GI - Acute and Chronic Diarrhea + IBS and IBD Flashcards
Ddx infective and non-infective causes of acute diarrhea
Infective: → Gastroenteritis (vast majority) → C. difficile infection → Other GI infections, eg. diverticulitis → Malaria
GI non-infective:
→ IBD
→ CA colon
Metabolic: → DKA → Hypocalcaemia → Uraemia → Thyrotoxicosis → Neuroendocrine diseases
Drugs: antibiotics, NSAIDs, cytotoxic agents, PPI
Toxins: ciguatera fish poisoning, heavy metal poisoning
Acute diarrhea
4 pathological groups of infective causes + examples
- Food poisoning - preformed toxins:
B. cereus
S. aureus
Clostridium perfringens
2. Non-inflammatory, small bowel: V. cholerae Enterotoxigenic E. coli Norovirus Rotavirus (children) Giardia lamblia Cryptosporidium parvum
3. Inflammatory, large bowel: EHEC* Shigella* Campylobacter Non-typhoidal Salmonella Clostridium difficile Entamoeba histolytica*
- Invasive:
Salmonella typhi
Salmonella paratyphi
(Yersinia)
Infective food poisoning
- Bacteriology
- Pathogenesis
- Incubation period
- Presentation
Non-inflammatory acute GE
- Bacteriology
- Pathogenesis
- Incubation period
- Presentation
Inflammatory acute GE
- Bacteriology
- Pathogenesis
- Incubation period
- Presentation
Invasive acute GE
- Bacteriology
- Pathogenesis
- Incubation period
- Presentation
Acute GE in winter months, children predominant
Present with vomiting, diarrhea, prodromal features for few days
Most common pathogens
Viral causes: majority of acute GE, usually mild
□ Norovirus: accounts for >1/3 of outbreaks
→ Esp common in winter months
□ Other viruses: usually causes ds in children
→ Eg. rotavirus, adenovirus, astrovirus
Acute GE presents with severe watery diarrhea within hours of meal
Similar features in people who share meals
Most likely causative pathogens
□ Toxin-mediated: a/w food poisoning
→ S/S: prominent N/V w/ short incubation
→ Eg. B. cereus typically a/w rice
→ Eg. S. aureus typically a/w prepared food
Acute GE, presents with watery, large volume diarrhoea a/w abdominal cramping, bloating and gas
Over 3-5 days
No blood in stool or fever
Most likely causative agents
Non-inflammatory pathogens:
V. cholerae Enterotoxigenic E. coli Norovirus Rotavirus (children) Giardia lamblia Cryptosporidium parvum
Acute GE, presents with frequent, regular, small volume and often painful bowel movements
a/w fever and bloody/mucoid stools
Most likely pathogens
Inflammatory pathogens
EHEC* Shigella* Campylobacter Non-typhoidal Salmonella Clostridium difficile Entamoeba histolytica*
Define likely pathogens associated with following food:
Rice Seafood Raw eggs Uncooked meat, poultry Unpasteurized dairy products Canned food
Rice: Bacillus cereus
Seafood: Norovirus, Vibrio spp, hepatitis A
Raw eggs: Salmonella spp
Uncooked meat, poultry: Salmonella spp, Campylobacter spp, EHEC, C. perfringens
Unpasteurized dairy products: Salmonella spp, Campylobacter spp, EHEC, Yersinia enterocolitica
Canned food: C. botulinum
Outline history taking for acute diarrhea
□ Diarrhoea: syndrome, duration, amount, frequency, presence of blood, mucus or fat
□ Associating symptoms: abdominal pain, fever, N/V, poor appetite
□ Food history: intake, changes in preparation or content, unhygienic food
□ Travel, occupation, contact, cluster
□ Dehydration: frequent profuse watery diarrhoea, vomiting, poor fluid intake, concurrent fever, dry lips, oliguria
□ Other Hx: recent Antibiotics use, immunodeficiency
Clinical definition of diarrhea
Increase daily stool volume, frequency and fluidity
Stool weight > 250g/ 4h
> 2-3 times/ day or liquidity
First-line investigations for acute diarrhea
Indication for investigation
Basic metabolic panel: CBC, L/RFT, electrolytes ± blood culture
Stool examination:
→ Stool culture for bacterial pathogen
→ Stool microscopy for RBC, WBC, ova and cyst (if inflammatory or persistent)
→ Multipathogen panel for bacterial, viral and parasitEic pathogens (if inflammatory)
→ Specific toxin tests: E. coli O157:H7 test, Shiga toxin test, C. difficile toxin testing
Malaria workup: thick/thin blood smear if returning traveler
Indications:
