Today’s lecture was about inpatient management by Dr. Polyak. He also used an algorithm he developed with our very own Dr. Dhedhi (currently GI fellow at SLU).
You can find here the:
Slides – Inpatient Management of IBD 2020
Associated article – Inpatient Management of Inflammatory Bowel Disease Related Complications. CGH 2020
Algorithm –Severe UC Protocol v8
Crohn’s presents with skipped lesions and affects any part of the GI tract from mouth to anus, most often found in terminal ileum. It may have non-caseating granulomatous inflammation, and cobble-stoning. Crohn’s causes transmural inflammation with deep ulcers on endoscopy. Types of Crohn’s include stenosing, inflammatory and fistulizing disease.
Ulcerative colitis causes continuous inflammation that can involve only the rectum (ulcerative proctitis), the left side of the colon to the splenic flexure, or the entire colon (pancolitis). Typical histological (microscopic) lesion of ulcerative colitis is the crypt abscess, in which the epithelium of the crypt breaks down and the lumen fills with polymorphonuclear cells. UC affects only the mucosal layer leading to shallow ulcers on endoscopy.
Risk factors: Both genetics and environmental factors (related to urban development) are responsible. Smoking is a risk factor in crohn’s but protective in UC. Fats are a risk factor while fiber may be protective.
Symptoms: Crohn’s may present with RLQ pain, weight loss, perianal disease, fistulas, and obstruction. While UC more commonly presents with GI bleeding, diarrhea, tenesmus, urgency and constipation without diarrhea. Extraintestinal Manifestations: Include episcleritis, uveitis, stomatitis, aphthous ulcers, gallstones, sclerosing cholangitis, kidney stones, hydronephrosis, fistulas and UTIs, axial and peripheral arthritis, erythema nodosum, pyoderma gangrenosum and phlebitis.
Diagnosis: It’s established by a combination of clinical, radiographic, endoscopic and pathological findings. Rule out C.diff/ enteric infections and obtain inflammatory markers. Check for anemia, hypoalbuminemia and signs of dehydration. Endoscopy with biopsy can help with diagnosis. CT is NOT enough to make the diagnosis. It is helpful in Crohn’s when obstructive/penetrating pattern is suspected or in UC when toxic megacolon or perforation is suspected.
Treatment: 5-ASA drugs are relatively safe. Used in Mild to moderate disease, especially in UC. Look for pericarditis, pancreatitis and nephritis.
Steroids can be used in moderate or severe disease. Look for immunosuppression, osteoporosis, hyperglycemia, HTN, acne, weight gain, psych issues.
Immunomodulators can be used in refractory and steroid sparing disease. Look out for leukopenia, transaminitis and pancreatitis.
Jak inhibitor and biologics may be used when patients do not respond to steroids. Look for lymphoma, shingles, neuro disorders, drug induced lupus, hepatitis and PML.
Surgery is curative in UC, not in crohn’s. Indications include growth failure, severe bleeding, toxic, megacolon, impending perforation, intolerance to immunosuppression, colonic strictures, and dysplasia or carcinoma
Malignancy-Risk factors for malignancy include: Duration of disease, extent of colonic involvement, primary sclerosing cholangitis, family history of colorectal cancer, and severity of ongoing colonic inflammation. Screen every 1-2 years after 8-10 years of disease. The frequency of screening is dependent on risk factors listed above.
Vaccines: Must include annual influenza, pneumococcal, Td/Tdap, Hep A and Hep B. Must consider, HPV, meningococcal and recombinant shingles. Avoid live vaccines – BCG, intranasal influenza, MMR & varicella.
Dexa: Must consider in all patients on steroids for > 3 months at or above 7.5mg/day.
References: 1) Mady R, Grover W, Butrus S. Ocular Complications of Inflammatory Bowel Disease. Scientific World Journal. 2015. PMID: 25879056 2) Orchard T. Management of Arthritis in Patients with Inflammatory Bowel Disease. Gastroenterology Hepatology. 2012. PMID: 22933865 3) Abegunde A, Muhammad B, Bhatti O, Ali T.Environmental Risk factors for IBD. Evidence Based Literature Review. World Journal of Gastroenterology. 2016. PMID: 27468219 4) Crohn’s Disease-Introduction. John’s Hopkins Medicine. 2001-2013. 5) Ulcerative Colitis-Introduction.John’s Hopkins Medicine. 2001-2013.
Internal Medicine Grand Rounds
March 7, 2019
Miller Lecture: Inflammatory Bowel Disease: What the Internist Needs to Know
Ezra Burstein, MD, PhD, UT Southwestern Medical Center
Post by Roger D. Struble MD