Inflammatory Bowel Inflammatory Bowel DiseaseDiseaseCrystal M. Byerly, PA-CCrystal M. Byerly, PA-C

Seton Hill University PA ProgramSeton Hill University PA Program

Grant from Centocor, Inc.Grant from Centocor, Inc.

Learning ObjectivesLearning Objectives

Describe the disease process of Crohn’s Describe the disease process of Crohn’s versus Ulcerative Colitisversus Ulcerative Colitis

Identify the clinical presentation of a Identify the clinical presentation of a patient with Crohn’s Disease and patient with Crohn’s Disease and Ulcerative ColitisUlcerative Colitis

Discuss the various diagnostic workups Discuss the various diagnostic workups and how they may differentiate Crohn’s and how they may differentiate Crohn’s from other GI ailmentsfrom other GI ailments

Select appropriate treatments for a patient Select appropriate treatments for a patient with Crohn’s Disease and Ulcerative Colitiswith Crohn’s Disease and Ulcerative Colitis

Inflammatory Bowel DiseaseInflammatory Bowel Disease

Artwork is reproduced, with permission, from the Johns Hopkins Gastroenterology and Hepatology Resource Center, Artwork is reproduced, with permission, from the Johns Hopkins Gastroenterology and Hepatology Resource Center, www.hopkins-gi.org,copyright 2006, Johns Hopkins University, all rights reserved.www.hopkins-gi.org,copyright 2006, Johns Hopkins University, all rights reserved.

IBDIBD= Crohn’s Disease and = Crohn’s Disease and Ulcerative ColitisUlcerative Colitis

Both are chronic inflammatory disorders of the GI Both are chronic inflammatory disorders of the GI tract that currently have no real cure.tract that currently have no real cure.

disorders of unknown cause involving genetic and disorders of unknown cause involving genetic and immunological influence on the gastrointestinal immunological influence on the gastrointestinal tract's ability to distinguish foreign from self-tract's ability to distinguish foreign from self-antigens.antigens.

Artwork is reproduced, with permission, from the Johns Hopkins Gastroenterology and Hepatology Resource Center,Artwork is reproduced, with permission, from the Johns Hopkins Gastroenterology and Hepatology Resource Center, www.hopkins-gi.org,copyright 2006, Johns Hopkins University, all rights reserved.www.hopkins-gi.org,copyright 2006, Johns Hopkins University, all rights reserved.

Ulcerative ColitisUlcerative Colitis

Disease Process of Ulcerative Disease Process of Ulcerative ColitisColitis

Disorder in which Disorder in which inflammation affects inflammation affects the mucosa and the mucosa and submucosa of the submucosa of the colon and terminal colon and terminal ileum.ileum.

Peak incidence in Peak incidence in ages 15-30 years old.ages 15-30 years old.

Artwork is reproduced, with permission, from www.medicinenet.inc all rights reserved. 2007

Ulcerative ColitisUlcerative Colitis Ulcerative ProctitisUlcerative Proctitis refers to inflammation that is refers to inflammation that is

limited to the rectum.limited to the rectum. In many patients with ulcerative proctitis, mild In many patients with ulcerative proctitis, mild

intermittent rectal bleeding may be the only intermittent rectal bleeding may be the only symptom.symptom.– If no bloody stools (ever), its not UCIf no bloody stools (ever), its not UC

Other symptoms:Other symptoms:– rectal pain rectal pain – urgency urgency

sudden feeling of having to defecate and a need to rush to sudden feeling of having to defecate and a need to rush to the bathroom for fear of soilingthe bathroom for fear of soiling

– tenesmus tenesmus ineffective, painful urge to move one's bowels ineffective, painful urge to move one's bowels

Ulcerative ColitisUlcerative Colitis Universal ColitisUniversal Colitis or or PancolitisPancolitis refers to refers to

inflammation affecting the entire coloninflammation affecting the entire colon– right colon, left colon, transverse colon and the right colon, left colon, transverse colon and the

rectum. rectum. Symptoms of Pancolitis include:Symptoms of Pancolitis include:

– bloody diarrheabloody diarrhea– abdominal pain and cramps abdominal pain and cramps – weight lossweight loss– fatigue fatigue – fever fever – night sweatsnight sweats– Extraintestinal disease Extraintestinal disease

Ulcerative ColitisUlcerative Colitis

Clinical presentation:Clinical presentation:A 26 year old woman gives a history of A 26 year old woman gives a history of increasing abdominal pain with blood and increasing abdominal pain with blood and mucus in the stool. mucus in the stool.

