Inflammatory Bowel Disease

1. Inflammatory Bowel Disease Dawn Kershaw (FY1)

2. Recognise the possibility of IBD in patient’s presenting with lower GI symptoms • Recognise the possibility of systemic symptoms associated with IBD • Recognise the differences in presentation between Crohn’s and UC – and how these relate to underlying pathology • Initiate appropriate investigations in a patient with suspected IBD • Initiate appropriate management in a patient with IBD • Explain to patients the nature of and the rationale for maintenance treatment of IBD Objectives

3. Recognise the possibility of IBD in patient’s presenting with lower GI symptoms = GI symptoms of IBD • Recognise the possibility of systemic symptoms associated with IBD = Extra-intestinal symptoms • Recognise the differences in presentation between Crohn’s and UC – and how these relate to underlying pathology = Differences between UC and Crohn’s: Pathology and presentation • Initiate appropriate investigations in a patient with suspected IBD = Investigations • Initiate appropriate management in a patient with IBD = Management of IBD • Explain to patients the nature of and the rationale for maintenance treatment of IBD = Explain in lay terms why we give medications to prevent flare ups Objectives

4. Definition? • Aetiology? Crohn's verses UC

5. Definition • Chronic • Relapsing and remitting • Inflammatory bowel disease • Chrons: any part of GI tract - often terminal ileum • UC: large bowel • Aeitology • Unknown • Genetic • Environmental Crohn's verses UC

6. Pathology?

7. Crohn’s

8. Crohn’s • Tranny Granny Skipped down Cobblestone street • Strictures • Fistulae • Abscesses

9. Crohn’s

10. Ulcerative colitis • Starts from rectum • Extends proximally • Continuous • Mucosa only • Proctitis = rectum • Proctosigmoiditis = rectum and sigmoid colon • Left sided Colitis • Pancolitis – Whole of large colon

11. Objectives • Recognise the differences in presentation between Crohn’s and UC – and how these relate to underlying pathology • Recognise the possibility of IBD in patient’s presenting with lower GI symptoms

12. Crohn’s

13. Crampy abdominal pain • Inflammation; fibrosis; bowel obstruction • Diarrhoea • Blood • Steatorrhea • Weight loss • Fever • Anaemia • Obstruction: Distension, Vomiting • Abscesses • Fistulae: Enteroenteral; Anorectal; Vesicointestinal; Rectovaginal Crohn’s

14. Ulcerative Colitis

15. Crampy abdominal pain • Relieved by defecation • Left iliac fossa • Diarrhoea • Blood ++ • Mucous • Urgency • Tenesmus • Weight loss • Fever • Anaemia • Severity: Truelove Witts Criteria Ulcerative Colitis

16. Objectives • Recognise the possibility of systemic symptoms associated with IBD.

17. Eyes • Iritis; uveitis; episcleritis • Skin • Erythema nodosum; pyoderma gangrenosum • Joints • Seronegative spondyloarthropathy • Large joints; Spine; Sacroiliitis; Can affect small joints • Other • Clubbing • DVT • Primary sclerosing cholangitis (UC) • Heamolytic anaemia (autoimmune) (Crohn’s) • Osetoporosis (Crohn’s) Extra-intestinal symptoms

18. Erythema nodosum • Pyoderma gangrenosum

19. Uveitis • Clubbing

20. Complete first 3 boxes on form based on what we have just done. • What are your differential diagnosis to consider in a patient presenting with IBD symptoms? • Abdominal pain • Diarrhoea • PR bleeding/ mucous • Weight loss • Malabsorption (Thanks to Zoe Campbell for providing the basis to this form) Get into 2 groups

21. Initiate appropriate investigations in a patient with suspected IBD • Bedside • Bloods • Imaging • Special tests

22. Bedside • Stool MC&S • Faecal calprotectin • Bloods • FBC (low Hb; High WCC) • ESR; CRP (high) • LFTs: Low albumin • U&Es: Chronic diarrhoea – electrolyte imbalance • Heamatinics: ferritin, Vitamin B12, folate • Amylase • Cross match Investigations

23. Imaging • Abdominal X-ray • Erect Chest X-ray • Barium Meal (Crohn's) • Fibrosis, Strictures, Ulceration (‘rose thorn’) • Barium enema (UC) • Featureless narrow colon, Loss of haustral pattern • CT/MRI enterography (Crohn’s) • Special test • Flexible sigmoidoscopy • Colonoscopy • Gastroscopy • BIOPSY Investigations Not in acute flare!!!

24. Initiate appropriate management in a patient with IBD • Acute • Chronic • Lifestyle • MDT

25. Acute • A-E; Bowel rest; Analgesia (not NSAIDs); • Steroids: IV; oral; rectal • Antibiotics • 5-ASAs • Chronic • 5-ASAs • Per rectum steroids • Immunosuppressant's • Azathioprine • Methotrexate (Crohn’s) • Anti-TNF: Infliximab • Surgery: Resection Management

26. Lifestyle • Diet: Elemental • Stop smoking? • MDT • Consultant’s: Gastroenterologist; Surgeons • IBD specialist nurse • Dietician • Smoking cessation • Stoma nurse Management

27. 5-ASAs • Steroids • Azathioprine/ Mercaptopurine (Immunosuppressant) • Methotrexate (Crohn's) • Infliximab (Anti-TNF) Medications used in IBD

28. Complete the rest of the form Get back into groups

29. Objectives • Explain to patients the nature of and the rationale for maintenance treatment of IBD

30. Patient.co.uk • Once a flare-up has settled, without treatment, there is ~1 in 2 chance that another flare-up will develop within a year. • Increased likelihood of flares depends on: • extent of the disease in your gut • age, • the extent of treatment needed to control the initial flare-up. • If flares not frequent/mild/ respond well to acute treatment then - may not need to /wish to take regular meds • For others regular meds can improve QOL ++

31. The treatment options that may be considered to prevent flare-ups) include: • Immunosuppressants – take daily • Mesalazine – used daily (less common now) • Anti-TNF – selected cases where flares severe and other treatments not worked: Have infusion in hospital every 8 weeks. • Steroid medication is not generally used long-term to prevent flare-ups • These treatments increase the chance of remaining free of flare-ups, but they do not always work. • Balance between benefits and the possible side-effects.

32. Understanding the pathophysiology of UC and Crohn’s is actually useful! • Symptoms • Investigations • Management • Communication is key- in exams AND in real life: • Patient.co.uk • Easy marks in exams if you practice! • Structured answers in exams • Investigations • Bedside; Bloods; Imaging; Special tests • Acute; chronic • Management • Acute; Chronic; lifestyle; MDT • Conservative; Medical; Surgical 3 key points to take away