Inflammatory Bowel Disease Steven N. Carter, MD Colon and Rectal Surgery Assistant Professor...

Inflammatory Bowel Disease

Steven N. Carter, MDColon and Rectal Surgery

Assistant ProfessorUniversity of Oklahoma

Crohn’s and Colitis Clinic: 405-271-8478Clinic appointment: 405-271-8478

IBD Nurse Practioner: 405-271-5428 Ext. 53424IBD Center Office: 405-271-5428

Office fax: 405-271-5803GI Endoscopy lab: 405-271-8737

OUMC operator: 405-271-5656Colon and Rectal Surgery Clinic 405-271-1400

Objectives

• 1. Discuss the diagnosis and evaluation of suspected inflammatory bowel disease.

• 2. Be able to differentiate Crohn's disease from Ulcerative Colitis.

• 3. Discuss treatment and surveillance of inflammatory bowel disease.

• No Disclosures

Inflammatory Bowel Disease

• Epidemiology• Classification• Evaluation• Treatment• Surveillance• Simply Case Presentations

Inflammatory Bowel Disease• 1932 – Crohn, Ginzburg, and Oppenheimer

described 13 cases if regional ileitis• 1959 & 1960 – Brooke and Lockart-Mummery

described the segmental nature of Crohn’s Colitis

• 1959-Truelove and Witts high dose cortisone for CD

• 1978- Parks and Nicholls describe ILAA 1. Crohn BB, Ginzburg L, Oppenheimer GD. Regional ileitis. AMA Am J Dis Child, 1932; 99: 1323-9.

2. 2. Brooke BN. Granulomatous disease of the intestine. Lancet 1959; 2 (7106):745-9.3. Lockhart-Mummert HE, Morson BC. Crohn’s disese (regional enteritis)of the large intestine and its distinction from UC. Gut. 1960; 1:87-105.

4. Truelove SC, Witts LJ, Bourne WA, et al. Cortisone and cortitropin in UC. Br Journal of Medicine. 1959; 1(5119): 387-94.5. Parks AG, Nicholls RJ. Proctocolectomy without ileostomy for UC. British Journal of Medicine. 1978; 2:85-88.

Epidemiology

• Prevalence varies greatly throughout the world– Symptoms often wax and wane

• Incidence has been increasing over the past 20-30 years– Crohn’s 5/100k annually– UC .5-24.5/100k annually– Suggests an environmental component

• Occurs in the 2nd-3rd decade of life1. Loftus Jr. EV, Schoenfeld P., Sandborn, WJ. The epidemology and natural history of Crohn’s disease in population based patient

cohorts from North America: a systemic review. Aliment Pharmacol Ther. 2002; 16: 51-60.2. CDC

Epidemiology

• Interplay between environment and genes• The relative risk for concordance of CD in a

monozygotic twin pair is approximately 800-fold greater than the general population– Less so for UC

• Some examples of early IBD related to genetic defects in T-Cell regulation, cytokines, etc.

Kaser A, et. Al. Genes and Environment: How Will Our Concepts on the Pathophysiology of IBD Develop in the Future? Genes and Environment: How Will Our Concepts on the Pathophysiology of IBD Develop in the Future? Dig Dis. 2010 October; 28(3): 395–405.

Epidemiology

Kaser A, et. Al. Genes and Environment: How Will Our Concepts on the Pathophysiology of IBD Develop in the Future? Genes and Environment: How Will Our Concepts on the Pathophysiology of IBD Develop in the Future? Dig Dis. 2010 October; 28(3): 395–405.

Hygiene Hypothesis

• Helminthes have colonized humans for thousands of years.

• Immunological influence on host cells– Prevent excessive immune response

• Aggressive hygienic practices in the West may negatively affects immune system development

• Therapeutic implications

Weinstock JV and Elliot DE. Helminths and the IBD Hygiene Hypothesi. Inflammatory Bowel Disease. 2009 January; 15 (1) 128-133.

Epidemilogy

• Whites & Blacks >> Hispanics and Asians• Northern Climates• Urban>Rural• Sugar Consumption (Crohn’s)• EtOH (decreases UC incidence)• Higher socioeconomic status• OCP’s• Cigarettes

– Decrease in UC– Increase in CD

• Appendectomy – decreases incidence in Crohn’sASCRS Textbook

Classification and DiagnosisCrohn’s Disease vs Ulcerative Colitis

Crohn’s Disease• 75% complain of Abdominal pain and Diarrhea• 40-60% complain of Wt Loss, Fever, and bleeding• Many different classification systems have been

proposed– Vienna classification is based on behavior

• Stricture vs Fistula• Most important predictor of future disease is past behavior

– Mostly academic• Majority of patients have years of quiescence (60-70%)– 10-20% have chronic unrelenting disease

ASCRS Textbook

Munkholm et al

• Regional Cohort Study– Copenhagen – 373 patients– 1962-1987

• Examined the long term disease course of Crohn’s disease– Remission Predictive Factors– Relapse Predictive Factors

Munkholm P, Langholz M, et a. Disease Activity Courses in a Regional Cohort of Crohn’s Disease patients. Scandanavian Journal of Gastro. 1995 Jul;30(7):699-706.

