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Inflammatory Bowel Disease

Inflammatory Bowel Disease. Steven N. Carter, MD Colon and Rectal Surgery Assistant Professor University of Oklahoma.

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Inflammatory Bowel Disease

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  1. Inflammatory Bowel Disease Steven N. Carter, MD Colon and Rectal Surgery Assistant Professor University of Oklahoma

  2. Crohn’s and Colitis Clinic: 405-271-8478Clinic appointment: 405-271-8478IBD Nurse Practioner: 405-271-5428 Ext. 53424IBD Center Office: 405-271-5428Office fax: 405-271-5803GI Endoscopylab: 405-271-8737OUMC operator: 405-271-5656Colon and RectalSurgery Clinic 405-271-1400

  3. Objectives • 1. Discuss the diagnosis and evaluation of suspected inflammatory bowel disease. • 2. Be able to differentiate Crohn's disease from Ulcerative Colitis. • 3. Discuss treatment and surveillance of inflammatory bowel disease. • No Disclosures

  4. Inflammatory Bowel Disease • Epidemiology • Classification • Evaluation • Treatment • Surveillance • Simply Case Presentations

  5. Inflammatory Bowel Disease • 1932 – Crohn, Ginzburg, and Oppenheimer described 13 cases if regional ileitis • 1959 & 1960 – Brooke and Lockart-Mummery described the segmental nature of Crohn’s Colitis • 1959-Truelove and Witts high dose cortisone for CD • 1978- Parks and Nicholls describe ILAA Crohn BB, Ginzburg L, Oppenheimer GD. Regional ileitis. AMA Am J Dis Child, 1932; 99: 1323-9.  2. Brooke BN. Granulomatous disease of the intestine. Lancet 1959; 2 (7106):745-9. Lockhart-Mummert HE, Morson BC. Crohn’sdisese (regional enteritis)of the large intestine and its distinction from UC. Gut. 1960; 1:87-105. Truelove SC, Witts LJ, Bourne WA, et al. Cortisone and cortitropin in UC. Br Journal of Medicine. 1959; 1(5119): 387-94. Parks AG, Nicholls RJ. Proctocolectomy without ileostomy for UC. British Journal of Medicine. 1978; 2:85-88.

  6. Epidemiology • Prevalence varies greatly throughout the world • Symptoms often wax and wane • Incidence has been increasing over the past 20-30 years • Crohn’s 5/100k annually • UC .5-24.5/100k annually • Suggests an environmental component • Occurs in the 2nd-3rd decade of life Loftus Jr. EV, Schoenfeld P., Sandborn, WJ. The epidemology and natural history of Crohn’s disease in population based patient cohorts from North America: a systemic review. Aliment PharmacolTher. 2002; 16: 51-60. CDC

  7. Epidemiology • Interplay between environment and genes • The relative risk for concordance of CD in a monozygotic twin pair is approximately 800-fold greater than the general population • Less so for UC • Some examples of early IBD related to genetic defects in T-Cell regulation, cytokines, etc. Kaser A, et. Al. Genes and Environment: How Will Our Concepts on the Pathophysiology of IBD Develop in the Future? Genes and Environment: How Will Our Concepts on the Pathophysiology of IBD Develop in the Future? Dig Dis. 2010 October; 28(3): 395–405.

  8. Epidemiology Kaser A, et. Al. Genes and Environment: How Will Our Concepts on the Pathophysiology of IBD Develop in the Future? Genes and Environment: How Will Our Concepts on the Pathophysiology of IBD Develop in the Future? Dig Dis. 2010 October; 28(3): 395–405.

  9. Hygiene Hypothesis • Helminthes have colonized humans for thousands of years. • Immunological influence on host cells • Prevent excessive immune response • Aggressive hygienic practices in the West may negatively affects immune system development • Therapeutic implications Weinstock JV and Elliot DE. Helminthsand the IBD Hygiene Hypothesi. Inflammatory Bowel Disease. 2009 January; 15 (1) 128-133.

  10. Epidemilogy • Whites & Blacks >> Hispanics and Asians • Northern Climates • Urban>Rural • Sugar Consumption (Crohn’s) • EtOH (decreases UC incidence) • Higher socioeconomic status • OCP’s • Cigarettes • Decrease in UC • Increase in CD • Appendectomy – decreases incidence in Crohn’s ASCRS Textbook

  11. Classification and Diagnosis Crohn’s Disease vs Ulcerative Colitis

  12. Crohn’s Disease • 75% complain of Abdominal pain and Diarrhea • 40-60% complain of Wt Loss, Fever, and bleeding • Many different classification systems have been proposed • Vienna classification is based on behavior • Stricture vs Fistula • Most important predictor of future disease is past behavior • Mostly academic • Majority of patients have years of quiescence (60-70%) • 10-20% have chronic unrelenting disease ASCRS Textbook

  13. Munkholm et al • Regional Cohort Study • Copenhagen • 373 patients • 1962-1987 • Examined the long term disease course of Crohn’s disease • Remission Predictive Factors • Relapse Predictive Factors Munkholm P, Langholz M, et a. Disease Activity Courses in a Regional Cohort of Crohn’s Disease patients. Scandanavian Journal of Gastro. 1995 Jul;30(7):699-706.