The plain film shows visible gas-filled colon The plain film shows visible gas-filled colon with variable mucosal thickening, giving with variable mucosal thickening, giving typical typical thumb-printingthumb-printing appearance. appearance.

The colon appears shorter than normal The colon appears shorter than normal and has lost its usual haustral pattern and has lost its usual haustral pattern giving the giving the lead pipe appearancelead pipe appearance term. term.

Classifications of UC Classifications of UC SeveritySeverity

MILDMILD– < 4 loose BM/day with small amounts of blood< 4 loose BM/day with small amounts of blood– No sign of toxicity: No fever or tachycardiaNo sign of toxicity: No fever or tachycardia– Mild anemiaMild anemia– Normal ESR<30 mm/hrNormal ESR<30 mm/hr

MODERATEMODERATE– > 4 stools/d> 4 stools/d– Minimal signs of toxicityMinimal signs of toxicity

SEVERESEVERE– >6 bloody stools/d>6 bloody stools/d– Fever, tachycardiaFever, tachycardia– AnemiaAnemia– Elevated ESRElevated ESR

FULMINANTFULMINANT– >10 stools/d with continuous bleeding>10 stools/d with continuous bleeding– ToxicityToxicity– Abdominal tenderness/distentionAbdominal tenderness/distention– Transfusion requirement due to anemiaTransfusion requirement due to anemia– Colonic dilatation on xrayColonic dilatation on xray

Complications of Severe UCComplications of Severe UC

Toxic MegacolonToxic Megacolon– The inflammatory complications extend The inflammatory complications extend

beyond the submucosa into the muscularis, the beyond the submucosa into the muscularis, the colon dilates and produces a toxic patientcolon dilates and produces a toxic patient HR>120bpm, fever, hypotension, electrolyte HR>120bpm, fever, hypotension, electrolyte

disturbances, MS changes, abdominal distentiondisturbances, MS changes, abdominal distention

Perforation of colonPerforation of colon– As a result of toxic megacolon or severe UC As a result of toxic megacolon or severe UC

Strictures Strictures – 12% patients will develop between 5-25 yrs. 12% patients will develop between 5-25 yrs.

after dxafter dx

Crohn’s DiseaseCrohn’s Disease

Crohn’s Crohn’s Three Main Patterns of Three Main Patterns of

DistributionDistribution 40% Ileum and Cecum40% Ileum and Cecum 30% confined to small intestine30% confined to small intestine 25% of colon only25% of colon only

– 2/3 pancolonic2/3 pancolonic– 1/3 segmental1/3 segmental

About 80% of patients have small bowel About 80% of patients have small bowel involvementinvolvement

Crohn’s DiseaseCrohn’s Disease

Can involve any part of the GI tract.Can involve any part of the GI tract.

The esophagus, mouth, and liver can The esophagus, mouth, and liver can also become inflamed.also become inflamed.

Peak incidence 15-25 y.o, but often Peak incidence 15-25 y.o, but often <10 yrs. old<10 yrs. old

Crohn’s Disease SymptomsCrohn’s Disease Symptoms

Diarrhea Diarrhea Abdominal painAbdominal pain

– From serosal inflammationFrom serosal inflammation– Intermittent partial obstructionsIntermittent partial obstructions

Weight lossWeight loss– Can be up to 20% of body weightCan be up to 20% of body weight– Malabsorption and decreased oral intakeMalabsorption and decreased oral intake

Relapsing and remitting symptoms that Relapsing and remitting symptoms that can spontaneously improve in 30% can spontaneously improve in 30% casescases

Crohn’s DiseaseCrohn’s Disease Thickened bowel wall Thickened bowel wall

with secondary with secondary narrowing of the bowel narrowing of the bowel lumen occurs.lumen occurs.

Discontinuous Discontinuous (skip)(skip) lesionslesions are a are a characteristic feature.characteristic feature.

““Cobblestone”Cobblestone” appearance comes from appearance comes from the confluent ulcers.the confluent ulcers.

