IBD

Subtitle
Definitions
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Epidemiology
• Peak incidence 15-30 years
• 20% CD, 12% UC dx before 20 years
• Children: delayed puberty, growth failure, more likely to have sx of colitis
– 10-15% children present before 6 years

• CD: 15% small bowel, 24% colon, 61% both

• 30% structuring, more in those diagnosed as adolescents (vs children)
Presenting Symptoms
• GI
– Bloody or loose stools, tenesmus, abdominal pain (RLQ), vomiting

• Growth
– Delayed puberty, growth failure (decreased height velocity  delayed bone age)
– Many children are overweight upon dx of IBD

• Extraintestinal: 10% upon dx, 30% in first few years

– Aphthous stomatitis, uveitis, jaundice, hepatomegaly, arthritis, erythema nodosum, pyoderma gangrenosum,
venous thromboembolism, nephrolithiasis, cholelithiasis, pancreatitis, osteopenia, granulomatous inflammation,
fever, fatigue

• Physical exam
– TTP and/or mass (RLQ), +guaiac, anal skin tags / fissures/ fistulae
Extraintestinal manifestations: Skin
Extraintestinal manifestations: Eye
Extraintestinal manifestations: Oral cavity
Labs
• CBC
• ESR
• CRP
• Albumin
• FOBT
• Fecal calprotectin
Dx and workup
• No specific diagnostic criteria
• P-ANCA, ASCA
• Stool testing for enteric pathogens
• Colonoscopy
• UGI/SBFT
• MRE
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UC versus CD
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Paris classification of UC
Paris classification of CD
CD: Complications
• Fistulae
– Enteroenteric
– Enterovesicular
– Enterogenital
– Enterocutaneous
– Tx: abx, biologics, immunomodulators, TPN with bowel rest, surgery

• Peritonitis
– From microperforation
– RLQ
– Tx: broad spectrum abx, bowel rest

• Abscesses
– Near inflamed bowel loops, can become fistula
– Dx: imaging

• SBO
– From strictures
CD: Treatment
• Medications
• Nutrition
• Surgery
• Psychiatric support
• Cancer screening
• Step up versus top down therapy
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CD Treatment: Glucocorticoids
• Prednisone: short term induction for moderate CD
• Budesonide: short term induction for mild to moderate CD affecting ileum and R colon
• Methylprednisolone: induction of remission in severe CD of small bowel and colon
• AE: Facial swelling, moodiness, sleep disturbance, hirsutism, adrenal suppression (with physiologic
doses for more than two to three weeks); hyperglycemia, osteoporosis, increased risk of varicella
infection; cataracts, aseptic necrosis of bone
CD Treatment: Aminosalicylates
• Mesalamine
– Pentasa: time released. For maintenance of remission in mild CD in small bowel or colon
– Asacol: pH released. For maintenance of remission in mild CD of ileum or colon
– AE: rashes, pancreatitis, interstitial nephritis

• Sulfasalazine
– For maintenance of remission in mild colonic CD
– AE: hypersensitivity, HA, photosensitivity, leukopenia, hepatitis, pancreatitis, pericarditis, myocarditis,
pneumonitis
CD Treatment: Immunomodulators
• 6MP, azathioprine
– For maintenance of remission in refractory CD
– Helpful in growth failure, fistulizing disease
– Assess TPMT before
– AE: pancreatitis, myelosuppression, hepatitis, pneumonitis, opportunistic infections, hypersensitivity, nausea,
emesis, increased risk of lymphoma (EBV)

• MTX
– For maintenance in refractory Crohn’s disease
– AE: Bone marrow suppression, hepatotoxicity, oral ulcers, nausea, pneumonitis
CD Treatment: Biologics
• Infliximab: anti-TNF
– AE: increased risk of TB, lymphoma

• Adalimumab: anti-TNF
– AE: infections, increased risk of lymphoma, TB

• Vedolizumab
• Ustekinumab
CD Treatment: Abx
• Cipro
– For induction of remission in mucosal or perianal disease
– AE: hypersensitivity, increased risk of C diff, tendon rupture, photosensitivity, arthropathy

• Flagyl
– For postop recurrence, induction of remission in mucosal or perianal disease
– AE: nausea, alteration of taste, peripheral neuropathy
PCDAI
• 0-10: inactive
• 11-30: mild
• >30: moderate to sever e
• Decreased > 12.5: clinical improvement
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