severe illness, inflammatory diarrhea with high fever, persistent for > 1 week, high risk comorbidities and diseases
First-line management of acute diarrhea
Fluid: ORS or IV fluid if shock, unconscious
Antibiotics: ONLY FOR SEVERE or INFLAMMATORY DIARRHEA
Empirical Tx: azithromycin (if inflammatory) or fluoroquinolones
Specific Tx: metronidazole (C. dificile), amoxicillin/cotrimoxazole (Listeria)
Anti-diarrhoeal, eg. loperamide (Imodium), bismuth salicylate for inflammatory diarrhea
Clinical definition of chronic diarrhea
Categorize chronic diarrhea into 3 main pathophysiological groups
Definition: Loose stool > 4 weeks with >3 loose stools/ day
- Inflammatory: Inflammatory bowel diseases, chronic infections, colonic diseases
- Watery: Secretory, Osmotic and Motility problems
- Malabsorption
Inflammatory causes of chronic diarrhea
Inflammatory bowel ds:
Crohn’s disease
Ulcerative colitis
Chronic infections:
C. dificile
M. tuberculosis
Other colonic diseases:
CA colon
Chronic ischaemia
Malabsorptive causes of chronic diarrhea
Causes: small bowel diseases, gut resection, bacterial overgrowth, pancreatic diseases
e. g.Enteropathy: celiac disease, short gut syndrome, Crohn’s disease
e. g. Pancreatic insufficiency: chronic pancreatitis, CA pancreas
Secretory causes of chronic diarrhea
Endocrine tumours: VIPoma, carcinoid syndrome, Zollinger-Ellison syndrome
Bile salt malabsorption e.g. terminal ileum diseases/ resection
Laxative abuse
Osmotic causes of chronic diarrhea
Lactase deficiency
Osmotic laxative
(Malabsorption)
Hyper-motility causes of chronic diarrhea
IBS
Metabolic: hyperthyroidism
Chronic diarrhea presenting with Mucoid, bloody stools with PMN in stools
Most likely causes?
Inflammatory bowel ds
Crohn’s disease
Ulcerative colitis
Chronic infections
C. dificile
M. tuberculosis
Other colonic diseases
CA colon
Chronic ischaemia
Chronic diarrhea presenting with watery diarrhea that changes in fasting state, with no pus/blood/ fatty stool
Most likely causes
How to differentiate between causes?
Secretory - Persists with fasting
Endocrine tumours: VIPoma, carcinoid syndrome, Zollinger-Ellison syndrome
Bile salt malabsorption
Laxative abuse
Osmotic - Stops with fasting
Lactase deficiency
Osmotic laxative
(Malabsorption)
Motility
IBS
Metabolic: hyperthyroidism
Chronic watery diarrhea
+ steatorrhoea
+ weight loss
+ nutritional deficiency
Most likely causes
Malabsorptive: small bowel diseases, gut resection, bacterial overgrowth, pancreatic diseases
Enteropathy: celiac disease, short gut syndrome, Crohn’s disease
Pancreatic insufficiency: chronic pancreatitis, CA pancreas, CF
Drug-induced diarrhea
Most common causative drugs?
□ Acid-suppressing agents: antacids (esp Mg-containing), H2RA, PPI
□ Alcohol
□ Antibiotics
□ Caffeine: coffee, tea, cola
□ Sorbitol/mannitol: dietectic food, gums, mints (osmotic diarrhoea)
□ Others: β-blocker, NSAID/5-ASA, colchicine, misoprostol, theophylline
Outline P/E for chronic diarrhea
General:
- Dehydration: fluid and electrolyte depletion
- Nutritional status/ weight loss/ vitamin deficiency: Malabsorptive causes
Differentials:
- Hyperthyroidism causing hyper-motility: goitre, thyrotoxic signs
- IBD causing inflammation: episcleritis/uveitis, oral ulcers, arthritis, skin rashes, flushing
- Crohn’s or CA colorectal causing inflammation: PR exam
Signs of toxicity
- Fever
- Abdominal distension, peritoneal signs
First-line blood and stool investigations for chronic diarrhea
Blood tests:
- CBC: anaemia, leukocytosis, eosinophilia, thrombocytosis
- APR: ESR, CRP
- LFT: albumin (malabsorption, protein-losing enteropathy)
- RFT: electrolyte disturbance, hydration
- Serology:
→ AutoAb for IBD: p-ANCA (UC), ASCA (CD)
→ Serum Ig level: hypogammaglobulinaemia → recurrent GE
→ ± HIV Ab if noted lymphopenia - TFT for hyperthyroidism
Stool tests:
- Occult blood**
- Na, K for osmolal gap
- pH
- Leucocytes, microbiology**
- Fecal calprotectin
Differentials of eosinophilia
- Neoplasm
- Allergy
- Collagen vascular diseases
- Parasite infestation
- Eosinophilic gastroenteritis
Define spot stool analysis metrics and rationale
What’s tested and why?
