#138 Inflammatory Bowel Disease: Crohn’s and Ulcerative Colitis

February 4, 2019 | By Paul Williams

Simplify IBD care with Dr Adam Ehrlich’s expert advice

Learn expert tips for the diagnosis and management of inflammatory bowel disease (IBD) from Dr. Adam Ehrlich, Assistant Professor of Medicine and co-director of the Inflammatory Bowel Disease Program at Temple University Hospital.  In this episode, we learn about the initial work-up, general principles of management, and important primary care considerations for Crohn’s disease and ulcerative colitis (ie endoscopic surveillance, immunizations, bone health/osteoporosis, and more!).

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Credits

Written and produced by: Paul Williams MD

Edited by: Matthew Watto MD

Hosts: Matthew Watto MD, Stuart Brigham MD, Paul Williams MD

Guest: Adam Ehrlich MD

Sponsor

Time Stamps

Intro and background

• 00:00 Sponsor: MKSAP 18
• 00:32 Disclaimer, Intro, guest bio
• 04:05 Guest one-liner, Adam’s movie rec – RBG (documentary), career advice, Paul’s movie rec – Edge of Tomorrow
• 09:25 Sponsor: ACP’s MKSAP 18
• 11:25 Definitions and pathophysiology of inflammatory bowel disease (IBD)

Ulcerative Colitis

• 13:40 A case of ulcerative colitis; Classic symptoms; Initial approach and basic differential diagnosis
• 19:10 Smoking and ulcerative colitis
• 21:17 Initial workup for suspected IBD; Fecal calprotectin
• 25:50 A bit more on CRP and IBD
• 26:55 When to refer for colonoscopy
• 27:58 Back to the case; a typical colonoscopy reports in ulcerative colitis (UC)
• 30:33 Extraintestinal manifestations of UC
• 34:50 Initial counseling for newly diagnosed IBD; natural history of IBD, prognosis
• 39:50 Treatment of ulcerative colitis
• 43:02 Some specifics on steroids, plus topical therapies

Crohn’s disease

• 47:05 A case of Crohn’s disease; initial approach and differential diagnosis
• 50:25 Initial diagnostic testing; colonoscopy findings in Crohn’s; IBD trivia
• 53:58 Treatment of Crohn’s disease
• 58:26 Specifics about biologic therapy for IBD; Endpoints
• 62:25 Steroid sparing agents, immunomodulators like azathioprine, 6-mercaptopurine
• 64:48 Can drug therapy be stopped or tapered in IBD?
• 66:50 Prognosis in Crohn’s and initial patient counseling

Primary Care considerations

• 68:35 Surveillance endoscopy,
• 71:47 Do diet and lifestyle changes for IBD work? What about pregnancy?
• 76:31 Immunizations
• 79:25 Bone health, osteoporosis and IBD, screening for iron and nutritional deficiencies
• 82:27 Take home points
• 86:28 Outro

“You are not going to get anything if you don’t ask for it” -Dr Erlich giving us some career advice

Inflammatory Bowel Disease Pearls

Tenesmus is the feeling of fecal urgency without significant bowel output. It should raise concern for rectal inflammation.

Fecal urgency that awakens the patient from sleep is characteristic of organic pathology ie NOT irritable bowel or another functional disorder.

Smoking cessation increases the risk of developing ulcerative colitis.

The more severe complications of IBD (e.g. pyoderma gangrenosum, uveitis) do not mirror disease activity.

Primary sclerosing cholangitis (PSC) is associated with IBD (ulcerative colitis more than Crohn’s)–if PSC is diagnosed, there is probably underlying IBD that merits diagnostic colonoscopy.

IBD Definitions and pathophysiology

1. Inflammatory bowel disease includes a spectrum of disease that includes Crohn’s disease, ulcerative colitis, and indeterminate colitis (10-15% of cases).
2. The major pathophysiologic mechanism is immune dysregulation, but there are a number of implicated genetic, environmental, and microbiota factors implicated.

Initial diagnostic approach and general considerations

1. When IBD is suspected, begin by checking stool studies (eg stool culture, C. difficile, +/- ova & parasites), plus stool tests for inflammation.  Elevated fecal calprotectin and lactoferrin indicate gastrointestinal tract inflammation.  
2. Negative fecal calprotectin can help rule out ulcerative colitis. However, be warned that it may not be covered by insurance, and is not really necessary if you are proceeding to colonoscopy anyway.
3. Don’t miss checking for Clostridium difficile–~25% of ulcerative colitis patients can have flares associated with C. difficile in the absence of traditional risk factors like antibiotic use and recent hospitalization.
4. Extraintestinal manifestations of IBD primarily affect the joints, skin, and the eyes.  Erythema nodosum manifests as tender nodules on the shins that mirror disease activity.  Pyoderma gangrenosum is an ulcerative skin condition that does not parallel disease activity.  Joint manifestations can range from vague polyarthralgias to ankylosing spondylitis.  Episcleritis parallels disease activity, while uveitis does not.
5. Age of diagnosis less than 40, early hospitalizations, need for steroids, and patients with C. difficile tend to have poorer prognosis.

