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Extra GI Manifestations Extra GI Manifestations of IBDof IBD
Dr. Matt W. Johnson Dr. Matt W. Johnson
BSc MBBS MRCP MDBSc MBBS MRCP MDConsultant GastroenterologistConsultant Gastroenterologist
Luton & Dunstable FT HospitalLuton & Dunstable FT Hospital
LuminologyLuminology
To the ileum …and beyondTo the ileum …and beyond
Extra GI Manifestations of IBD Extra GI Manifestations of IBD =40%=40%
OrganOrgan ComplicationsComplications
MouthMouth Glossitis / Angular stomatitis / Orofacial Glossitis / Angular stomatitis / Orofacial granulomatosisgranulomatosis
EyesEyes Episcleritis / Iritis / UveitisEpiscleritis / Iritis / Uveitis
SkinSkin Erythema nodosum / Pyoderma GangrenosumErythema nodosum / Pyoderma Gangrenosum
BonesBones Sacroiliitis / Enteropathic Arthropathy / Ankylosing Sacroiliitis / Enteropathic Arthropathy / Ankylosing Spondylitis / OsteoporosisSpondylitis / Osteoporosis
LungsLungs Fibrosing Alveolitis (UIP)Fibrosing Alveolitis (UIP)
LiverLiver AICAH / Granulomatous Hepatitis / AmyloidAICAH / Granulomatous Hepatitis / Amyloid
Biliary TractBiliary Tract Gallstones / Bile acid malabsorption / Primary Gallstones / Bile acid malabsorption / Primary Sclerosing Cholangitis / AI pancreatitis / Sclerosing Cholangitis / AI pancreatitis / CholangiocarcinomaCholangiocarcinoma
KidneysKidneys Stones (uric acid, oxalate)Stones (uric acid, oxalate)
BloodBlood Fe + B12 + Folate deficiency / A+V ThrombosisFe + B12 + Folate deficiency / A+V Thrombosis
ConstitutionConstitutionalal
Toxic megacolon / Weight loss / Growth retardationToxic megacolon / Weight loss / Growth retardation
Post-Post-SurgicalSurgical
Bile acid malabsorption / abscess / strictures / Bile acid malabsorption / abscess / strictures / fistulaefistulae
EGIM of IBDEGIM of IBDCrDCrD UCUC BothBoth ActivityActivity IBD RxIBD Rx
OFGOFG ++ ++ +/-+/-
GallstoneGallstone + sb+ sb -- --
PSCPSC ++ -- --
PBCPBC ++ -- --
AIPAIP ++ -- --
Epi/Epi/ScleritisScleritis
++ ++ ++
Iritis/Iritis/UveitisUveitis
++ ++ ++
ENEN ++ ++ ++
PGPG ++ +/-+/- +/-+/-
SerositisSerositis ++ ++ ++
SacroilitisSacroilitis ++ ++ ++
T1 ArthroT1 Arthro ++ ++ ++
T2 ArthroT2 Arthro ++ -- --
AnkSpondAnkSpond ++ -- --
MouthMouth
1)1) Glossitis - Glossitis -
2)2) Angular StomatitisAngular Stomatitis
3)3) Orofacial granulomatosisOrofacial granulomatosis
GlossitisGlossitis
• B12 deficiencyB12 deficiency– Red “beefy” tongue Red “beefy” tongue
• Fe deficiencyFe deficiency– Atrophic smooth Atrophic smooth
tongue tongue
Rx = SupplementsRx = Supplements
Angular StomatitisAngular Stomatitis
• Fe deficiencyFe deficiency
Rx = SupplementsRx = Supplements
Orofacial GranulomatosisOrofacial Granulomatosis
• Rare chronic Rare chronic inflammatory conditioninflammatory condition
• Characterised by lip Characterised by lip swellingswelling
• 64% have histological 64% have histological granulomas similar to granulomas similar to CrDCrD
• Rx = Elemental or Rx = Elemental or Cinnamon and benzoate Cinnamon and benzoate free dietfree diet
EyesEyes
1)1) EpiscleritisEpiscleritis
2)2) Iritis Iritis
3)3) UvietisUvietis
4)4) Steroid CataractsSteroid Cataracts
EpiscleritisEpiscleritis
Incidence = 5% Incidence = 5%
