IBD & Celiac's Flashcards
IBD consists of
Chrohn Disease (CD) Ulcerative Colitis (UC)
Risk factors for IBD
15-35 YO (bimodal w/ second peak 50-80) Men- UC Women: CD Caucasian and Jewish 1st degree relative w/ IBD Smoking (increases CD; decreases UC) potential association w/ "western" diet imbalance in gut microbiome
Crohns disease overview
GI tract from mouth to anus
patchy/skip lesions
Transmural inflammation
Ulcerative Colitis
limited to colon, involves rectum
extends proximally w/ continuous, circumferential involvement
mucosal layer inflammation
Severity of CD involvement
entire GI from mouth to anus w/ SKIP lesions
- mouth (apthous ulcers) or gastroduodenal area
- ileum –> ileitis (most common) **
- terminal ileum (TI) & proximal ascending colon –> ileocolitis
- colon –> colitis “chrohn colitis”
perianal disease (abscess, fistula)
transmural – entire thickness of mucosa
PENETRATING DISEASE- ulcer, stricture, fistula, abscess
FISTULA (Tunnel) between two epithelial lined organs
skip lesion
CD
mucosal inflammation
UC
transmural inflammation
CD
Types of fistulas
enteroenteric
enterovesical
enterovaginal
enterocutaneous
Presentation of CD
depends on severity:
mild - inflammation
moderation- inflammation, strictures
severe - inflammation, strictures, fistula
insidious onset, usually intermittent - alternate bw exacerbations and relative remission
Hx and PE for CD
+/- fever, chills, fatigue, weight loss
+/- n/v, diarrhea (nocturnal), fecal urgency, tenesmus, rectal bleeding, perianal pain, fissure, abscess, IDA, B12 deficiency (TI involvement)
ABDOMINAL PAIN: RLQ pain/tenderness; tender, palpable RLQ mass (if abscess)
Extra-intestinal manifestations of CD
oral apthous ulcers episcleritis, iritis, uveitis erythema nodosum pyoderma grangrenosum ARTHRALGIAS **
Dx of CD
CBC, CMP, ESR/CRP (+/- IBD specific antibodies)
Stool study: culture, c.diff, O&P, fecal calprotectin or lactoferin
Scope: colonoscopy w/ TI intubation; +/- IBD **
Imaging:
+/- CT, MR enterography, UGI w/ SBFT, capsule endoscopy (not in intestinal stricture)
Contra of capsule endoscopy
patients w/ suspected intestinal stricture
Diagnostic findings in CD
skip lesions ulcerations, cobblestoning possible fistulas rectal sparing in most pts bx = GRANULOMAS (30% PTS) and chronic inflammation
CT/MR enterograph - inflammation, stricture, abscess, fistula
UGI w/ SBFT - “string sign”
fecal calprotectin
shows inflammation in bowed (IBD)
Complications of colon cancer
Colon CA
strictures, abdominal and perianal fistulas, abscess - SMALL BOWEL OBSTRUCTION/PERFORATION
malabsorption* (Fe, B12)
How often should CD get colonoscopy
every 1-2 years beginning 8 years after disease/sx onset
UC severity/extent
colon only; continuous, circumferential; mucosal surface only – friability, erosions, bleeding
Presentation of UC
mild: <4 stools/day, no systemic
mod: >4 stools daily, anemia, low grade fever
severe: >6 stools, systemic toxicity
insidious, intermittent
Hx and PE for UC
• +/- Fever, chills, fatigue, weight loss
• +/- Nausea/vomiting
• Abdominal pain***
- Periumbilical/LLQ pain
• Bloody diarrhea
• Fecal urgency, tenesmus, rectal bleeding • Constipation (if proctitis)
• +/- iron deficiency anemia
Extra-intestinal manifestations of UC
- Episcleritis, iritis, uveitis
- Erythema nodosum
- Pyoderma gangrenosum
- Sclerosing cholangitis – (Alk phos) **
- Arthralgias*
Labs for UC
CBC, CMP, ESR, +/- IBD antibodies