Stool for occult blood: GIB
Stool for Na, K:
→ Stool osmolal gap: ↑ in osmotic, ↓ in secretory
Stool for pH:
→ <5.6 → carbohydrate malabsorption
Stool for leukocytes for inflammatory cause
Stool for microbiology for infective vs inflammatory
→ C. dificile toxin
→ Culture for Aeromonas, Plesiomonas
→ Microscopy for ova and cyst for protozoan and parasites
Fecal calprotectin: ↑ in inflammatory conditions
Fecal Calprotectin test
- Function
- MoA
Function: High in following causes of chronic diarrhea
- Infectious diarrhea
- Crohn’s disease and Ulcerative colitis
- Cancer
MoA: 24kDa dimer of Ca binding proteins released by neutrophils»_space; indicate migration of neutrophils into gut mucosa
First-line imaging investigations for chronic diarrhea
AXR: calcifications in chronic pancreatitis
Ba studies for mucosal abnormalities
→ Ba follow through/SB enema for SB mucosal abnormalities e.g. IBD, polyps, cancer
USG for pancreatic disease
CT/MR enterography for IBD and its complications
Lymaphangiogram for lymphagiectasia
Endoscopy
Protein losing enteropathy
- Disease entities
- Workup
Diseases:
IBD, Whipple’s disease, Allergic gastroenteropathy, Intestinal lymphangiectasia…etc
Workup:
1. Labeled human serum scan (find source of protein pooling)
- Fecal alpha-1-antitrypsin concentration (excessive GI protein loss)
- Serum alpha-1-antitrypsin clearance
Endoscopic investigation for chronic diarrhea
- Modalities
- Function
OGD, Capsule/ small bowel balloon enteroscopy, colonoscopy, sigmoidoscopy
obtain mucosal Bx for
→ IBD
→ Opportunitistic infections, eg. CMV colitis
→ Microscopic colitis
Management plan for chronic diarrhea
List options for supportive treatment and malabsorption
Specific Tx for underlying cause of disease
Supportive Tx:
□ Antidiarrhoeal drugs, eg. Lomotil, Imodium
□ Octreotide: ↓motility, useful in neuroendocrine tumour
□ Intraluminal absorbants, eg. charcoal
□ Bile acid-binding resin (cholestyramine) for bile acid malabsorption
□ Bismuth compounds
Treat malabsorption:
□ Dietary supplements: Ca, Mg, Fe, folate, vitamin A, B12, D, K
□ Pancreatic enzyme supplement, eg. pancreatin
□ Enteral and parenteral supplementation
Irritable bowel syndrome
Demographic
Associated conditions
Demographics: ↑ in younger (<50y) and female (14% vs 9%)
Associations:
→ Non-organic: eg. fibromyalgia, chronic fatigue syndrome, dysmenorrhea, functional dyspepsia, NCCP
→ Psychiatric: eg. depression, anxiety, somatization
Diagnostic criteria of IBS
Rome IV criteria with no alarming features
Recurrent abdominal pain on average ≥1 day/week
A/w ≥2 of
→ Related to defecation
→ A/w change in frequency of stools
→ A/w change in form (appearance) of stools
For the past 3 months
With symptom onset ≥6mo before diagnosis
Alarming feature against diagnosis of IBS
PMH: features of malignancy
- Weight loss
- Rectal bleeding and anaemia
- Age >50, Male sex
- Family history of colon cancer or IBD
Investigation results:
- Positive fecal occult blood test
- Anaemia with leukocytosis and high ESR
- Abnormal biochemistry
IBS
Clinical subtypes
□ IBS w/ diarrhoea (IBS-D): loose or watery stools ≥25% with hard stools <25% of bowel mov’t
□ IBS w/ constipation (IBS-C): hard stools ≥25% with loose/watery stools <25% of bowel mov’t
□ Mixed IBS (IBS-M): both hard + loose/watery stools ≥25%
□ Unsubtyped IBS (IBS-U): insufficient abnormality to meet above criteria
IBS
Pathogenesis
- Altered bowel motility, visceral hypersensitivity, intestinal inflammation and Serotonin imbalance
- Luminal factors:
- Altered gut microbes
- Small intestinal bacterial overgrowth
- Post-GE
- Gluten intolerance - CNS: autonomic nervous system and brain gut axis dysfunction
- Psychosocial/ psychiatric comorbidities
IBS
Clinical features
Recurrent abdominal pain:
- Usu cramping/colicky pain ± bloating, flatulence or belching
- ↑ by emotional stress, meals and throughout the day
