2012 physicians assistance winter conference march 10, 2012
TRANSCRIPT
IS IT IBD OR IBS 2012
2012 Physicians Assistance
WINTER CONFERENCE
March 10, 2012
IS IT IBD OR IBS
Jannine Purcell, CNP
Rapid City Medical Center
Division of Gastroenterology and
Hepatology
IRRITABLE BOWEL SYNDROME
IBS is a gastrointestional syndrome characterized by chronic abdominal pain and altered bowel habits in the absence of any organic cause
THIS IS THE MOST COMMONLY DIAGNOSED GI
CONDITION
IBS affects men, women, young patients and the elderly
There is a 2:1 female predominance in North American females
IBS comprises 25-50% of all
referrals to GI
IBS accounts for a significant number of visits to primary care and is the second highest cause of work absenteeism after the common cold
IBS has been associated with increased health care cost with studies suggesting annual direct and indirect costs up to $30 billion
ANNUALLY
Altered bowel habits ranging from diarrhea, constipation, alternating diarrhea and constipation
INFLAMMATORY BOWEL
DISEASE
Chronic inflammatory bowel disease (IBD) include:
Ulcerative ColitisCrohn’s Disease
ULCERATIVE COLITIS
Ulcerative Colitis
A disorder in which inflammation affects the mucosa and submucosa of the colon
CROHN’S DISEASE
Crohn’s Disease
A disorder in which inflammation is transmural and may involve any or all segments of the gastrointestional tract
GROSS DIFFERENCE IN PATHOLOGY OF ULCERATIVE COLITIS AND CROHN’S DISEASE
Ulcerative colitis1.Disease in continuity2.Rectum almost always involved3.Terminal ileum involved infrequently4. Granular and ulcerated mucosa
diffusely5. Often intensely vascular6. Normal serosa7. Muscular shortening of colon: fibrous
strictures very rare8. Spontaneous fistulae not typical
9. Inflammatory polyposis common and extensive10. Malignant change is well recognized11. Anal lesions uncommon
GROSS DIFFERENCE IN PATHOLOGY OF ULCERATIVE COLITIS AND CROHN’S DISEASE
Crohn’s Disease1.Disease discontinuous2.Rectum frequently spared3.Terminal ileum frequently involved4. Discretely ulcerated mucosa; with fissuring5. Vascularity seldom pronounced6. Serositis common7. Shortening due to fibrosis; fibrous strictures common
9. Inflammatory polyposis less prominent and less extensive10. Malignant change11. Anal lesions more common
MICROSCOPIC DIFFERENCES IN THE PATHOLOGY OF ULCERATIVE COLITIS AND CROHN’S DISEASE
Ulcerative Colitis
1. Diffuse mucosal and submucosal inflammation2. Width of submucosal normal or reduced3. Often intense vascularity, little edema4. Focal lymphoid hyperplasia restricted to the mucosa and superficial submucosa5. “Crypt abscesses” very common with diffuse inflammation6. Anal lesions- non-specific if present
MICROSCOPIC DIFFERENCES IN THE PATHOLOGY OF ULCERATIVE COLITIS AND CROHN’S DISEASE
Crohn’s Disease
1. Transmural inflammation with fistulae formation2. Width of submucosa normal or increased3. Vascularity seldom prominent, edema marked4. Lymphoid aggregates in mucosa, submucosa, serosa and pericolic tissues5. Sarcoid-type granulomas, characteristic with focal patchy inflammation6. Anal lesions; granulomatous foci often present
Incidence and prevalence of ulcerative colitis are:
2 – 10 and 35 -100, respectively per 100,000 population in the US
Incidence and prevalence of Crohn’s disease are 1-6 and 10 – 100 respectively per 100,000 population in the US
There is an increased incidence of IBD in relatives of patients with IBD indicating a genetic disposition
Both conditions are more prevalent in Jews and less common in African Americans
The peak age of onset of both diseases is between
15- 25 yrs and then a second peak is observed between
55 -65 yrs
Incidence equal between men and women
Ulcerative colitis is more common than Crohn’s disease in children younger then ten years old
POTENTIAL TRIGGERS
Viruses and bacteria- there is little data but suspect
MeaslesMycobacterium paratuberculosis
Dietary antigen activates abnormal immune response
Auto antigen expressed on patients intestional epithelium
