INFLAMMATORY BOWEL
DISEASE
Anusha Reddy
FY1 SWFT
3rd Feb 2014
OBJECTIVES
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2 Case Studies: Crohn’s Vs Colitis
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THINK:
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AETIOLOGY
EPIDEMIOLOGY
SIGNS AND SYMPTOMS
INVESTIGATIONS
MANAGEMENT
CASE STUDY 1
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22 Female
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PC: 6/52 of 5 x loose, non-bloody stools daily

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Right lower quadrant abdominal pain (especially
after eating)
8kg weight loss
Bilateral knee and ankle pains
MORE INFORMATION REQUIRED

Full history
Nil PMH, no hx of foreign travel
 No medications or allergies
 Current smoker- 5 pack-years


Examination
Definite and moderately tender 5-cm mass in the
right lower quadrant
 No joint effusion or skin lesions are noted

DIFFERENTIAL DIAGNOSIS
Gastroenteritis
 Crohn’s Disease
 Ulcerative Colitis
 Irritable Bowel Syndrome
 Behcet’s Disease

Bowel Cancer
 Tuberculosis
 Amyloidosis
 Acute Appendicitis

WHAT DO WE THINK THIS IS?

22 Female

PC: 6/52 of 5 x loose, non-bloody stools daily



Right lower quadrant abdominal pain (especially
after eating)
8kg weight loss
Bilateral knee and ankle pains
CROHN’S DISEASE- DEFINITION
Chronic Inflammatory Bowel Disease (IBD)
 Unknown Aetiology
 Characterised by

1.
2.
3.
4.
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Focal
Asymmetrical
Transmural
Occasionally granulomatous
inflammation
Any part of the GI tract- mouth anus
CROHN’S DISEASE- EPIDEMIOLOGY
Incidence: 9.56 per 100,0001
 Prevalence: 115,000 in the UK
 Age of onset: 2 peaks 1) 15-30 Y (more common)
2) 60-80 Y
 Female: Male 1.8:1 Children this is reversed!
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Risk Factors2
Mycobacterium paratuberculosis, Pseudomonas spp. &
Listeria spp.
 ↑TNF-alpha
 High-fat diets
 Genetic mutations
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1) Steed H, Walsh S, Reynolds N; Crohn's disease incidence in NHS Tayside. Scott Med J. 2010 Aug;55(3):22-5
2) Rangasamy P et al; Crohn Disease, Medscape, Jun 2011
CROHN’S DISEASE- SYMPTOMS
•
•
•
•
•
•
•
•
•
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Abdominal pain, cramping or swelling
Anaemia
Fever
Gastrointestinal bleeding
Joint pain
Malabsorption
Persistent or recurrent diarrhoea
Stomach ulcers
Vomiting
Weight loss
CROHN’S DISEASE- ON EXAMINATION

General ill health- weight loss & dehydrated
Hypotension, tachycardia and pyrexia
 Abdominal tenderness or distension, palpable
masses.
 Anal and perianal lesions (abscesses, fistulae)
 Mouth Ulcers
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Extra-intestinal manifestations of Crohn’s ......
CROHN’S DISEASE- EXTRA INTESTINAL
INVESTIGATIONS
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Bloods
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FBC, CRP, U&Es, LFTs
Stool culture and microscopy
anti-S. cerevisiae antibodies Perinuclear
antineutrophil cytoplasmic antibody (p-ANCA)
(UC>CD)
Abdo Xray
Ileocolonscopy and biopsy from the terminal ileum as
well as the affected sites
Small bowel follow through
If upper GI symptoms- Upper GI endoscopy
If lower GI symptoms- Flexible sigmoidoscopy/EUA
CROHN’S DISEASE- MANAGEMENT
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1.
First presentation (NICE guidelines)
Glucocorticoids
1.
2.
3.
Prednisolone, Methylprednisolone IV
hydrocortisone
Budesonide
5-ASA
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+/- ADD ON Azathioprine or Mercaptopurine
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Biologic: Infliximab and Adalimumab
CROHN’S DISEASE- MANAGEMENT
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Maintaining Remission (NICE guidelines)
Offer Azathioprine or Mercaptopurine as
Monotherapy
Methotrixate
Surgery- if limited to distal ileum (weighing out
the risk Vs benefits) and for complications...
CROHN’S DISEASE- COMPLICATIONS
B
A
C
C
CASE STUDY 2
32 Male
 Bloody diarrhoea 4/52
 Bilateral lower abdominal cramping
 Malaise and weight loss
 No associated fever, visual changes, arthralgias,
or skin lesions
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Previously fit and well contractor
 Non-smoker, 14-18 units/week drinker
 FHx: Diabetes Mellitus Type 1
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ULCERATIVE COLITIS- DEFINITION
Chronic Inflammatory
Bowel Disease
 Unknown aetiology

