slide1
Download
Skip this Video
Download Presentation
INFLAMMATORY BOWEL DISEASE

Loading in 2 Seconds...

play fullscreen
1 / 29

Inflammatory Bowel Disease - PowerPoint PPT Presentation


  • 903 Views
  • Uploaded on

INFLAMMATORY BOWEL DISEASE. Norman H. Gilinsky, M.D., FACP, FACG Associate Professor of Medicine Medical Director, Digestive Diseases Center University of Cincinnati. Objectives At completion of this lecture, the student will be able to:.

loader
I am the owner, or an agent authorized to act on behalf of the owner, of the copyrighted work described.
capcha
Download Presentation

PowerPoint Slideshow about 'Inflammatory Bowel Disease' - Jimmy


An Image/Link below is provided (as is) to download presentation

Download Policy: Content on the Website is provided to you AS IS for your information and personal use and may not be sold / licensed / shared on other websites without getting consent from its author.While downloading, if for some reason you are not able to download a presentation, the publisher may have deleted the file from their server.


- - - - - - - - - - - - - - - - - - - - - - - - - - E N D - - - - - - - - - - - - - - - - - - - - - - - - - -
Presentation Transcript
slide1

INFLAMMATORY BOWEL DISEASE

Norman H. Gilinsky, M.D., FACP, FACG

Associate Professor of Medicine

Medical Director, Digestive Diseases Center

University of Cincinnati

slide2

ObjectivesAt completion of this lecture, the student will be able to:

  • Describe the main manifestations of each of the inflammatory bowel disorders
  • State the main clinical features that differentiate Crohn’s disease from ulcerative colitis
  • Formulate a management plan for diagnosis of disease extent and severity of each disorder
  • Develop a strategy to treat each disease
  • Differentiate treatment modalities that are more applicable to the management of Crohn’s disease than ulcerative colitis
inflammatory bowel disease ulcerative colitis and crohn s disease
Inflammatory Bowel DiseaseUlcerative Colitis and Crohn’s Disease

Similarities

  • Chronic inflammation, usually limited to GIT
  • Majority young, therefore life-long disorder
  • Natural history: tends to relapse
  • Medications utilized generally similar

Differences

  • Anatomic location and pathology (and therefore, presentation)
  • Nutritional consequences
  • Response to medical therapies
  • Surgical strategy, if required
slide4

IBD: Location and Extent

5% Gastroduodenitis

40% Distal/ Left-sided colitis

30% Proctitis

25% Colitis

40% Ileocolitis

30% Ileitis

30% Extensive/ Pancolitis

Ulcerative Colitis Crohn’s Disease

ibd pathogenesis
IBD: PATHOGENESIS

Chromosome 16 (IBD1)

Chromosome 12 (IBD2)

Chromosome 6 (IBD3-HLA)

Chromosome 14

NOD2

Genetic susceptibility

IBD

Infection

Diet

Smoking

NSAIDs

Immune dysregulation

Environmental trigger

TH 1

TH 2

Ahmad et al, Aliment Pharmacol Ther 2001; Hugot et al, Science 2001

inflammatory bowel disease extra intestinal manifestations
Inflammatory Bowel DiseaseExtra-Intestinal Manifestations

Joints

  • Peripheral arthritis
  • Ankylosing spondylitis, sacroileitis

Skin

  • Pyoderma gangrenosum, Erythema nodosum

Eyes

  • Episcleritis, uveitis, keratoconjunctivitis

Biliary

  • Sclerosing cholangitis,cholangiocarcinoma

Other

  • Hypercoagulability
ulcerative colitis clinical features
Ulcerative Colitis – Clinical Features

Presents with bloody diarrhea

  • Majority have limited left-sided disease
  • Majority consitutionally well
  • Majority safely managed in office setting
  • Profuse bloody diarrhea; >6 stools/day
  • Weight loss, anemia, hypoalbuminemia
  • Fever, abdominal pain, distension

Red Flags

ulcerative colitis differential diagnosis
Ulcerative Colitis: Differential Diagnosis

Infection

  • Salmonella, shigella, campylobacter, amebiasis, etc.

