IS IT IBD OR IBS 2012

2012 Physicians Assistance

WINTER CONFERENCE

March 10, 2012

IS IT IBD OR IBS

Jannine Purcell, CNP

Rapid City Medical Center

Division of Gastroenterology and

Hepatology

IRRITABLE BOWEL SYNDROME

IBS is a gastrointestional syndrome characterized by chronic abdominal pain and altered bowel habits in the absence of any organic cause

THIS IS THE MOST COMMONLY DIAGNOSED GI

CONDITION

IBS affects men, women, young patients and the elderly

There is a 2:1 female predominance in North American females

IBS comprises 25-50% of all

referrals to GI

IBS accounts for a significant number of visits to primary care and is the second highest cause of work absenteeism after the common cold

IBS has been associated with increased health care cost with studies suggesting annual direct and indirect costs up to $30 billion

ANNUALLY

Altered bowel habits ranging from diarrhea, constipation, alternating diarrhea and constipation

INFLAMMATORY BOWEL

DISEASE

Chronic inflammatory bowel disease (IBD) include:

Ulcerative ColitisCrohn’s Disease

ULCERATIVE COLITIS

Ulcerative Colitis

A disorder in which inflammation affects the mucosa and submucosa of the colon

CROHN’S DISEASE

Crohn’s Disease

A disorder in which inflammation is transmural and may involve any or all segments of the gastrointestional tract

GROSS DIFFERENCE IN PATHOLOGY OF ULCERATIVE COLITIS AND CROHN’S DISEASE

Ulcerative colitis1.Disease in continuity2.Rectum almost always involved3.Terminal ileum involved infrequently4. Granular and ulcerated mucosa

diffusely5. Often intensely vascular6. Normal serosa7. Muscular shortening of colon: fibrous

strictures very rare8. Spontaneous fistulae not typical

9. Inflammatory polyposis common and extensive10. Malignant change is well recognized11. Anal lesions uncommon

GROSS DIFFERENCE IN PATHOLOGY OF ULCERATIVE COLITIS AND CROHN’S DISEASE

Crohn’s Disease1.Disease discontinuous2.Rectum frequently spared3.Terminal ileum frequently involved4. Discretely ulcerated mucosa; with fissuring5. Vascularity seldom pronounced6. Serositis common7. Shortening due to fibrosis; fibrous strictures common

9. Inflammatory polyposis less prominent and less extensive10. Malignant change11. Anal lesions more common

MICROSCOPIC DIFFERENCES IN THE PATHOLOGY OF ULCERATIVE COLITIS AND CROHN’S DISEASE

Ulcerative Colitis

1. Diffuse mucosal and submucosal inflammation2. Width of submucosal normal or reduced3. Often intense vascularity, little edema4. Focal lymphoid hyperplasia restricted to the mucosa and superficial submucosa5. “Crypt abscesses” very common with diffuse inflammation6. Anal lesions- non-specific if present

MICROSCOPIC DIFFERENCES IN THE PATHOLOGY OF ULCERATIVE COLITIS AND CROHN’S DISEASE

Crohn’s Disease

1. Transmural inflammation with fistulae formation2. Width of submucosa normal or increased3. Vascularity seldom prominent, edema marked4. Lymphoid aggregates in mucosa, submucosa, serosa and pericolic tissues5. Sarcoid-type granulomas, characteristic with focal patchy inflammation6. Anal lesions; granulomatous foci often present

Incidence and prevalence of ulcerative colitis are:

2 – 10 and 35 -100, respectively per 100,000 population in the US

Incidence and prevalence of Crohn’s disease are 1-6 and 10 – 100 respectively per 100,000 population in the US

There is an increased incidence of IBD in relatives of patients with IBD indicating a genetic disposition

Both conditions are more prevalent in Jews and less common in African Americans

The peak age of onset of both diseases is between

15- 25 yrs and then a second peak is observed between

55 -65 yrs

Incidence equal between men and women

Ulcerative colitis is more common than Crohn’s disease in children younger then ten years old