Transmural thickening Transmural thickening and ultimate fibrosis and ultimate fibrosis produces the produces the “string “string sign” on CT = sign” on CT = stricturesstrictures..

Crohn’s ComplicationsCrohn’s Complications Extension of a mucosal breach through the Extension of a mucosal breach through the

intestinal wall into extraintestinal tissue results in:intestinal wall into extraintestinal tissue results in: AbcessesAbcesses

– Occur in 15-20% of patientsOccur in 15-20% of patients– Most commonly terminal ileum but not exclusivelyMost commonly terminal ileum but not exclusively

FistulasFistulas – During a Crohn’s pt.’s lifetime ~1/2 will develop a fistulaDuring a Crohn’s pt.’s lifetime ~1/2 will develop a fistula– 83% of fistulas require surgical intervention83% of fistulas require surgical intervention– can be multiple sites:can be multiple sites:

EnteroentericEnteroenteric EnterocutaneousEnterocutaneous EnterovesicalEnterovesical EnterovaginalEnterovaginal

Extraintestinal manifestations Extraintestinal manifestations of IBDof IBD

Colitic arthritisColitic arthritis SacroiliitisSacroiliitis Ankylosing spondylitisAnkylosing spondylitis Hepatobiliary Hepatobiliary

complicationscomplications Osteopenia, Osteopenia,

osteoarthritisosteoarthritis Avascular necrosisAvascular necrosis Renal stonesRenal stones

UTI due to fistulaeUTI due to fistulae Pyoderma Pyoderma

gangrenosumgangrenosum Erythema nodosumErythema nodosum Sweet syndromeSweet syndrome UveitisUveitis EpiscleritisEpiscleritis DVT/PE, intracranial, DVT/PE, intracranial,

intraocular intraocular thromboembolic thromboembolic eventsevents

Artwork is reproduced, with permission, from the Johns Hopkins Gastroenterology and Hepatology Artwork is reproduced, with permission, from the Johns Hopkins Gastroenterology and Hepatology Resource Center, Resource Center, www.hopkins-gi.org,copyright 2006, Johns Hopkins University, all rights reserved.www.hopkins-gi.org,copyright 2006, Johns Hopkins University, all rights reserved.

Genetics of IBDGenetics of IBD

IBD is a polygenic disorder. Not all of IBD is a polygenic disorder. Not all of the genes have been identified.the genes have been identified.

Phenotypes change throughout the Phenotypes change throughout the course of diseasecourse of disease

10-15% of IBD is familial10-15% of IBD is familial– Smokers get Crohn’sSmokers get Crohn’s– Nonsmokers get UCNonsmokers get UC

ColoRectal Cancer and IBDColoRectal Cancer and IBD Both CD and UC are known risk factors for Both CD and UC are known risk factors for

colorectal cancer. colorectal cancer. The risk of development of colorectal The risk of development of colorectal

cancer is related to the severity and cancer is related to the severity and duration of the disease. duration of the disease.

IBD patients should undergo colonoscopic IBD patients should undergo colonoscopic surveillance for epithelial dysplasia, a surveillance for epithelial dysplasia, a precursor to cancer, at routine intervals. precursor to cancer, at routine intervals. – Surveillance should be performed every 1–2 Surveillance should be performed every 1–2

years in patients with 8-10 years duration of years in patients with 8-10 years duration of disease disease

– annually in those with disease history of over annually in those with disease history of over 15 years15 years

Diagnosing IBDDiagnosing IBD

Differential Diagnosis of IBDDifferential Diagnosis of IBD

Chronic infectious colitisChronic infectious colitis Ischemic colitisIschemic colitis DiverticulitisDiverticulitis Irritable Bowel SyndromeIrritable Bowel Syndrome Small Bowel Bacterial OvergrowthSmall Bowel Bacterial Overgrowth Crohn’s DiseaseCrohn’s Disease Ulcerative ColitisUlcerative Colitis Colon CancerColon Cancer

Current Diagnostic Tools for Current Diagnostic Tools for Initial IBD DiagnosisInitial IBD Diagnosis

History and History and Physical Physical Exam=clinical Exam=clinical suspicionsuspicion

Stool studiesStool studies ColonoscopyColonoscopy Serology studiesSerology studies Small Bowel Small Bowel

Series/SBFTSeries/SBFT Barium EnemaBarium Enema

WCE=Wireless WCE=Wireless Capsule EndoscopyCapsule Endoscopy

EUS=Endoscopic EUS=Endoscopic UltrasoundUltrasound

Pelvic MRIPelvic MRI MRI EnterographyMRI Enterography CT EnterographyCT Enterography PET ScanPET Scan WBC ScanningWBC Scanning

There is no ONE single test to There is no ONE single test to dx IBD.dx IBD.

