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01 14 2021 GERD Inflammatory Bowel Disease Irritable Bowel Syndrome ALLEN
01 14 2021 GERD Inflammatory Bowel Disease Irritable Bowel Syndrome ALLEN
Georgia Allen, DO
Internal Medicine
Assistant Professor, Primary Care Dept.
January 14, 2021
Objectives
Explain the etiology and pathology of Ulcerative
Colitis and Crohn’s disease.
Understand the differences between UC and CD
Describe the clinical presentation of IBD
Recognize extraintestinal manifestations of IBD
Describe the basic work-up for a patient with
suspected IBD
Understand different modes of therapy for both UC
and CD
Understand complications from these diseases
Definition
Inflammatory bowel
disease is simply
Ulcerative colitis- chronic inflammatory
inflammation of the condition characterized by relapsing and
bowel, and is
comprised of two remitting episodes of inflammation on
major disorders: the mucosal layer of the colon that starts
ulcerative colitis
and Crohn’s disease at the colon and extends proximally in a
continuous fashion.
Crohn’s Disease- transmural
inflammation that may involve the entire
GI tract from mouth to perianal area and
typically consists of “skip lesions”.
Epidemiology
Incidence of IBD varies geographically, by region and
even by season, leading many to believe there are both
genetic and environmental components to these
diseases.
In one of the largest studies in the US, the prevalence
of UC was 238/100,000 adults, and the prevalence of
CD was 201/100,000 adults.
Incidence of both of these diseases has been changing
over time. At one point ulcerative colitis was more
common, now ulcerative colitis and Crohn disease is
roughly equivalent in North America and Europe.
Risk Factors
Age of onset 15-40 years
Pathogenesis of Incidence of IBD lower in black and Hispanic
IBD remains
populations compared to whites
unclear, some risk
factors have been ~10-25% of patients with IBD have first degree
identified. relative with IBD as well
Smoking increases risk of Crohn’s disease
“Western” diet increases risk of CD and possibly UC
Increased physical activity decreases risk of CD,
obesity may alter course of disease
Some infections may be a risk factor for developing
IBD
Breastfeeding is protective against CD
Other questionable risk factors: antibiotic use,
NSAID’s, oral contraceptives, stress, sleep deprivation
Ulcerative Colitis
Pathology, Presentation, Diagnosis, Management
Pathophysiology
Recurring episodes of inflammation limited to the
mucosal layer of the colon. Commonly involving the
rectum and extending proximally in continuous fashion.
Not yet fully understood…
Believed to be a dysregulated proinflammatory response
to gut flora.
Also, may have MUC2 gene mutation which codes for a
protective mucin that coats the gut epithelium. HLA
alleles may play a role as well.
Patient Presentation
Biopsy shows:
distortion of crypt
architecture, mucin Pseudopoly
cell depletion in ps
epithelium, Paneth
cell metaplasia,
increased lamina
propria,
inflammatory cells
Management
Management is 5-aminosalicylic acid (5-ASA)
based on disease
extent and clinical suppositories/enemas. Preferred over
severity. Different topical corticosteroid preparations.
management to
induce remission Oral 5-ASA preparations if fail topical
and maintain
remission as well.
or unable to tolerate.
Combination of oral/topical 5-ASA and
corticosteroid preparations.
Oral steroids for flares and to induce
remission.
Management of severe disease
IV or oral steroids for extended periods used to induce remission
If the patient has fever and/or any other toxic symptoms, IV
antibiotics should be started
Maintenance therapy: oral 5-ASA, azathioprine (AZA), 6-
mercaptopurine (6-MP), or anti-TNF (infliximab/adalimumab)
If the symptoms are severe (fulminant)- progressing to toxic
megacolon/perforation
NPO, IV fluids, IV antibiotics
Refractory cases
Cyclosporine
Infliximab
Colectomy
Acute complications
Severe bleeding- massive
hemorrhage may necessitate
transfusions and urgent
colectomy
Toxic megacolon- severe colitis
may progress to enlarged colon
and signs of systemic toxicity as
inflammatory process extends
into muscle layers of the colon
Perforation- commonly occurs
with above, is a surgical
emergency. Perforation with
peritonitis has about a 50%
mortality rate.
