Irritable bowel disease/syndrome
- 2. Introduction • Two idiopathic diseases of the GIT • Closely related clinical presentations. • Diseases are – Ulcerative colitis (UC) and Crohn disease (CD) . • UC – chronic recurring mucosal inflammation of the colon.. • CD – chronic recurring trans mural inflammation of the GIT from the mouth to the anus. CD most commonly affects the small bowel and colon.
- 3. Definition- “a functional bowel disorder in which abdominal pain or discomfort is associated with defecation or changes in bowel habits with features of disordered defecation”
- 5. IBD vs IBS IBD IBS chronic inflammation of the gastrointestinal tract . Involves …..UC and CD. characterized by symptoms of abdominal pain or discomfort that is associated with disturbed defecation patterns. It includes: Proctitis. Inflammation of the rectum. Pancolitis. Disease affecting the entire colon Backwashileitis. Inflammation of the terminal ileum Ileocolitis. (affecting the ileum and colon) Ileitis. (affecting the i leum) Crohn disease.(affecting the stomach and duodenum) Jejunoileitis. (inflammat ion of the jejunum and i leum) Involves constipation predominant( IBS-C) diarrhea predominant ( IBS-D) type with patients alternating between the two ( IBS-A)
- 7. Epidemiology • CD is higher in urban areas. • UC is higher in rural areas. • IBD rates higher in developed countries compared to less developed countries. • Asians appear to be at lower risk for developing IBD than whites. • IBD is more common in young adults than older patients. • Men and women are at similar risk of developing IBD. • IBS is more common in women than men. • IBS appears to be as common in Asia/India as in Western countries.
- 8. Manifestations IBD IBS UC increasing stool urgency and frequency. bloody stool and mucus in the stool. varied disease intensity interspersed with asymptomatic periods. pain relieved by defecation. alternating bowel habits. abdominal distention. mucus in the stool. sensation of incomplete defecation. CD patterns of symptoms relate to disease location and type (e.g. , inflammatory, fibrostenotic, fistulizing) that can be useful in determining therapy decisions. Constipation-predominant IBS Pain/periodic constipat ion alternating with normal periods. Pain(periodic, and/or a continuous dull ache) eating can commonly trigger symptoms. Other common symptoms are bloating, nauseas, dyspepsia, flatulence, and heartburn. Diarrhea-predominant IBS characterized by precipitous diarrhea occurring during meals or immediately postprandial. pain, bloating, rectal urgency, and incontinence.
- 9. Causes IBD IBS Environmental factors Exact cause of IBS is unknown Genetic factors IBD occurs 30-100 times more frequently in first -degree relatives of IBD patients Comorbid factors. Viral gastroenteritis. emotional health,. Diet. environment . concur rent drug therapy, and hormones Anxiety disorders. Panic disorder . Major depressive disorder Emotional conflict. Possibility of sexual or physical abuse. Abnormal immune response overly vigorous and abnormally long immune response. immune system activation with subsequent infiltration of the tissue by lymphocytes, macrophages, and other cells. Virus or bacterial infect ion, dietary antigens or inappropriate immune response to normally non-antigenic microbes Clostridium difficile, fungal protozoal viral , and helminthic pathogens. Drug- induced enterocolitis can induce IBD- like symptoms. Non-steroidal ant i - inflammatory drugs (NSAIDs) , Gold compounds, oral contraceptives, enteric potassium supplements, pancreatic enzymes
- 10. Pathophysiology IBD IBS UC. edema followed by loss of fine vascular pattern and increased mucosal friability. Ulceration may also be present . Colon may begin to become featureless and tubular in nature. Constipation: Abnormality in intestinal motility Under lying muscle dysfunction as well as hyperactive response to factors, such as food. Abnormal increases in frequency of contractions can lead to functional constipation. CD. Inflammation and subsequent injury of tissue known as cryptitis. leads to crypt abscess and subsequently focal aphthoid-ulceration. Influx and proliferation of macrophages and other inflammatory cells. May lead to lymphedema and bowel wall thickening. This thickening can lead to fibrosis. Diarrhea Diminished motor function of the under lying musculature can lead to diarrhea. Pain of IBS may be caused by abnormally strong contraction of the intestinal smooth muscle. The first few days of menstruation can lead to transiently elevated prostaglandin E2 (PGE2 ) , resulting in increased pain and diarhea.