Ischemia

Radiation

Vasculitis

Medications

Toxins

Practice Point: Consider clinical setting, stool studies

ulcerative colitis consequences of disease
Ulcerative Colitis: Consequences of Disease

Acute

  • Fluid, electrolyte disturbance
  • Anemia
  • Fulminant colitis, toxic megacolon, perforation

Chronic

  • Related to chronic disease, treatment
  • Related to extra-intestinal manifestations
  • Cancer
colorectal cancer in ibd
Colorectal Cancer in IBD
  • Increased risk associated with:
    • Duration of disease
    • Anatomic extent of disease
  • Cancers develop in a dysplasia-to-cancer sequence
  • Cancers often flat, multiple, at advanced stage.

Practice Point: Colonoscopy with biopsy necessary for periodic cancer surveillance in patients with IBD.

ulcerative colitis diagnostic work up
Ulcerative Colitis - Diagnostic Work-Up
  • Clinical suspicion
  • Stool studies
  • Endoscopy (with biopsy)
  • (Radiology)
  • Hematology and biochemistry (especially if clinically severe – i.e. CBC, albumin, electrolytes)
  • Serologies (if uncertainties remain, e.g. amebiasis; specific IBD serologies experimental)
slide12

IBD: Treatment Modalities

5-Aminosalicylic Acid

[sulfasalazine, mesalamine]

Administered topically PO and/or PR

Corticosteroids

Administered PO, PR or IV

Immunomodulation

[6-MP, Azothioprine, Cyclosporine, etc]

Surgery

inflammatory bowel disease sulfasalazine 5 aminosalicylates
Inflammatory Bowel DiseaseSulfasalazine / 5-Aminosalicylates
  • Ulcerative colitis
    • Induction therapy in mild to moderate disease (anticipate about 80% response)
    • Maintenance therapy, to reduce chances of relapse, once remission obtained
  • Crohn’s disease
    • Data not convincing
    • Best effects with high doses and for ileal disease
  • Balsalazide
slide14

Inflammatory Bowel DiseaseSulfasalazine / 5-Aminosalicylates

5-ASA-diazo bond-sulfapyradine

  • Action
    • Topical / mucosal anti-inflammatory
  • Side-effects
    • Intolerance [gastric distress, headache]
    • Allergy
    • Cytopenias, hemolysis, folate deficiency
    • Nephritis, hepatitis
    • Pneumonitis, pancreatitis
    • Hypospermia
  • Balsalazide
slide15

Inflammatory Bowel DiseaseMesalamine (5-ASA preparations)

  • Route of administration
    • Oral
    • Enema
    • Suppository
  • Side-effect profile
    • Less intolerance
    • No hypospermia, folate deficiency
  • Efficacy
    • No better (than sulfasalazine) for colitis
  • Cost
    • More expensive
  • Balsalazide
inflammatory bowel disease role of corticosteroids
Inflammatory Bowel DiseaseRole of Corticosteroids
  • Good drug for controlling acute flare (available oral, rectal or IV – use depending on disease location, clinical severity)
  • Of no value in maintenance situation
  • High frequency side-effects
  • Symptoms may flare with tapering
  • Steroid dependency common
slide17

Inflammatory Bowel DiseaseRole of Immunosuppressive Agents

6-Mercaptopurine, azathioprine, methotrexate, cyclosporine

  • Steroid-sparing
  • Induces remission in majority
  • Speed of onset variable
  • Maintains remission
  • Useful in chronic grumbling disease, wish to avoid surgery, compliant patient
  • Requires periodic monitoring
  • Generally acceptable side-effect profile
slide18

Inflammatory Bowel DiseaseManagement of Severe Colitis

  • Hospitalize, IV therapy
  • IV steroids, antibiotic cover
  • May require nutritional support
  • Rule out infection, megacolon
  • Frequent monitoring
    • Clinical condition, vitals
    • CBC, albumin
    • Radiology
  • Surgery if deteriorates, doesn’t settle
  • Concern = perforation, high relapse rate
slide19

