Ulcerative Colitis&

Extraintestinal ManifestationsKimberly Persley, MD

April 20, 2005

Case Presentation

• 36 yo WP transfer from OSH with severe, steriod refractory UC– 11/2004 – Bloody diarrhea and abdominal pain

• Treated with Colazol 6.75 gm/d

• Prednisone 60 mg /d

– 12/2004 – Imuran started secondary to refractory symptoms but developed ITP and the Imuran stopped

Case Presentation

– 2/26/2005 – underwent colonoscopy that showed “mild to moderately active colitis in the left colon

– 2/28/2005 – admitted to OSH with fevers, increased bloody diarrhea and abdominal pain

• Negative ID workup

– 3/6/2005 – transfer to PHD for further management• 10-12 bloody bowel movements daily, abdominal pain,

persistent fever, anorexia

• No joint pain, oral ulcers or rashes

Case Presentation

• PMH– ITP – first diagnosed 11/2004

• Bone marrow biopsy – megakaryocytic hyperplasia

• Treated with steroids, WinRho and IVIG

– Patent foramen ovale

• Meds– Flagyl, Cipro, Solumedrol, Morphine and Phenergan

• Family History– Paternal Grandfather with colon cancer

Case Presentation

• Physical Exam– BP 124/69, Pulse 96, Temp 98.4– No skin lesions– CV – RRR with systolic murmur– Abdomen – NABS, tenderness in the lower

abdomen, no masses, no splenectomy– Ext – no edema

Case Presentation

• Labs– WBC 15.3 (45% segs, 38% bands)– Hgb 12 g/dl, ferritin 150, vit B12 1163 pg/ml– Platelet 137k, ESR 67– K 3.1, chol 123– Creat 0.9– Stool and blood cultures - neg

Case Presentation

• Hospital Course– Repeated stool and blood cultures– Solumedrol 60 mg IV continuous infusion– Platelet count decrease

• Treated with IVIG

– IV Cyclosporine (2mg/kg) started without significant improvement (received 13 days)

• Flex sig – grade 4 colitis (severe)

Flexible Sigmoidoscopy

Ulcers

Laboratory Data

Mar 6 Mar 9 Mar 22 Mar 29

Platelets 95k 10k 46k 144k

WBC 17.7 10.6 7.9 16.4

HgB

(g/dl)

13.0 10.0 8.8 11.8

Case Presentation

3/23/2005- underwent lap assisted colectomy with ileostomy

3/27/2005- discharged home

Spectrum of IBD

Ulcerative colitis Crohn’s Disease

Indeterminant colitis

Normal Intestine Vs. IBD

Environmentaltriggers (infection,bacterial products)

Moderatelyinflamed

Failure to down-regulate

Chronic uncontrolledinflammation = IBD

Down-regulate

Normal gutcontrolled inflammation

Normal gutcontrolled inflammation

Disease Distribution at Presentation

n=1116n=1116

37%37%

17%17%

46%46%

Farmer RG. Dig Dis Sci;38:1137-1146

IBD Treatment Pyramid

5-ASA

Antibiotics

Steroids

Immunomodulators

Biologicsseverity

ImuramMTXCyclosporine

AsacolColazolsulfasalazine

Remicade(not approved for UC

EyeEyeinflammationinflammation**

Liver andLiver andbile ductbile duct

inflammationinflammation

Skin lesionsSkin lesions

Arthritis and Arthritis and joint painsjoint pains

KidneyKidneystonesstones

Growth failureGrowth failurein childrenin children

LowerLowerbone density*bone density*

Subfertility*Subfertility*

IBD: Systemic Complications

*Higher incidence in women.*Higher incidence in women.

GallstonesGallstones

OvariesOvaries

UterusUterus

EIMs and Response to Treatment

• Responds to treatment of underlying bowel disease

– Peripheral arthritis

– Erythema nodosum

– Episcleritis

• Independent of treatment of underlying bowel disease

– Axial arthritis– Pyoderma

gangrenosum– Uveitis– PSC

IBD and Hematology

• Anemia is common in patients with IBD– Iron loss– Defective iron transport– Impaired Vitamin B12 and Folate absorption– Insufficient erythropoietin production– Autoimmune Hemolytic Anemia

ITP and IBD

• Not a frequent association

• Usually associated with Ulcerative Colitis

• Decrease in platelet counts observed during flares

• Various treatment modalities used to induce remission

ITP and IBD

• 24 cases of IBD in ITP reported– 21 Ulcerative Colitis– 3 Crohn’s Colitis

• IBD usually preceeded ITP be several months to years

• No standardized approach to therapy• No other cases reported with colectomy

only

Molecular Mimicry

platelet

APC

colon

bacteria

antibodies

Spleen

Platelet destruction

Zlatanic et al. AJG 92,1997

ITP and IBD

• Treatment– Short course of steroids– IVIG– Splenectomy may be required to maintain

platelet count• + colectomy if active colitis

– Colectomy should be considered if colitis remains active despite medical therapy

Case Presentation (follow up)

• Platelet count 275k on March 31, 2005

• On prednisone taper

• Will return in next 2-3 months for a Ileal pouch anal anastomosis