- 11. Clinical presentation/Sign n Symptoms UC. Altered stool frequency. Bowel sensation, and abdominal pain. Begin as mild disease,worsens as the disease progresses. Patients may suffer from continuous or intermittent attacks. Hematochezia(blood in stool), Tenesmus, Lower left quadrant pain. Nausea, vomiting, and weight loss. Aphthous ulcers, Iritis and uveitis IBS Abdominal pain (crampy, localized to the lower left abdomen) Alteration of bowel habits. Diarrhea, constipation, and alternating diarrhea and constipation. Bloating, gas, belching, heartburn, reflux disease, Achalasia, early feeling of fullness on eating Nausea. Painful menstruation, sexual dysfunction, and frequent or urgent urination. CD. Symptoms mimicking appendicitis or intestinal obstruction. Abdominal pain,Diarrhea,Weight loss,Fever. Arthralgias,Acute peripheral arthritis Ankylosing spondylitis, peripheral arthritis Iridocyclitis, uveitis, and episcleritis.
- 12. Clinical evaluation/Diagnosis IBD (Table 53-1. CPR) IBS UC Patient symptoms. Most common. Severity of symptoms correlates with disease severity. Increased C- reactive protein. Platelet count , erythrocyte sedimentation rate (ESR). Decrease in hemoglobin. Serum albumin can fall quickly in severe disease Sigmoidoscopy can be useful for assessing disease Identifying positive symptoms by medical history/Physical exam . Routine blood testing. Sigmoidoscopy and colonoscopy are done to visualize the bowel Guided by Rome II & I I I cr i ter ia. Rome II diagnostic criteria Pain relieved by defecation; Pain associated with a change in frequency and form of stool. Abnormal stool frequency. Abnormal stool form. Abnormal stool passage. Passage of mucus. Bloating. CD Elevated ESR,C- reactive protein. Hypo-albuminemia, anemia, and leukocytosis. Right lower quadrant pain. Malabsorption. Dietary deficiency, electrolyte imbalances, coagulopathy, and increased risk of bone fractures. low-grade fever. Rome III diagnostic criteria Improvement with defecation Onset associated with a change in form & frequency of stool. Criteria fulfilled for the last 3 months. Discomfort (an uncomfortable sensation not described as pain)
- 13. Disease classification Ulcerative Colitis Chron’s Disease Mild UC…less than four stools per day with/without blood,normal ESR. Moderate UC ..more than four stools per day but minimal signs of toxicity fever , tachycardia, anemia, elevated ESR. Severe UC…more than six bloody stools per day, evidence of toxicity(fever , tachycardia, anemia, elevated ESR) Fulminate..more than ten bowel movements, continuous bleeding, toxicity, abdominal tenderness/distension, need for blood transfusion,. Mild to moderate disease patients who are ambulatory,are able to take food orally;have no symptoms of dehydration, no signs of toxicity , no abdominal tenderness/painful mass/ obstruction; have weight loss > 10%. Moderate to severe disease failed to respond to therapy for mild to moderate disease.Fever , significant weight loss, abdominal pain , intermittent nausea or vomiting , anemia. Severe to fulminant disease persisting symptoms despite therapy with steroids. high fever , persistent vomiting, obstruction, rebound tenderness, evidence of abscess. Remission patients who have responded to acute medical therapy or who have had surgical intervention
- 14. COMPLICATIONS Musculoskeletal Arthralgias(joint pain). Peripheral arthritis pain. Ankylosing spondylitis. CD fistulas and abscess Inflammation may progress into penetrating disease, abscess formation, and fistula formation. Hemorrhage Severe bleeding tends to occur early in the course of disease. Strictures narrowing of the colon or rectum. Toxic megacolon occurs when the inflammatory process causes the colon to dilate, with subsequent bowel wall thinning. bowel becoming more fragile. major risk is bowel perforation. Cancer . colorectal cancer Related to duration and extent of UC as well as patient -specific risk factors. Primary sclerosing cholangitis. Hepatobiliary complication of IBD. Osteoporosis diminished bone density
- 15. Treatment objectives • Induce remission with control of acute inflammatory flare. • Maintain remission as long as possible. • Normalize bowel function when possible. • Maintain nutritional status • Improve quality of life (QOL). • Alleviate discomfort.