Patient mounts an initial immune response against a lumenal antigen, which persists and may be amplified
CLINICAL FEATURES OF UC Dominant symptom in the US is often bloody, frequent low volume bowel movements
Abdominal pain, usually in the lower quadrant and rectum
Localized rectal involvement may be characterized by:
bloody diarrhea, with or without urgency,
tenesmus, pain or fecal incontinence
CLASSIFICATION OF UC
Mild disease:Diarrhea, rectal bleeding and usually normal physical exam
Most patients with ulcerative proctitis have mild disease
Moderate disease:
Occurs in 27% of patients
5 -6 bloody stools, abdominal pain, tenderness, low grade fever, fatigue
Severe disease
19 % patients have severe ulcerative colitisFrequent bloody stools, profound weakness, weight loss, fever, tachycardia
Hypotension, abdominal tenderness, anemia as well as hypoalbuminemia
Abdominal distention with severe disease may mean toxic megacolon
Usually ulcerative colitis will begin indolently and gradually worsen
Initial presentation- colitis extending to the cecum in 20% patients
75% patients have no disease proximal to the sigmoid
15% patients with initial proctitis will extend their disease more proximally
Patients with mild disease
More than 90% will go into remission after first attack
Patients who present initially with severe disease often require colectomies
Usually 50% of those patients within the first 1 -2 yrs
The usual pattern of chronic disease is long quiescent periods interspersed with acute attacks
RELAPSE
Non compliance with medicationsNSAID useAntibiotics Colonic infections (c-diff)Smoking cessation
TOXIC MEGACOLON
Temp greater then 38.6 CHR > 120Neutrophil count > 10,500DehydrationMental status changesElectrolyte imbalances
HypotensionAbdominal distentionTenderness
CROHN’S DISEASE
Involvement of the ileum and cecum: 40% of patientsSmall bowel: 30% of patientsColon only: 25% of patients
Pancolic: 2/3Segemental: 1/3
PATHOLOGY OF CROHN’S DISEASEEarly changes
Aphthous ulcers-> deep ulcerations-> confluent ulcerations
“cobblestone” appearanceThickened mucosal foldsAsymmetric involvement Inflammatory pseudopolypsSegmental distributionSkip lesions
Symptoms
DiarrheaWeight lossAbdominal pain
CROHN’S DISEASE ACTIVITY INDEX Stool frequency Abdominal pain Sense of well being Systemic manifestations Use of antidiarrhea agents Abdominal mass Hematocrit Body weight
Crohns disease is a relapsing and remitting disease that will spontaneously improve without treatment in 30% of cases
Patients in remission can expect to remain in remission for 2 yrs in 50% of cases
However, 60% of patients require surgery within 10 years of diagnosis
Of those patients who require surgical resection, 45% will eventually require reoperation
Crohns disease can produce significant disability, and 50% of patients make major changes in employment to accommodate decreased working hours and leaves of absence
CROHNS COMPLICATIONS
Abscesses and fistulas result from extension of a mucosal break through the intestional wall into the extra intestional tissue
Abscesses occur in 15 -20% of patients usually arising from the terminal ileum
Abscesses present with fever, localized tenderness and palpable mass
Infection is usually polymicrobial
E coli, bacteroides fragilis, enterococcus, and alpha hemolytic streptococcus
20-40% of Crohn’s patients have fistulizing disease
Fistula may be enteroenteric,
Enterocutaneous, enteovesical, or enteovaginal
Large enteroenteric fistulae produce diarrhea, malabsorption, and weight loss
Enterocutaneous fistulae produce persistent drainage that usually is refractory to medical therapy
Rectovaginal fistulae lead to foul-smelling vaginal discharge
Enterovesical fistulae produce pneumaturia and recurrent urinary tract infections
Obstruction, especially of the small intestine, is a common complication caused by mucosal thickening, muscular hyperplasia and scarring from prior inflammation or adhesions
Perianal disease, including anal ulcers, abscesses and fistulae can affect the groin, vulva or scrotum