POTENTIAL TRIGGERS

Viruses and bacteria- there is little data but suspect

MeaslesMycobacterium paratuberculosis

Dietary antigen activates abnormal immune response

Auto antigen expressed on patients intestional epithelium

Patient mounts an initial immune response against a lumenal antigen, which persists and may be amplified

CLINICAL FEATURES OF UC Dominant symptom in the US is often bloody, frequent low volume bowel movements

Abdominal pain, usually in the lower quadrant and rectum

Localized rectal involvement may be characterized by:

bloody diarrhea, with or without urgency,

tenesmus, pain or fecal incontinence

CLASSIFICATION OF UC

Mild disease:Diarrhea, rectal bleeding and usually normal physical exam

Most patients with ulcerative proctitis have mild disease

Moderate disease:

Occurs in 27% of patients

5 -6 bloody stools, abdominal pain, tenderness, low grade fever, fatigue

Severe disease

19 % patients have severe ulcerative colitisFrequent bloody stools, profound weakness, weight loss, fever, tachycardia

Hypotension, abdominal tenderness, anemia as well as hypoalbuminemia

Abdominal distention with severe disease may mean toxic megacolon

Usually ulcerative colitis will begin indolently and gradually worsen

Initial presentation- colitis extending to the cecum in 20% patients

75% patients have no disease proximal to the sigmoid

15% patients with initial proctitis will extend their disease more proximally

Patients with mild disease

More than 90% will go into remission after first attack

Patients who present initially with severe disease often require colectomies

Usually 50% of those patients within the first 1 -2 yrs

The usual pattern of chronic disease is long quiescent periods interspersed with acute attacks

RELAPSE

Non compliance with medicationsNSAID useAntibiotics Colonic infections (c-diff)Smoking cessation

TOXIC MEGACOLON

Temp greater then 38.6 CHR > 120Neutrophil count > 10,500DehydrationMental status changesElectrolyte imbalances

HypotensionAbdominal distentionTenderness

CROHN’S DISEASE

Involvement of the ileum and cecum: 40% of patientsSmall bowel: 30% of patientsColon only: 25% of patients

Pancolic: 2/3Segemental: 1/3

PATHOLOGY OF CROHN’S DISEASEEarly changes

Aphthous ulcers-> deep ulcerations-> confluent ulcerations

“cobblestone” appearanceThickened mucosal foldsAsymmetric involvement Inflammatory pseudopolypsSegmental distributionSkip lesions

Symptoms

DiarrheaWeight lossAbdominal pain

CROHN’S DISEASE ACTIVITY INDEX Stool frequency Abdominal pain Sense of well being Systemic manifestations Use of antidiarrhea agents Abdominal mass Hematocrit Body weight

Crohns disease is a relapsing and remitting disease that will spontaneously improve without treatment in 30% of cases

Patients in remission can expect to remain in remission for 2 yrs in 50% of cases

However, 60% of patients require surgery within 10 years of diagnosis

Of those patients who require surgical resection, 45% will eventually require reoperation

Crohns disease can produce significant disability, and 50% of patients make major changes in employment to accommodate decreased working hours and leaves of absence

CROHNS COMPLICATIONS

Abscesses and fistulas result from extension of a mucosal break through the intestional wall into the extra intestional tissue

Abscesses occur in 15 -20% of patients usually arising from the terminal ileum

Abscesses present with fever, localized tenderness and palpable mass

Infection is usually polymicrobial

E coli, bacteroides fragilis, enterococcus, and alpha hemolytic streptococcus

20-40% of Crohn’s patients have fistulizing disease

Fistula may be enteroenteric,

Enterocutaneous, enteovesical, or enteovaginal

Large enteroenteric fistulae produce diarrhea, malabsorption, and weight loss

Enterocutaneous fistulae produce persistent drainage that usually is refractory to medical therapy

Rectovaginal fistulae lead to foul-smelling vaginal discharge

Enterovesical fistulae produce pneumaturia and recurrent urinary tract infections

Obstruction, especially of the small intestine, is a common complication caused by mucosal thickening, muscular hyperplasia and scarring from prior inflammation or adhesions

Perianal disease, including anal ulcers, abscesses and fistulae can affect the groin, vulva or scrotum