Chronic Complications
Strictures
Caused by repeated episodes of inflammation
Most common in the rectosigmoid colon
Cause symptoms of obstruction
Colorectal cancer- risk based on severity and duration
of disease
Incidence ~ 2.5% after 20yrs and 7.6% after 30yrs of
disease
Mortality- slightly higher mortality rate than the
general population
This number is decreasing over time!
Crohn’s Disease
Pathology, Presentation, Diagnosis, Management
Pathophysiology
MRE
image
Cobblestoning
seen with barium
study
Diagnosis
Clinical history and
laboratory studies
suggestive of Crohn’s
disease and ruling out
other disease processes.
Diagnosis is usually
established with
endoscopic or imaging
findings
Endoscopy & Biopsy
Endoscopy:
Ulcerations, may be
large enough to
demaracate islands
of mucosa
(“cobblestoning”),
fistulas, strictures,
thickened mesentary
encasing bowel
(“creeping fat”)
Biopsy: transmural
inflammation,
fistulas, crypt
abscesses,
noncaseating
granulomas
Management of mild to moderate CD
Many therapies exist for Crohn’s disease. Choice of
medication is based on location and severity of
disease, as well as induction/maintenance medication.
5-aminosalicylates (5-ASA) – oral
Antibiotics (Ciprofloxacin, Metronidazole)
Glucocorticoids – oral
Non-systemic glucocorticoids (Budesonide)
Immunomodulators (Azathioprine, 6-mercaptopurine,
methotrexate)
Biologics (Inflixamab, Adalimumab)
Other therapies
Probiotics have been shown to be helpful in some
patients
Dietary modifications: lactose avoidance, low carb
diet, fiber?, other elimination diets based on individual
triggers
Remember your viscerosomatic reflexes!
Management of severe CD
For patients who fail outpatient management,
hospitalize for IV steroids to induce remission
If not responding, patient may need bowel rest (NPO)
and total parenteral nutrition (TPN)
Georgia Allen, DO
Internal Medicine
Assistant Professor, Primary Care Dept.
Objectives
Recognize the epidemiology of irritable bowel
syndrome
Be able to define IBS using the Rome III criteria
Understand key factors that play a role in the
pathogenesis of IBS
Know how a patient with IBS may present and what a
basic work-up would entail
Recognize different management modalities for IBS
Definition
GI disorder
characterized by chronic
abdominal pain and
altered bowel habits in
the absence of structural
abnormalities or any
organic cause.
Previously thought of as
solely a somatic
manifestation of
psychological stress
Epidemiology
Most commonly diagnosed GI condition
25-50% of all GI referrals
Most patients diagnosed before age 45
Women are 2 times more likely than men to be
diagnosed with IBS
Prevalence of IBS in the US is 10-15% of the
population
Pathophysiology
Still remains unclear
Thought to be due to number of factors, including
genetic and environmental
Factors that play a role in IBS
Alteration in GI motility
Prolonged colonic transit time in some patients with
constipation-predominant IBS
Exaggerated response in diarrhea-dominant patients
Visceral hypersensitivity
Stimulation of receptors in the gut wall transmit signals
that eventually signal pain to the brain (sensitivity in GI
vs brain?)