Only Large Colon
 Classification:

Distal Disease
 More extensive disease
 Pancolitis
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ULCERATIVE COLITIS- EPIDEMIOLOGY
More common than Crohn’s
 Incidence: 10 per 100,000
 Prevalence 240 per 100,000 in the UK
 Age of onset: 2 peaks 1) 15-25 Y (more common)

2) 55-65 Y
Male:Female= 1:1
 Idiopathic: ?autoimmune condition triggered by
colonic bacteria  inflammation
 Genetic component: sibling of an individual who
has IBD 17-35 x more risk of development
 Risk of UC decreased in smokers

1) Ulcerative Colitis; NICE Clinical Guideline (Jun 2013)
ULCERATIVE COLITIS- SYMPTOMS
Bloody diarrhoea
 Abdominal Pain
 Tenesmus
 Systemic symptoms: malaise, fever, weightless
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ULCERATIVE COLITIS- ON EXAMINATION
Unwell, pale, febrile, dehydrated
 Abdo pain and tenderness .. + distension
 TOXIC MEGACOLON
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Worrying signs: Tachycardia, anaemia and fever
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Extra- intestinal disease...
ULCERATIVE COLITIS- EXTRA-INTESTINAL
Aphthous ulcers
 Ocular manifestations 5%
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Episcleritis
 Anterior uveitis
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Acute arthropathy affecting the large joints 26%
Sacroiliitis
 Ankylosing Spondylitis 3%
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Deramatology 19%
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Pyoderma gangrenosum
Erythema nodosum
Primary Sclerosing Cholangitis
ULCERATIVE COLITIS- INVESTIGATIONS
Bloods: FBC, LFTs, U+Es, CRP
 Serology- pANCA Vs. ASCA
 Stool cultures
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Imaging
Abdo x-ray- acute setting
 Barium enema- can show mucosal structure
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Flexible Sigmoidoscopy and Biopsy- for diagnosis
ULCERATIVE COLITIS- MANAGEMENT
a) Topical aminosalicylate
alone (suppository or
enema
b) ?ADD PO
aminosalicylate to a topical
aminosalicylate OR
c) consider an PO
aminosalicylate alone
a) PO Aminosalicylate
- High induction
dose of an
b) ?ADD topical
Aminosalicylate OR
PO beclometasone
dipropionate
- If no improvement 72 hrs
despite IV Hydrocortisone
OR
-Symptoms worsen to
pancolitis:
a) ADD IV Ciclosporin to IV
steroids
ULCERATIVE COLITIS- MANAGEMENT

Indications for Surgery:
Unresponsive to medical treatment
 Significantly affecting quality of life
 Growth retardation in Children
 Life-threatening complications...
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Bleeding
 Toxic Megacolon
 Impending perforation
 Carcinoma
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ANY QUESTIONS?
SUMMARY
SUMMARY: CROHN’S VS. UC (1)
Symptoms of Crohn's
Disease
Symptoms of Ulcerative
Colitis
• Abdominal pain, cramping or •Bloody diarrhoea
swelling
•Abdominal pain or discomfort
•Anaemia
•Anaemia caused by severe
•Fever
bleeding
•Gastrointestinal bleeding
•Dehydration
•Joint pain
•Fatigue
•Malabsorption
•Fever
•Persistent or recurrent
•Joint pain
diarrhoea
•Loss of appetite
•Stomach ulcers
•Malabsorption
•Vomiting
•Rectal bleeding
•Weight loss
•Urgent bowel movements
•Weight loss
SUMMARY: CROHN’S VS. UC (2)
SUMMARY- CROHN’S VS. UC (3)
SUMMARY: CROHN’S VS. UC (2)
LEARNING POINTS
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RELAPSE AND REMITTING
MANAGE THE PATIENT
BONE PROTECTION- IF ON LONG-TERM
STROIDS
TEST FOR TB BEFORE STARTING
INFLIXIMAB
RISK OF COLONIC CARCINIMA IN UC
THANK YOU!!