A Case of Inflammatory Bowel Disease Dr Barrie Rathbone www.le.ac.uk
26 year old Polish woman Admitted as emergency under surgeons RUQ and RIF pain Abdominal pain had occurred intermittently for a few years Associated with diarrhoea and PR bleed Previous colonoscopy in Poland 2005 normal On examination RUQ and RIF tenderness Bowel sounds present
Initial investigations Blood investigations Hb12.6 WCC 8.4 Plts 351 CRP 24 amylase 76
Ultrasound imaging Marked thickening and increased vascularity of the long segment of the terminal ileum Free fluid in the right iliac fossa Appendix thickened CT carried out
CT Segment (15-20cm) of grossly thickened terminal ileum with ileal wall thickening of up to 1.5cm Impression: Acute distal small bowel Crohn s disease, probably complicated by enteroenteric fistulation
Management Transferred to gastroenterology Commenced on IV hydrocortisone 5 days Changed to oral Prednisolone (40mg daily) Discharged on reducing dose of prednisolone and Pentasa (5-ASA) Oupatient colonoscopy appointment
Readmission 6 weeks later Admitted with pyrexia and right sided abdominal pain Worsening diarrhoea and PR bleeding had restarted No vomiting
Assessment Temperature 38.4 Pulse 105 BP 98/66 RIF tenderness Bloods WCC 11.4 CRP 120 Plts - 327
Impression?
Initial management Recommenced on IV hydrocortisone Urgent scan
6 weeks later
Further Management Blood cultures positive for staphylococcus Commenced on IV Imipenem On discussion - commenced on ciprofloxacin and metronidazole Converted to oral Prednisolone
Medical/surgical discharge plan Continue antibiotics pro tem Tail steroids Monitor abscess with ultrasound to ensure resolution Outpatient combined surgical and gastroenterology follow up Cold right hemi-colectomy Start on immunosuppressant therapy post surgery Advised to seek medical advice in interim in case of deterioration
Points of interest
Crohn s disease vs ulcerative colitis Both young people runs in families associated eye, skin, joint and hepatobiliary problems increased cancer risk Crohn s Ulcerative colitis inflammatory condition of gut transmural inflammation non-continuous inflammation presents abdominal pain and diarrhoea inflammatory condition of colon mucosal inflammation inflammation in continuity, rectum always affected presents with bloody diarrhoea
Crohn s disease Age at diagnosis <16 17-40 >40 A1 A2 A3 Extent Ileal col il/col upper/isol L1 L2 L3 L4 Behaviour Nsnp strict pen perianal B1 B2 B3 P Extra-GI No I EN PG SI AS IA SC
Unusual features Poor healing Different phenotypes Increasingly common Becoming more aggressive Geographical difference Family history Associated conditions Social economic variation Other environmental factors
IBD pathogenesis Genetics Immune system Environment Microbes Diet Smoking
Genetics Downloaded from: Clinical Gastroenterology and Hepatology (on 13 October 2007 03:40 PM) 2007 Elsevier
Bacteria - Animal studies (Sartor) Germ free Pathogen free IL10 deficient mice No colitis Colitis HLA-B27 transgenic rats No colitis Colitis
Bacteria - Animal studies (Sartor) Enterococcus faecalis E. coli Pseudomonas fluorescens Bacteroides vulgatus IL10 deficient mice colitis colitis No colitis No colitis HLA-B27 transgenic rats No colitis colitis
Diet Omega 6 vs omega 3 Fish oils post op Space diets smoking
Immunology - Paneth cells Secretory epithelial cells in small intestinal crypts Secrete antimicrobial protein defensins Small bowel CD patients decreased defensin function
Immunology - Acute inflammation (Marks) CD patients decrease neutrophil and IL-8 production locally Decreased IL-8 from stimulated peripheral macrophages Decreased skin blood flow in reponse to skin injections of heat killed E.coli (more marked in colonic CD patients)
Immunology and genetics - IL23 (discovered 2000) Related to IL12 (subunit in common) Essential mediator of intestinal inflammation Orchestrates inflammatory cascade including TNF, IL6, IFN, IL17 IL23 axis appears to regulate inflammation at the mucosal surface in IBD Variations in IL23R gene linked to IBS susceptibility
IBD summary Complex conditions with varied genotype and phenotype Exact phenotype determined by genotype environment (bacterial) interaction mediated through disturbed defence mechanisms and immune response
Treatments Increased emphasis on mucosal healing resulting in increasingly aggressive immunosuppression steroids 5 amino salicylic acid immunosuppressants biologicals
New treatments Anti-TNF Anti-integrins Other monoclonals Probiotics
Provided by The Leicester Gondar Link Collaborative Teaching Project This work is licensed under a Creative Commons Attribution-NonCommercial- NoDerivs 3.0 Unported License.