Inflammatory Bowel Disease (IBD)

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🌱 來自: Huppert’s Notes

Inflammatory Bowel Disease (IBD)🚧 施工中

Inflammatory Bowel Disease (IBD)

•   History:

-   Even if you suspect IBD, always rule out infection first! Take a good travel and dietary history, ask about recent antibiotic use, assess risk factors for being immunocompromised.

-   Ask about extraintestinal manifestations of IBD (see Table 4.7)

TABLE 4.7 • Features of Ulcerative Colitis vs. Crohn’s Disease

-   Quantify diarrhea and ask about tenesmus (fecal urge; suggests rectal involvement)

-   Ask about family history of autoimmune disease or IBD

•   Diagnosis:

-   General: CBC with differential, BMP, INR

-   Rule out infection: Bacterial stool culture, Shiga toxin, E. coli 0157, C. diff, Giardia, O+P. Viral colitis (e.g., CMV) will not be evident on culture, so take biopsies during colonoscopy to rule out.

-   ESR, CRP, and fecal calprotectin are inflammatory markers that can be elevated in IBD flares. It is helpful to check at baseline when the patient is asymptomatic and then again if there is concern for an IBD flare.

-   Imaging:

•   Before initial colonoscopy in the inpatient setting, consider an abdominal plain film to ensure that there are no anatomic variations that would make colonoscopy more dangerous. There is no need for imaging if the patient is stable as an outpatient.

•   CT abdomen/pelvis is indicated in patients with severe pain to rule out complications of IBD, such as toxic megacolon, perforation, intraabdominal abscess, or bowel obstruction. Imaging can also be used to help rule out other causes of hematochezia, such as mesenteric ischemia.

-   Colonoscopy with biopsies is always indicated when evaluating for a new diagnosis of IBD

•   Treatment:

-   Induction therapy: Steroids (prednisone, budesonide). These should only be used for induction, not maintenance; patients with IBD should not be placed on oral steroids indefinitely.

-   Maintenance therapy: Depends on the severity and extent of disease

•   Mild/moderate disease: 5-ASA, sulfasalazine

•   Severe disease: TNF-alpha inhibitor (e.g., infliximab, adalimumab), thiopurines (azathioprine, 6-MP), methotrexate, anti-integrin (vedolizumab), IL-12/23 inhibitor (ustekinumab), JAK inhibitor (tofacitinib)

-   IBD flare: Depends on the severity. For severe flares:

•   Consider hospital admission

•   Diagnostics/labs:

-   Rule out infection: Stool culture, C. diff testing, stool O&P, fecal calprotectin

-   Prepare for the possibility of a rescue therapy with a biologic: Place PPD, send hepatitis serologies, perform cocci testing if risk factors, consider checking levels of antibiotics to biologic if prior exposure to biologics (e.g., infliximab ab)

•   Initiate IV corticosteroids; use symptoms, stool count/quality, and inflammatory markers (usually on hospital day 3 and 5) to predict corticosteroid failure and, if high probability of corticosteroid failure, consider surgical consultation and rescue therapy (e.g., infliximab)

•   Other aspects of care: Nutrition workup/consult, administer VTE prophylaxis (highly inflammatory state is prothrombotic; administer even if stools are bloody), control pain with APAP or tramadol (do not use opiates unless perioperative, as they may increase all-cause mortality in patients with IBD)

•   Surveillance: Patients with UC and Crohn’s colitis have an increased risk of colorectal cancer. Therefore, begin screening colonoscopies 8–10 yr after the initial diagnosis, and continue screening every 1–2 yr.