  14. Probability of only having one attack ~22% at 5 years Munkholm P, Langholz M, et a. Disease Activity Courses in a Regional Cohort of Crohn’s Disease patients. Scandanavian Journal of Gastro. 1995 Jul;30(7):699-706.

  15. Active Disease the Year Prior Active Disease • One year probability of having active disease vs remission • Patients with Active Disease the Year before Remission Munkholm P, Langholz M, et a. Disease Activity Courses in a Regional Cohort of Crohn’s Disease patients. Scandanavian Journal of Gastro. 1995 Jul;30(7):699-706.

  16. Remission the Year Prior • One year probability of having active disease vs remission • Patients in Remission the year before Remission Active Disease Munkholm P, Langholz M, et a. Disease Activity Courses in a Regional Cohort of Crohn’s Disease patients. Scandanavian Journal of Gastro. 1995 Jul;30(7):699-706.

  17. Active Disease imparts a 70-80% probability of maintaining a similar state the following year • Remission imparts a 80% probability of remission the following year • Regardless of year after diagnosis Munkholm P, Langholz M, et a. Disease Activity Courses in a Regional Cohort of Crohn’s Disease patients. Scandanavian Journal of Gastro. 1995 Jul;30(7):699-706.

  18. Crohn’s Disease Colonic Disease -30% of patients -Diarrhea and bleeding Crohn’s Disease -40% of patients -Abdominal pain -Also associated with perianal disease

  19. Crohn’s flare / exacerbation Acute Chronic Stricture Fistula

  20. Ulcerative Colitis • Extent of disease is related to location • Always starts at Rectum and extends proximally • No skip lesions • Bloody and Mucus diarhea • Rectal disease • Diarrhea • Hematochezia • Tenesmus • Incontinence • Proximal Disease • Wt loss • Abdominal Pain

  21. GI SymptomsSigns and Symptoms • Crohn’s • Mouth to Anus • Discontinuous • Transmural inflammation • Most common complaint: pain + diarrhea • U.C. • Rectum and moves proximally • Continuous • Mucosal Disease • Severe disease can be transmural • Classical Bloody Diarrhea Indeterminate Colitis

  22. Extraintestinal Manifestations • Musculoskeletal • Osteoporosis/osteopenia • Arthritis • Ankylosing Spondylitis (5%) • PyodermaGangrenosum • Primary Sclerosing Cholangitis – UC • Ophthalmological • Coagulopathy http://en.wikipedia.org/wiki/File:Crohnie_Pyoderma_gangrenosum.jpg ASCRS textbook

  23. Evaluation • Difficult to make diagnosis • Rule out infectious sources • C. Diff • Stool Studies • Diagnosis is dependent • Clinical suspicion • Radiological evaluation • Pathology

  24. Radiology • Abdominal X-Ray • Signs of obstruction • Loss of haustra markings • Contrast Studies (Small Bowel Follow Through) • Crohn’s SB Strictures/Fistulas • Superior to CT’s for many fistulas • Computed Tomography • Evaluate thickness of the bowel • r/o other etiologies of abdominal pain • MRI

  25. Evaluation • Colonoscopy is the study of choice for patients suspected of having UC or colonic involvement of Crohn’s • Allows for pathology • Monitor response to treatment • Cancer surveillance • Office procedures include rigid proctoscopy and flexible sigmoidoscopy

  26. Serum Tests • Acute phase reactants • ESR and C-Reactive Protein • Active disease vs stricture • Nutritional parameters • Immune regulatory pathway markers • Aid in differentiating Crohn’svs UC • Any patient with diarrhea or suspected of having a flare should have common causes ruled out • C. Diff • Stool cultures

  27. Standard Workup in Acute Settings • Stabilize the patient • Basic labs, CRP and ESR • Infectious workup • Empiric antibiotics? • Abdominal Series • Colonoscopy vs CT of Abd/Pelvis • Bloody Diarrhea – Colonoscopy • Abdominal Pain -- CT

  28. Treatment As far as I’m concerned, if something is so complicated that you can’t explain it in 10 seconds, then it’s probably not worth knowing anyway.