Studies have shown that patients with IBS have
increased sensitivity to intestinal balloon distension than
controls
Other studies show that patients with IBS who complain
of bloating have similar volumes of gas to controls, but
More factors
Intestinal inflammation
Some IBS patients have increased levels of inflammatory
cells in their GI tract
Infectious
Two meta-analyses showed increased risk of IBS in patients
with an episode of gastroenteritis
More specific risks: young age, prolonged fever, anxiety,
depression
Alteration of fecal flora and bacterial overgrowth
Fecal microbiota differs between individuals with IBS vs
healthy controls
Conflicting evidence in association of IBS with abnormal
hydrogen breath tests
Food sensitivities
Some patients with IBS report sensitivities to certain foods,
but this is all individualized
Food allergies
Improved symptoms with elimination diets if a patient had
elevated IgG levels to certain foods
Carbohydrate malabsorption
No current evidence to suggest that patients with IBS have
impaired carbohydrate absorption
Gluten sensitivity
Some studies suggest some overlap, especially with +IgG
antigliadin antibodies and HLA-DQ2/8+ without vilious
atrophy
Psychosocial factors
Some studies show increased anxiety and depression
in patients with IBS vs controls
One interesting study:
Corticotropin releasing factor (CRF) is a peptide that is
released during a stress response
Increased CRF contributes to anxiety and depression
Administration of CRF (IV) induced abdominal pain and
diarrhea to a higher degree in IBS patients vs controls
Patient Presentation
Varied presentation between
patients
Most commonly: abdominal
pain and altered bowel habits
Abdominal pain is varied in
location, crampy and can be
mild to severe
Red flags: anorexia,
malnutrition, weight loss,
prevents sleep
Combination of diarrhea,
constipation, or both. Can also
have intermittent normal
stooling as well
GI symptoms
Diarrhea- frequent loose stools
during the day, usually after a
meal, feeling of incomplete
evacuation, urgency and
incontinence
Red flags: large volume, bloody stools,
nocturnal diarrhea, greasy stools
Constipation- hard, pellet shaped
stools. May have feelings of
incomplete evacuation
Other patients may complain of:
gastroesophageal reflux,
dysphagia, early satiety, dyspepsia,
nausea, abdominal bloating,
increased gas production
Differential Diagnosis
Dependent on symptom and location of abdominal pain
Parasitic/bacterial infections Hypothyroidism,
GERD, PUD, pancreatic hypoparathyroidism
disease, biliary tract dx Side effect of
IBD, diverticular disease,
medications
colon cancer
Acute intermittent
Gastroparesis, partial
obstruction porphyria, lead
Lactase deficiency, poisoning
malabsorption,
hyperthyroidism
Work-up
CBC, CMP, ESR, ?thyroid studies
Should be normal
If patient has symptoms suggestive of IBS, no red flag
symptoms, no family hx of IBD or colorectal cancer,
then no further testing is warranted.
If they have any alarming symptoms, further imaging
and/or colonoscopy is needed.
Further work-up
Diarrhea-predominant Constipation-predominant
Stool cultures and O&P Xray
Celiac screening Colonoscopy
TTG IgA and serum
IgA
24 hour stool collection
Looking for
malabsorption
Colonoscopy and
biopsy
Diagnosis
Chronic abdominal pain and altered bowel habits
IBS is diagnosis of exclusion
Rome criteria developed to standardize a definition of
IBS
Management
Dependent on symptoms and severity of disease
First step is developing a healthy physician-patient
relationship
Discuss diagnosis, validate symptoms, reassurance,
establish realistic expectations
Next is dietary modification
Exclude gas producing foods
Trial of Lactose-free diet
Next…low FODMAP diet
Low FODMAP diet
This should be done under guidance of trained
dietician to avoid over-restriction
This is done for 6-8 weeks until symptom resolution
Then start adding back these foods to determine
individual intolerance to specific foods
If that doesn’t work…
Trial of gluten-free diet for 2 weeks
Limited evidence to support this
Fiber supplementation
Controversial evidence, but very low
side-effect profile
Physical activity has shown some
benefit!
20-60 min of moderate to vigorous
exercise 3-5 times per week
Pharmacologic therapy
Laxative- polyethylene Loperamide-
glycol (PEG), lactulose, antidiarrheal
milk of magnesia Cholestyramine- bile
Lubiprostone and acid sequestrant
Linactolide are newer Dicyclomine and
medications that Hyoscyamine-
increase intestinal fluid antispasmodics
secretion Tricyclic
antidepressants- slow
intestinal transit time
Rifixamin- antibiotic
Probiotics can be tried
Other therapies
Behavior modification
Anxiolytics (short term)
Accupuncture
OMM
Viscerosomatic reflexes
References
Harrison’s Principles of Internal Medicine, 19 th Edition.
Irritable Bowel Syndrome.
www.uptodate.com
Pathophysiology of irritable bowel syndrome
Clinical manifestations and diagnosis of irritable bowel
syndrome in adults
Treatment of irritable bowel syndrome in adults
Weinberg, DS, et al. “American Gastroenterological
Association Institution Guideline on the
Pharmacological Management of Irritable Bowel
Syndrome.” Gastroenterology 2014; 147:1146-1148.
Questions?