- 16. Drugs Used IBD Aminosalicylates sulfasalazine:1st choice ……………………(dosing details Table 53-2 CPR) At higher concentrations they inhibit prostaglandins and prostacyclins. Disadvantages.. increased incidence of adverse events Steroids. Systemic corticosteroids. Topical and non-systemic steroids(enemas, suppositories, and ileal release formulations). Budesonide has been shown to be effective in IBD. Azathioprine Disrupting the inflammatory response seen in IBD. Effective at inducing and maintaining remission in IBD. Response is slow and may take months to be fully effective. Methotrexate Given parenterally is an effective treatment. with multiple modes of ant i - inflammatory effects. Cyclosporine. Potent immunosuppressive agents. used for severe IBD. potent inhibitors of T lymphocyte activation. Biologics. Infliximab, adalimumab and certolizumab. preventing the cytokine from binding to cell surface receptors and subsequently decreasing inflammation due to activated T lymphocytes and monocytes. (Table 53-3 CPR) Antibiotics. Metronidazole (Flagyl ) and ciprofloxacin If.. increased risk of perforation or bacteremia.
- 17. Probiotic and prebiotic therapy. Exogenously administered bacteria such as Lactobacillus GG, Saccharomyces boulardii , and nonpathogenic E. coli . Normalizes the intestinal environment flora and thus decrease inflammatory triggers. facilitating growth of commensal gut flora to displace possible antigenic microorganisms. Antispasmodics and Anti-diarrheals. to treat cramping or discomfort in IBD inflammation. Anti-depressants and anxiolytics use as adjuvant therapy. Analgesics. Narcotics are to be avoided in UC therapy. NSAID medications should be avoided because they have been implicated in inducing IBD flares.
- 18. Drug Therapy for IBD/UC based on anatomic disease extent Distal disease…. treated effectively with topical therapy-Extensive disease…. requires systemic therapy. Severity is generally defined as mi ld, moderate, severe, or fulminate. mild to moderate distal disease. oral and topical amino-salicylates. Topical Steroids.(Topical mesalamine is superior.) Topical mesalamine plus oral amino-salicylate is superior to either alone. oral 5-ASA drugs tend to work in 2-4 weeks and are effective in a high percentage of patients. Budesonide has been effective in UC treatment Mild to moderate extensive disease. Oral 5-ASA (sulfasalazine in regard to efficacy) Oral steroids Higher doses for longer periods increase risk of corticosteroid-associated risk. Patients receiving corticosteroids for > 3 months should be evaluated/dual -energy x- ray absorptiometry (DEXA) bone -testing. Corticosteroid- induced osteoporosis…. bisphosphonates, calcium supplementation at 1- 1.5 g per day, and vitamin D supplementation at 800 mg per day. Moderate to severe disease. may require hospitalization. Infection with enteric pathogens should be ruled out . indication for surgical resection or alternate intravenous therapy such as with cyclosporine. Total parenteral nutrition is used when oral feeds are not tolerated.
- 19. Doses/UC Moderate distal disease. Maintenance therapy Oral 5-ASA doses Sulfasalazine 4-6 g/day in 4 divided doses Mesalamine 2-4.8 g /day in 3 divided doses Balsalazide 6.75 g /day in 3 divided doses Olsalazine 1.5-3 g / day in divided doses Mesalamine suppositories 500 mg twice a day. Mesalamine enemas 1-4 g per day. Balsalazide 3-6 g/ day Mesalamine Eudragrit -S 3.2 g/day Mesalamine suppository 500 mg every day or twice a day Mesalamine enema 2-4 g daily, every other day, or every third day Olsalazine 1 g /day Sulfasalazine 2 g /day. Mesalamine 1.6 g orally /day plus 4-g enemas twice weekly Oral CS Budesonide Topical therapy generally induces remission more quickly. Hydrocortisone enema 100 mg per day Corticosteroids, topical/oral , are not effective and should not be used. Mild to moderate extensive disease Maintenance therapy Oral 5-ASA Sulfasalazine 4-6 g/day in 4 divided doses. The dosages used are a minimum of 2 g/Day maximum of 4.8 g/day Balsalazide 3-6 g/ day Mesalamine 2-4 g /day Olsalazine 1 g/day Sulfasalazine 2-4 g/ day 6-MP and azathioprine 100-250 mg/ day, maximum of 2.5 mg/kg/day Oral Cs Prednisone 40-60 mg/day….followed by a dose taper of 5-10 mg weekly until a daily dose of 20 mg is reached.
