Definitions UC Inflammation confined to mucosa Inflammation confined to mucosa Starting in rectum...
-
Upload
felix-mills -
Category
Documents
-
view
221 -
download
3
Transcript of Definitions UC Inflammation confined to mucosa Inflammation confined to mucosa Starting in rectum...
DefinitionsDefinitions
UCUC Inflammation confined Inflammation confined
to mucosato mucosa Starting in rectumStarting in rectum
May involve entire May involve entire coloncolon
Crypt abscessCrypt abscess RareRare
Rectal sparingRectal sparing DiscontinuousDiscontinuous Only proctitisOnly proctitis
Crohn’sCrohn’s Superficial ulcer to Superficial ulcer to
submucosa, submucosa, muscularis and serosamuscularis and serosa Transmural Transmural
inflammationinflammation Any portion of the Any portion of the
alimentary tractalimentary tract Mouth to anusMouth to anus
FistulasFistulas GranulomasGranulomas
Only a minority of Only a minority of patientspatients
Epidemiology & Genetics Epidemiology & Genetics - IBD- IBD
M=FM=F Increased riskIncreased risk
Turners, Hermansky-Pudlak, GSD type 1B, Turners, Hermansky-Pudlak, GSD type 1B, Leukocyte adhesionLeukocyte adhesion
First degree relativeFirst degree relative Single greatest risk factor (30 to 100 times)Single greatest risk factor (30 to 100 times)
Multiple genetic lociMultiple genetic loci pANCA pANCA
70% UC70% UC ASCAASCA
50-60%CD50-60%CD
PathogenesisPathogenesis
Cause unknownCause unknown Abnormalities in gastrointestinal Abnormalities in gastrointestinal
immunoregulationimmunoregulation Cytokines, arachidonic acid Cytokines, arachidonic acid
metabolites, reactive oxygen metabolites, reactive oxygen intermediates and growth factorsintermediates and growth factors
DiarrheaDiarrhea
Factors increase electrolyte secretionFactors increase electrolyte secretion Increased fluid lossIncreased fluid loss
Loss of bile salts from terminal ileumLoss of bile salts from terminal ileum MalabsorptionMalabsorption Bacterial overgrowthBacterial overgrowth CDCD
Exudation of serum proteins and bloodExudation of serum proteins and blood PLEPLE CDCD
Intestinal ManifestationsIntestinal Manifestations
UCUC Bloody diarrheaBloody diarrhea Proctitis Proctitis
May have formed May have formed stoolstool
Pain with Pain with defecationdefecation
BothBoth Nausea and/or vomitingNausea and/or vomiting FeverFever
*Know the clinical manifestations and distinguish*Know the clinical manifestations and distinguish
Crohn’sCrohn’s DiarrheaDiarrhea
50%50% Occasionally bloodyOccasionally bloody
Abdominal painAbdominal pain More severeMore severe
Perirectal Perirectal inflammationinflammation 25%25% Fissure and/or fistulaFissure and/or fistula
Aphthous ulcersAphthous ulcers
*Understand that chronic perianal *Understand that chronic perianal lesions or recurrent aphthous lesions or recurrent aphthous ulcers can be an early sign of CDulcers can be an early sign of CD
Intestinal ManifestationsIntestinal Manifestations
Extraintestinal Extraintestinal ManifestationsManifestations
25-35%25-35%
Directly related to disease activityDirectly related to disease activity Unrelated to disease activityUnrelated to disease activity Result from the presence of diseased Result from the presence of diseased
bowelbowel Arise from therapyArise from therapy
Extraintestinal Extraintestinal ManifestationsManifestations
Growth FailureGrowth Failure 20-30% CD20-30% CD
MultifactorialMultifactorial Chronic undernutrition, steroids,Chronic undernutrition, steroids,
cytokinescytokines 10% UC10% UC
Prolonged steroidsProlonged steroids Don’t forget delayed pubertyDon’t forget delayed puberty *May be a presenting sign*May be a presenting sign
*Know the reasons for growth failure in patients with IBD*Know the reasons for growth failure in patients with IBD*Know that pts with CD may have GF secondary to *Know that pts with CD may have GF secondary to
decreased caloric intakedecreased caloric intake
ArthritisArthritis PeripheralPeripheral
10%10% Larger jointsLarger joints Related to active colonic diseaseRelated to active colonic disease
AxialAxial Ankylosing spondylitis/SacroiliitisAnkylosing spondylitis/Sacroiliitis Rare in childrenRare in children
*Recognize that arthritis may occur in patients with IBD*Recognize that arthritis may occur in patients with IBD
Extraintestinal Extraintestinal ManifestationsManifestations
SkinSkin Pyoderma Pyoderma
gangrenosgangrenosumum
Erythema Erythema nodosumnodosum
Extraintestinal Extraintestinal ManifestationsManifestations
