Embedded Files
Crohn's Disease
Crohn's Disease
- Any part of GI tract from the mouth to the rectum
- Transmural involvement
- Endoscopy: Skip lesions, cobblestoning, ulcerations, strictures
- Histology: Neutrophilic inflammation, noncaseating granulomas, Paneth cell metaplasia, and intestinal villi blunting
Ulcerative Colitis
Ulcerative Colitis
- Continuous lesions starting in rectum (generally only in colon)
- Mucosa and submucosal involvement only
- Endoscopy: Pseudopolyps, continuous areas of inflammation
General Overview
General Overview
Presentation
Presentation
- Peak incidence 15-40yo with possible second peak 50-80yo
- Abdominal pain
- Diarrhea
- Fatigue
- Fever
- GI bleeding
- Unintentional weight loss
Risk factors for IBD
Risk factors for IBD
- Smoker in CD, but may be **protective for the development UC**
- Ashkenazi Jewish, White (compared to Black, Hispanic)
- Sedentary lifestyle, Obesity
- "Western" diet (processed, fried, sugar)
- Acute gastroenteritis, recent antibiotic use
- NSAID use
- Family history of IBD
Extraintestinal manifestations of IBD (CD and UC)
Extraintestinal manifestations of IBD (CD and UC)
- Arthritis
- Peripheral arthritis
- Ankylosing Spondylitis (UC)
- Sacroileitis
- Dermatological
- Aphthous stomatitis
- Erythema nodosum
- Pyoderma gangrenosum
- Ocular
- Episcleritis and Scleritis (CD)
- Uveitis
- Primary sclerosing cholangitis (UC)
DDx of IBD
DDx of IBD
- Infectious colitis
- Ischemic colitis
- Radiation-induced colitis
- Diverticulitis
- Appendicitis
- Colorectal malignancy (obstructing/perforating), lymphoma
- Celiac
- IBS
Initial testing
Initial testing
- CBC
- BUN
- Creatinine
- Liver enzymes
- CRP and ESR
- Consider stool Cx and C. diff toxin PCR
- Consider fecal calprotectin if IBS vs. IBD
Subsequent testing
Subsequent testing
- Iron profile
- Vitamin B12, Folate
- Albumin, prealbumin
- Vitamin D, calcium
Diagnostic Tests
Diagnostic Tests
- Colonoscopy with ileoscopy and biopsy
- Capsule endoscopy (avoid in strictures)
- CT enterography
- MR enterography
- Small bowel follow-through
- Esophagogastroduodenoscopy recommended if upper GI symptoms, unexplained iron deficiency anemia, active Crohn's disease with normal colonoscopy
Preventive measures
Preventive measures
- Smoking cessation
- Consider avoid NSAIDs (may exacerbate disease)
- Avoid pregnancy in women of childbearing age
- Conflicting data about OCP and IBD, may have small risk of association
- Ensure routine immunizations
- Tetanus and diphtheria, Polio, MMR, Varicella, Meningitis
- HPV
- Herpes zoster
- Influenza
- Pneumococcal
- Hepatitis A and B
- Prior to starting anti-TNF agents, obtain PPD testing and CXR (rule out TB), and update immunizations including Hep B
- Anxiety/depression
- Osteoporosis
- Screening/prevention if on chronic systemic steroids
- Colorectal Cancer
- Screening for colorectal cancer based on extent of disease
- Usually begin 8y after onset, q1-2 years (with random biopsies)
- Cervical Cancer
- Consider more frequent screening if on immunosuppressive therapy
Induction of Remission
Induction of Remission
- 5-ASA (sulfasalazine, mesalamine)
- Pentasa total 4g daily divided QID or BID
- If achieve remission, maintain dose or reduce to 3g daily
- Creat at 6w, 3mo, 6mo, 12mo, then yearly
- Pentasa total 4g daily divided QID or BID
- Glucorticoids (Topical Ileal release budesonide (Entocort EC), prednisone)
- Prednisone 40 mg PO x 1 week and then taper 5mg weekly for total duration of 8 weeks
Maintenance
Maintenance
- 5-ASA (sulfasalazine, mesalamine)
- Immunomodulators (azathioprine and 6-mercaptopurine, methotrexate)
- Anti-TNF agents (infliximab, adalimumab)
- Consider Probiotics Lactobacillus GG and Escherichia coli Nissle 1917
Symptomatic
Symptomatic
- Loperamide if no systemic (fever, tachycardia)
- Avoid opioids as may mask acute abdomen
- Consider avoid NSAIDs (limited data may worsen disease)
Google Sites
Report abuse