Altered bowel habits:
- Diarrhoea: frequent loose stools of small to moderate volume
- Constipation: infrequent passage of ‘pellety’ stools
Ddx of IBS
□ Coeliac disease: steatorrhoea, malabsorption (eg. Fe-def/megalob anaemia, weight loss), child-onset, hyposplenism, duodenal Bx
□ IBD: constitutional Sx, inflammatory diarrhoea (S/S + Ix), characteristic colonoscopic appearance
□ CA colon: bloody stool, tenesmus, pencil-thin stools, FHx+, elderly male
IBS
Management plan outline
□ Reassurance and education
□ Dietary changes
□ Pharmacotherapy directed towards predominant symptoms
□ Psychotherapy if refractory to medications
IBS
Treatment for diarrhea
Diet: Low FODMAP diet
Drugs: Opioid agonist (loperamide) Bile salt sequestrants (cholestyramine) Probiotics Rifaximin
IBS
Treatment for constipation
High fiber diet
Dietary fibre (Psyllium)
Laxative (PEG)
Chloride channel activator (lubiprostone)*
Guanylate cyclase C agonist (linaclotide)*
IBS
Treatment for abdominal pain
Peppermint oil
Antispasmodics (otilonium, mebeverine)
Tricyclic antidepressant (amitriptyline, desipramine)
SSRI (citalopram, paroxetine, sertraline)
Chloride channel activator (lubiprostone)*
Guanylate cyclase C agonist (linaclotide)*
IBD
Differentiate demographics between UC and CD
Crohn’s
- Any, median age of onset 30
- Bimodal: 2nd-3rd decade + 7th decade
- 65% male
- ↑incidence
UC:
- Any, median age of onset 41
- Bimodal: 2nd-3rd decade + 7th decade
- 56% male
- Incidence static
Both have family history in 3%
IBD
Differentiate risk factors between UC and CD
Crohn’s
- ↑ w/ smoking
- Defective innate immunity and autophagy (NOD2, ATG16L1, IRGM)
UC
- ↓ w/ smoking, ↓w/ appendicectomy
- HLA-DR*103, colonic epithelial barrier function (HNF4a, LAMB1, CDH1)
IBD
Differentiate extent of GIT involvement between UC and CD
Crohn’s: Mouth to anus, skip lesions, rectal-sparing
- Small intestines and colon (40-55%)
- Small intestinal only (25-30%)
- Colon only (20-25%)
- Anorectal (30-40%)
- Upper GI tract (3-5%)
UC: Colon only, continuous, anus-sparing
- Begins at anorectal margin
- Proctitis alone (40-50%)
- Lt colitis alone (30-40%)
- Pancolitis (20%)
IBD
Differentiate endoscopic appearance between UC and CD
Crohn’s
- Cobblestone appearance
- Aphthous lesion
- Solitary, deep ulcers w/ fissures
UC:
- Pseudopolyps
- Hyperemic mucosa
- Shallow, diffuse ulceration
- Diffusely granular appearance
IBD
Differentiate histology between UC and CD
Crohn’s
- Patchy, transmural infl’n
- Abscesses and fistulas often present
- Glands relatively preserved
- Granulomas common
- Goblet cells present
UC:
- Continuous, superficial infl’n
- Cryptitis ± cryptal abscesses
- Gland atrophy in chronic cases
- Granulomas rarely seen
- Goblet cells depleted
Crohn’s disease
Major intestinal manifestations, S/S
Crohn’s ileitis (commonest)
- Episodic colicky abdominal pain
- Watery, fatty or inflammatory (less common) diarrhoea
- Malabsorptive features
- ± subacute/acute IO (fibrotic strictures)
- ± RLQ mass (Crohn’s abscess)
Crohn’s colitis (similar to UC)
- Mucoid and bloody diarrhoea
- A/w episodic colicky abdominal pain
Ulcerative colitis
Major intestinal manifestations, S/S
Proctitis
- Rectal bleeding with mucus discharge
- A/w urgency, tenesmus, incontinence and changes in bowel habits
Left and extensive colitis
- Mucoid and bloody diarrhoea
- A/w episodic colicky abdominal pain
- ± toxic megacolon
Extra-intestinal manifestations of IBD
- Skin
- Joints
Dermatological:
□ Erythema nodosum (3-15%): raised, tender, red/violet non-ulcerative subcutaneous nodules
□ Pyoderma gangrenosum (0.75%): deep, necrotic ulcers, usually on leg, a/w sterile abscess on Bx
Joints: acute pauciarticular peripheral arthritis (IBD-associated SpA)
□ polyarthritis (3-4%), sacroiliitis (4-18%), AS, enthesitis and dactylitis
Extra-intestinal manifestations of IBD
- Eyes
- HBP