Superficial redness of Superficial redness of the episclera and the episclera and conjuctivaconjuctiva
Burning + itching due Burning + itching due to dilated vesselsto dilated vessels
Mx = Self resolves +/- Mx = Self resolves +/- NSAIDSNSAIDS
ScleritisScleritis Deeper redness of Deeper redness of
sclerasclera Serious inflammatory Serious inflammatory
condition condition Ocular pain, Ocular pain,
photophobia, tearing, photophobia, tearing, blindness blindness
Rx = Treat the IBD + Rx = Treat the IBD + Systemic steroids, Systemic steroids, NSAIDS, antibiotics or NSAIDS, antibiotics or immunosuppressantimmunosuppressant
Iritis / UveitisIritis / Uveitis Inflammation of the iris Inflammation of the iris
(anterior uveitis)(anterior uveitis)
0.5-3%0.5-3%
Acute self resolves within Acute self resolves within weeksweeks
Chronic persists for Chronic persists for months and needs Rxmonths and needs Rx
Ocular pain, photophobia, Ocular pain, photophobia, blurry vision, synechia blurry vision, synechia
IritisIritis
Complications Complications include; include; synechia, synechia, cataracts, cataracts, glaucoma, glaucoma, blindness blindness
Rx = Steroids Rx = Steroids (PO + drops, (PO + drops, subconjuctival subconjuctival injections)injections)
UveitisUveitis Inflammation of Inflammation of
middle/inner eyemiddle/inner eye
10% of blindness in USA 10% of blindness in USA
Mx = Urgent referral to Mx = Urgent referral to ophthalmologistophthalmologist
Treat the IBDTreat the IBD
Rx = Steroids (PO + Rx = Steroids (PO + drops, subconjuctival drops, subconjuctival injections), dilators + injections), dilators + pressure reducing drops pressure reducing drops (brimonidine tartrate) +/- (brimonidine tartrate) +/- MTX, IFXMTX, IFX
SkinSkin
1)1) Erythema NodosumErythema Nodosum
2)2) Pyoderma gangerenosumPyoderma gangerenosum
Erythema NodosumErythema Nodosum
• 8-15% of UC + CrD8-15% of UC + CrD
• Usually reflects active Usually reflects active diseasedisease
• Can precede the IBD Can precede the IBD diagnosisdiagnosis
• Red hot nodules on extensor Red hot nodules on extensor surfacessurfaces
• Assoc with pauciarticular Assoc with pauciarticular arthropathyarthropathy
• Rx the IBD and you Rx the ENRx the IBD and you Rx the EN
Pyoderma GangerenosumPyoderma Gangerenosum• 5% UC 5% UC
• 2% of CrD patients2% of CrD patients
• 50% assoc with IBD 50% assoc with IBD activityactivity
• Starts with a red area + Starts with a red area + central pustules then central pustules then develops into a painful develops into a painful necrotic ulcernecrotic ulcer
• Steroids, IFX, CyclosporinSteroids, IFX, Cyclosporin
• Colectomy does not Colectomy does not always helpalways help
Airway inflammationAirway inflammation UC > CrD UC > CrD Chronic cough and mucopurulent Chronic cough and mucopurulent
sputumsputum Progressive airways narrowing leads Progressive airways narrowing leads
to Chronic bronchitis + bronchiectasis to Chronic bronchitis + bronchiectasis + bronchiolitis obliterans+ bronchiolitis obliterans
CXRs frequently normal, needs HRCTCXRs frequently normal, needs HRCT Rx = Large airways - Inhaled steroids Rx = Large airways - Inhaled steroids
Small airways - Systemic steroids Small airways - Systemic steroids