Historically the two main tests used:Historically the two main tests used:– ColonoscopyColonoscopy– SBFTSBFT

Lab studies have become an Lab studies have become an additional tooladditional tool

Common Bloodwork Common Bloodwork in diagnosing IBDin diagnosing IBD

C-Reactive ProteinC-Reactive Protein– Inflammation reflects inflammatory Inflammation reflects inflammatory

disease activity initiallydisease activity initially– Can be used as a marker to treatment Can be used as a marker to treatment

responseresponse pANCApANCA= Anti-neutrophil cytoplasmic = Anti-neutrophil cytoplasmic

antibody with perinuclear stainingantibody with perinuclear staining ASCAASCA= anti-saccharomyces = anti-saccharomyces

cerevisiaecerevisiae

Differentiating type of IBDDifferentiating type of IBD

LAB LAB TESTTEST

SENSITIVITSENSITIVITYY

SPECIFICITSPECIFICITYY

TYPE IBDTYPE IBD

+ pANCA+ pANCA 50-65%50-65% 85-92%85-92% UCUC

+ASCA+ASCA 55-61%55-61% 88-95%88-95% CROHN’SCROHN’S+pANCA+pANCA & & ASCA -ASCA -

44-57%44-57% 81-97%81-97% UCUC

-pANCA-pANCA & & ASCA+ASCA+

38-56%38-56% 94-97%94-97% CROHN’SCROHN’S

Sandborn WJ et al, Inflamm Bowel Dis 2001;7:192-201Peeters M et al, AM J Gastroenterology 2001; 96:730-4

Immune Markers being Immune Markers being studied for diagnosing IBDstudied for diagnosing IBD

Anti-12Anti-12 = antibody to pseudomonas = antibody to pseudomonas flourescens transcription factorflourescens transcription factor

Omp COmp C = antibody to Escherichia coli = antibody to Escherichia coli outer membrane porin Couter membrane porin C

PABPAB = Pancreatic antibodies = Pancreatic antibodies Fecal lactoferrinFecal lactoferrin = fecal inflammation = fecal inflammation

iron-binding glycoproteiniron-binding glycoprotein Anti-flagellinAnti-flagellin = CBir 1 antigen = CBir 1 antigen

IBD ManagementIBD Management

Management Management can be can be divided intodivided into– Acute Acute

exacerbationexacerbation– Maintenance Maintenance

of remission: of remission: conventional conventional and biologic and biologic therapiestherapies

– SurgicalSurgical

Artwork is reproduced, with permission, from the Johns Hopkins Artwork is reproduced, with permission, from the Johns Hopkins Gastroenterology and Hepatology Resource Center, Gastroenterology and Hepatology Resource Center, www.hopkins-gi.org,copyright 2006, Johns Hopkins University, all rights www.hopkins-gi.org,copyright 2006, Johns Hopkins University, all rights reserved.reserved.

Acute Management of IBDAcute Management of IBD IV->PO Hydrocortisone or MethylprednisoloneIV->PO Hydrocortisone or Methylprednisolone

– Fast symptom reliefFast symptom relief– Not advised for prolonged use (120 day max)Not advised for prolonged use (120 day max)– No mucosal healingNo mucosal healing– Does not improve long term surgery ratesDoes not improve long term surgery rates

Cipro +/- Metronidazole Cipro +/- Metronidazole – Effectiveness arguable but often seen used anywayEffectiveness arguable but often seen used anyway

IV Cyclosporine 2-4 mg/kgIV Cyclosporine 2-4 mg/kg– Effective for induction of remission but not long-term Effective for induction of remission but not long-term

maintenancemaintenance Bowel RestBowel Rest Rectal +/- Oral 5-ASA; SulfasalazinesRectal +/- Oral 5-ASA; Sulfasalazines

