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- Genetics : HLA B27 , B5-DR2
- Epidemiology
- Pediatric presentation
- Systemic Complications : GI
- Liver
- Treatment : Medical
- Pediatric
- Ulcerative Colitis Epidemiology
- Diagnosis
- Treatment of IBD : Avoid
Eosinophilic GastroenteritisPresentation: N/V, abdominal pain, wt loss, steatorrhea, protein-losing enteropathy Effects any segment of GI tract, peripheral eosinophilia in 75% Treatment: steroids Inflammatory Bowel Disease Crohn’s Disease / Ulcerative colitis Differential: radiation, ischemia, infections, antibiotics (pseudomembranous colitis), other causes Genetics: HLA B27, B5-DR2, AW24, BW25 / 10% have positive family history (15-20% of healthy relatives with intestinal hyperpermeability) / inflammation is the common pathway Crohn’s Disease General: entire GI tract (33% small bowel alone, 20% colon involvement, generally does NOT affect rectum) / transmural inflammation, creeping fat, granulomas, fistulas, obstructions, psoas/hepatic abscesses (must be drained), systemic manifestations Epidemiology: Jews >> whites > blacks, developed countries, northern US / bimodal 15 to 25 yrs (more) and 55 to 65 yrs (less) Pathology: intestinal strictures / sharp demarcations, skip lesions, linear ulcers (may have fistula to bowel, bladder, vagina, rectum, skin, retroperitoneum), non-caseating granuloma (20%), granuloma (crypt abscesses), colon (crypt atrophy, paneth or pyloric metaplasia), lymphoid aggregates/granulomas (50%, may occur in uninvolved regions) Presentation: insidious or abrupt onset of pain, fever, diarrhea (symptoms may or may not mirror mucosal pathology) / chronic pain, intestinal obstruction, acute inflammation (mimics acute appendicitis) / Pediatric presentation: fever, anemia, arthritis / children also more likely to present with upper GI symptoms Ddx: appendicitis, Yersinia, lymphoma, intestinal tuberculosis, Behçet’s Diagnosis: colonoscopy KUB: ileitis, string sign, skip lesions Labs: anemia, thrombocytosis, increased ESR, increased CRP orosomucoid, decreased albumin, increased fecal a1AT (not available in all labs), leukocyte scan/excretion / P-ANCA (not MPO) positive in 30% Systemic Complications: GI: malabsorption, iron deficiency anemia, steatorrhea (bile malabsorption may also cause oxalate renal stones and cholesterol gall stones) / pathos stomatitis (more common in children) / perianal fistulae and abscess / increased incidence of gallstones (supersaturated biliary cholesterol, not enough bile acids) Urologic: renal stones (10%, usually after small bowel resection or ileostomy), fistulae, hydronephrosis, amyloidosis (fat malabsorption leads to calcium being taken away to saponify acids, which leads to build-up of oxalic acid) Liver: hepatic involvement, fatty liver, sclerosing cholangitis (10% in adults, 3% in children) and autoimmune hepatitis (may need to do liver biopsy to differentiate as sometimes involvement is solely intra-hepatic ductal) Joint: polyarthritis (10-20%, associated with flare-ups, can happen w/out GI Sx / destructive changes not seen), sacroiliitis (20%, progresses independently, similar to ankylosing spondylitis) Skin: erythema nodosum (!5%), clubbing fingertips, pyoderma gangrenosum (rare) Eye: uveitis (common) (photophobia, blurred vision, headache) Cancer risk: minimal (2.5 x normal risk) / insurance won’t pay for annual flexible endoscopy in Crohn’s (2.5 risk) Treatment: Medical: see below (steroids) / antibiotics, anti-diarrheal, cholestyramine (for steatorrhea), see (treatment of PSC) Surgical: operate only when necessary (obstruction, fistula) / recurrence after operation is 50% by 10 years (occurs most at site of anastomosis) / liver transplant only cure for PSC and autoimmune hepatitis Pediatric: consider surgery in kids to let them go through puberty before recurrence Prognosis: 10% spontaneous remission, most relapse eventually Measuring disease status: diarrhea, abdominal pain, nausea/vomiting, rectal bleeding (hematochezia only from colonic affects / obstruction), weight loss, fever, growth retardation, fistula, more… Ulcerative Colitis Epidemiology: Jews >> whites > blacks, developed countries, northern US / bimodal 15 to 25 yrs (more) and 55 to 65 yrs (less) / 1 in 20,000 / 20% will have 1st degree relative Presentation: may have more diarrhea than Crohn’s due to circulating secretagogues released from colonic inflammation Course: continuous inflammation begins in rectum and proceeds proximally, pseudopolyps, normal thickness, serosa / dysplasia / leads to carcinoma (stricture) Labs: 15% have elevated ESR/CRP during attack (mod-sever > 30), P-ANCA (not MPO) positive in 30% Complications: Colonic: toxic megacolon (> 6cm) (follow closely with serial KUB), lead pipe, usually does not have severe bleeding [note: steroids can mask pain of acute abdomen] // Note: start broad spectrum antibiotics (before perforation!, not after!) Arthritis: monoarticular, asymmetrical, large > small joints, no synovial destruction, NO subcutaneous nodules, seronegative (no RF) / do not treat like RA with NSAIDS / does not resolve with remission of GI disease / ankylosing spondylitis, which may progress even after colectomy Skin: erythema nodosum (10-50%), pyoderma gangrenosum (1-10%), erythema multiforme, maculopapular eruptions [skin conditions resolve with treatment of GI disease] Eye: episcleritis, iritis, uveitis (urgent ophthalmology consult, can cause blindness) Liver: fatty liver (common), sclerosing cholangitis (15%) (85% of sclerosing cholangitis due to UC / indication for liver transplant), cholangiocarcinoma (no liver transplant) Cancer risk: 10-20% by 20 yrs of disease (increases 1% per year after 7-10 yrs) [not always removed immediately; some say yearly colonoscopy starting 8 yrs after disease begins] Diagnosis: colonoscopy [pic] Indications for surgery: Emergent: hemorrhage (exsanguinations), toxicity and/or perforation (toxic megacolon) Neoplastic: suspected/confirmed cancer, significant dysplasia General: growth retardation, systemic complications, intractability Colectomy with mucosal proctectomy and ileo-anal anastomosis – small bowel mucosa replaces removed colonic mucosa - better than bag, only an increased number of bowel movements, preserves sexual function, complications: infection of pouch (Rx: metronidazole) Treatment of IBD: Avoid: anticholinergics, anti-diarrheal, antibiotics (may use metronidazole Crohn’s for overgrowth) corticosteroids mainly useful in acute attacks, not for long term prevention oral prednisone 20-60 mg parenteral corticosteroids parenteral ACTH topical steroids corticosteroids enema 80-200 mg/d
olsalazine (2 5-asa bound) 1.5-3 g/d oral 5-asa (mesalamine) 1.5-4.8 g/d topical 5-asa & 4-asa (rectal prep) mesalamine enema 1-4 g/d
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