Clinical Approach To IBD And IBS Flashcards
Crohn’s disease
Chronic inflammatory disease that affects any aspect of the GI tract
- usually seen in in ileum or colon though
- commonly shows: skip lesions, cobblestoning with creeping fat, transmural infarcts
More common Symptoms:
- diarrhea
- abdominal pain
- rectal bleeding
- fever
- weight loss
- fatigue
- peak age of onset (20-40s)
Location of Crohn’s disease and associated symptoms
Ileum and colon = 35%
- diarrhea
- cramping
- abdominal pain
- weight loss
Colon only = 32%
- diarrhea
- rectal bleeding
- perirectal abscess
- fistula/ulcers
Small bowel only = 28%
- diarrhea
- cramping
- abdominal pain
- weight loss
- abscesses and fistula
most rare form is only gastroduodenal region
Prevalence of extraintestinal manifestations in Crohn’s disease
9-75% = anemia
- most common!
13-34% = Cholelithiasis
10-35% = inflammatory arthropathies
2-30% = osteoporosis
Aphthous stomatitis and uveitis is also possible
Risk factors for Crohn’s disease
NOD2 gene (20-40x increased risk)
Smoking
Oral contraceptives
Widespread Antibiotic use
Regular use of NSAIDs
Urban environment
Caucasian race
Risk resistant factors for Crohn’s disease
Exposure to pets and farm animals
Having more than 2 siblings
High fiber intake
Fruit consumption
Physical activity
What are the most common differential diagnosis?
Celiac disease
Chronic pancreatitis
Colorectal cancer
Diverticulitis
Yersinia mycobacterium infections
Irritable bowel syndrome**
Ischemic colitis
NSAID associated enteropathy
Infectious enterocolitis
Lymphoma of small bowel
Sarcoidosis
Ulcerative colitis**
** = most common
Subsections of classification based of the Montreal classification table
Age of diagnosis
- <16 years = A1
- 17-40 years = A2
- > 40 years = A3
Disease location
- ileal only disease = L1
- colonic only disease = L2
- ileocolonic disease = L3
- upper isolated GI disease = L4
Disease behavior
- non penetrating or structuring = B1
- structuring = B2
- penetrating = B3
- perianal disease = p
When do you get surgery for Crohn’s?
Once fistula/abscesses develop
Sometimes strictures as well if they causes a permanent bowel obstruction
Ulcerative colits
Is a chronic idiopathic bowel disease that starts at the rectum mucosa and Submucosa layers ONLY and then works up from rectum
- has continuous lesions rather than skip lesions
Symptoms: (gradual onset)
- bloody diarrhea
- abdominal pain
- tenesmus and urgency
- weight loss (more common in CD though)*
- low grade fever (more common in CD though)*
- peak age = 30-40years
Common extraintestinal manifestations of ulcerative colitis
Arthritis (21%)
- most common
Aphthous stomatitis (4%)
Primary sclerosing cholangitis (4%)
(more common in UC than CD)
Erythema nodosum (3%)
Ankylosing spondylitis (3%)
What are the 4 main subtypes of UC?
1) proctitis (most common)
- UC limited only to the rectum
2) Proctosigmoidits
- UC limited only to the rectum and sigmoid colon
3) left sided UC
- UC limited only to the left side of the colon
4) extensive colitis
- any UC that extends past just the left colon
Risk factors for UC
Genetic and environment
- family history (increases 8-14x)
- living in western world
- living in higher altitudes
Widespread antibiotic use
GI infections (salmonella and C. Jejuni ar most common)
- NSAID chronic and high dose use
smoking is actual helpful, but never counsel patients to start smoking since negatives far outweigh benefits
Evaluation and diagnosis of UC
Stool studies to rule out other diarrhea causes
ESR/CRP/fecal calprotectin/fecal lactoferrin
- non specific though but is good for IBD vs IBS
Biopsy are confirmatory
differences in symptoms from mild to fulminant ulcerative colitis
Mild:
- less than 4 bowel movements per day
- intermittent bloody stool
- temp/HR and hemoglobins re normal
- ESR is relatively normal (<30 mm/h)
- colon and clincial signs are normal
Severe
- greater than 6 movements per day
- frequent bloody stools
- fever >37.5C
- HR = > 90 beats
- hemoglobin is <10.5 g/dL but doesn’t require transfusion
- ESR is greater than 30 mm/h
- edemtous colonic wall
- abdominal tenderness is present
Fulminant
- greater than 10 movements per day
- continuously bloody stools
- fever >37.5C
- HR = > 90 beats
- hemoglobin is <10.5 g/dL and requires transfusion
- ESR is greater than 30 mm/h
- dilation of colonic wall
- abdominal tenderness and distention is present
What factors signal poor prognosis of ulcerative colitis?
Age <40 years at diagnosis
Extensive colitis
Severe endoscopic disease
- requires mayo score 3 or greater OR/AND UCEIS score of 7 or greater
Was hospitalized for UC
Low serum albumin
the more factors above that are seen, the higher the likelihood of needing a colonectomy
Irritable bowel syndrome (IBS)
Is a chronic and sometimes disabling functional bowel disorder that always produces recurrent ab pain associated with defecation or in association with a change in stool frequency/form
Subtypes are:
1) IBS w/ constipation
2) IBS w/ diarrhea
3) IBS w/ mixed symptoms of constipation and diarrhea (needs greater than 25% constipation and diarrhea)
4) IBS unclassified
Clinical features of IBS
Varies tremendously
Symptoms:
- # 1 is chronic ab pain/discomfort especially when defecting (sometimes improves the pain however but this is rare)
- abdominal bloating with belching and flatulence increased occurrences
- has abnormal stool (varies with how its abnormal)
Triggers:
- emotional stress
- certain meals
What are the 7 types of IBS based on the Bristol stool form scale?
All based on how the stool looks
1) = hard separate lumps (look like nuts)
2) sausage lumpy shaped stool
3) sausage with out lumps but has cracks
4) smooth and soft snake like appearance
5) soft blobs with clear edges
6) soft blobs without clear edges and is more mushy
7) watery entirely liquid
** Types 1/2 = constipation; Types 3-5 = normal; types 6-7 = diarrhea**
Common Differential diagnosis of IBS
Carcinoid tumors
Celiac disease
Colorectal cancer
Diverticular disease
Overuse of opiates/analgesics/CCBs and antidepressants
GI infections (especially giardia)
Hyper/hypothyroidism
IBD
Ischemic colitis
Lactose intolerance
What are the warning signs that rule out IBS?
Age is greater than 50 yrs w/ no prior colon cancer screening
Recent change in bowel habits (less than 1 month)
Overt GI bleeding is present
Nocturnal pain or passage of stools at night
unintentional weight loss
Family history of colorectal cancer or IBD
Palpable abdominal mass or lymphadenopathy
Evidence of iron-deficiency anemia on blood testing
Positive fecal occult blood test
What is the low FODMAP diet?
A diet where the following is restricted:
- fructose/lactose and galactose
- oligo /disaccharides
has low evidence for efficacy but is being researched
Requires 3 steps:
- 1) elimination = 2-6 weeks of complete removal of foods (wait until symptoms go away)
- 2) reintroduction = 6-8 weeks after symptoms go away and slowly bring back food groups and try to identify food triggers
- 3) personalization = as needed
Common foods to avoid
- wheat
- dairy products
- honey/apples/pears/peaches
- fruit juice
- lentels/legumes
- green beans
- coffee/soda
- sugar-free gum
