Inflammatory bowel disease Flashcards
What defines a severe UC flare
> 6 bloody bowel movements per day, severe abdominal cramps, weight loss, tachycardia, fever, anemia and elevated ESR/CRP
what should we evaluate for in a pt who has a suspected UC flare up?
infectious colitis, culture, ova and parasaite and C diff and flexible sigmoidoscopy to evaluate for extent of disease
Rule out toxic megacolon and colonic perforation
Management of a severe UC flare
systemic steroids and high dose 5 aminosalicylic acid (5ASA) compounds
Do we give empiric antibiotics for UC flares
no
only meant for severe UC if the pt has signs of severe systemic toxicity
(high fever, marked WBC with left shift and bandemia) or
toxic megacolon or
peritonitis
When do do you transition someone from IV steroids to PO steroids in a UC flare up
reassess in 3-5 days and if those who fail to respond after 7 to 10 days are steroid refractory and need cyclosporine or TNF inhibitor (infliximab)
if still refractory to TNF alpha inhibitors or cyclosporine, may need colectomy
Is a CT abd helpful in UC flare up?
when do you get one?
only helpful for evaluation of toxic megacolon and perforation
but not needed if physical exam and XR abd is unremarkable.
Try to limit CT scans given the amount that patient will likely experience in their life.
Tobacco use increases risk for
Crohn’s dx
protective for UC
inflammatory bowel disease has a bimodal age presentation:
in 20’s- 40’s and then 70-80’s years
Ulcerative colitis presentation:
diarrhea abdominal discomfort, rectal bleeding and tenesmus
can be slow and insidious onset and so may present looking like a infectious colitis.
Note diarrhea may not always be present too.
most commonly affected area of GI tract with Crohn’s
ileocecal area
what is hallmark of Crohn’s disease presentation
see fistula, abscess or strictures.
two most common skin manifestations of IBD are:
erythema nodosum
and pyoderma gangrenosum.
ocular manifestations of IBD
epicleritis (infection of sclera and conjunctiva) and uveitis (can present with headache blurred vision and photophobia)
Uveitis - this is a ocular emergency and need to see eye doctor.
what does fecal calprotectin do?
helps differentiate between IBD and irritable bowel syndrome
present in IBD
What is also seen on labs with IBD:
fe deficiency anemia, see thrombocytosis, leukocytosis and ESR and CR elevation.
earliest endoscopic findings of Crohn’s dx is
aphthous ulcers which can coalesce and form stellate ulcers or cobble stone appearance on the mucosa
what is also seen in EGD findings of Crohn’s dx?
skip lesions - and see granulomatous inflammation on mucosal biopsies.
Treatment of IBD is based on four categories of drugs;
5 aminosalicylates, glucocorticoids, immunomodulators, and biologics.
Goals are to induce and maintain remission and prevent disease or treatment related complications.
startification based on clinical severity is based on guiding IBD management but there is no consensus definition of mild, moderate, severe IBD. but we look at:
Dx in the patient (quality of life, clinical symptoms, and disability)
inflammatory burden (extent, location, and severity of bowel involvement)
disease course (structural damage)
surgery is used for:
refractory symptoms and complications.
proctitis is
rectal inflammation and seen in UC pts.
Proctitis can lead to frequent defecatory urges and passage of small liquid stools containing mucus and blood.
what are IBD pts at risk for if they ever get surgery?
VTE and so if they ever go get surgery they need subcut heparin and this is only held in severe GI bleeding, severe anemia, tachycardia, or hypotension.
mainstay of treatment to mild to moderate UC (has a dose dependent response)
5 aminosalicylate - these help an anti inflammatory effect.
Better to use oral AND topical 5 ASA.
Also helpful for maintaining remission.
UC with proctitis or left sided disease should get
GIVE 5 ASA or mesalamine combined ORAL (topical) AND suppositories and enemas.
sulfasalazine adverse reactions
5 ASA - mesalamine
- fever, rash, nausea, vomiting and headache.
can cause reversible sperm abnormalities
impairs folate absorption.
are 5 ASA helpful for Crohn’s
no.
how to treat severe flare ups of IBD and help induce remission?
use glucocorticoids.
Prefer to use oral budesonide - controlled release glucocorticoid with high first pass metabolism in the liver and has minimal systemic adverse effects.
do we use steroids for maintenance therapy for IBD?
no. not effective for maintenance therapy and have significant side effects
what are the IBD immunomodulators?
these are drugs that help with maintenance to keep disease in remission and steroid sparing
azathioprine and 6 mercaptopurine (6 MP)
how long does it take for azathioprine and 6 mercaptopurine to start working?
about 3-6 months
so in meantime while they start to work , pt with IBD is on glucocorticoids. (can be tapered from glucocorticoid)
what must be checked in patient prior to using thiopurine therapy?
thiopurine methyl transferase (TPMT) which helps to metabolize azathioprine and 6 mercaptopurine has population polymorphism and so some pts on these meds can develop severe bone marrow toxicity.
