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  1. Ulcerative Colitis&Extraintestinal Manifestations Kimberly Persley, MD April 20, 2005

  2. Case Presentation • 36 yo WP transfer from OSH with severe, steriod refractory UC • 11/2004 – Bloody diarrhea and abdominal pain • Treated with Colazol 6.75 gm/d • Prednisone 60 mg /d • 12/2004 – Imuran started secondary to refractory symptoms but developed ITP and the Imuran stopped

  3. Case Presentation • 2/26/2005 – underwent colonoscopy that showed “mild to moderately active colitis in the left colon • 2/28/2005 – admitted to OSH with fevers, increased bloody diarrhea and abdominal pain • Negative ID workup • 3/6/2005 – transfer to PHD for further management • 10-12 bloody bowel movements daily, abdominal pain, persistent fever, anorexia • No joint pain, oral ulcers or rashes

  4. Case Presentation • PMH • ITP – first diagnosed 11/2004 • Bone marrow biopsy – megakaryocytic hyperplasia • Treated with steroids, WinRho and IVIG • Patent foramen ovale • Meds • Flagyl, Cipro, Solumedrol, Morphine and Phenergan • Family History • Paternal Grandfather with colon cancer

  5. Case Presentation • Physical Exam • BP 124/69, Pulse 96, Temp 98.4 • No skin lesions • CV – RRR with systolic murmur • Abdomen – NABS, tenderness in the lower abdomen, no masses, no splenectomy • Ext – no edema

  6. Case Presentation • Labs • WBC 15.3 (45% segs, 38% bands) • Hgb 12 g/dl, ferritin 150, vit B12 1163 pg/ml • Platelet 137k, ESR 67 • K 3.1, chol 123 • Creat 0.9 • Stool and blood cultures - neg

  7. Case Presentation • Hospital Course • Repeated stool and blood cultures • Solumedrol 60 mg IV continuous infusion • Platelet count decrease • Treated with IVIG • IV Cyclosporine (2mg/kg) started without significant improvement (received 13 days) • Flex sig – grade 4 colitis (severe)

  8. Flexible Sigmoidoscopy Ulcers

  9. Laboratory Data

  10. Case Presentation 3/23/2005- underwent lap assisted colectomy with ileostomy 3/27/2005- discharged home

  11. Spectrum of IBD Ulcerative colitis Crohn’s Disease Indeterminant colitis

  12. Normal Intestine Vs. IBD Environmental triggers (infection, bacterial products) Failure to down- regulate Chronic uncontrolled inflammation = IBD Moderately inflamed Down-regulate Normal gut controlled inflammation Normal gut controlled inflammation

  13. 37% 46% 17% Disease Distribution at Presentation n=1116 Farmer RG. Dig Dis Sci;38:1137-1146

  14. IBD Treatment Pyramid Remicade (not approved for UC Biologics severity Imuram MTX Cyclosporine Immunomodulators Steroids Antibiotics Asacol Colazol sulfasalazine 5-ASA

  15. IBD: Systemic Complications Growth failurein children Eyeinflammation* Lowerbone density* Kidneystones Liver andbile ductinflammation Subfertility* Ovaries Uterus Gallstones Arthritis and joint pains Skin lesions *Higher incidence in women.

  16. Responds to treatment of underlying bowel disease Peripheral arthritis Erythema nodosum Episcleritis Independent of treatment of underlying bowel disease Axial arthritis Pyoderma gangrenosum Uveitis PSC EIMs and Response to Treatment

  17. IBD and Hematology • Anemia is common in patients with IBD • Iron loss • Defective iron transport • Impaired Vitamin B12 and Folate absorption • Insufficient erythropoietin production • Autoimmune Hemolytic Anemia

  18. ITP and IBD • Not a frequent association • Usually associated with Ulcerative Colitis • Decrease in platelet counts observed during flares • Various treatment modalities used to induce remission

  19. ITP and IBD • 24 cases of IBD in ITP reported • 21 Ulcerative Colitis • 3 Crohn’s Colitis • IBD usually preceeded ITP be several months to years • No standardized approach to therapy • No other cases reported with colectomy only

  20. Molecular Mimicry Zlatanic et al. AJG 92,1997 antibodies platelet Spleen APC bacteria colon Platelet destruction

  21. ITP and IBD • Treatment • Short course of steroids • IVIG • Splenectomy may be required to maintain platelet count • + colectomy if active colitis • Colectomy should be considered if colitis remains active despite medical therapy

  22. Case Presentation (follow up) • Platelet count 275k on March 31, 2005 • On prednisone taper • Will return in next 2-3 months for a Ileal pouch anal anastomosis