Chronic Therapy of IBDChronic Therapy of IBD

Goals: Goals: – remission of bowel inflammationremission of bowel inflammation– 1-4 BM/day with mucosal healing1-4 BM/day with mucosal healing– Prevention of strictures, fistulas, other Prevention of strictures, fistulas, other

complicationscomplications– Prevention of need for surgeryPrevention of need for surgery

Hopefully feeling NORMAL, not just Hopefully feeling NORMAL, not just betterbetter

CorticosteroidsCorticosteroids

Severe IBD with hospitalization should Severe IBD with hospitalization should be treated with IV steroids for rapid be treated with IV steroids for rapid symptom relief.symptom relief.

Not a long-term solutionNot a long-term solution Convert IV to PO then taper off advisedConvert IV to PO then taper off advised Steroid dependence occurs in 28% pts.Steroid dependence occurs in 28% pts. Should be used in combination with Should be used in combination with

AZA/ 6-MP +/- cyclosporine for severe AZA/ 6-MP +/- cyclosporine for severe IBD symptomsIBD symptoms

Cyclosporine Cyclosporine

IV dosing effective for induction of IV dosing effective for induction of remission in severe UCremission in severe UC

Little efficacy for maintenance of Little efficacy for maintenance of remissionremission

No data on mucosal healingNo data on mucosal healing Nephrotoxicity, seizures rare SENephrotoxicity, seizures rare SE

Mesalamines:Mesalamines:5-ASA/Aminosalicylates5-ASA/Aminosalicylates

Aminosalicylates Aminosalicylates has been the mainstay of has been the mainstay of therapy because of its anti-inflammatory therapy because of its anti-inflammatory activities. activities.

50-70% response in high doses for UC.50-70% response in high doses for UC. Some mucosal healing found.Some mucosal healing found. Excellent safety profile.Excellent safety profile. Not always beneficial. Be quick to move on Not always beneficial. Be quick to move on

if patient is not seeing benefit.if patient is not seeing benefit. No fistula closure benefits to treatment No fistula closure benefits to treatment

found.found.

Mesalamines continuedMesalamines continued Different formulations have been released Different formulations have been released

and are thought to target specific regions of and are thought to target specific regions of the bowel in oral and rectal formulations:the bowel in oral and rectal formulations:

Sulfasalazine and BalsalazideSulfasalazine and Balsalazide– Are primarily released in the colonAre primarily released in the colon– Folic acid supplement advised with sulfasalazineFolic acid supplement advised with sulfasalazine

Dipentum and AsacolDipentum and Asacol– Releases in the distal ileum and colonReleases in the distal ileum and colon

PentasaPentasa– Releases in the distal colonReleases in the distal colon

RowasaRowasa– Primarily effective in the distal colon and rectumPrimarily effective in the distal colon and rectum

ThiopurinesThiopurines

Azathioprine/ 6-MP (mercaptopurine)Azathioprine/ 6-MP (mercaptopurine)– up to 6-12 weeks until effectiveup to 6-12 weeks until effective– Has been shown beneficial in both induction Has been shown beneficial in both induction

and maintenance of remissionand maintenance of remission– NOT as beneficial a 5-ASA for UCNOT as beneficial a 5-ASA for UC– Not as many trials for data with UC as with CDNot as many trials for data with UC as with CD– Some chance of fistula closure with useSome chance of fistula closure with use– Must monitor CBC and LFTs with useMust monitor CBC and LFTs with use

Bone marrow suppressionBone marrow suppression Liver toxicity possibleLiver toxicity possible

MethotrexateMethotrexate Used with patients who are allergic or Used with patients who are allergic or

unresponsive to trial of Thiopurines (6-MP unresponsive to trial of Thiopurines (6-MP or AZA) at adequate dosing.or AZA) at adequate dosing.

Has been shown to induce and maintain Has been shown to induce and maintain remission. remission.