Thrombo-embolic disordersThrombo-embolic disorders
• TE events occur in 25%TE events occur in 25%• 3 fold increase above general population3 fold increase above general population• Recurrence risk is 10-15%Recurrence risk is 10-15%
UCUC CrDCrD
Incidence per 10,000Incidence per 10,000 5050 4040
Increase risk of DVTIncrease risk of DVT 2.82.8 2.92.9
Increase risk of PEIncrease risk of PE 3.63.6 4.74.7
Liver + PancreasLiver + Pancreas
1)1) Abnormal LFTs = 30% eg. AZAAbnormal LFTs = 30% eg. AZA
2)2) Gallstones = 13-34% of sb Gallstones = 13-34% of sb Crohn’sCrohn’s
3)3) PSCPSC
4)4) PBCPBC
5)5) AI PancreatitisAI Pancreatitis
Primary Sclerosing Primary Sclerosing CholangitisCholangitis
5% of UC and 1-2% CrD5% of UC and 1-2% CrD Can precede colitis by yearsCan precede colitis by years Symptoms = Pruritis, Symptoms = Pruritis,
fatigue, RUQ pain, jaundice, fatigue, RUQ pain, jaundice, cholangitischolangitis
Bedding and stricturing of Bedding and stricturing of IHDsIHDs
Associated with Associated with cholangiocarcinoma 6-20%cholangiocarcinoma 6-20%
Increased risk of U+L GI Increased risk of U+L GI cancer x6 and ampullary cancer x6 and ampullary cancercancer
Colonoscopy every year, Colonoscopy every year, with OGD every 2 years with OGD every 2 years
Survival if symptomatic = Survival if symptomatic = 15-18y15-18y
Primary Biliary CirrhosisPrimary Biliary Cirrhosis More commonly More commonly
seen with UCseen with UC
High cholesterolHigh cholesterol
Deficiencies in the Deficiencies in the fat soluble fat soluble vitamins DEAKvitamins DEAK
Leads to Leads to cholestasischolestasis
BonesBones
1)1) OsteoporosisOsteoporosis
2)2) SacroileitisSacroileitis
3)3) Arthropathies (RhA, AnkSpond)Arthropathies (RhA, AnkSpond)
Osteopenia / OsteoporosisOsteopenia / Osteoporosis
Peak bone mass reached in our 20-Peak bone mass reached in our 20-30s30s
Then 0.5-1% per year thereafterThen 0.5-1% per year thereafter
15% BMD lost in first 5y post 15% BMD lost in first 5y post menopausemenopause
Osteopenia occurs in 40-50%Osteopenia occurs in 40-50%
Osteoporosis occurs in 2-30%Osteoporosis occurs in 2-30%
Lifetime risk of fractures in IBD = Lifetime risk of fractures in IBD = 41%41%
CrD women have 2.5 fold increase CrD women have 2.5 fold increase fracture risk fracture risk
OsteoporosisOsteoporosisPreventionPrevention
1)1) Weight bearing exerciseWeight bearing exercise2)2) Stop smokingStop smoking3)3) Reduce weightReduce weight4)4) Moderate Xol intakeModerate Xol intake5)5) Ca intake (1000-1500mg/d) = 1 pint of semi skimmed is 700mgCa intake (1000-1500mg/d) = 1 pint of semi skimmed is 700mg6)6) Stop steroids ASAPStop steroids ASAP
1)1) Bone loss starts rapidly Bone loss starts rapidly 2)2) Occurs even with low dosesOccurs even with low doses3)3) Fracture risk improves on cessationFracture risk improves on cessation
7)7) Ca + Vit D = All patients on steroidsCa + Vit D = All patients on steroids8)8) Bisphosphonates = steroids >3m, those >65y or low impact Bisphosphonates = steroids >3m, those >65y or low impact
(fragility) fractures(fragility) fractures9)9) HRT eg testosterone in steroid induced hypogonadismHRT eg testosterone in steroid induced hypogonadism
