Inflammatory Bowel
Disease
Dawn Kershaw (FY1)
Objectives
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Recognise the possibility of IBD in patient’s
presenting with lower GI symptoms
Recognise the possibility of systemic symptoms
associated with IBD
Recognise the differences in presentation
between Crohn’s and UC – and how these
relate to underlying pathology
Initiate appropriate investigations in a patient
with suspected IBD
Initiate appropriate management in a patient
with IBD
Explain to patients the nature of and the
rationale for maintenance treatment of IBD
Objectives
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Recognise the possibility of IBD in patient’s
presenting with lower GI symptoms = GI
symptoms of IBD
Recognise the possibility of systemic symptoms
associated with IBD = Extra-intestinal symptoms
Recognise the differences in presentation between
Crohn’s and UC – and how these relate to
underlying pathology = Differences between UC
and Crohn’s: Pathology and presentation
Initiate appropriate investigations in a patient with
suspected IBD = Investigations
Initiate appropriate management in a patient with
IBD = Management of IBD
Explain to patients the nature of and the rationale
for maintenance treatment of IBD = Explain in lay
terms why we give medications to prevent flare
ups
Definition?
 Aetiology?
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Crohn's verses UC
Crohn's verses UC
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Definition
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Chronic
Relapsing and remitting
Inflammatory bowel disease
Chrons: any part of GI tract - often terminal
ileum
◦ UC: large bowel
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Aeitology
◦ Unknown
◦ Genetic
◦ Environmental
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Pathology?
Crohn’s
Crohn’s
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Tranny Granny Skipped down Cobblestone
street
Strictures
 Fistulae
 Abscesses
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Crohn’s
Ulcerative colitis
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Starts from rectum
Extends proximally
Continuous
Mucosa only
Proctitis = rectum
 Proctosigmoiditis = rectum and sigmoid
colon
 Left sided Colitis
 Pancolitis – Whole of large colon
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Objectives
Recognise the differences in presentation
between Crohn’s and UC – and how these
relate to underlying pathology
 Recognise the possibility of IBD in
patient’s presenting with lower GI
symptoms
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Crohn’s
Crohn’s
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Crampy abdominal pain
◦ Inflammation; fibrosis; bowel obstruction
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Diarrhoea
◦ Blood
◦ Steatorrhea
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Weight loss
Fever
Anaemia
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Obstruction: Distension, Vomiting
Abscesses
Fistulae: Enteroenteral; Anorectal;
Vesicointestinal; Rectovaginal
Ulcerative Colitis
Ulcerative Colitis
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Crampy abdominal pain
◦ Relieved by defecation
◦ Left iliac fossa
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Diarrhoea
◦ Blood ++
◦ Mucous
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Urgency
Tenesmus
Weight loss
Fever
Anaemia
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Severity: Truelove Witts Criteria
Objectives
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Recognise the possibility of systemic
symptoms associated with IBD.
Extra-intestinal symptoms
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Eyes
◦ Iritis; uveitis; episcleritis
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Skin
◦ Erythema nodosum; pyoderma gangrenosum
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Joints
◦ Seronegative spondyloarthropathy
 Large joints; Spine; Sacroiliitis; Can affect small
joints
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Other
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Clubbing
DVT
Primary sclerosing cholangitis (UC)
Heamolytic anaemia (autoimmune) (Crohn’s)
Osetoporosis (Crohn’s)
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Erythema nodosum
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Pyoderma
gangrenosum
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Uveitis
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Clubbing
Get into 2 groups
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Complete first 3 boxes on form based on what
we have just done.
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What are your differential diagnosis to consider
in a patient presenting with IBD symptoms?
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Abdominal pain
Diarrhoea
PR bleeding/ mucous
Weight loss
Malabsorption
(Thanks to Zoe Campbell for providing the basis to this form)
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Initiate appropriate investigations in a
patient with suspected IBD
Bedside
 Bloods
 Imaging
 Special tests
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Investigations
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Bedside
◦ Stool MC&S
◦ Faecal calprotectin
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Bloods
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FBC (low Hb; High WCC)
ESR; CRP (high)
LFTs: Low albumin
U&Es: Chronic diarrhoea – electrolyte
imbalance
◦ Heamatinics: ferritin, Vitamin B12, folate
◦ Amylase
◦ Cross match
Investigations
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Imaging
◦ Abdominal X-ray
◦ Erect Chest X-ray
◦ Barium Meal (Crohn's)
 Fibrosis, Strictures, Ulceration (‘rose thorn’)
◦ Barium enema (UC)
 Featureless narrow colon, Loss of haustral pattern
◦ CT/MRI enterography (Crohn’s)
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Special test
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Flexible sigmoidoscopy
Colonoscopy
Gastroscopy
BIOPSY
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Initiate appropriate management in a
patient with IBD
Acute
 Chronic
 Lifestyle
 MDT
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Management
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Acute
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A-E; Bowel rest; Analgesia (not NSAIDs);
Steroids: IV; oral; rectal
Antibiotics
5-ASAs
Chronic
◦ 5-ASAs
◦ Per rectum steroids
◦ Immunosuppressant's
 Azathioprine
 Methotrexate (Crohn’s)
◦ Anti-TNF: Infliximab
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Surgery: Resection
Management
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Lifestyle
◦ Diet: Elemental
◦ Stop smoking?
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MDT
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Consultant’s: Gastroenterologist; Surgeons
IBD specialist nurse
Dietician
Smoking cessation
Stoma nurse
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5-ASAs
Steroids
Azathioprine/ Mercaptopurine
(Immunosuppressant)
Methotrexate (Crohn's)
Infliximab (Anti-TNF)
Medications used in IBD
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Complete the rest of the form
Get back into groups
Objectives
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Explain to patients the nature of and the
rationale for maintenance treatment of
IBD
Patient.co.uk
 Once a flare-up has settled, without
treatment, there is ~1 in 2 chance that
another flare-up will develop within a year.
 Increased likelihood of flares depends on:
◦ extent of the disease in your gut
◦ age,
◦ the extent of treatment needed to control the
initial flare-up.
If flares not frequent/mild/ respond well to
acute treatment then - may not need to
/wish to take regular meds
 For others regular meds can improve QOL
++
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The treatment options that may be considered
to prevent flare-ups) include:
Immunosuppressants – take daily
Mesalazine – used daily (less common now)
Anti-TNF – selected cases where flares severe
and other treatments not worked: Have
infusion in hospital every 8 weeks.
Steroid medication is not generally used longterm to prevent flare-ups
These treatments increase the chance of
remaining free of flare-ups, but they do not
always work.
Balance between benefits and the possible
side-effects.
3 key points to take away
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Understanding the pathophysiology of UC and
Crohn’s is actually useful!
◦ Symptoms
◦ Investigations
◦ Management
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Communication is key- in exams AND in real
life:
◦ Patient.co.uk
◦ Easy marks in exams if you practice!
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Structured answers in exams
◦ Investigations
 Bedside; Bloods; Imaging; Special tests
 Acute; chronic
◦ Management
 Acute; Chronic; lifestyle; MDT
 Conservative; Medical; Surgical