Little data to prove fistula closure on this Little data to prove fistula closure on this drugdrug

1mg Folate supplementation advised1mg Folate supplementation advised Monitor CBC and LFTsMonitor CBC and LFTs

– Bone marrow suppressionBone marrow suppression– Risk of hypersensitivity pneumonitisRisk of hypersensitivity pneumonitis– Liver toxicityLiver toxicity

Biologic Therapy –vs- Biologic Therapy –vs- Conventional Therapy in IBDConventional Therapy in IBD

Conventional Conventional therapytherapy– Aimed at symptom Aimed at symptom

reliefrelief– Reduces Reduces

hospitalizationshospitalizations– Doesn’t reduce long Doesn’t reduce long

term surgery ratesterm surgery rates– Doesn’t maintain Doesn’t maintain

mucosal healingmucosal healing

Biologic therapyBiologic therapy– 25-50% remission 25-50% remission

sx at 1 monthsx at 1 month– Reduces Reduces

hospitalizationshospitalizations– Lowers surgery Lowers surgery

ratesrates– Maintains long term Maintains long term

mucosal healingmucosal healing– Fistula closures Fistula closures

more oftenmore often

Biologic Therapy with CDBiologic Therapy with CD

If patients are not able to be in If patients are not able to be in complete remission on Azathioprine complete remission on Azathioprine with mucosal healing, and off with mucosal healing, and off steroids, the clinician should consider steroids, the clinician should consider starting biologic therapy and discuss starting biologic therapy and discuss this with their patient as an effective this with their patient as an effective treatment option.treatment option.

Biologic TherapyBiologic Therapy

Infliximab is currently approved for Infliximab is currently approved for use in Crohn’s Disease.use in Crohn’s Disease.– CD mucosal healing has been confirmed CD mucosal healing has been confirmed

with endoscopywith endoscopy– Lower rates of hospitalization and surgeryLower rates of hospitalization and surgery– Lessened fistulas Lessened fistulas – 800,000 patients treated with NO infusion 800,000 patients treated with NO infusion

reaction deathsreaction deaths– Some delayed hypersensitivity reactionsSome delayed hypersensitivity reactions

AdalimumabAdalimumab

Recombinant human IgG1 Recombinant human IgG1 monoclonal antibody directed monoclonal antibody directed against tumor necrosis factoragainst tumor necrosis factor

Approved for tx of CDApproved for tx of CD Subcutaneous injectionSubcutaneous injection

Combination Therapy for Combination Therapy for Crohn’sCrohn’s

AZA + Biologic combinationsAZA + Biologic combinations– Slightly higher benefitSlightly higher benefit– Higher blood concentrations with Higher blood concentrations with

demonstrated lower C-Reactive Proteindemonstrated lower C-Reactive Protein– Tolerated wellTolerated well– Lower rates of antibody formation to the Lower rates of antibody formation to the

drugdrug

Biologic therapy with UCBiologic therapy with UC

Infliximab approved for moderate-Infliximab approved for moderate-severe Ulcerative Colitis who have severe Ulcerative Colitis who have had inadequate response to steroids had inadequate response to steroids and AZA.and AZA.– Best results in overall sx reduction and Best results in overall sx reduction and

healing with remission for UC.healing with remission for UC. Future therapiesFuture therapies

– VisilizumabVisilizumab– MLN-02MLN-02– NatalizumabNatalizumab

IBD Surgery IBD Surgery TreatmentTreatment

Crohn’s SurgeryCrohn’s Surgery

Probability of needing surgery increases Probability of needing surgery increases with timewith time

By 30 years post-diagnosis nearly 100% By 30 years post-diagnosis nearly 100% of patients will have had one surgeryof patients will have had one surgery

Previous to biologic therapy the rate of Previous to biologic therapy the rate of surgery increased 10% per year with CDsurgery increased 10% per year with CD

Studies are looking at ways to predict Studies are looking at ways to predict future surgery needs based on new tx future surgery needs based on new tx and serologies.and serologies.

Surgical Therapies with Surgical Therapies with FistulaFistula

I & D for abcessesI & D for abcesses Seton- keeps open with permanent Seton- keeps open with permanent

suture material to prevent recurrent suture material to prevent recurrent abcess.abcess.

