Inflammatory Bowel Disease

Thank you to Dr Ehrlich for a very insightful lecture on Inflammatory Bowel Disease (IBD)!

Click here for the lecture powerpoint!

See Lecture Video Database for the lecture recording (coming soon).

Epidemiology

  • 1.4 million people in US
  • Urban population
  • Northern climates
  • Bimodal age incidence distribution
    • 15-30 yo
    • 50-65 yo
  • No known dietary triggers. So for the most part patients can eat whatever they want.

Disease Characteristics

  • See powerpoint Slide #5 for table describing differences between UC and Crohn’s.
  • Note: Patients are at increased risk of cancer due to chronic inflammation

Medications for Ulcerative Colitis (UC)

Topical Medications

  • 5asa suppository or enema
  • Steroid suppository, foam, enema

Oral Medications

  • 5-ASA
  • Immunomodukators (6mp, azathioprine)
  • Steroids
  • Cyclosporine (rarely used anymore)
  • Methotrexate
  • Biologics (Anti TNF alpha inhibitors):
    • Infliximab (IV infusion)
    • Adalimumab (SC injection)
    • Golimumab: similar to the other drugs on the market
  • Budesonide MMX: newer agent; tablet that only gets released when it hits the colon. For mild to moderate UC. Use as an adjunct to 5asa to get pt back in remission

Treatment Strategy:

  • Combination oral and topical initially. Then just oral when it’s better controlled
    Avoid steroids if possible

Medications for Crohn’s Disease

Topical Medications

  • Only useful in Crohn’s Colitis.

Oral Medications

  • Immunomodukators (6mp, azathioprine)
  • Steroids
  • Antibiotics
  • Methotrexate as adjunct
  • Biologics (anti TNF alpha: Infliximab (IV infusion),  Adalimumab (SC injection)
  • Natalizumab: causes pml so not used anymore
  • Vedolizumab: antibiotics integrin prevents leukocyte tracking. Similar to natalizumab, but specific to the gut. No PML so far. IV on weeks 0, 2, 6 and every 8 weeks thereafter
  • More effective in UC compared to crohn’s
  • Ustekinumab (Stelara) il 23 inhibitor, previously approved for psoriasis. Note at a higher dose for crohn’s.
  • Check out the Uniti1 and Uniti2 Trials for more information

Health Maintenance in IBD Patients

Vaccines in Immunosuppressed Patients

As is inherent in the term, the immune response is blunted with immunosuppressives and thus live vaccines are contraindicated.  BUT, there is no evidence that giving a vaccine will cause an IBD flare.

Definition of immunosuppression:

  • Prednisone 20mg daily for two or more weeks and within three months of discontinuation
  • Treatment with immunomodulators or biologics and within three months of discontinuation
  • Significant protein/calorie malnurition

And other vaccines are contraindicated in immunosuppressives

Inactivated vaccines are able to be given in immunosuppression:

  • Ex: TDaP, HPV, Influenza, Hepatitis A, Hepatitis B, Pneumococcal

Live vaccines should NOT be given in immunosuppression:

  • Ex: Varicella, Herpes Zoster, MMR

Bone Health in IBD

Assess bone density (via DEXA) in the following conditions:

  • Total steroid use >3 months
  • Inactive disease but past chronic steroid use of at least 1 year but within the last 2 years
  • Inactive disease but maternal history of osteoporosis
  • Inactive disease but malnourished or very thin
  • Inactive disease but amenorrheic
  • Post menopausal women regardless of disease status

Skin exam yearly if on immunosuppressed

Colonoscopy and Cancer Screening in IBD

  • IBD with greater than 1/3 of colon affected? If yes, then start colon cancer screening 8 to 10 years after initial diagnosis. Then, screen every 1-2 years.
    • Chromoendoscopy preferred
  • Tobacco cessation
    Depression screening

Tidbits on Medications

  • 5-ASA: commonly causes renal insufficiency (check once yearly Cr)
  • Immunomodulators (AZA, 6MP, MTX): monitor for blood and liver abnormalities;  cancer(lymphoma), pancreatitis
    • Check these tests weekly for a monthly then space out
  • Anti-TNF alpha: Check HBV and TB before initiation

IBD during Pregnancy

  • MTX absolutely contraindicated
  • Sulfasalazine causes reversible azoospermia in men
  • Key Point: Keep sxs controlled. Most meds can be continued during pregnancy

Updates on Fecal Microbiota Transplant

Microbiome is the ecological community of commensal, symbiotic, and pathogenic microorganisms that share our body space.

Clostridium difficile epidemic (30,000 deaths/year), with a cost of $5.2 billion annually.  Recurrence rate 15-35% and increase up to 45-65% after more than one episode.

Risk factors- antibiotic use, hospitalization/health care exposure, long term care facility resident, advanced age, PPI use, IBD, pregnancy, immunocompromised.

Decreased fecal diversity noted in C. diff, with further decreases in diversity with recurrent infections.

Fecal microbiota transplant (FMT) can work because normal fecal flora may “out compete” C. diff.  There could be production of antimicrobials or an increase in secondary bile acid production

Indications for FMT:

  • Recurrent or relapsing CDI- 3 episodes of mild to moderate C. diff infection or 2 episodes of moderate to severe.
  • Moderate C. diff not responding to therapy for 1 week
  • Fulminant cases not improving in 48 hours

Results from data collected for OpenBiome (the main stool banking company) shows an overall clinical cureof 84% with a single treatment.  Lower GI delivery had superior results.

Risk factors for failure included severe/complicated disease, prior hospitalization for C. diff, being inpatient.

Risk of recurrent C. diff is increased by post FMT antibiotic use.  Risk is unchanged if there is prophylactic use of C. diff antibiotics or probiotics.

Use of FMT in patients with IBD has shown a significant improvement in steroid free clinical remission and endoscopic response/remission

Approach to Abdominal Pain

Abdominal Pain History:

  • Position/palliating and provoking factors
  • Quality (sharp, dull, sore, burning, cramping)
  • Region, radiation, referral
    • Ask patient to use one finger to confirm location
    • Referred pain: Kehr’s sign (diaphragmatic irritation can cause shoulder pain), Ipsilatral scapula (biliary disease)
  • Severity
  • Temporal factors (time/mode of onset, progression, previous episodes)
    • Remember to ask about recent surgeries or procedures, new medications, social history (tobacco use in AAA, ob/gyn history)

Physical Exam:

  • Palpation strategies/questions: Work from least to most painful areas, do not be afraid to push, care the complaints out of proportion to exam, when did they get pain meds?
  • Peritonitis: Perforation, malignancy, mesenteric ischemia, strangulated hernia
    • Evaluation Techniques: Cough test, Inspiration test, peritoneal irritation (tapping heel, bumping bed)
    • Specific Maneuvers:
      • Murphy’s Sign- Inspiratory arrest during pressure to RUQ while patient taking a deep breath.
      • Psoas Sign- pain with passive hip extension
      • Obturator Sign- pain with passive internal/external rotation of right hip
      • Rovsing Sign- pain in RLQ when there is pressure exerted in LLQ