LiverLiver SteatosisSteatosis Elevated enzymesElevated enzymes Chronic hepatitisChronic hepatitis Sclerosing cholangitisSclerosing cholangitis CholelithiasisCholelithiasis Acalculous cholecystitisAcalculous cholecystitis Budd-Chiari SyndromeBudd-Chiari Syndrome
Extraintestinal Extraintestinal ManifestationsManifestations
PancreasPancreas PancreatitisPancreatitis
BoneBone OsteopeniaOsteopenia Aseptic NecrosisAseptic Necrosis
EyeEye UveitisUveitis EpiscleritisEpiscleritis KeratitisKeratitis
Extraintestinal Extraintestinal ManifestationsManifestations
UrologicUrologic NephrolithiasisNephrolithiasis Obstructive hydronephrosisObstructive hydronephrosis Enterovesical fistulaEnterovesical fistula NephritisNephritis Amyloidosis Amyloidosis
Extraintestinal Extraintestinal ManifestationsManifestations
HematologicHematologic AnemiaAnemia
IronIron FolateFolate B12B12 AutoimmuneAutoimmune
ThrombocytosisThrombocytosis ThrombocytopeniaThrombocytopenia
HypercoaguableHypercoaguable
Extraintestinal Extraintestinal ManifestationsManifestations
DiagnosisDiagnosis No substitute for H&PNo substitute for H&P LabsLabs
AnemiaAnemia Most due to iron deficiencyMost due to iron deficiency
ThrombocytosisThrombocytosis ESR – 80% CD, 40% UCESR – 80% CD, 40% UC CRPCRP
Sensitive for active diseaseSensitive for active disease Low albuminLow albumin
Protein loss and malnutritionProtein loss and malnutrition Elevated liver enzymesElevated liver enzymes pANCA, ASCApANCA, ASCA
DiagnosisDiagnosis RadiographsRadiographs
UGI with SBFTUGI with SBFT CDCD
EndoscopyEndoscopy GrossGross MicroscopicMicroscopic
ComplicationsComplications CTCT
Abscess Abscess
*Plan the initial evaluation of a patient with suspected IBD*Plan the initial evaluation of a patient with suspected IBD
Admit?Admit?
Severe ColitisSevere Colitis FeverFever HypoalbumnemiaHypoalbumnemia Anemia Anemia >5 bloody stools/day>5 bloody stools/day
Bowel rest, TPN, IV Bowel rest, TPN, IV steroids and careful steroids and careful monitoringmonitoring
ManagementManagement
PharmacologicPharmacologic AminosalicylatesAminosalicylates
Mesalamine, sulfasalazineMesalamine, sulfasalazine Mild colonic inflammationMild colonic inflammation
CorticosteroidsCorticosteroids Prednisone, budesonidePrednisone, budesonide Moderate to severe symptomsModerate to severe symptoms
>5 bloody stools/day, fever, hypoalbuminemia, >5 bloody stools/day, fever, hypoalbuminemia, anemiaanemia
Goal is to decrease symptoms then change to Goal is to decrease symptoms then change to maintenance therapymaintenance therapy
ManagementManagement
PharmacologicPharmacologic ImmunomodulatorsImmunomodulators
Azathioprine, 6-MP, methotrexateAzathioprine, 6-MP, methotrexate Steroid dependant or refractorySteroid dependant or refractory Maintenance Maintenance
BiologicsBiologics InfliximabInfliximab Steroid dependant or refractorySteroid dependant or refractory MaintenanceMaintenance
ManagementManagement
PharmacologicPharmacologic AntibioticsAntibiotics
Metronidazole, ciprofloxacinMetronidazole, ciprofloxacin Perirectal fistula, abscessPerirectal fistula, abscess
ProbioticsProbiotics Lactobacillus GG, Saccharomyces boulardiiLactobacillus GG, Saccharomyces boulardii Adjunctive therapyAdjunctive therapy
ManagementManagement
Nutrition TherapyNutrition Therapy PrimaryPrimary AdjunctiveAdjunctive Important for Important for
RemissionRemission Chronic undernutritionChronic undernutrition Growth failureGrowth failure
ManagementManagement
Surgical TherapySurgical Therapy Uncontrolled GI bleedingUncontrolled GI bleeding Bowel perforationBowel perforation ObstructionObstruction Unacceptable medication toxicityUnacceptable medication toxicity Intractability Intractability Growth failureGrowth failure Some perirectal diseaseSome perirectal disease CancerCancer
PrognosisPrognosis
UCUC 70% remission in 3 months70% remission in 3 months 50% remission for 1 year50% remission for 1 year 10-26% colectomy within 5 years10-26% colectomy within 5 years 70% likelihood of severe disease if 70% likelihood of severe disease if
proctitis presentproctitis present
PrognosisPrognosis
CDCD 1% will not have at least one relapse1% will not have at least one relapse IleocolitisIleocolitis
Responds poorly to medical therapyResponds poorly to medical therapy Greater need for surgeryGreater need for surgery
70% will have surgery within 10-20 70% will have surgery within 10-20 years of diagnosisyears of diagnosis
CancerCancer Colitis >10 y and extentColitis >10 y and extent Sclerosing cholangitisSclerosing cholangitis