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Inflammatory Bowel Disease (UC (risk factors (FHx (largest independent…
Inflammatory Bowel Disease
Crohn's
can affect any part of the GI tract
incidence = 4-10 per 100,000 annually
risk factors
FHx
largest independent risk factor
1 in 5 have relative affected
NOD2/autophagy/Th17 genes implicated
smoking
increased risk
NSAIDs
hygiene
lower prevalence in poor and large families
nutrition
suggested high sugar and fat
breastfeeding is protective
chronic stress
appendectomy
increased risk
intestinal microbiota
intestinal dysbiosis
E. coli
defective chemical barrier/defensins
immune system
deficiency in inflammasome
skip lesions
development of fistulae
strictures
deep ulcers and fissures
cobblestone appearance
non-caseating granulomas
may be ASCA+
~50% of patients will require resection within 5y of diagnosis
diarrhoea in 80%
anal and perianal disease
management
induction of remission
glucocorticosteroids
response 60-90%
oral pred in moderate-severe
budesonide in mild-moderate ilioceacal
aminosalicylates
Abx
abscess
perianal disease
exclusive enteral nutrition
particularly in paeds
maintenance of remission
may not be needed in mild cases
azathioprine
TPMT
mercaptopurine
methotrexate
anti-TNF
ifliximab
adalimumab
refractory disease
induce immune cell apoptosis
surgical
UC
affects only the colon
incidence = 6-15 per 100,000 annually
risk factors
FHx
largest independent risk factor
1 in 6 have relative affected
smoking is protective
NSAIDs
nutritional factors
chronic stress
appendectomy is protective
intestinal microbiota
defective chemical barrier/defensins
immune system
deficiency in inflammasome
extends proximally from rectum
backwash ileitis
reddened and inflamed mucosa
(friable)
pseudo-polyps
crypt abscesses
inflammatory infiltrate in lamina propria
may be ANCA+
presents with diarrhoea with blood and mucus
toxic megacolon may occur
management
5-ASA
rectal suppositories for proctitis
enema for L sided colitis
oral for extensive colitis
chemoprotective for UC-associated CRC
steroids
oral or topical pred as second line
anti-TNF
infliximab/adalimumab
anti-integrin
vedolizumab
IV hydrocortisone and SC LMW-heparin if very severe
severe colitis
6 stools/day with blood
fever >37.5
tachycardia>90bpm
ESR>30mm/h
Hb <100g/L
albumin <30g/L
IBS
NOT AN IBD
1 in 5 of Western populations
coexists with fibromyalgia,
chronic fatigue and TMJ dysfunction
associated with affective disorders
diagnosis
at least 3 days/month over 3 months with abdo pain
at least 25% improvement with defecation
at least 25% onset assoc with change in stool frequency
at least 25% onset assoc with change in stool form
management
GI
identify dietary triggers
high-fibre diet
rifaximin -
short-term benefit
anti-diarrhoeals
e.g. loperamide
anti-constipation
e.g. prucalopride
psych
explanation
psychotherapy
CBT
hypnotherapy
antidepressants
e.g. clomipramine, amitriptyline
CUTE
10% of cases
neither UC nor Crohn's
microscopic collitis
lymphocytic
surface epithelial injury
prominent lymphocytic infiltration in surface epithelium
increase lamina propria mononuclear cells
collagenous
thickened subepithelial collagen layer adjacent to basal membrane
infiltration of lamina propria with lymphocytes and plasma cells
surface epithelial damage
middle-aged/elderly females
associated with autoimmune disorders