ibd masterclass 14.06 - mucosal .ibd masterclass 14.06.2017. 2 ... masterclass lab exams at first

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  • MASTERCLASS

    Prof. Xavier Roblin

    gastro-entrologue au CHU de Saint-tienne

    xavier.roblin@chu-st-etienne.fr

    Organiser : Pascal Juillerat, MD, MSc

    IBD Masterclass 14.06.2017

  • 2

    Masterclass

    CASE 1

    Brindusa Diaconu

  • 3

    Masterclass

    Mr CS, 7.07.1983

    Crohns disease, diagnosed 2001 , Montral A2L4B3

    No extraintestinal manifestations

    Previous therapies

    Long term Steroids -low dose

    Imurek 50mg daily

    Humira 40mg eow since 2011 for small intestinal fistulas

    Endoscopic dilation of duodenal stenosis

  • 4

    Masterclass

    First consultation Inselspital 04/2016

    Acute, self limited diarrhea

    Clinical exam

    H=168cm, Weight=46.5 kg (BMI 16.5)

    No perianal fistulas

  • 5

    Masterclass

    Lab exams at first consultation

    Low vit D, Hb, Vit B12 and folic acid normal

    TPMT activity 71 (Normal values 35-115)

    6 TGN : 129 (>235) / 6MMP : 170 (

  • 6

    Masterclass

    Ulcera in the bulbus

  • 7

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    Relative Stenosis bulbus?pars II and fistula orifices

  • 8

    Masterclass

    MR Enteroclysis

    In the duodenum and jejunum segmental thickening of

    nondistended bowell walls, partially with enhancement of

    the wall-compatible with subacute inflammation

    Increased number and volume of mesenterial lymph nodes

    in the left upper abdomen

    No fistulas, no abscesses

  • 9

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  • 10

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  • 11

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    Therapeutic options ?

    Continuing the therapy

    Increase of the dosis of Imurek

    Increase of the dosis of Imurek and PPI 2x40mg daily

    Switch from Humira to Infliximab

    Infliximab plus Imurek plus PPI 2x40mg

    Infliximab plus Imurek

  • 12

    Masterclass

    Answer Prof.Roblin

    Switch from ADA to IFX plus Imurek Plus PPI

    (there are some data from GETAID group that suggest that

    IFX could be better than ADA for small bowel involvement)

  • 13

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    Therapy

    Switch from Humira to Infliximab

    PPI 2x40mg daily

    Increase of the dosis of Imurek to 2x50mg daily

  • 14

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    Evolution

    Abdominal pain

    Vomiting, Diarrhea

    Loss of weight

    No fever, no extraintestinal manifestations

  • 15

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    Cause of the worsened evolution

  • 16

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    Cause of the worsened evolution

    Compliance

  • 17

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    Cause of the worsened evolution

    Compliance

    Acute infection: bacterial, viral

  • 18

    Masterclass

    Cause of the worsened evolution

    Compliance

    Acute infection: bacterial, viral

    Non response to therapy-trough levels, antibodies against

    TNF inhib

  • 19

    Masterclass

    Cause of the worsened evolution

    Compliance

    Acute infection: bacterial, viral

    Non response to therapy-trough levels, antibodies against

    TNF inhib

    Occurence of complications

  • 20

    Masterclass

    Lab

    CRP=26, L=11.800, Hb 136 to 125, Alb=18g/L

    Stool cultures negative, Clostridium difficile neg

    Infliximab trough level 2.23 microgr/ml

    Antibodies IFX negativ

    Shortening of administration period to 4 weeks

  • 21

    Masterclass

    ulcers in the esophagus

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    GERD

  • 23

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    Ulcera in the duodenum

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    Fistula

  • 25

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    Histology and virology

    Virology and immunhistochemistry- neg for CMV, HSV

    Esophagus- Reflux esophagitis

    Stomach, duodenum- inflammatory changes/no possible

    distinction between upper Crohn or peptic disease

  • 26

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    Colonoscopy:

    2-3 aphtoid lesions in the terminal ileum, colon-normal

    MR Enteroclysis -no abscesses or fistulas

  • 27

    Masterclass

    Therapy

    Enteral nutrition via naso-jejunal tube, later protein drinks

    and Modulen

    3x40mg Pantoprazol for 3 days, for longer time 2x40mg

    p.o

    IFX 600mg (10 mg/Kg) every 4 weeks

    Azathioprin 2x50mg

    Substitution iron, Vit D

  • 28

    Masterclass

    Evolution

    Under IFX 10 mg/kg every 4 weeks aggravation of

    vomiting

  • 29

    Masterclass

    Questions/discussion

    Inflammatory or fibrotic stenosis in the duodenum?