Probability of only having one attack

~22% at 5 years


• One year probability of having active disease vs remission

• Patients with Active Disease the Year before

Active Disease

Remission


Active Disease the Year Prior

Active Disease

Remission

• One year probability of having active disease vs remission

• Patients in Remission the year beforeMunkholm P, Langholz M, et a. Disease Activity Courses in a Regional Cohort of Crohn’s Disease patients. Scandanavian

Journal of Gastro. 1995 Jul;30(7):699-706.

Remission the Year Prior

• Active Disease imparts a 70-80% probability of maintaining a similar state the following year

• Remission imparts a 80% probability of remission the following year

• Regardless of year after diagnosis


Crohn’s DiseaseCrohn’s Disease-40% of patients-Abdominal pain-Also associated with perianal disease

Colonic Disease-30% of patients-Diarrhea and bleeding

Stricture

Fistula

Acute

Chronic

Crohn’s flare / exacerbation

Ulcerative Colitis

• Extent of disease is related to location– Always starts at Rectum and extends proximally– No skip lesions

• Bloody and Mucus diarhea• Rectal disease

– Diarrhea– Hematochezia– Tenesmus– Incontinence

• Proximal Disease– Wt loss– Abdominal Pain

GI SymptomsSigns and Symptoms

• Crohn’s– Mouth to Anus– Discontinuous– Transmural inflammation– Most common

complaint: pain + diarrhea

• U.C.– Rectum and moves

proximally – Continuous– Mucosal Disease

• Severe disease can be transmural

– Classical Bloody Diarrhea

Indeterminate Colitis

Extraintestinal Manifestations

• Musculoskeletal – Osteoporosis/osteopenia– Arthritis• Ankylosing Spondylitis (5%)

• Pyoderma Gangrenosum• Primary Sclerosing Cholangitis – UC• Ophthalmological • Coagulopathy

http://en.wikipedia.org/wiki/File:Crohnie_Pyoderma_gangrenosum.jpgASCRS textbook

http://en.wikipedia.org/wiki/File:Crohnie_Pyoderma_gangrenosum.jpg

Evaluation

• Difficult to make diagnosis• Rule out infectious sources– C. Diff– Stool Studies

• Diagnosis is dependent – Clinical suspicion– Radiological evaluation – Pathology

Radiology

• Abdominal X-Ray– Signs of obstruction– Loss of haustra markings

• Contrast Studies (Small Bowel Follow Through)– Crohn’s SB Strictures/Fistulas– Superior to CT’s for many fistulas

• Computed Tomography – Evaluate thickness of the bowel– r/o other etiologies of abdominal pain

• MRI

Evaluation

• Colonoscopy is the study of choice for patients suspected of having UC or colonic involvement of Crohn’s– Allows for pathology– Monitor response to treatment– Cancer surveillance

• Office procedures include rigid proctoscopy and flexible sigmoidoscopy

Serum Tests

• Acute phase reactants– ESR and C-Reactive Protein– Active disease vs stricture

• Nutritional parameters• Immune regulatory pathway markers– Aid in differentiating Crohn’s vs UC

• Any patient with diarrhea or suspected of having a flare should have common causes ruled out – C. Diff– Stool cultures

Standard Workup in Acute Settings

• Stabilize the patient• Basic labs, CRP and ESR• Infectious workup– Empiric antibiotics?

• Abdominal Series• Colonoscopy vs CT of Abd/Pelvis– Bloody Diarrhea – Colonoscopy– Abdominal Pain -- CT

TreatmentAs far as I’m concerned, if something is so complicated that you can’t explain it in 10 seconds, then it’s probably not worth knowing anyway.

Treatment

• Crohn’s vs UC– Location of Crohn’s– Behavior of Crohn’s

• Acute vs Chronic Pathology

Stricture

Fistula

Acute/Medical management

Chronic/Surgery

Crohn’s Disease

Crohn’s DiseaseMedical Management

• Mild to Moderate Disease– Sulfasalazines– 5-Aminosalicylates– Antibiotics• Ciprofloxacin has been shown to be as effective as 5-

ASA compounds in mild-moderate disease• Metronidazole

– Budesonide• Topical Steroid

Medical Management

• Mild to Severe – Steroids– Immunomodulators• 6-mercaptopurine• Azathioprine• Delayed benefit, durable results

– Methotrexate– Biologic Therapy

Top – Down Approach

• SONIC Trial 2010– 508 randomized– Overall looked at

280 patients at 26 weeks

– Extended to 50 weeks with similar results.

