Inflammatory Bowel Disease When is diarrhea not just diarrhea? Jackie Kazik, MA, PA C CME Resources CAPA Annual Conference, 2011 Inflammatory Bowel Disease Objectives Discuss what is known about the pathophysiology of IBD Compare and contrast Crohn s disease and Ulcerative colitis in terms of Patient presentation including epidemiology Physical exam findings Diagnostic findings Select appropriate medical therapies Recognize systemic manifestations of IBD Case 29 year old woman with episodes of diarrhea for 6 weeks. Has had similar episodes in past, but they resolved after 2 weeks on their own. No vomiting, no melena. Low grade fevers for weeks on and off. Mild abdominal discomfort. Mild to moderate weight loss Generalized fatigue/malaise FamHx no colon cancer/ +IBS No ill contacts/antibiotics/foreign travel Dx? Inflammatory Bowel Disease Two major types of IBD Crohn s disease Incidence 5 per 100,000 persons Prevalence 90 per 100,000 persons Ulcerative colitis Incidence 10 per 100,000 persons Prevalence 200 per 100,000 persons 1
Inflammatory Bowel Disease Etiology not clearly discernable. Combination of genetic predisposition and environmental exposures. **Ages 15 30 (second incidence 60 80) Highest incidence in Jewish ethnicity, then N. European, least in SE Asian or African Americans Men slightly increased Crohn s disease Other names/nomenclature Regional enteritis secondary to skip lesions Granulomatous enteritis secondary to granulomas that may be seen on histologic section Pattern % at presentation Ileocecal disease 40 50 Small bowel only 30 40 Colon only 20 2
Differential Diagnosis Acute appendicitis with RLQ pain Ectopic pregnancy, tubo ovarian abscess/pid Cecal diverticulitis Lymphoma, cecal carcinoma Colonic disease infectious Bacterial colitis Salmonella, Shigella, Campylobacter Amebiosis Yersinia enterocolitica CMV (immunocompromised patient) Colonic disease noninfectious, radiation, ischemia Symptoms Right lower quadrant pain and diarrhea, usually intermittent in nature Hematochezia occurs in a minority of patients Low fever and weight loss also possible High fever and pain may be indicative of a complication, e.g., perirectal abscess. Signs Abdominal pain, especially RLQ Rectal illness is limited may reveal a perirectal mass Abdominal distention/sbo picture Peritoneal signs in patients who have fistulized or ruptured. Lab findings generally nonspecific ESR usually elevated may be normal when disease in remission Anemia both low iron from anemia of chronic disease and low B12 secondary to ileal involvement or resection Leukocytosis and thrombocytosis Hypoalbuminemia 3
Imaging Colonoscopy preferable in evaluating the colon allows biopsies in addition to direct visualization. Barium Enema best to evaluate for fistulas and strictures Both can provide evaluation of the terminal ileum to help distinguish Crohn s from UC Imaging Enteroclysis Allows imaging of small bowel with less barium Tablet Enteroscopy Swallow a small pill that is a video recorder. Records a video image of the small bowel. Transmits an image to a video receiver that then visualizes the small bowel. Recovery of the pill is problematic Imaging Studies Small bowel follow through drink barium and take pictures as it transits the small bowel Imaging Abdominal CT not as useful as an initial diagnostic study but is extremely helpful in managing complications of Crohn s disease, e.g., evaluating for an intra abdominal abscess or fistula 4
Classic Findings Aphthous Ulcers Skip lesions Crohn s does not affect the intestinal mucosa in a continuous fashion Cobblestoning owing to mucosal fissures Luminal narrowing/strictures string sign Fistulas Aphthous ulcers 5
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Complications of Fistula formation up to 40% of patients Enteroenteric Enterovesicular recurrent UTIs and pneumaturia Enterocutaneous rectovaginal, fistula in ano Perianal abscesses Intra abdominal abscess PerforationStricture/ small bowel obstruction Nutritional deficiencies vitamin B12 is predominantly absorbed in the terminal ileum, as are bile acids and fat soluble vitamins (ADEK) Small Bowel Obstruction Complications Cancer: small bowel adenocarinoma Cancer: colon??? 7
Differential Diagnosis Infection: Campylobacter, Shigella, Salmonella, Yersinia, E. coli 0157:H7, amebiasis, Clostridium difficile Noninfectious: Crohn s disease, ischemic colitis, radiation colitis Immunocompromised host: CMV, HSV, GC, Blastocystis hominis, Chlamydia Symptoms Bloody diarrhea Crampy abdominal pain Tenesmus urgent feeling of needing to evacuate to the rectum. Fever, weight loss also possible 15 25% have extra intestinal manifestations Signs Hemoccult positive LLQ pain mild to severe Can present acutely extremely ill with fever, tachycardia, orthostasis Lab Findings as in Crohn s, nonspecific ESR usually elevated in active disease Mild anemia Leukocytosis Thrombocytosis (acute phase reactant) Stool studies negative (culture, C.diff toxin, O&P) 8
Imaging Lead pipe colon Sig/Colonoscopy definitive study. This allows for direct visualization and biopsy sampling. Double contrast barium enema may show mucosal changes and distal ulcers. Classic long standing finding is the lead pipe colon. 9
Complications Toxic Megacolon: 15 50% mortality Perforation Cancer: increasing risk of dysplasia with increased time from onset of disease. Time from onset: 20 30 Risk of cancer: 5 13% 13 34% Cancer In usual colon adenocarcinoma, the cancer starts as a polyp sitting on or above the mucosal surface. In UC, the dysplastic changes occur in flat epithelium. Thus, cancer is not seen until it is a late finding. This is the reason that multiple biopsies are taken during screening colonoscopy in patients with UC. Prognosis Severity of disease is somewhat predictive of the future course and the need for colectomy. In one study, the colectomy rate was 24% at 10 years and 30% at 25 years. Total colectomy is 100% curative! 10
Extra intestinal Manifestations of IBD Reactive arthropathy present with active disease Episcleritis seen more commonly in Crohn s disease Erythema Nodosum Crohn s > UC Pyoderma Gangrenosum UC > Crohn s Extra intestinal Manifestations of IBD Sacroiliitis 10% patients with IBD. Association with HLA B27 Scleritis and uveitis Primary sclerosing cholangitis usually with UC Clinical Findings PANCE/PANRE REVIEW Crohn s Perianal disease common Fistulas common (40%) Abscess common (20%) Strictures common Rare Rare Rare Rare 11
Colonoscopy Findings Radiologic Findings Crohn s Crohn s Usually rectum spared Skip lesions Always rectal involvement Continuous from rectum proximally Ileal findings (75%) Rare findings Histologic Findings Crohn s Transmural mucosal changes Uncommon granulomas Ulcerative colitis Mucosal to submucosal Involvement Granulomas (20%) 12