    Fistula?

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    Interdisciplinary discussion

    Ballon dilatation ?

    Temporary stent ?

    Gastro-Enterostomy ?

  • 32

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    Therapy

    Gastro-enterostomy

    2 weeks after surgery restart IFX

    Imurek, Pantoprazol

  • 33

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    Evolution

    Weight reduction of 2 kg in 3 months

    Vomiting 2 times a week

  • 34

    Masterclass

    Questions

    New flare ?

    Technical problem with anastomosis?

  • 35

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    Upper endoscopy

    Duodenal stenosis- acute ulcerations

    Efferent loop stenotic: passage with nasal endoscope and

    blind biopsies

  • 36

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    Gastro-entero -anastomosis

  • 37

    Masterclass

    Radiology evacuation mainly through bulbus, stenosis of efferent loop

  • 38

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    Histology

    High inflammatory activity in the duodenum and in the

    jejunum, compatible with Crohn s disease

  • 39

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    Questions-therapy

    Parenteral nutrition plus IFX optimisation according to

    trough levels plus Azathioprin ?

    Parenteral nutrition plus IFX plus Azathioprin plus

    corticosteroids for short term cortcosteroid treatment ?

    Switch to another class-Ustekinumab?

  • 40

    Masterclass

    Answer Prof.Roblin

    Parenteral nutrition mandatory !!!plus switch to

    Ustekinumab

  • 41

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    CASE 2

    Ioannis Kapoglou

  • 42

    Masterclass

    Patient: Mr. W.L. 21 yo

    Indeterminate Colitis Diagnosed 3/14

    Colonoscopy at diagnosis:

    - proctosigmoiditis and erosions at ileoceacal valve and term. Ileum, Calprotectin: >1`800 mg/kg

    - mesalazin oral (3g) and local with inadequate response

    Sigmoidoscopy 6 months later:

    - moderate left sided colitis

    - Hb 8,3 g/l

    - addition of foam budesonide (not well tolerated)

    Induction with systemic steroids

    Despite therapy escalation persistent symptoms

  • 43

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    02.02.2015 follow up visit

    3-4 bowel movements per day occasionaly with blood

    MR-enteroclysis 14.01.2015: wall thickened Sigma (20

    cm), otherwise normal

    Osteodensitometry 02.02.2015: normal

  • 44

    Masterclass

    Question 1

    How to proceed?

    AZA?

    Anti-TNF?

    Vedolizumab?

    Combination?

    Watch and wait?

  • 45

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    Answer

    Both options available:

    Anti-TNF alone

    Anti-TNF with Immunomodulator

  • 46

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    02.06.15 follow up

    After induction with IFX and under prednison 10mg 1-0-0,

    Mesalazine 500 mg 2-2-2 fewer symptoms

    Decision to taper prednisone

    Calprotectin 10.07.2015: 97 mg/kg

  • 47

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    14.07.2015 till 18.07.2015

    Hospitalization due to increasing symptoms

    15.07.2015 rectosigmoidoscopy:

    rektosigmoiditis Mayo Score 3.

    Other causes such as C. diff, viral superinfection were

    excluded

    Stool culture :Campylobacter concisus

    Adenovirus-Ag positive

  • 48

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    Question 2: How to treat?

  • 49

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    Question 2: How to treat?

    All measures below were justified:

  • 50

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    Question 2: How to treat?

    All measures below were justified:

    Systemic prednison was paused

  • 51

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    Question 2: How to treat?

    All measures below were justified:

    Systemic prednison was paused

    Budesonide foam

  • 52

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    Question 2: How to treat?

    All measures below were justified:

    Systemic prednison was paused

    Budesonide foam

    Ciprofloxacin and metronidazol

  • 53

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    Question 2: How to treat?

    All measures below were justified:

    Systemic prednison was paused

    Budesonide foam

    Ciprofloxacin and metronidazol

    Mesalazine was suspended

  • 54

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    11.8.15 follow up

    Under IFX 400 mg every 8w and prednisone 10 mg 1-0-0

    4-5 bowel movements daily, no blood

    Decision to further taper prednison

  • 55

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    13.10.15 follow up

    1 month after prednisone cessation

    New flare (10 bloody bowel movements daily)

    Increase steroids to 30 mg for 7 days then tapered again

    November 15: new flare prednisone to 50 mg/d

  • 56

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    07.12.2015 follow up

    Pat. still takes 30mg prednisone

    Generally better

    More symptoms just before the next IFX-Application

    Calprotectin 824 mg/kg

  • 57

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    Question 3: How to proceed?

    Change IFX to other anti-TNF?

    Change Class?

    Measure trough levels and Ab?