Definition:
Inflammatory bowel disease is inflammation of all or part of the gastrointestinal tract. The majority of cases are caused by Crohn’s disease or Ulcerative colitis.
Signs:
General:
Young, pale, cachectic patient
TPN line may be visible
Finger clubbing
Skin signs – which include erythema nodosum, pyoderma gangrenosum (especially common around stoma site)
Abdo:
Abdominal scars – (laparotomy, previous stoma sites, healed enterocutaneous fistulae)
Abdominal masses e.g. RIF mass
Abdominal tenderness
Stoma – comment on contents and surrounding stoma skin
Bowel sounds
Signs related to immunosuppression e.g. steroids, ciclosporin, azathioprine
Extraintestinal signs:
Aphthous ulcers in the mouth
Enteropathic arthropathy
Conjunctivitis/episcleritis/anterior uveitis
Symptoms:
Diarrhoea
Abdominal pain
PR bleeding and bloody stools
Weight loss
Fever
Malaise and lethargy
Causes:
Genetic and environmental factors are thought to play a part in the development of IBD such as smoking and infections
Investigations:
Stool MC+S and C Diff toxin
FBC/U+E/LFT/inflammatory markers/albumin (marker of severity)
Abdominal imaging – AXR, CT abdo pelvis
Flexible sigmoidoscopy/colonoscopy with biopsy are recommended for a histological diagnosis
Other imaging techniques for IBD include barium follow through and capsule endoscopy
Management:
Crohns: – as per NICE 2012 guideline. Treatment is complex with new drugs being developed
Remission: Steroid either PO or IV
In younger people enteral nutrition can be used to induce remission if there are concerns regarding steroid use
Drugs such as azathioprine/mercaptopurine/methotrexate can be added in to help induce remission
Maintenance: azathioprine/mercaptopurine/methotrexate are the most common drugs used
Biologic agents including infliximab/adalimumab for ongoing active disease
Surgery should be considered in limited disease (such as distal ileum), refractory disease, life threatening acute flare
Nutritional support is very important
Patients are managed with MDT support including physicians, surgeons, specialist nurses, dieticians and psychologists
UC – as UC often causes more localised disease rectal treatments are frequently used such as mesalazine enemas
Oral Mesalazine is often the treatment of choice for induction of remission and maintenance therapy
Steroids PO/IV are also often used to induce remission
Other maintenance medications include azathioprine and mercaptopurine
IV ciclosporin can be used for severe refractory colitis but has a considerable side-effect profile and can be poorly tolerated
Surgery is a potentially curative treatment and should be considered for disease refractory to medical treatment, life-threatening acute flares or for treatment of complications such as colorectal carcinoma
Top tips:
To complete make sure you state you would like to assess for perianal disease. Also say you want to do a thorough search for any extra-intestinal complications as well as complications of treatment such as anaemia and infection.
Extra-intestinal complications include:
Arthropathy – this is often an asymmetrical oligoarthritis with a predilection for large joints or sacroiliac joints
Eye involvement including– conjunctivitis, anterior uveitis, episcleritis
Anaemia
Aphthous Ulcers
Skin changes such as – pyoderma gangrenosum and erythema nodosum
Primary Sclerosing Cholangitis is associated with UC
Cholangiocarcinoma – particularly associated with UC
Renal stones – particularly associated with Crohns
Written by Jo Corrado
Resources used to write this document are listed in the references section of this webpage