PO 5ASAs or Steroids • Antibiotics • Immunomodulators • Surgery • Carter MJ. Gut 2004;53:v1-v16 on behalf of the IBD Section of the BSG • Regueiro MD. Clin Gastroenterol. 2004 Oct;38(9):733-40.

  6. IBD Differential Diagnoses • Proctitis • Non specific, self resolving • Food allergy • Solitary rectal ulcer syndrome • Post-Infectious (eg. CDT, Campylobacter, Shigella, Escherichia coli, Salmonella, and amebiasis) • STDs (HSV, HIV, Syphilis, LGV, Gonorrhoea, Chancroid, TB) • Trauma • XR + Ischaemia + Drug induced (NSAIDS) • Sigmoiditis • Diverticular disease associated colitis

  7. Non-Specific Self Resolving Proctitis • Paediatric study of 38 • 11/38 29% extended into distal UC after median 6y FU • Progression tends to occur in 1st 2y • Progression rare after 5y • Hyams J, Pediatr Gastroent Nutr. 1997 Aug;25(2):149-52. • Adult studies • Proctitis accounted for 20-55% of UC patients • Langholz - Progression was seen 27% 5y, 41% 10y, 53% 15y • 12% underwent Colectomy • CRC is not increased (unlike in UC) • Meucci - Progression into sigmoid 8% at 5y and 30% at 10y • 10% at 10y E3 (extensive progression) • Majority “burn out” in time • Russell M G, Dis Colon Rectum. 1998;41:33–40. • Langholz E, Scand J Gastroenterol. 1996;31:260–266. • Meucci G, Am J Gastroenterol. 2000;95:469–473. • Whitlow CB. Clin Col Rect Surg. 2004 Feb; 17(1): 21–27.

  8. Allergic Proctitis • Markedly increased number of IgE containing cells in the lamina propria of rectal mucosa biopsies. • 8/12 were sucessfully treated with disodium cromoglycate (DSCG). The remaining 4 had mild proctitis and did not require Rx. • P C Rosekrans, GUT 1980 December; 21(12): 1017–1023. • Diagnosis requires objective improvement on withdrawing suspected food Ag and recurrence with subsequent reintrduction

  9. Solitary Rectal Ulcer Syndrome

  10. Post-Infectious Campylobacter Tinea (thread worms) CDT Shigella Salmonella Amoebia

  11. STDs • 10% of S. London men have paid for sex • 18% of US men have had unprotected anal sex • Causes • 45% no STDs • Gonorrhoea 20% - 50% are asymptomatic • Herpes 13% - Very painful • Chlamydia 11% • Syphillis 9% - Snail track ulcers, condylomata lata • Mixed 8% • BSG 2005

  12. STDs HSV - 2>1 Syphillis LGV

  13. STDs HIV Gonorrhoea Chancroid

  14. Practicalities • Serology • HIV 1+2 • HSV + HVZ • CMV • HepB • Histopathological Staining • CMV • PCR • TB • Chlamydia + LGV

  15. STD Ix + Rx

  16. TB

  17. Trauma

  18. XR - Radiation Proctography

  19. Ischaemia

  20. NSAID Induced

  21. Sigmoiditis

  22. DD associated Colitis • An immunologically mediated process • Typically it does not effect the rectum • Can proceed the development of the diverticulae by several years • Many patients respond to treatment directed toward diverticulitis • A subset of patients require immunosuppressive therapy and /or surgery

  23. DD associated Colitis • A small subset progresses to develop classic ulcerative / Crohn’s colitis. • It is essential that endoscopists provides • a full description of the macroscopic appearance of the inflammatory changes at endoscopy • limitations of extent to a segment of diverticular disease • So that the pathologist can provide a more informative interpretation

  24. DD associated Colitis Good Clinical Care: Diverticular Disease. T. Banerjee, S Verma, M. W. Johnson. Foundation Years Journal. 2011: 5(8); 29–35.

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