Inflammatory Bowel Disease

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Clare Donnellan
Consultant Gastroenterologist Leeds Teaching Hospitals
Key features of IBD
 History & examination
 Investigations
 Treatment including DMARDs
 Flares – what should GPs do?
 What’s new?


Incidence UC
10 per 100,000

Incidence CD
6-7 per 100,000

Prevalence
400 per 100,000
(250/150)
Onset between 15 and 40 years of age
 Similar in males and females


Ulcerative colitis
◦ Proctitis
◦ Left-sided disease
◦ Pan-colitis

Crohn’s Disease
◦ Affects anywhere





Small bowel (80%)
Small & Large bowel (50%)
Peri-anal disease (35%)
More likely to get complications
IBD-unclassified 5%

Genetics
◦ 10-25% of patients have at least one other
family member affected
◦ No particular gene identified in UC
◦ NOD2/CARD15 gene abnormalities in CD
 Terminal ileal disease
 Possibly more chance of requiring surgery

Environmental factors
◦ Smoking
 Protective for UC
 Worsens outcome for CD
◦ Appendicectomy
 Protective for UC
 Unlikely effect for CD
◦ Diet?
◦ Bacteria?

Episcleritis/scleritis
◦ 2 to 5% of patients
◦ Activity linked to GI tract

Anterior uveitis
◦
◦
◦
◦
0.5-3%, but much more serious
Females:males 4:1
75% of patients have arthritis
Activity not linked to GI tract

Erythema nodosum
◦ Most common skin
manifestation of IBD (up to
15%)
◦ Typically flares at same
time as GI symptoms

Pyoderma grangrenosum
◦ Up to 5% of patients
◦ More chronic course

Related to GI activity
◦ Peripheral arthritis
◦ Episcleritis/scleritis
◦ Erythema nodosum

Not related to GI activity
◦ Spondylitis/sacroiliitis
◦ Anterior uveitis
◦ Pyoderma Gangrenosum

Bloody diarrhoea or prolonged diarrhoea (-ve
MC&S)
◦ Abdominal pain
◦ Urgency
◦ Tenesmus

If 1st presentation
◦
◦
◦
◦
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Stool frequency/day & night ◦ Travel
Systemic features
◦ DH (Abx, NSAIDs
Weight loss
◦ FH
Fever
◦ SH
Extra-GI features

‘The professional patient’
◦ Is it like a ‘usual’ flare?
◦ What are the usual strategies?
◦ IBD Helpline 0113 206 8679

Is it severe?
◦ Truelove and Witts criteria
 ≥6 bloody stools per day
 Systemic toxicity (HR>90, T>37.8, ESR>30) or
Hb<10.5
 NEEDS ADMITTING for IV steroids

Much more challenging to ΔΔ IBD vs. IBS….
◦
◦
◦
◦
◦
Abdominal pain
Diarrhoea (ask re: nocturnal symptoms)
Weight loss
Systemic features
Extra-GI manifestations

‘The professional patient’
◦ Is it like a ‘usual’ flare?
◦ What are the usual strategies?
◦ IBD Helpline 0113 206 8679

Systemically unwell?
◦ Fever
◦ Tachycardia





Dehydration
BMI/weight
Abdominal tenderness/distension/bowel
sounds
Palpable mass
Peri-anal examination


Follow ‘usual’ strategy
Call helpline (pt or GP) if concerned
◦ Advice
◦ Early access to IBD clinic

Admit if systemically unwell



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
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FBC, U&E, LFT, CRP
Haematinics
Stool MC&S
Stool C diff
(Stool OC&P)
Urgent referral to gastroenterology if high
index of suspicion

UC
◦
◦
◦
◦
◦
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Bloods
AXR
Urgent stool cultures
Urgent flexible sigmoidoscopy within 24 hours
(CMV PCR and CMV on biopsies)
CT if risk of perforation

Crohn’s
◦ Varies on symptoms/distribution
◦ Low threshold for CT abdo/pelvis
◦ Flexible sigmoidoscopy often unhelpful
◦ MR pelvic if abscess/fistulising disease

Small bowel
◦
◦
◦
◦
◦
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
Small bowel meal if suspected CD/suspected SB CD
MR enterography (enteroclysis) if known SB CD
OGD
Ultrasound
Wireless capsule endoscopy
Isotope (labelled white cell scans)
Colon
◦ Colonoscopy
◦ CT colonography

5-ASAs
◦ Prescribe by drug name
◦ But lower cost equivalents (Asacol = Mesren =
Octasa)
◦ Dose
 Asacol 2.4 g vs. 4.8 g
 Minimum 2 g for maintenance (1.2 g cancer prevention)
◦ OD as effective and better adherence for
maintenance
◦ Tablets + Local therapy often avoids steroids
 5-ASA enemas better than steroid enemas

DMARDs
◦ Azathioprine 2-2.5 mg/kg
◦ 6-mercaptopurine 1-1.5 mg/kg
◦ Weekly bloods for 4/52
◦ Then monthly
◦ Then 3 monthly
◦ S/E
 (Raised MCV and lymphopaenia)

Other DMARDs
◦ Methotrexate
 Evidence not great
◦ Mycophenolate
 Some evidence

Optimise 5-ASAs first if sole treatment
◦ Maximise dose
◦ Add in local therapy (5-ASAs, not steroids)

Prednisolone 30 mg daily with Ca/Vit D
cover
◦ More prolonged course

If not settling (or severe UC) IV steroids

Is it severe?
◦ Truelove and Witts criteria
 ≥6 bloody stools per day
 Systemic toxicity (HR>90, T>37.8, ESR>30) or
Hb<10.5
 NEEDS ADMITTING for IV steroids
 Colectomy rate approx. 30%

Day 3 (Travis criteria)
◦ If stool frequency > 8 or CRP > 45
◦ 85% chance of colectomy

3 options
◦ Surgery
◦ Infliximab
◦ Cyclosporin
as a bridge to Aza/6-MP

Ciclosporin/infliximab
◦ 70 – 80% leave hospital with colon
◦ 30% long-term

Infection risks


No role for 5-ASAs except if mild colitis
? Role after surgery in preventing relapse

If luminal disease
◦ Oral steroids
◦ IV steroids if no response
◦ Still no response?
 No role for ciclosporin
 Give infliximab +/- azathioprine for 1 year
◦ Nutrition support key

If peri-anal disease
◦ Drain any sepsis
◦ Antibiotics
◦ Seton sutures
◦ Escalate therapy as appropriate

DMARDS
◦
◦
◦
◦

Azathioprine
Methotrexate (s/c)
Mycophenolate
Tacrolimus
Surgery
◦ For complications

Biologicals
◦ Infliximab
◦ Adalimumab (Humiara)
◦ NICE assessment at 1 yr


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Liquid diet for Crohn’s
Bone protection
Endoscopic dilatation of strictures

Calprotectin
◦ Diagnosis
◦ Activity assessment

Azathioprine metabolite levels
◦ Optimise dose
◦ Minimise side-effects
◦ ? Reduce number of patients needing biologicals

Leucocytapheresis

Mucosal healing

Guided self-management

More nurse-led clinics

Reduce follow-up waits…

Less ‘black and white’ in/out of service

Significant morbidity

Early, focused management

Use helpline 0113 206 8679



Admit if systemically unwell
Stool cultures
Appropriate steroid course
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