Fistulectomy-currative with superficial Fistulectomy-currative with superficial fistulafistula

Diverting surgical proceduresDiverting surgical procedures Rectal advancement flap or sleeveRectal advancement flap or sleeve Proctectomy or total proctocolectomyProctectomy or total proctocolectomy

Ileal Resection in Crohn’s Ileal Resection in Crohn’s DiseaseDisease

Indications:Indications:– Failure of medical therapyFailure of medical therapy– Recurrent obstructionRecurrent obstruction– PerforationPerforation– FistulaFistula– AbcessAbcess– HemorrhageHemorrhage– Growth retardation (children)Growth retardation (children)– carcinomacarcinoma

Artwork is reproduced, with permission, from the Johns Hopkins Gastroenterology and Hepatology Resource Artwork is reproduced, with permission, from the Johns Hopkins Gastroenterology and Hepatology Resource Center, Center, www.hopkins-gi.org,copyright 2006, Johns Hopkins University, all rights reserved.www.hopkins-gi.org,copyright 2006, Johns Hopkins University, all rights reserved.

Post-Op Recurrence of CDPost-Op Recurrence of CD

Commonly see recurrence near the Commonly see recurrence near the ileocolonic anastomosis from ileocolonic anastomosis from previous surgery.previous surgery.

Endoscopic recurrence is found as Endoscopic recurrence is found as high as 73% only 1 year later.high as 73% only 1 year later.

Prevention of recurrences usingPrevention of recurrences using– Mesalamine/5-ASA, 6-MP, probiotics Mesalamine/5-ASA, 6-MP, probiotics

(lactobacillus), metronidazole(lactobacillus), metronidazole

Ulcerative Colitis Surgery Ulcerative Colitis Surgery IndicationsIndications

ABSOLUTE ABSOLUTE INDICATIONS:INDICATIONS:– HemorrhageHemorrhage– PerforationPerforation– Cancer or dysplasiaCancer or dysplasia– Unresponsive acute Unresponsive acute

sxsx

RELATIVE RELATIVE INDICATIONS:INDICATIONS:– Chronic Chronic

intractabilityintractability– Steroid dependencySteroid dependency– Growth retardationGrowth retardation– Systemic Systemic

complications complications associated with UCassociated with UC

Surgery types with UCSurgery types with UC

IPAA = Ileal pouch-anal anastomosisIPAA = Ileal pouch-anal anastomosis– Gold standard as “cure” but not without Gold standard as “cure” but not without

its own complicationsits own complications Incontinence, diarrhea, sexual dysfunction, Incontinence, diarrhea, sexual dysfunction,

decreased fertility, pouchitis, cuffitisdecreased fertility, pouchitis, cuffitis

Conventional Ileostomy (Brooke)Conventional Ileostomy (Brooke) Continent ileostomy (Koch pouch)Continent ileostomy (Koch pouch) Ileorectal anastomosisIleorectal anastomosis

Artwork is reproduced, with permission, from the Johns Hopkins Gastroenterology and Hepatology Artwork is reproduced, with permission, from the Johns Hopkins Gastroenterology and Hepatology Resource Center, Resource Center, www.hopkins-gi.org,copyright 2006, Johns Hopkins University, all rights reserved.www.hopkins-gi.org,copyright 2006, Johns Hopkins University, all rights reserved.

Artwork is reproduced, with permission, from the Johns Hopkins Gastroenterology and Hepatology Artwork is reproduced, with permission, from the Johns Hopkins Gastroenterology and Hepatology Resource Center, Resource Center, www.hopkins-gi.org,copyright 2006, Johns Hopkins University, all rights reserved.www.hopkins-gi.org,copyright 2006, Johns Hopkins University, all rights reserved.

ConclusionConclusionReview of Learning ObjectivesReview of Learning Objectives

Describe the disease process of Crohn’s Describe the disease process of Crohn’s versus Ulcerative Colitisversus Ulcerative Colitis

Identify the clinical presentation of a Identify the clinical presentation of a patient with Crohn’s Disease and patient with Crohn’s Disease and Ulcerative ColitisUlcerative Colitis

Discuss the various diagnostic workups Discuss the various diagnostic workups and how they may differentiate Crohn’s and how they may differentiate Crohn’s from other GI ailmentsfrom other GI ailments

Select appropriate treatments for a patient Select appropriate treatments for a patient with Crohn’s Disease and Ulcerative Colitiswith Crohn’s Disease and Ulcerative Colitis

Thank YouThank You