- Haematological
- Renal
Ocular: uveitis, episcleritis, scleritis
HBP: Fatty liver, liver abscess, liver amyloidosis, granulomatous hepatitis
Haematological: DVT, mesenteric or portal vein thrombosis
Renal: ureteric calculi (oxalate, urate), renal amyloidosis
List complications + S/S of Crohn’s disease
Malnutrition:
- Cause: poor intake, protein-losing enteropathy, malabsorption
- S/S: weight loss, deficiency anaemias, coagulopathy, osteomalacia, hypoCa
Abscesses and fistula:
- Transmural inflammation forms sinus tracts
- e.g. Enteroenteric fistula: diarrhoea, malabsorption; Enterovesical fistula: recurrent UTI, pneumaturia
Strictures and obstruction:
- S/S: partial (colicky abd pain) or frank IO
Perianal disease (>1/3): - Anal fissure, perianal fistula, anorectal abscess
CA colon
List complications of Ulcerative colitis
Severe hemorrhage
Toxic megacolon
Colorectal cancer
Toxic megacolon in UC
- Cause
- S/S
- Imaging features
- Mx
- Cause: severe colitis → massive colon dilatation → bacterial toxin pass freely through mucosa into blood
- S/S: Severe colitis, bleeding diarrhea, abd pain with distension
- Systemic: dehydration, hypotension, fever, tachycardia
- Imaging features: AXR: grossly dilated colon (3-6-9 rule) with thumbprinting, multiple fluid levels
- Mx:
Avoid colonscopy, anti-diarrhea and anti-spasmodic drugs
Resuscitation, NG tube decompression, IV steroids, Broad-spectrum antibiotics
Urgent colectomy if refractory
CA colon and IBD
- Typical onset after IBD?
- Monitoring methods
Time frame: ~8-10y after onset in extensive disease, ~10-15y after onset in limited or L-sided disease
Surveillance colonoscopy (AGA): every 1-2y after 8y for pan-colitis and 15y for left-sided colitis
First-line serological investigations for IBD and typical findings
CBC with differential: anaemia + lymphocytosis
APR: ESR, CRP
↓serum Fe, vitamin D, B12
Stool: ↑WBC/calprotectin, -ve for culture, ova/parasite and C. difficile toxin
Serology:
- Crohn’s: ASCA +ve, pANCA –ve
- UC: ASCA –ve, pANCA +ve
First-line radiological investigation for IBD and typical findings
Crohn’s:
- Small bowel imaging: narrowed lumen (‘string sign’), bowel wall thickening with ‘rose-thorn’ ulcers, mucosal nodular filling defects with cobble-stoning, ± fistulas
- CT ± enteroclysis: screen complications (eg. abscess, perforation)
- MRI: thickened, hyperintense bowel wall
UC:
- Colonoscopy
- AXR for toxic megacolon
- Double contrast enema: ‘carpeting’ diffuse involvement with button-shaped ulcers or pseudopolyp, lead-pipe sign
- CT colonoscopy
Ddx for Crohn’s disease
- IBS: never PR bleed, no constitutional features, normal ileocolonoscopy, imaging, stool markers
- Lactose intolerance: diarrhoea, abd pain and flatulence a/w ingestion of milk-related products
- Infective enteritis: esp Yersinia and TB
- UC: ↑bleeding and ↓constitutional Sx, limited to colon with rectal involvement sparing anus, continuous lesion with no granuloma and limited to mucosa
Ddx of Ulcerative colitis
- Infectious colitis (bacterial, amoebic, TB, CMV): may have similar clinical and endoscopic findings, excluded with stool/tissue culture, stool studies, colonic biopsy
- Crohn’s disease: no gross bleeding, perianal involvement, fistulating disease
- Radiation colitis: may have similar endoscopic appearance, histology with eosinophilic infiltrates, epithelial atypia
- Others: solitary rectal ulcer syndrome, GVHD of GIT, diverticular colitis, NSAID colitis
IBD treatment
Aims
2 approaches to treatment
- Induction of remission during acute flare
- Maintenance of remission
- Modify clinical course: reduce complications, surgery, cancer; improve QoL, nutrition
Choice of treatment: based on treatment hierarchy and disease severity
→ Top-down approach for moderate to severe disease
→ Step-up approach for mild disease
Main treatment options for IBD - medical and surgical?
