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DAPPSSICAMP
Description Aetiology Pathophysiology Predisposing factors Symptoms Signs Investigations Complications Alternatives Management Prognosis
Areas of Interest
Causes (Genetics and others) Treatments (Drugs and surgery) Assessment
Description
Aetiology Pathophysiology Predisposing factors Symptoms Signs Investigations Complications Alternatives Management Prognosis
Crohns disease
Chronic inflammatory
condition Can affect any part of the gut Commonly: large bowel terminal ileum small bowel
- localised, diffuse
perianal
Description
Aetiology
Pathophysiology Predisposing factors Symptoms Signs Investigations Complications Alternatives Management Prognosis
Crohns disease
Prevalence: 40 per 100,000 Incidence: approx 0.7 - 1 per 1000 people
Western world
Description Aetiology
Pathophysiology
Predisposing factors Symptoms Signs Investigations Complications Alternatives Management Prognosis
Macroscopic features
Bowel thickened and narrowed Deep fissuring ulcers
cobblestoning
Lymphoid hyperplasia
Description Aetiology Pathophysiology Symptoms Signs Investigations Complications Alternatives Management Prognosis
Predisposing factors
SMOKING !
Increased risk of: Getting it in the first place Aggressive disease Relapse Hospital admissions Surgery Cancer
Genetics
Long known that Crohns / UC is commoner in
families / twins Not simple inheritance Sibling with CD/UC means 15-30x the risk 1 in 7 patients have a relative with the illness
Genetics (2)
THE HUMAN GENOME PROJECT
1996: Oxford group Showed Crohns and UC share some
Symptoms
Signs Investigations Complications Alternatives Management Prognosis
Symptoms
-depend on site of disease
Abdominal pain Weight loss Diarrhoea +/- blood Obstructive symptoms Complications of fistulae Complications of malabsorption
B12, Ca/Vit D, Zn, etc
Signs
Episcleritis
Erythema Nodosum
IBD
TB/ Sarcoid OCP, sulphonamides Streptococcal infections Yersinia, psitticosis Lymphogranuloma
Pyoderma Gangrenosum
Sacro-ileitis
Description Aetiology Pathophysiology Predisposing factors Symptoms Signs Complications Alternatives Management Prognosis
Investigations
Investigations
Blood tests and markers of nutrition
Hb, ESR/CRP, Albumin, LFTs
Endoscopy
OGD, enteroscopy, colonoscopy HISTOLOGY
X-ray / ultrasound
SB meal/enema, Ba enema, fistulogram, CT
Nuclear medicine
Labelled leucocyte scan
Laparoscopy
Non-invasive imaging
Virtual colonoscopy Fast CT scan after usual bowel prep Large memory computer Accompanying software
Description Aetiology Pathophysiology Predisposing factors Symptoms Signs Investigations Alternatives Management Prognosis
Complications
Complications
Social / financial days off work Psychosexual surgery, stomas Nutritional osteoporosis, B12 Multiple resections short bowel
0 2 4 6 8 10
15
20
25
30
Description Aetiology Pathophysiology Predisposing factors Symptoms Signs Investigations Complications Management Prognosis
Alternatives
Differential diagnosis
Initially often IBS Ulcerative colitis Infective diarrhoea
especially amoebic
Description Aetiology Pathophysiology Predisposing factors Symptoms Signs Investigations Complications Alternatives Prognosis
Management
Current treatments
5-ASA drugs Steroid enemas Budesonide Steroids (Elemental diets) Azathioprine Methotrexate Infliximab,
adalimumab Surgery
Diversion Resection
5-ASA drugs
Role in prevention of colorectal cancer Sulphasalazine
3% compliant patients 31% non-compliant patients
Mesalazine
Reduces risk by 81% at >1.2g/day
Surveillance
Total colitis Every 3 yrs after 8 years Every 2 years from 20-30 years Annually thereafter Left sided colitis After 15 years Proctitis nil
UC 58% 87%
starting therapy
Nausea within 2 weeks Deranged LFTs within 8 weeks Bone marrow toxicity within up to 12 weeks Step up dosing???
1 1
1 1
1 1
1 1
1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1
10%
5%
>11
homozygous TPMTL patients with low dose azathioprine: 0.1 0.3 mg/kg (eg: 70kg 7mg od)
Non-responders
Inverse correlation between TPMT and 6-TGN 6-TGN levels > 235 correlate with remission Increasing AZA dose: 1/3 will achieve remission 2/3 will not
6-TGN levels No change in 6-TGN levels BUT in mercaptopurine metabolites
Hepatotoxicity in 1/4
Allopurinol
Used at 200mg with reduction of azathioprine
dose to 25% Drives pathway towards 6TG by blocking XO arm Needs careful monitoring
TPMT - summary
1 : 300 absent activity; 10% relative deficiency Measure it before you start therapy? Identify those prone to early leucopenic episodes Identify those who may need supra-normal doses
26%)
60% increase risk of relapse 10 year post surgical requirement for
immunosuppressants
54% for smokers 24% for non-smokers
year
Methotrexate in Crohns
Weekly 25mg IM for 4-6 months then Weekly 15mg IM for up to a year 65% maintain remission Remission for up to 3 years but early relapse
when stopped
Infliximab
Anti-TNF monoclonal antibody Infusion
Single / multiple doses (5mg/kg)
Resistant and fistulating Crohns disease Potential for anaphylaxis 70% remission at 1 year
Infliximab
Licensed by NICE for those with: Severe active Crohns with or without fistulae Crohns refractory to other immune modulating drugs or who have toxicity from them Those for whom surgery is inappropriate Given either as single infusion or at weeks
0, 2 and 6
What is Infliximab ?
The first licensed therapeutic anti-TNF
Summary
There is no such thing as simply
Crohns disease.
Summary
Dear Dr. Diagnosis: 1. Stricturing distal ileal Crohns disease: 1995 2. On azathioprine Sept 2002 (MCV 84 93) 3. TPMT 36.5 4. Normal DEXA scan Oct 2002 5. Last steroid course ended July 2001
Summary
Crohns 5-ASA Osteoporosis Rx Methotrexate Infliximab Stop smoking UC
5-ASA Osteoporosis Rx Ciclosporin
Azathioprine
Description Aetiology Pathophysiology Predisposing factors Symptoms Signs Investigations Complications Alternatives Management
Prognosis
Prognosis
Average life expectancy = 10 years less than
general population