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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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
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)
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
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?
79:25 Bone health, osteoporosis and IBD, screening for iron and nutritional deficiencies
82:27 Take home points
“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
Inflammatory bowel disease includes a spectrum of disease that includes Crohn’s disease, ulcerative colitis, and indeterminate colitis (10-15% of cases).
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
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.
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.
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.
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.
Age of diagnosis less than 40, early hospitalizations, need for steroids, and patients with C. difficile tend to have poorer prognosis.
Commonly presents with diarrhea, often associated with bleeding. The presence of tenesmus, indicative of rectal inflammation, is common.
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.
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.
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.
Budesonide comes in a PO formulation, or as a rectal foam. High first pass metabolism by the liver limits the systemic effects.
Characterized more by diarrhea and cramping. Commonly affects the small bowel, and is less commonly associated with bleeding.
Histopathologically characterized by rectal sparing, skip lesions (normal mucosa with areas of inflammation), and cobblestoning.
Fecal calprotectin will only be elevated if there is large bowel involvement, and so is of variable diagnostic utility in Crohn’s.
Cigarette smoking significantly worsens disease activity in Crohn’s. Tobacco cessation is mandatory.
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.
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.
Crohn’s flares can be treated with 40-60 mg of prednisone. –Dr Ehrlich’s expert opinion.
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
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.
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.
Bone health: Patients on chronic steroids should receive supplemental calcium and vitamin D. These patients should also be aggressively screened and treated for osteoporosis.
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.
Immunosuppressed patients should undergo annual gynecologic examinations and skin cancer screening.
Consider screening for depression in IBD patients, as the disease can have a significant impact on overall quality of life.
Dr. Ehrlich reports no relevant financial disclosures. The Curbsiders were sponsored by the ACP and MKSAP 18 for this episode.
Goals and Learning objectives
Listeners will gain a better understanding of the diagnosis, management, and primary care considerations for patients with inflammatory bowel disease.
After listening to this episode listeners will be able to…
Discuss the initial work-up for patients with suspected inflammatory bowel disease.
Describe the presentation and associated complications of ulcerative colitis and Crohn’s disease.
Describe the general treatment strategies for ulcerative colitis and Crohn’s disease.
Recall the primary care considerations for patients with inflammatory bowel disease.