Top Down Approach• CHARM Study

– 854 Patients– Placebo vs adalimunab– Adalimunab has a 50%

reduction in all hospitalizations compared to placebo

• 33% will eventually fail to respond to biological therapy– Antibody formation may

reduce effectiveness over time• Combination therapy may

alleviate this.

Hanauer SB, Feagan BG, Lichtenstein GR. et al. Maintance Infliximab for CD: the ACCENT I randomized trial. Lancet. 2002; 359(9317):1541-9.

Week 26 Week 560

5

10

15

20

25

30

35

40

Placebo Adalimumab 40 mg EOW

Weekly

Patie

nts

%

Top Down Approach

Surgery and Crohn’s Disease

• Not Curable• Conservative Resection• Area of previous anastomosis is most likely site of

recurrence• Indications– Obstruction– Fistula– Hemorrhage– Colitis– Neoplasia– Failed medical management

Ulcerative Colitis

• Colonoscopy to evaluate extent of disease• Mild to Moderate and Distal to the splenic

flexure– Topical steroids, 5-ASA– Oral – 5-ASA

• Mild to Moderate and proximal to the splenic flexure – 5-ASA– Steroids

Ulcerative Colitis Treatment

• Goal is mucosal healing• Severe colitis– Intravenous Steroids– Azathioprine– 6-mercaptopurine– Cyclosporine– Tacrolimus– Infliximab (Remicade)• Decreases rate of colectomy at 3 months and 1 year

Ulcerative Colitis and Surgery

• 20-30% of patients will require surgery• Emergent/Urgent Indications– Hemorrhage– Toxic Megacolon– Perforation– Serve Colitis unresponsive to medial management

• Elective Indications– Cancer/Dysplasia– Adverse events/symptoms from medical therapy– Medical Failure

Ulcerative colitis

• Emergent Surgery– Total Colectomy with end ileostomy– Reversal at a later date

• Elective– Total Colectomy with end ileostomy– Total Colectomy with ileorectal anastomosis– Total Proctocolectomy with Ileostomy– Total Proctocolectomy with Ileo-anal Anastomosis• Procedure of choice

– Continent ileostomies

Ulcerative Colitis – J-Pouch

• Removal of all colon and rectum

• Patients can expect to have 6 BM’s per day– Control with Immodium or

Lomotil– Minor Incontinence

• Stricures 5-35%• Pouchitis

J-Pouch

• Over 95% are happy with their pouches and would not go back to a ileostomy

• Perianal Hygiene– Hairdryer– Moisture Barrier– Pad

• Failures – Crohn’s– Pelvic Sepsis– Poor Function ASCRS Textbook

Surveillance

• Crohn’s Colitis and Ulcerative Colitis– Random Biopsies to r/o Dysplasia every 1-2 years– Age to begin Screening• 7-8 years after onset of pan colitis• 12-15 years after the onset of left sided colitis

• Ulcerative Colitis– 10% risk of Cancer after 20y of disease– All UC patients have a 4% prevalence of cancer

ASCRS TextbookASCRS Practice Parameters

Crohn’s disease and Surveillance

• Relative Risk of Developing Cancer compared to general population– Small Bowel – 28.4– Colorectal – 2.4– Extra-intestinal Cancer -1.27– Lymphoma – 1.42

Diarrhea in the IBD patient

• Common things are common• C. Diff• Stool studies• Colonoscopy vs Flexible sigmoidoscopy• Treatment– Cipro/Flagyl– Probiotics• Xifanin

Small Bowel Obstruction in Crohn’s

• Etiology• CRP/ESR along with basic labs• Patience• If active flare -7-10 course of steroids– Unlikely to resolve after this.

Conclusion

• 40yo/female with LLQ crampy abdominal pain and watery diarrhea– Colonoscopy– Imaging– Stool Studies– Treatment• Probiotics• Antibiotics• 5-ASA• Budesonide• Biological Therapy

Conclusion

• 32yo/male complains of bloody diarrhea– Toxic?– Endoscopy– Stool Studies– Treatment• 5-ASA• Probiotics• Steroids?• Remicade

Conclusion

• Inflammatory Bowel Disease requires a high degree of suspicion to make the diagnosis

• Appropriate imaging or endoscopy can greatly aid in the diagnosis

• Treatment should be tailored to the individual patient

• Cancer screening must be addressed in all IBD patients

Crohn’s and Colitis Clinic: 405-271-8478Clinic appointment: 405-271-8478

IBD Nurse Practioner: 405-271-5428 Ext. 53424IBD Center Office: 405-271-5428

Office fax: 405-271-5803GI Endoscopy lab: 405-271-8737

OUMC operator: 405-271-5656Colon and Rectal Surgery Clinic 405-271-1400

Inflammatory Bowel Disease Steven N. Carter, MD Colon and Rectal Surgery Assistant Professor...

Documents

Transcript of Inflammatory Bowel Disease Steven N. Carter, MD Colon and Rectal Surgery Assistant Professor...