- 20. Moderate to severe disease. Remmission maintenance Therapy. IV steroid therapy. Prednisolone (40-60 mg) , hydrocortisone (300 mg) , or methylprednisolone (32-48 mg/day Empiric broad-spectrum antibiotics are of little use. narcotics, anti-diarrheals, and anticholinergics should be avoided. Intravenous cyclosporine at 2-4 mg/kg / day. 5-ASA should be stopped in the acute settings. azathioprine or 6-MP can be beneficial when added for maintenance. Sulfamethoxazole/ trimethoprim should be added as prophylaxis against Pneumocystis pneumonia for patients on cyclosporine. Fulminant disease. Treated as noted for severe disease and should not take anything by mouth. Broad spectrum antibiotics are of ten used empirically. Immediate colectomy.
- 21. Drug Therapy for IBD/CD depends on the disease location, disease severity and any complications. Mild to moderate CD 5-ASA orally Mesalamine 3.2-4 g/day Sulfasalazine 3-6 g/day. Sulfasalazine may be more effective. Oral broad-spectrum antibiotics Metronidazole 750-1500 mg/day Ciprofloxacin 1000 mg/ day CS Budesonide orally 9 mg/ day for 8-16 weeks Tapered 3 mg per week over 2-4 weeks Moderate to severe CD Systemic steroids Prednisone 40-60 mg per day antimetabolite drugs Azathioprine 2-3 mg/kg/day or 6-MP 1-1.5 mg/kg/day. Methotrexate 25 mg/week IM, tapered to 15 mg/week IM after 16 weeks Anti -TNF therapy For patients who do not tolerate systemic steroids and immunosuppressant therapy. Infliximab 5 mg/kg at 0, 2, and 6 weeks. concomitant dosing of azathioprine, 6-MP, or methotrexate(MTX) Adalimumab 160 mg day one, and 80 mg day 15 followed by 40 mg every other week starting.
- 22. Maintenance Severe or fulminant CD IV fluids and bowel rest (parenteral nutrition). IV antibiotics with metronidazole, aminoglycosides, and broad-spectrum penicillin. IV CS. Surgical intervention may be required in patients who do not respond to IV corticosteroids. Mesalamine 2.4-4.8 g / day or sulfasalazine 2-4 g/day Budesonide Doses of 6-9 mg per day Azathioprine, 6-MP, methotrexate, and anti -TNF therapy have been used in maintenance; but adverse events must be weighed carefully, Systemic steroids are normally avoided in long- term therapy secondary to systemic toxicity;
- 23. Treatment of IBS based on the nature and severity of symptoms Mild IBS Diet and lifestyle changes. Moderate IBS Anti-cholinergics used as antispasmodics. Dicyclomine 20 mg by mouth 4 times a day Hyoscyamine 0.15-0.3 mg by mouth 4 times a day Clidinium plus chlordiazepoxide (Librax) 2.5/5 mg 1-2 tabs by mouth before every meal and at bed-time. Hyoscyamine + scopolamine, atropine, phenobarbital 1-2 tablets every 6-8 hr. Loperamide ( Imodium) 4 mg followed by 2 mg after each unformed bowel movement up to a maximum of 16 mg /day. Low-dose tricyclic antidepressants : Lubiprostone…a chloride channel activator indicated for idiopathic constipation. Polyethylene glycol…. laxative solution. Severe IBS Selective serotonin reuptake inhibi tors. Anxiolytic drugs, including diazepam, are occasionally used. These drugs should be taken for only short periods of time.
- 24. Surgery • Proctocolectomy with permanent ileostomy. • Proctocolectomy with continent ileostomy. • Colectomy with ileorectal anastomosis. • Ileal pouch anal anastomosis ( IPAA). • Ileostomy. • Colectomy.
- 25. Patient Education/Counseling • Education about the disease. • Diet and lifestyle changes. • Smaller meals are preferable. • Decrease fatty foods, gas-producing foods. • Decrease alcohol. • Decrease caffeine • Avoid dairy in lactose- intolerant patients • Prepare strategies to handle stress.