Inflammatory Bowel Disease

Inflammatory Bowel Disease – Francesca Raffa

Background

  • Ulcerative colitis (UC): colon only (can be backwash ileitis); contiguous lesions; mucosal inflammation
  • Crohn’s disease (CD): any part of the GI tract; “skip lesions”; transmural inflammation
  • Important historical considerations to include in your documentation and presentation:
    • Location of disease (CD: LB/SB, LB only, SB only; UC: proctitis, left-sided or pancolitis)
    • Complications: Fistulizing, strictures, perianal, prior surgeries, current IBD treatment
    • Include last endoscopies and imaging findings; current and prior IBD treatment and reason for transition (SEs, failure), primary IBD provider

 

Presentation

  • UC: frequent diarrhea (often bloody), tenesmus, urgency, abdominal pain; may have fever, malaise, and weight loss
    • Complications: severe bleeding/anemia, fulminant colitis, toxic megacolon 
  • CD: abdominal pain, nausea/vomiting, fever, malaise, weight loss; May also have diarrhea (± bloody depending on CD location)
    • Complications: fistulas (entero-enteric, entero-vesicular, entero-cutaneous, rectovaginal, perianal, retroperitoneal), abscesses, strictures, obstruction
  • Extra-intestinal (EI): arthritis, sacro-iliitis, uveitis, episcleritis, aphthous ulcers, erythema nodosum, pyoderma gangrenosum, PSC (esp. UC), nephrolithiasis, thromboembolism

 

Evaluation

  • CBC w/diff, CMP, CRP, ESR, ± blood cultures
  • If diarrhea: GI Pathogen panel and C. diff
  • If anemic: obtain iron studies and type & screen
  • If weight loss or concern for malnutrition: albumin, pre-albumin, Vitamin D, B12, folate
  • Imaging:
      • CT Enterography (oral contrast) preferred in CD, for luminal/extra-luminal complic.
      • How to order CTE: “CT abdomen pelvis enterography”, order barium (Volumen) 0.1% oral suspension x2, 1st dose to be given by nurse 60 min before study, 2nd study to be given 30 min before (nurse should be in contact with CT tech)Management

 

Acute Flare

  • Pain control: usually a major component of hospital course
      • Avoid NSAIDs, oral pain medications are preferred
      • If pain is difficult to control, consider Acute Pain Service consult
      • Narcotics and Imodium are contraindicated in toxic megacolon
  • Antibiotics: appropriately treat infections (intra-abdominal or perianal abscess) with antibiotics (consider prior culture data, often use cipro/flagyl)
  • VTE Prophylaxis: All IBD patients, even if having blood in stool (unless requiring transfusion) as they are at much higher risk of VTE
  • Nutrition: Nutrition consult for all IBD patients; For severe malnutrition or if prolonged bowel rest is needed, TPN is sometimes initiated (discuss w/ fellow or attending before placing a TPN consult); If TPN needed, will require PICC line  
  • Anemia: Ferritin <100 or iron sat <20 with ferritin <300, consider iron infusions (if no bacteremia) or transfuse for severe anemia
  • Smoking Cessation (esp. with CD): discuss smoking cessation & consult tobacco cessation
  • Consult Colorectal Surgery (not EGS):  SBO, toxic megacolon, bowel perforation, peritonitis

 

Immunosuppression: (Infections must be ruled out and/or treated before starting)

  • First, steroids: methylprednisolone (Solumedrol)- often 20 mg BID for three days
      • Transition to oral (40 mg prednisone daily) once clinically improved/tolerating PO; typically prescribe a prolonged taper on discharge (often down by 5 mg every week)
      • If severe proctitis: consider rectal steroids (hydrocortisone enema/foam)
  • Second, if lack of response: additional medical therapy (biologics), bowel rest with TPN, or surgical intervention
      • Infliximab (Inflectra) is available at VUMC
      • If patient fails to respond to steroids, should consider possibility of CMV colitis (usually evaluated by biopsy on flex sig or colonoscopy)
      • Biologic workup: prior to initiating a biologic, all patients must have the following negative studies within the last year: Quantiferon Gold and CXR, Hepatitis B serologies, HIV, urine histoplasma Ag (some providers)