5-aminosalicylic acid (5-ASA), eg. sulphasalazine (prodrug), mesalazine, osalazine (analogues)
Corticosteroids, eg. budesonide (1st line), prednisone
Immunomodulators, eg. thiopurines (azathioprine, 6-mercaptopurine), methotrexate
Biologics, eg. anti-TNF (infliximab, adalimuab, etanercept, certolizumab), natalizumab, vedolizumab
Surgical therapy: bowel resection
IBD
Treatment for mild severity
Corticosteroids, eg. budesonide (1st line), prednisone
Antibiotics (Crohn’s only)
Aminosalicylates (ASA)
IBD
Treatment for moderate severity
Immunomodulators, eg. thiopurines (azathioprine, 6-mercaptopurine), methotrexate
Biologics, eg. anti-TNF
Corticosteroids, eg. budesonide (1st line),
IBD
Treatment for severe disease
Surgical resection
Bowel rest - defunctioning colostomy
Cyclosporine
Biologics, eg. anti-TNF
5-aminosalicylic acid (5-ASA)
Examples Indication MoA RoA S/E
5-aminosalicylic acid (5-ASA), eg. sulphasalazine (prodrug), mesalazine, osalazine (analogues)
□ Indications: induction + maintenance in mild-moderate UC (± CD)
□ MoA: local anti-inflammatory action
□ RoA: PO, topical (suppository, enema) (mesalazine only)
□ S/E for sulphasalazine: skin rash, haemolysis, neutropenia, male infertility, pancreatitis
Corticosteroids for IBD
- Indication
- RoA
Corticosteroids, eg. budesonide (1st line), prednisone
□ Indications: induction in mild-moderate CD or UC, NOT for long-term use
□ RoA: PO (enteric coated), topical (suppository for proctitis, foam/enema for distal colitis)
Immunomodulators for IBD
- Examples
- Indications
- Immediate or delayed onset?
- S/E
Immunomodulators, eg. thiopurines (azathioprine, 6-mercaptopurine), methotrexate
Indications: induction + maintenance for both CD and UC
→ Frequently relapsing disease
→ Steroid-sparing therapy
→ Fistulating Crohn’s disease
Effect: delayed onset for 3mo
S/E: well-tolerated, 10% may have S/E incl. BM suppression, allergy, hepatotoxicity, pancreatitis
Biologics for IBD
- Examples
- Indication
- C/I
- Risks
Biologics, eg. anti-TNF (infliximab, adalimuab, etanercept, certolizumab), natalizumab, vedolizumab
Indications: induction + maintenance for both CD and UC if
→ Refractory to standard treatment
→ Fistulizing CD
→ Extra-intestinal manifestations, eg. pyodermal gangrenosum, uveitis, severe arthritis
C/I: Sepsis, TB, Optic neuritis, Infusion reaction, Cancer
Risks:
→ Infections: reactivation of latent TB and viral infections (eg.HBV)
→ Malignancies: eg. lymphoma
→ Autoimmunity: haemolytic anaemia, lupus-like disease, anti-dsDNA or ANA positive
Surgical resection for IBD
- Indications
- Options
- Curative or not?
Indications: severe UC/ Crohn’s
- Severe bleeding
- Severe fistula, strictures, perforation, abscess
- Failed medical treatment
Options:
- Resect diseased intestine
- Stricturoplasty
- Colectomy, proctocolectomy
Not curative, disease recur close to anastomosis
