inflammatory Bowel disease
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Inflammatory Bowel Disease , case, signs and symptoms, diagnosis, investigations and treatment.
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inflammatory Bowel disease
- 2. 6 year school going boy presented with Chronic diarrhea for 6 months associated with abdominal pain, Progressive weight loss and reduced appetite. • Continuous, 4-5x a day , with bleeding and mucusDiarrhea •Diffuse , Dull aching Abdominal pain
- 3. Past Medical History Anal fistulas since 2 years- taking medical therpay 1-1.5 years diarrhea on/off Took antibiotics multiple times but no effective improvement Family History One Sister have psoriasis Developmental History Normal development ,4th grader Vaccination History Completed Nutritional History Eats healthy normal diet, but reduced appetite since 1-1.5 years
- 4. Physical examination • Wasted, lethargicLook • presentPallor • absentLymph nodes • present ( MILD)Clubbing • absentCyanosis • DehydratedHydration
- 5. Physical examination CVS Normal Heart examination CNS No CNS Examination CHEST Normal Chest examination ENT Normal ENT examination ABDOMEN Diffuse tenderness, no distention, no masses palpable, no organomegaly, bowel sounds present. Anal fistulas and fissures are present
- 6. Initial Investigations LABS Results WBC 11 x 10^3 U/L mainly neutrophils HgB 10 g /dl ( LOW) MCV 70 fl ( LOW) RDW 16% ( Increased) PLT 500 x 10^3 U/L PT and PTT normal LFT normal CRP Raised ESR Raised
- 7. Mucus: present RBCs: 10-20 /HPF Pus cells: Numerous OVA and Parasites: not seen Rota and adeno virus : negative Stool for reducing substances: negative Culture: Normal C. Diff toxin : normal Fecal Calprotectin and Lactoferrin: Raised Stool Routine and culture
- 8. • No blood in stool • Positive for Anti-gliadin antibody IgACeliac disease • ova and parasites seen in series of stool examinations • No blood in stool Giardiasis • History of exposureG.I. T.B. • Reducing substances should be positive in stool • Hydrogen Breath test: positive Lactose Intolerance • Recurrent URTI and LRTI • Sweat chloride should be positive Cystic Fibrosis Differential diagnosis
- 10. •Mild erythema distal esophagus Esophagus •Patchy erythema ,mainly antrum Stomach •Patchy erythema and edema Colon Esophago- duodenoscopy Colonoscopy Endoscopic findings
- 14. • UnknownCause • Most common in Adolescents Age group • Family History • Mutations: Turner, Glycogen storage Diseases Risk Factors
- 15. Clinical Presentation 72 56 22 5862 74 84 31 0 20 40 60 80 100 abdominal pain diarrhea bleeding weight loss crohns disease ulcerative colitis
- 16. 74 35 20 20 18 0 20 40 60 80 100 Anemia Arthritis Erythema Nodosum Stomatitis Scleritis & Uveitis Inflammatory Bowel disease Extraintestinal Manifestation
- 17. Laboratory Crohn’s Disease Ulcerative Colitis CBC ESR CRP LFT Fecal Calprotectin or Lactoferrin P-ANCA ASCA Negative Positive Investigations ↓↓ Hemoglobin ↑↑ Platelets ↑ or normal ↑ or normal ↓ Albumin Positive Positive Negative
- 18. Crohn’s Disease Ulcerative Colitis Esopahgo- duodenoscopy edema, erythema, friability, granulation • StricturesColonoscopy Colonoscopy edema, erythema, friability, granulation • Pseudopolyps Macroscopic appearance
- 19. Cobble stoning In CROHN’S Pseudopolyps In Ulcerative Colitis
- 20. Microscopic appearance 0 20 40 60 80 100 Crypts distortion crypts abscess Granuloma Crohns Disease Ulcerative colitis
- 21. Steatorrhea Renal Stones Growth Retardation Sclerosing Cholangitis Colon Cancer Complications • Crohn’s disease = Biliary system or Ileum • Ulcerative Colitis = Biliary system • Excessive Oxalate absorption • Reduced appetite and/or decreased absorption • Fibrosis of intra and extra hepatic bile ducts • Long term inflammation and damage, >10 years
- 28. Diet Management Flares Small several Meals Low Fiber Low Fat Simple carbohydrate Protein rich Modulen Milk
- 29. Description: Modulen® IBD is a whole protein powdered formulation. It is 100% casein based and provides 25% of the fat as MCT
- 30. Induction Transition Maintenance Drug Management •Modulen milk •SteroidsInduction • 5-ASA • Azathipurine • 6-Mercaptopurine Maintenance
- 31. Modulen Milk Oral Budesonide IV methyl Prednisolone Induction THERAPY NON REMITTING SEVERE MILD
- 32. 5-ASA Azathiopruine 6-MP Methotrexate Infliximab Maintenance THERAPY TMPT TEST TUBERCULIN TEST NON-RESPONSIVE Start
- 33. Surgical Management Indication • Perforation • Strictures • Fistulas • Perianal abscess • Intractable Bleeding • TOXIC MEGACOLON Complications • Recurrence of strictures at site of surgery. • Leak at site of anastomosis
Editor's Notes
- Both can be considered different variants of the same problem. Both are equally common among children , CD> UC
- Crohn’s Disease: Anywhere from Mouth to anus Ulcerative Colitis: involves the rectum and colon
- Cause: According to Nelson the Cause is disproportionate response of environmental factors in genetically susceptible individuals. Age group: 10- 20 years most common, in pediatric population cases come between 6-10 years, < 1% below 1 year. Risk factors: FH: one member: 7-30% , both parents : > 35% , Turner , hermansky – pudalk syndrome , Glycogen storage disease Poor associations: Living in industrialized nation, on western diet, early and frequent antibiotic usage, decreased exposure to microbes. Protective factors: Cigarette smoking in Ulcerative colitis
- Presenting Symptoms such as abdominal pain, diarrhea, bleeding and weight loss are common to both variants of IBD, although bleeding as a symptom is more common in UC but still its part of CD presentation as well.
- It is uncommon to see Extraintestinal Manifestations as presenting signs and symptoms, and is something that may develop overtime
- Management : surgery and antibiotics for perianal abscess
- Surgery: stricturoplasty
- Management : sugery
- Modulen Milk : anti-inflammatory properties, Atleast 2 week , PO or NG , only with water, no other diet necessary ; advantage over normal diet is , it doesn’t induces early satiety, less likely to induce abdominal pain, diarrhea
- 5-ASA= Penatasa, asacol, rowasa TMPT test: positive we start therapy if negative we dont Methotrexate: folic acid Biological agent: adalimumab, vedolizumab,
- Relapse: unknown , even after good treatment.? NSAID ? Enteric infeections such as clostridium difficile Retarded height and osteopenia: vit d deficiency, reduced appetite, malabsorption , steroid usage Drug side effects : due to usage of immunomodulators such as AZA, 6-MP, methotrexate results in myelotoxicity hepatitis, pancreatitis then effects of steroids. Colon cancer: after 8-10 years of condition need colonoscopy after every 1-2 years , may need colectomy if severe dysplasia