  29. Treatment • Crohn’svs UC • Location of Crohn’s • Behavior of Crohn’s • Acute vs Chronic Pathology

  30. Crohn’s Disease Acute/Medical management Chronic/Surgery Stricture Fistula

  31. Crohn’s DiseaseMedical Management • Mild to Moderate Disease • Sulfasalazines • 5-Aminosalicylates • Antibiotics • Ciprofloxacin has been shown to be as effective as 5-ASA compounds in mild-moderate disease • Metronidazole • Budesonide • Topical Steroid

  32. Medical Management • Mild to Severe • Steroids • Immunomodulators • 6-mercaptopurine • Azathioprine • Delayed benefit, durable results • Methotrexate • Biologic Therapy

  33. Top – Down Approach • SONIC Trial 2010 • 508 randomized • Overall looked at 280 patients at 26 weeks • Extended to 50 weeks with similar results.

  34. Top Down Approach • CHARM Study • 854 Patients • Placebo vsadalimunab • Adalimunab has a 50% reduction in all hospitalizations compared to placebo • 33% will eventually fail to respond to biological therapy • Antibody formation may reduce effectiveness over time • Combination therapy may alleviate this. Hanauer SB, Feagan BG, Lichtenstein GR. et al. MaintanceInfliximab for CD: the ACCENT I randomized trial. Lancet. 2002; 359(9317):1541-9.

  35. Top Down Approach

  36. Surgery and Crohn’s Disease • Not Curable • Conservative Resection • Area of previous anastomosis is most likely site of recurrence • Indications • Obstruction • Fistula • Hemorrhage • Colitis • Neoplasia • Failed medical management

  37. Ulcerative Colitis • Colonoscopy to evaluate extent of disease • Mild to Moderate and Distal to the splenic flexure • Topical steroids, 5-ASA • Oral – 5-ASA • Mild to Moderate and proximal to the splenic flexure • 5-ASA • Steroids

  38. Ulcerative Colitis Treatment • Goal is mucosal healing • Severe colitis • Intravenous Steroids • Azathioprine • 6-mercaptopurine • Cyclosporine • Tacrolimus • Infliximab (Remicade) • Decreases rate of colectomy at 3 months and 1 year

  39. Ulcerative Colitis and Surgery • 20-30% of patients will require surgery • Emergent/Urgent Indications • Hemorrhage • Toxic Megacolon • Perforation • Serve Colitis unresponsive to medial management • Elective Indications • Cancer/Dysplasia • Adverse events/symptoms from medical therapy • Medical Failure

  40. Ulcerative colitis • Emergent Surgery • Total Colectomy with end ileostomy • Reversal at a later date • Elective • Total Colectomy with end ileostomy • Total Colectomy with ileorectalanastomosis • Total Proctocolectomy with Ileostomy • Total Proctocolectomy with Ileo-anal Anastomosis • Procedure of choice • Continent ileostomies

  41. Ulcerative Colitis – J-Pouch • Removal of all colon and rectum • Patients can expect to have 6 BM’s per day • Control with Immodium or Lomotil • Minor Incontinence • Stricures 5-35% • Pouchitis

  42. J-Pouch • Over 95% are happy with their pouches and would not go back to a ileostomy • Perianal Hygiene • Hairdryer • Moisture Barrier • Pad • Failures • Crohn’s • Pelvic Sepsis • Poor Function ASCRS Textbook

  43. Surveillance • Crohn’s Colitis and Ulcerative Colitis • Random Biopsies to r/o Dysplasia every 1-2 years • Age to begin Screening • 7-8 years after onset of pan colitis • 12-15 years after the onset of left sided colitis • Ulcerative Colitis • 10% risk of Cancer after 20y of disease • All UC patients have a 4% prevalence of cancer ASCRS Textbook ASCRS Practice Parameters

  44. Crohn’s disease and Surveillance • Relative Risk of Developing Cancer compared to general population • Small Bowel – 28.4 • Colorectal – 2.4 • Extra-intestinal Cancer -1.27 • Lymphoma – 1.42

  45. Diarrhea in the IBD patient • Common things are common • C. Diff • Stool studies • Colonoscopyvs Flexible sigmoidoscopy • Treatment • Cipro/Flagyl • Probiotics • Xifanin

  46. Small Bowel Obstruction in Crohn’s • Etiology • CRP/ESR along with basic labs • Patience • If active flare -7-10 course of steroids • Unlikely to resolve after this.

  47. Conclusion • 40yo/female with LLQ crampy abdominal pain and watery diarrhea • Colonoscopy • Imaging • Stool Studies • Treatment • Probiotics • Antibiotics • 5-ASA • Budesonide • Biological Therapy

  48. Conclusion • 32yo/male complains of bloody diarrhea • Toxic? • Endoscopy • Stool Studies • Treatment • 5-ASA • Probiotics • Steroids? • Remicade

  49. Conclusion • Inflammatory Bowel Disease requires a high degree of suspicion to make the diagnosis • Appropriate imaging or endoscopy can greatly aid in the diagnosis • Treatment should be tailored to the individual patient • Cancer screening must be addressed in all IBD patients

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