Stool studies: fecal calprotectin or lactoferrin
Scope* - Flex Sigmoidoscopy or Colonoscopy
Imaging: CT A/P
Diagnostic findings for UC
• Inflammation begins distally, spreads proximally
• Continuous circumferential pattern, no skip lesions
• Loss of vascular markings
• Superficial inflammation: erythematous,
exudate, friability/erosions
• Strictures rare
• Biopsy shows – crypt abscesses
Complications
Colon CA
Hemorrhage
Toxic Megacolon** - chronic dilation >6 cm w/ signs of toxicity
Goal of IBD management
obtain and remain remission; healing mucosa
Medical therapies used
Salicylates (5-ASA)
corticosteroids
immunomodulators (6MP, Azathiopurine, Methotrexate)
Biologics (anti-TNFs)
Antibiotics (CD)*** - due to perianal disease (abscess/fistulas)
surgery
Step-up therapy
low risk patients w/ mild disease
Step-down
high-risk pts w/ moderate to severe disease
5-ASA MOA
anti-inflammatory effects
Indications for ASA
mild/mod UC (primarily) and CD (less efficacy)
Options for 5-ASA
Sulfasalazine (must take folic acid)
Mesalamine (generic name for):
- PO: Asacol, Apriso, Lialda, Pentasa – small bowel and colon
- Topical: Canasa suppository; Rowasa enema (left colon)
SE of 5-ASA
nausea
diarrhea*
kidney injury*
pancreatitis
MOA of cortciosteroids
anti-inflammatory
suppress immune system
Indications of corticosteroids
FLARES in UC & CD
- short term use
- exit strategy to avoid dependence
- requires slow taper
Options for Corticosteroids
Oral Prednisone (caution systemic side effects)
• Oral Budesonide (modified steroid provides targeted therapy with less systemic side effects)
- Entocort – (CD), ileocecal disease
- Uceris (UC)
• Hydrocortisone suppositories, enemas, foams – distal colonic disease
SE of Oral Prednisone
- Mood changes
- Insomnia
- Weight gain
- Worsening of Diabetes • Increased infection risk • Osteoporosis
- Cataracts
- Psychosis
- Adrenal insufficiency
Recommendations for oral prednisone
DEXA scan in those with lifetime use of steroids >3 months
Ca and Vit D supplementation
MOA of immunomodulators
modifies immune system activity; decreases inflammatory response
Indication of immunomodulators
moderate to severe UC & CD**; steroid sparing agent; can be used in
combination with biologics to prevent immunogenicity
Options for immunomodulators
• 6- Mercaptopurine (6MP), Imuran (Azathioprine)
- Optimal response takes 3-6 months
- Genetic testing* necessary to determine patient metabolism of drug
- Be aware of systemic risks
• Methotrexate
- Requires folate supplementation
- Tetratogenic
SE of 6MP, Azathioprine
- Bone marrow suppression • Secondary infection
- Pancreatitis
- Hepatotoxicity
- Non-Hodgkin lymphoma
- HPV-related cervical dysplasia • Non-melanoma skin cance
Recommendations fo 6MP, Azatioprine
CBC, LFT
annual derm exams
up to date on cervical CA screening
MOA of Anti-TNFs
Modulates immune response; prevents intestinal inflammation, improves mucosal healing
Indications of Anti-TNFs
Moderate to severe IBD; steroid sparing
• May be given as monotherapy or in combination with thiopurines
Options for anti-TNFs
- Infliximab (Remicade) - (UC &CD) Risk of infusion reaction
- Adalimumab (Humira) – (UC & CD)
- Golimumab (Simponi) – (UC)
- Certolizumab (Cimzia) – (CD)
Cons of Anti-TNFs
Effective, but can be associated with decreased or lost response
Clinicians utilize “Therapeutic drug monitoring” to help guide decision making – are there antibodies? change dosage?