Ulcerative colitis

1. Commonly presents with diarrhea, often associated with bleeding.  The presence of tenesmus, indicative of rectal inflammation, is common.
2. Histopathologically is characterized by continuous inflammation involving the rectum and moving proximally.  This can range from ulcerative proctitis to proctosigmoiditis to left-sided colitis to pancolitis.  Severity is commonly graded by the Mayo score for IBD.  Architectural distortion is the hallmark of IBD.
3. Mild to moderate disease is managed with 5-aminosalicylate and mesalamine products.  A combination of oral and rectal/topical therapies tends to be more effective.  Steroids can be used for more significant disease, as can biologic and immunomodulatory therapies.
4. Logistics: Rectal therapy is…less desirable to many patients. They must hold the enema for 15-30 minutes (“as long as they can”), which some patients cannot handle due to rectal inflammation. Suppositories are easier, but only cover about 15 cm of the distal colon.
5. Budesonide comes in a PO formulation, or as a rectal foam. High first pass metabolism by the liver limits the systemic effects.

Crohn’s disease

1. Characterized more by diarrhea and cramping.  Commonly affects the small bowel, and is less commonly associated with bleeding.
2. Histopathologically characterized by rectal sparing, skip lesions (normal mucosa with areas of inflammation), and cobblestoning.
3. Fecal calprotectin will only be elevated if there is large bowel involvement, and so is of variable diagnostic utility in Crohn’s.
4. Cigarette smoking significantly worsens disease activity in Crohn’s.  Tobacco cessation is mandatory.  
5. Historically managed with “step up” therapy, beginning with the mildest treatment and escalating therapy.  More recently, a “top down” approach is favored, as it appears more likely to modify the natural history of Crohn’s.
6. Patients should be screened for hepatitis B and tuberculosis prior to beginning biologic therapy.  Azathioprine and 6-mercaptopurine can be used to synergistically raise drug levels and prevent development of neutralizing antibodies.
7. Crohn’s flares can be treated with 40-60 mg of prednisone. –Dr Ehrlich’s expert opinion.
8. The ultimate goal of treatment is to reduce inflammation and concomitant risk of abscesses and fistula formation.

Random IBD treatment pearls

Typically, both clinical and endoscopic remission are the standard of care. Histologic remission is of uncertain benefit. -Dr Ehrlich

Biologic therapy: Don’t forget to test for Hep B and TB prior to initiation. Insurance approval can take weeks. The onset of action is within several days and the initial dose is often more aggressive.

Stopping therapy: Dr Erlich looks at inflammatory markers (eg CRP, fecal calprotectin), clinical symptoms, and evidence of endoscopic remission before “stepping down” therapy in IBD. There is a very high risk for flare when stopping therapies. Therefore, he favors continuing biologic agents long term.

Dietary or lifestyle interventions for IBD: None are proven. Avoid dairy if concomitant lactose intolerance. No specific dietary recommendations can be recommended at this time. Some patients feel better during pregnancy. -Dr Ehrlich

Primary Care in IBD

1. IBD is associated with a higher risk of colorectal cancer.  Colitis-associated colon cancer is likely driven by inflammation.  The more inflammation, the higher the risk.  Screening colonoscopy should be done 8 years after initial symptoms, with follow up screening recommended every 1-2 years thereafter.  European guidelines are somewhat less stringent.
2. Avoid live virus vaccines in your immunosuppressed patients.  The non-live recombinant zoster vaccine should be offered for patients receiving tofacitinib.  This may not be covered by insurance for patients under 50 years old.
3. Bone health: Patients on chronic steroids should receive supplemental calcium and vitamin D.  These patients should also be aggressively screened and treated for osteoporosis.
4. IBD patients are at risk for anemia given inflammation, bleeding, and malabsorption.  Consider checking iron stores, as well as vitamin B12 in patients with ileal disease or ileal resection.
5. Immunosuppressed patients should undergo annual gynecologic examinations and skin cancer screening.
6. Consider screening for depression in IBD patients, as the disease can have a significant impact on overall quality of life.

Disclosures

Dr. Ehrlich reports no relevant financial disclosures. The Curbsiders were sponsored by the ACP and MKSAP 18 for this episode.

Goals and Learning objectives

Goals

Listeners will gain a better understanding of the diagnosis, management, and primary care considerations for patients with inflammatory bowel disease.

Learning objectives

After listening to this episode listeners will be able to…

1. Discuss the initial work-up for patients with suspected inflammatory bowel disease.
2. Describe the presentation and associated complications of ulcerative colitis and Crohn’s disease.
3. Describe the general treatment strategies for ulcerative colitis and Crohn’s disease.
4. Recall the primary care considerations for patients with inflammatory bowel disease.

Links from the show

1. Edge of Tomorrow (film)
2. RBG (documentary)
3. Mayo score for IBD
4. Crohn’s and Colitis Foundation

Recommended Reading

1. An Update on Inflammatory Bowel Disease.  Primary Care 2017. https://www.sciencedirect.com/science/article/pii/S0095454317301045?via%3Dihub
2. Medical Progress: Ulcerative Colitis.  NEJM 2011. https://www.nejm.org/doi/full/10.1056/NEJMra1102942
3. Crohn’s Disease.  BMJ 2012. https://www.sciencedirect.com/science/article/pii/S0140673612600269?via%3Dihub
4. Inflammatory Bowel Disease.  Primary Care 2011. https://www.sciencedirect.com/science/article/pii/S0095454311000480?via%3Dihub
5. Cancers complicating inflammatory bowel disease.  NEJM 2015. https://www.nejm.org/doi/full/10.1056/NEJMra1403718
6. ACG clinical guideline update 2018 on Management of Crohn’s disease in adults. Am J Gastroenterol 2018 Apr; 113:481. (http://dx.doi.org/10.1038/ajg.2018.27)
7. NEJM Journal Watch Summary of guideline update https://www.jwatch.org/na46596/2018/05/01/management-crohn-disease-adults