BSG Mx of OsteoporosisBSG Mx of Osteoporosis
Calcium + Vit DCalcium + Vit D PO Bisphosphonates (eg alendronate, residronate)PO Bisphosphonates (eg alendronate, residronate) IV Bisphosphonates (eg. pamidronate)IV Bisphosphonates (eg. pamidronate)
In those with difficult side effects eg. oesophagitisIn those with difficult side effects eg. oesophagitis Poor mucosal absorptionPoor mucosal absorption Avoids the problems Avoids the problems
HRT (in PMP women) - risk of clots / breast+gynae HRT (in PMP women) - risk of clots / breast+gynae cancercancer
Raloxifene - modulator of OR, without increased of Raloxifene - modulator of OR, without increased of breast Cabreast Ca
SacroilitisSacroilitis Prevalence = 47%Prevalence = 47% Sacro-iliac painSacro-iliac pain Hazziness of Hazziness of
sacro-iliac jointsacro-iliac joint Can be one sidedCan be one sided
Rx = COX II Rx = COX II inhibitorsinhibitors
Try to avoid Try to avoid NSAIDSNSAIDS
Steroids / IFXSteroids / IFX Mx = Treat the Mx = Treat the
IBDIBD
IBD ArthropathyIBD Arthropathy 10-20% of IBD patients (esp in Colonic disease, EN, Eyes)10-20% of IBD patients (esp in Colonic disease, EN, Eyes) Not to be confused with Not to be confused with arthralgia secondary to steroid arthralgia secondary to steroid
withdrawal, AZA or steroid induced myopathy.withdrawal, AZA or steroid induced myopathy.
1) Type 1 (Large Joint) Arthropathy = 5%1) Type 1 (Large Joint) Arthropathy = 5% 6 joints, (typically 1 large joint eg. knee)6 joints, (typically 1 large joint eg. knee) Attacks assoc with active inflammatory relapses, EN + IritisAttacks assoc with active inflammatory relapses, EN + Iritis Usually self limiting, no role for NSAIDS Usually self limiting, no role for NSAIDS Treat the IBD = 5ASAs, Steroids, MTX, AZA, ColectomyTreat the IBD = 5ASAs, Steroids, MTX, AZA, Colectomy
2) Type 2 (Small Joint) Arthropathy = 3-4%2) Type 2 (Small Joint) Arthropathy = 3-4% Affects >5 joints, (typically small joints of hands and feet)Affects >5 joints, (typically small joints of hands and feet) No direct assoc with IBD activity or RxNo direct assoc with IBD activity or Rx
Rx Algorithm for IBD Rx Algorithm for IBD ArthropathyArthropathy1st 1st LineLine
Physical exercisesPhysical exercises
Simple analgesiaSimple analgesia
Intra-articular injectionsIntra-articular injections Steroids + LignocaineSteroids + Lignocaine
2nd 2nd LineLine
Sulfasalazine or Pentasa Sulfasalazine or Pentasa (sb)(sb)
NSAIDS!!! / Codeine !!!NSAIDS!!! / Codeine !!!
MTX (esp. Crohns)MTX (esp. Crohns)
(No evidence for (No evidence for AZA/Cyclo)AZA/Cyclo)
Bonner G.F. AmJG. 2002Bonner G.F. AmJG. 2002
Thompson GT. JRheum Thompson GT. JRheum 20002000
3rd 3rd LineLine
IFX (Type 1)IFX (Type 1)
Thalidomide (80% Thalidomide (80% AnkSpon)AnkSpon)
BisphosphonatesBisphosphonates
EGIM of IBDEGIM of IBDCrDCrD UCUC BothBoth ActivityActivity IBD RxIBD Rx
OFGOFG ++ ++ +/-+/-
GallstoneGallstone + sb+ sb -- --
PSCPSC ++ -- --
PBCPBC ++ -- --
AIPAIP ++ -- --
Epi/Epi/ScleritisScleritis
++ ++ ++
Iritis/Iritis/UveitisUveitis
++ ++ ++
ENEN ++ ++ ++
PGPG ++ +/-+/- +/-+/-
SerositisSerositis ++ ++ ++
SacroilitisSacroilitis ++ ++ ++
T1 ArthroT1 Arthro ++ ++ ++
T2 ArthroT2 Arthro ++ -- --
AnkSpondAnkSpond ++ -- --