be aware of systemic risks
SE of Anti-TNFs
• Secondary infections • Risk of reactivation of TB and HBV • Malignancies • Non-melanoma skin cancer • Non-Hodgkin lymphoma
Contraindications of Anti-TNFs
- Active infection
- History of CHF
- MS/optic neuritis
Condierations prior to anti-TNF therapy
TB, HBV testing
monitoring in Anti-TNFs
CBC, CMP
annual derm exams
Biologics MOA
Modulates immune response; prevents intestinal inflammation
inidcations for biologics
Considered in patients with inadequate or loss response to
conventional therapies
Options for biologics
- Vedolizumab (Entyvio) - (UC & CD)
- Natalizumab (Tysabri) - (CD)
- Rarely used given gut selectivity and safety profile of Vedolizumab
- Ustekinumab (Stelara) - (CD)
- No demonstrated increase in severe infections or malignancy
Abx indication
acute disease for CD - perianal disease * - fistulas, abscess
Abx choices
Cipro
Flagyl
Cipro SE
tendinitis (rupture)
photosensitivity
prolonged QT (arrhythmia)
Flagyl SE
peripheral neuropathy
metallic taste
disulfiram rxn (avoid ETCH and 3 days after tx)
Red flags for IBD
• Severe bleeding • Significant anemia • Severe abdominal pain • Peritoneal signs • Inability to tolerate PO • Signs of dehydration • Increased creatinine, tachycardia, hypotension - Signs of obstruction
Indications for surgery
severe hemorrhage
perforation
dysplasia/cancer
medical refractory disease
Risk factors assoicated w/ aggressive disease (benefit from early step-down tx)
high risk anatomic locations (extensive disease, perianal)
penetrating/fistualizing disease
steroid resistance/dependence
severe disease activity (malabsorption as evidenced by weight loss, nutrient deficiency, hypoalbuminemia)
young age
Change in BM and diarrea in IBD
check stool study (for infection)
NSAIDS exacerbate disease
ensure f/u compliance w/ GI
identify those w/ increased infection risk- steroids, immunomodulators, biologics
Exacerbate IBD
NSAIDS
Health Maintenance for IBD
- Immunizations
- Cancer screening (Colon, Skin, Cervical)
- Osteoporosis screening with DEXA
- Anxiety/Depression Screening
- Smoking cessation
- Routine laboratory monitoring (CBC/CMP)
Epidemiology of celiac disease
whites of northern european ancestry
originally in infants, but now more frequently in 10-40 YO
What is celiac’s disease
Immune-mediated disease triggered by the ingestion of gluten (wheat, rye, barley) in genetically susceptible individuals
Triggers in gluten for celiacs
wheat
rye
barley
Response of small intestine to gluten
- mucosal inflammation, crypt hyperplasia & abnormal villous architecture
- villous atrophy of small intestines –> loss of absorptive surface capcity and small bowel malabsorption
Associated w/ celiacs
genetic- HLA DQ2, HLA DQ8
autoimmune disease (DM, thyroid disease)
Down syndrome
Presentation of celiac
“classic” malabsorptive sx: diarrhea, steatorrhea, flatulence/bloating, weight loss
“atypical” GI sx: ab pain, constipation, dyspepsia
Silent: extra-intestinal manifestations
Extra-intestinal manifestations in celiac disease
- Nutrient deficiencies (Iron, B vitamins)*
- Osteopenia/Osteoporosis (Vitamin D & Calcium deficiencies)
- Transaminase elevation
- Dermatitis Herpetiformis***
- Neuropsychiatric symptoms
- In kids, may see FTT
- Reproductive disorders (infertility, miscarriages)
Dermatitis herpetiformis
burning and itching lesions
erythematous and papular, pustular or vesicles
pathognomonic of celiac
Dx of Celiacs
Serology AND Bx of small intestines while on gluten diet
(+) serologic antibody testing: IgA tissue transglutaminase (tTG Ab)***, IgA endomysial (EMA Ab titer), Deamidated GLiadin Peptide (DGP- IgA levels must be normal for test to be valid)
EGD w/ duodenal bx = GOLD STANDARD
- intraepithelial lymphocytes
- crypt hyperplasia
- villous atrophy
gold standar dx for celiac
villous atrophy on EGD bx
Primary antibody in celiacs
IgA tissue transglutaminage (tTG Ab)
Management of Celiac
gluten free diet - fresh fish, meat, poultry, milk, fruits/veggies
Supplements in celiac
Folate Iron Zinc Calcium B12 D
Overall managment of celiac
Consult w/ dietitian Educate about disease Lifelong gluten-free diet I- identify/tx nutrtional deficiencies Access advocacy groups/resources Continuous long-term f/u
Complications of celiac
malabsorption: Fe, B vitamin, Osteoporosis (Ca, vit D) - get DEXA at diagnosis
Slight increase of malignancy
- non-hodgkin lymphoma
- GI malignancies