Crohn’s Disease:

Main Characteristics (1)

  • Any or > 1 region of GIT involved (perianal, skip areas)
  • Colon spared in > 20%
  • Small bowel involved in > 60%; therefore predisposed to nutritional sequelae, malabsorption, metabolic disorders, trace element and vitamin deficiencies
  • Inflammation transmural, therefore efficiency of topical therapy limited
slide20

Crohn’s Disease:

Main Characteristics (2)

  • Disease pathology diverse
    • Inflammatory
    • Stricturing
    • Perforating
  • Presentation and outcome therefore diverse
  • No ‘cure’, therefore surgery (if required) limited to localized complications
  • Recurrences post-surgery not unusual
crohn s disease presentation
Crohn’s Disease - Presentation

Inflammatory

  • Pain, tenderness, diarrhea, RLQ mass

Obstuction

  • Cramps, distension, vomiting, obstruction

Fistulizing

  • Enererocutaneous, enteroenteric, rectovaginal, enterovesical, etc.
crohn s disease disease consequences
Crohn’s Disease: Disease Consequences

Constitutional

  • Fevers, weight loss, debilitation, pain

Nutritional sequelae

  • Malabsorption, depletion syndromes
  • Growth retardation

Perianal involvement

  • Abscess, fissure, fistula

Other

  • Short-bowel syndrome
  • Renal calculi, gallstones
  • QOL, Psychologic
slide23

Crohn’s Disease: Differential Diagnosis

  • Infectious etiologies
  • CMV, TB, Yersinia, C difficile, toxigenic E coli, etc.
  • Appendicitis
  • Diverticulitis
  • Ischemia
  • Carcinoma, lymphoma
  • Ulcerative colitis
  • Celiac disease

Practice Point: Great mimicker

slide24

Crohn’s Disease - Diagnostic Work-Up

  • Clinical suspicion
  • Stool studies
  • Endoscopy (with biopsy)
  • Radiology
    • Abdominal X-ray
    • Small bowel follow-through
    • CT scan, etc.
  • Hematology and biochemistry (especially if clinically severe – i.e. CBC, albumin, electrolytes)
  • Malabsorption
  • Serologies (specific IBD serologies experimental)
slide25

Crohn’s Disease: Treatment Modalities

5-Aminosalicylic Acid

Biologic Agents

[Monoclonal antibodies – Infliximab]

Antimicrobials

Surgery

Corticosteroids

Nutritional Aspects

Immunosuppressive

Psychologic Support

the future biologic therapies
The future – Biologic Therapies?
  • Approved

TNF- antibodies (infliximab, Remicade®)

  • Experimental
    • CDP-571
    • Interleukin 10
    • Gene therapies?
inflammatory bowel disease other issues for the specialist and primary care physician
Inflammatory Bowel DiseaseOther Issues for the Specialist and Primary Care Physician
  • Perineal / ano-rectal disease [CD]
  • Symptomatic fistula [CD]
  • Short bowel syndrome / nutritional support [CD]
  • The pediatric and adolescent patient
  • The pregnant patient
  • Bone disease
  • Work and Psychologic issues
ibd indications for surgery
Panproctocolectomy

Failure of medical therapy

Dysplasia or carcinoma

Debility, poor QOL

Intolerant of medications

Massive hemorrhage, perforation

Intractable pyoderma, hemolysis

Directed to specific complication

Symptomatic obstruction

Symptomatic fistulae

Perforation

Hemorrhage

Dysplasia or carcinoma

Perianal disease

IBD: Indications for Surgery

Ulcerative Colitis Crohn’s Disease

ibd other key references
IBD: Other Key References
  • Your Internal Medicine Textbook – plus:
  • Hanauer et al. Management of Crohn’s disease in adults. Am J Gastroenterol 2001; 96:634-43
  • Kornbluth et al. Ulcerative colitis practice guidelines in adults. Am J Gastroenterol 1996; 92:204-211
  • Lichtenstein. Inflammatory bowel disease. Gastroenterol Clin N Am 1999; 28:2
ad