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Inflammatory Bowel Disease, Variations - Coggle Diagram
Inflammatory Bowel Disease
Pathogenesis
Genetics factors: autophagy, bacteria handling, chemokines/cytokines
Environmental factors:
Symptoms and complications
abdominal cramps, diarrhoea, constipation, urgency, fever, loss of appetite, fatigue, weight loss, anaemia
Complications
- abscess (pus) as inflammation extends through bowel wall.
Fistulas - disease tracts outside of bowel via abscess extending through wall forming cavity
Stricture - narrowing of bowel due to inflammation/scarring causing possible blockage
Toxic Megacolon - severe ulceration causing large bowel to severely extent
Perforation - hole/break in wall (need urgent surgery)
Extraintestinal manifestations
- joint pain, skin conditions, eye inflammation, liver disorders, osteoporosis, asthma, coeliac, rheumatoid arthritis, multiple sclerosis, increased risk of cancers
Micronutrient deficiencies
- iron, vitamin D, vitamin B12, zinc, folate, calcium, magnesium
Medical mx
Respectful paradigm
Steroids... overtime suppress immune system increasing risk of infection, skin disorders, affect appetite, osteoporosis
Immunomodulators... for steroid dependent pt, inhibit Tcell function to stop inflammatory response
Biologics... anti TNFa via IV, although higher risk of infection
Surgery - for obstruction, fistula or refractory disease
GESA inflammation treatment
Aminosalicylates, corticosteroids, immunomodulators, biologics, antibiotics, exclusive enteral nutrition (EEN)
Dietetic management
Nutritional Goals
Improve/maintain nutritional status.
If weight stable …EER 100 – 125kJ/kg/day. EPR 1.2 – 1.5g/kg/day (with active inflammation).
If malnourished …EER 125 – 145kJ/kg/day (for repletion) EPR 1.2 – 1.5g/kg/day
Aim for symptom control
Identify and address malabsorption. Manage deficiencies: B12, bile salts, fat soluble vitamins, iron
Tackle nutrition knowledge. FAD diets/ food avoidances
Look for disordered eating
Consider supplementation if required - ONS, EEN
General management
Food fortifiaction if required
Focus on good quality, high nutrient, low processed foods
Don't restrict fibre unless risk of obstruction
Flare - up management
HPHE to address unintended weight loss/poor appetite
Low fibre for stricturing and obstructions
Hydration - consider isotonic drinks for electrolytes
Liquid diet or EEN - consideration for steroid dependent pt, SB disease, stricturing, fistulating or pre-existing malnutrition
EEN
Liquid polymeric diet (oral or enteral) for 6-8 weeks followed by food re-introduction phase
Negatives: palatability, lack of variety, lack of expertise
Positives: disease control efficacy, clinical remission, mucosal healing, anti-inflammatory properties, manage nutrient deficiencies, reduce anaemia, promote bone turnover, promote microbiome
Food reintroduction: gradual 5-10 days, food intolerances may present (possible relapse)
Monitor pt with active disease 1x/week. After initial 2 weeks of EEN therapy if pt is not improving consider alternate pathway.
Variations
Dx difficult - uses montreal categories
A1 catetory for dx age <16 years, A2/3 dx age 17;40 years. General affect population experience ulceration in terminal ilium and colon.
Montreal B (behaviour)
as structuring or penetrating
B1 without stricturing or penetration
B2 stricture (narrowing in intestine)
B3 penetrating (tract/fistula appears between two structures)
B4 Perianally penetratin
Montreal L
category L1 terminal ileum L2 colon L3 ileocolon L4 upper GI tract (stomach oesophagus)
Affects any region of intestine through discontinuous pattern
Crohn's Disease
Only affects colon and rectum in continuous retrograde pattern
Ulcerative Colitis
Transmural inflammation (full thickness)
Only affects mucosal/sub-mucosal layers
Formation of strictures (narrowing of bowel wall) or fistulas (tracts between the bowel and other organs).
Malnutrition in CD reported in 20-85% - anorexia, malabsorption, increased intestinal losses, systemic inflammation
Proctitis: only affects rectum 30-60% patients. Symptoms - rectal bleeding, tenesmus, urgency
Left-sided colitis: 16-45% patients. Symptoms - proctitis, diarrhoea, abdominal cramping
Extensive colitis: 15-35% patients. Symptoms - left sided colitis, constitutional symptoms, fatigue, fever