Must screen to prevent. Don’t start if there’s low or absent TPMT activity
how to follow and monitor pts who are on immunomodulatory therapy? (azathioprine and mercaptopurine)
CBC and LFTs testing (side effect can have leukopenia even if they don’t have TPMT mutations)
rare side effect of azathioprine and 6 mercaptopurine
hepatosplenic T cell lymphoma
must monitor their CBC
who qualifies for azathioprine and 6 mercaptopurine in UC pts?
if 5ASA is not enough and pt is on glucocorticoids to keep them from flaring up
OR:
required 2 courses of steroids for induction of remission within 1 year.
pts who require IV steroids for acute disease flare
methotrexate is helpful for:
immunomodulator that helps inducing and maintaining remission in Crohn dx but not UC
side effects of MTX
heptotoxicity interstitial pneumonitis peripheral neuropathy (check folate levels too)
biologics are:
TNF alpha inhibitors. THey are used to treat moderate to severe Crohn’s dx.
Treatment of moderate to severe Crohn’s dx
adalimumab and certolizumab
though there is increasing evidence of giving biologics earlier in dx course.
Infliximab is administered
IV only
these agents are helpful together than alone for controlling and achieving steroid free mission and mucosal healing:
infliximab and azathioprine (for UC and Crohn’s)
what should be tested prior to starting biologics?
check for TB and assessed for chronic hep B (and tx if needed)
if there is latent TB and pt needs to be on biologic agent what do you do?
Treat with isoniazid for at least 2 months prior to initiation of anti TNF alpha therapy.
these TNF alpha inhibitors are helpful for treating moderate to severe UC
infliximab, adalimumab, golimumab
anti adhesion agents natalizumab and vedolizumab are used to
treating and maintaining remission in moderate to severe Crohn’s dx
Ustekinumab is a
monoclonal antibody that blocks IL12 and IL23 to prevent cytokines of T cells and helpful treating severe Crohn’s dx.
Only used after biologics are not effective
indications for surgery for Crohn’s dx:
medically refractory fistula
fibrotic stricture with obstructive symptoms
symptoms refractory to medical therapy
or cancer
indications for surgery for UC dx:
total proctocolectomy with end ileostomy or ileal pouch anal anastomosis is performed for medically refractory disease , toxic megacolon or carcinoma.
IBD pts need these vaccinations
seasonal flu,
13 pneumococcal conjugate vaccine
23 valent pneumococcal polysaccharide vaccine
Do this prior to immunosuppressive therapy.
NO LIVE viruses like MMR varicella, or herpes zoster.
women who have IBD are greater risk for developing this long term complication
cervical dysplasia seen more with Crohn’s disease
women with IBD should get routine pap smears
every year and HPV vaccine is recommended.
Lifestyle considerations for IBD pts:
stop smoking and smoking increases risk for extra intestinal manifestations
IBD pts are also at greater risk for this endocrine complication long term. what is this complication
osteopenia and osteoporosis due to steroids and diminished Vit D and calcium absorption.
what cancers are IBD pts at greater risk for?
colorectal and cervix and skin.
if pt has primary sclerosing cholangitis what do they need?
at greater risk for colorectal cancer and so need to get surveillance colonoscopy at time of diagnosis and should reoccur every year
Skin considerations for IBD pts?
increased risk for melanoma and non melanoma skin cancers.
Doesn’t matter if pt is getting treatment for IBD or not, still at greater risk.
Need sunscreen, wear protective clothing, avoid tanning beds, and have yearly skin examination.
1st line treatment for mild to moderate UC after getting remission with steroids is (do we need maintenance therapy?)
5 aminosalicylate drugs like mesalamine
good for inducing and maintaining remission without serious side effects
mild ulcerative proctitis confined to the rectum who have remission with initial treatment needs:
no maintenance therapy
but if have left sided colitis or more extensive disease, tapering steroids off without initiating maintenance therapy can cause recurrence or flare up.
how to treat a UC pt who has required 2 courses of steroids for induction of remission within 1 year.
UC - azathioprine and 6 mercaptopurine
or if they have a flare up.
distribution of UC is divided into
- proctitis (involves the rectum only)
- left sided colitis (inflammation that does not go beyond the splenic flexure)
- pancolitis (extends beyond the splenic flexure)
treatment depends upon the extent and severity of inflammation.
Mild dx is seen with number of stools per day, intermittent hematochezia and normal CBC and CRP and normal vitamin signs = mild dx
Treatment of mild UC Is
mesalamine (combined oral and anal enema) mainstay
mesalamine enema can work up to:
splenic flexure of colon
works better if given also an oral mesalamine (5-ASA)
medication used to treat and keep in remission moderate to severe Crohn’s dx
Anti tumor necrosis agents - infliximab is one.
if someone has multiple flares of severe ileal Crohn’s dx that has needed multiple courses of tapering prednisone despite being on an immunomodulator (azathioprine) need to get a TNF alpha inhibitor.
if doesn’t respond to one TNF alpha switch to second or third ANTI TNF alpha agent.
treatment of mild flare ups of Crohn’s dx
budesonide but unlikely to help with putting someone in remission
