Crohns Disease Flashcards
Crohns Disease
transmural inflammation that can affect any part of the GI tract (UC is colon only)
Relapsing/remitting GI infl. episodes
Will see patchy infl. cobblestoning, ulcers, exudates, altered vascular patterns, edema and bleeding
% of patients under 20 years old
25%
presentation in kids <6 years
“very early onset IBD” VEO-IBD
more severe and refractory
More genetic
cause of Crohns
unknown
enviornmental triggers, microbiome, immune response, genetic succeptability
Enviornmental triggers
diet, hygiene, smoking, Vit D, stress, depression
dysbiosis
disruption of the microbiome balance
IBD is limited to
westernized industrial populations
Risk factors
smoking, prior appy, stress, depression
Presenting s/s
abd pain, diarrhea, rectal bleeding, wt loss, skin tags, peds patients have extensive s/s
Diagnostic lab tests
None for IBD or Chrons
CBC
leukocytosis, chronic anemia, thrombocytosis
HGB
Correlate HGB with MCV to assess chronicity
ESR and CRP
elevated inflammatory markers
serum albumin
marker of long standing intestinal damage
calprotectin and lactoferrin
neutrophil associated proteins
stool sample test for luminal inflammation
Scoping
esophagus, stomach, proximal duodenum
mucosal biopsies of upper and lower
Treatment:
Aminosalicytes (2)
Sulfasalazine and mesalamine
treat colonic Chrons
Treatments:
corticosteriods
Maintenance therapy or induction of remission?
prednisone/prednisilone
methylprednisolone sodium succinate
budesonide
Used to induce remission, NOT for maint therapy d/t serious advers effects
Treatments:
Immunomodulators (3)
Maintenance therapy or remission induction?
Azathioprine
6-mercaptopurine
methotrexate
Used to maint. steriod free remission
Use in conbo with biologic to decrease immunogenecity
Treatments
Biologic agents (5)
Maintenance or remission induction therapy?
nfliximab (infusion), adalimumab (subq)
certolizumab, vedolizumab, natalizumab
“rescue” therapy for severe steriod dependent or steriod refractory disease
Anit TNF agents considered first line depending on situation
Used for either induction or maintenance
Requires monitoring for infectious compl.
must be sure TB neg prior to admin
Surgery
for fibrotic disease if pharm therapy is not successful
Treatments
Antibiotics
metronidazole, cipro, rifaximin
controversial use
used in patients with active perianal disease
Treatments
Others
Calcineurin inhibitor - thalidomide
probiotics, lactobacillus, saccharomyces boulardil
“rescue” therapy for severe steriod dependent or refractory disease
bridging therapy for patients with refractory colitis
recurrent pouchitis p colectomy
role as maint therapy unknown
Diet
specific carbs, elimination diets, low-sulfur, ayurvedic diets
patients report benefit, no research support
supplements
ommega 3 fatty acids, probiotics,
aloe- anti-infl, antioxidant, immune stimulatory
herbals- indian ayurveda
accupuncture
biobehavioral methods
stress alters gut permiability and immune modulation
embarassing for adolescents
increased risk of psyc discorders
relaxation, meditation, prayer
CBT, gut focused hypnotherapy
Growth concers
impaired lineral growth may preceed GI symptoms- may be only presenting sign of IBD
Bone concerns
affected by disease and treatment
bone mass defects
nutr def, physical inactivity, infl cytokines and steriods negatively impact bone growth and formation
bone density can be marker of disease
failure to control infl = increased risk of fracture
bone delay may persist despite treatment
Vaccinations
aviod all live vaccines if immunosupressed or significant protien-cal malnutrition
give flu shot (no mist)
Pneumococcal, HPV- rates higher in immunosupresssed
EBV- higher risk of developing hemophagocytic lymphohistiocystosis ( body makes too many immune cells)
What is immunocompromised?
prednisone 20mg/day or 2mg/kg/day for two weeks or within 3 moths of stopping
thiopurines, methotetrexate, anti TNF, a agents or other biologics, or within 3 months of stopping
Referals- opthomology
annual eye exam - slit lamp, IOP meas
conjuctivitis, uveitis (can be asymptomatic), episcleritis
increased IOP from steriods
Referals - Derm
annual exam, monitor for skin cancer
derm manefestations of IBD - erythema nodosum, pyoderma gangrenosum, psoriasis
higher risk of non-melinoma skin cancer
Referral - Joint involvement
3 conitions:
ankylosing spondylitis, peripheral arthritis, enthesitis
differentiate between mechanical and infl pain
inspect symmetry and ROM
rheumathology if they have poor response to therapy or have persistant joint complaints after control of GI symptoms
Liver
transient elevation of liver enzymes, certain anomalies require further workup
Dietary and nutrition
Nutritional assessment at diagnosis and regularly after
May have decreased appetite
May need supplementation or enteral nutrition
iron deficiencies
iron deficiency anemia most common type
fatigue, lethargy, dizziness
higher rate of anemia with CD versus UD
folate and B12
rare in those newly diagnosed
common if patient is on antifolate medication - methotrexate or with terminal ileal disease
vitamin D
abd in small int to promote bone health
improvinf Vit D status may improve s/s and infl
Zinc
essential for the immune system
at risk in patients with IBD d/t losses from GI tract
Exclusive enteral nutrition (EEN)
use of nutritional interv. as antiinfl. therapy
elemental or polymeric formula for 6-8 weeks to induce remission especially in Chrons
guided by dietitian
patients with fibrotic strictures
may benefit from low residue diet
Infl in small intesting reults in
protien loosing enteropathy
fat malabsorption
risk of Vit D def
patients with active s/s have poor apetite and low energy
Psyc
increased risk of depression
med adherance issues
poor sleep quality- may impact school
CBT can be helpful
meds: seratonin and dopamine reuptake inhibitors help with anixety and depressive symptoms
Impact 3 questionare
for pateints with IBD 10+
IBD quality of life index
18 years and older
Resources
GIkids.org
crohnscolotosfoundation.org
