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G20 Gastroenterology
Small and Large Bowel
Toronto Notes 2019
Table 11. Extraintestinal Manifestations (EIM) of IBD
System
Dermatologic
Erythema nodosum Pyoderma gangrenosum Perianal skin tags
Oral mucosal lesions Psoriasis
Stomatitis
Rheumatologic
Peripheral arthritis Ankylosing spondylitis Sacroiliitis
Ocular (~10% of IBD)
Uveitis (vision threatening) Episcleritis (benign)
Hepatobiliary
Cholelithiasis PSC
Fatty liver Gallstones
Urologic
Calculi
Ureteric obstruction Fistulae
Others
Crohn’s Disease
15%
10%
75-80%
Common
Statistically associated in 5-10% of those with IBD but not an EIM
15-20% of those with IBD (CD>UC) 10% of those with IBD (CD>UC) Occurs equally in CD and UC
3-4% of IBD patients (CD>UC)
15-35% of patients with ileal Crohn’s 1-5% of IBD cases involving colon
Pigment stones in CD
Most common in CD, especially following ileal resection or extensive terminal Ileal disease (oxalate stones) Characteristic of Crohn’s
Ulcerative Colitis
10%
Less common Rare
Rare
Thromboembolism
Vasculitis
Osteoporosis
Vitamin deficiencies (B12, Vit ADEK) Cardiopulmonary disorders Pancreatitis (rare)
Phlebitis
Crohn’s Disease
Definition
• chronictransmuralinflammatorydisorderpotentiallyaffectingtheentiregutfrommouthtoperianal region (“gum to bum”)
Epidemiology
• incidence1-6/100,000;prevalence10-100/100,000
• bimodal:onsetbefore30yr,secondsmallerpeakage60;M=F
• incidenceofCrohn’sincreasing(relativetoUC)especiallyinyoungfemales • morecommoninCaucasians,AshkenaziJews
■ risk in Asians increases with move to Western countries
• smokingincidenceinCrohn’spatientsishigherthangeneralpopulation
Pathology
• mostcommonlocation:ileum+ascendingcolon
• linearulcersleadingtomucosalislandsand“cobblestone”appearance
• granulomasarefoundin50%ofsurgicalspecimens,15%ofmucosalbiopsies
Clinical Features
• naturalhistoryunpredictable;youngage,perianaldisease,andneedforcorticosteroidshavebeen associated with poor prognosis, but associations are not strong enough to guide clinical decisions
• most often presents as recurrent episodes of abdominal cramps, non-bloody diarrhea, and weight loss • ileitis may present with post-prandial pain, vomiting, RLQ mass; mimics acute appendicitis
• extra-intestinalmanifestationsaremorecommonwithcolonicinvolvement
• fistulae,fissures,abscessesarecommon
• deepfissureswithriskofperforationintocontiguousviscera(leadstofistulaeandabscesses) • enteric fistulae may communicate with skin, bladder, vagina, and other parts of bowel
Investigations
• colonoscopywithbiopsytovisualize(lessoftengastroscopy)
• CT/MRenterographytovisualizesmallbowel
• CRPelevatedinmostnewcases,usefultomonitortreatmentresponse(especiallyacutelyinUC) • bacterialcultures,O&P,C.difficiletoxintoexcludeothercausesofinflammatorydiarrhea
Increased in CD with/without prior steroids, in UC only after steroids usage
Effect of Tight Control Management on Crohn’s Disease (CALM): A Multi-Centre, Randomized Controlled Phase 3 Trial
Lancet 2017; 390:2779-2789
Purpose: To define the role of incorporating laboratory biomarkers in the management algorithm of active Crohn's disease.
Study: Randomized controlled trial.
Population: 224 adult patients (22 countries at
74 hospitals) with active Crohn’s disease were randomized to intensify treatment based on either laboratory biomarkers (serum C-reactive protein, fecal calprotectin) plus clinical evaluation (Crohn’s disease activity index and prednisone use) or treatment based on clinical evaluation alone. Outcomes: Mucosal healing via the absence of deep ulcers.
Results: At 2 years, more patients receiving treatment criteria that included laboratory tests had complete mucosal healing (i.e. no ulcers) than the group treated on basis of symptoms alone (46% vs 30%). Admittedly, the end-point of mucosal healing is not a strong clinically relevant result, but other studies have shown that the greater the mucosal ulceration, the more likely are complications, (strictures, fistulas, abscesses, hospitalizations
and surgery).
Conclusions: This is not definitive data but adds
to other evidence showing that the traditional management paradigm needs reversing, so
in most patients it is worthwhile aiming for endoscopic healing of Crohn’s disease irrespective of symptoms.