what is the different between IBS AND IBD
irritable bowel disease is where there is something structurally wrong with visual abnormalities, IBS is when there is something functionally wrong
IBD comes in 2 forms:
ulcerative colitis and crohns disease
what is the difference betwen ulcerative colitis and crohns disease?
ulcerative colitis only affecst the colon and rectum wheras crohns disease can affect any part of the GI tract
what are the stages in ulcerative colitis ?
- proctitis - rectal inflamamtion (suppositories)
- proctosigmoiditis - rectal and sigmoidal colon inflammation (foam preperations for rectal administration)
- Left sided colitis - inflamamtion up to and including the descendign colon (enemas)
- extensive colitis - inflammation affcets up to the transverse colon (oral)
in the cases of proctitis and proctosigmoiditis, use aminosalicytes rectally, a rectal corticostreoids or alternatively, you could use oral prednisolone. in the cases of left sided colitis, and extensive colitis, high dose oral aminosalicylates and rectal aminosalicylates or oral beclometasone or oral prednisolone
what are symtopsm of ulcerative colitis ?
Symptoms of ulcerative colitis include bloody diarrhoea, abdominal pain and acute flare ups. These can result in mouth ulcers, arthritis, weight loss and fatigue.
Long term complications will involve colorectal cancer, secondary osteoporosis due to the use of corticosteroids and dietary changes, venous thromboembolism and toxic megacolon acutely. Toxic megacolon is a form of colonic distention, associated with shock, fever and abdominal pain.
what are aminosalicylates?
aminosalicylates limit the inflammation in the lining of the GI tract
sulfasalazine, mesalazine, balsalazine, olsalazine
what is methotrexate?
Methotrexate inhibits the enzyme dihydrofolate reductase, essential for the synthesis of purines and pyrimidine.
side effects: GI toxicity - somatitis, liver toxicity - jaundice, nausea, vomiting, abdominal, discomfort, dark urine. blood disorders, bne marrow suppresiion - sore throat, brusiing, mouth uelrs fever, rash, lungs: pneumonitis and dry cough
monitoring: FBC, and renal and lvier fucntion teets every 1-2 weeks until stabislied dose, then 2-3 monhtly
what are streroids?
they suppress the immune resposne
side effects include:
▪ Adrenal suppression such as nausea, vomiting, weight loss, fatigue, headache, muscular weakness.
▪ Immunosuppression – chickenpox, measles, oral candidiasis.
▪ Psychiatric reactions: suicidal ideation, depression, insomnia – may warrant withdrawal of steroids or dose reduction.
what is azathiopurine and mercaptupurine?
Inhibits purine metabolism and consequently stops DNA/RNA synthesis and protein synthesis.
◦ Dose in Ulcerative Colitis and Crohn’s is generally 2–2.5 mg/kg daily, or lower in divided doses.
Side Effects
▪ Hypersensitivity reactions that present as a rash, fever, myalgia, arthralgia, malaise, interstitial nephritis, nausea, vomiting and diarrhoea. (Note that nausea tends to be common in the early stages of treatment and normally resolves in a few weeks without the need for dose alterations.)
▪ Causes bone marrow suppression, but both neutropenia and thrombocytopenia are dose dependent.
need to scan for thiopurine methyltransferase TPMT. low levels results in higher levels of myelosuppression.
Must reduce doses when the patient is on allopurinol. manufacturer advises reduce dose to one qurater of the usual dose with concurrent allopurinol
what is ciclosporin?
Is often used for organ transplants and tissue transplants, but can be used intravenously in the management of UC and Crohn’s.
Side Effects
▪ Kidneys = nephrotoxicity
▪ Liver = hepatotoxicity
▪ Bone marrow = blood dyscrasias
▪ Blood: hyperlipidaemia, hypertension, hyperkalaemia and hypomagnesia
▪ Visual disturbances: secondary to benign intracranial hypertension
▪ Gingival hyperplasia
▪ Neurotoxicity
avoid acess sun exposure to UV light, avoid grapefruit juice as this decreases serum ciclosporin, and avoid increasing potassium in the diet.
proctitis
First-line: Topical aminosalicylate.
If no remission in 4 weeks: Add oral aminosalicylate
or consider corticosteroids for 4-8 weeks.
For those disliking enemas/suppositories: Oral
aminosalicylate monotherapy (less effective).
If aminosalicylates unsuitable: Consider
corticosteroids for 4-8 weeks.
Proctosigmoiditis & Left-sided Ulcerative Colitis:
First-line: Topical aminosalicylate.
If no remission in 4 weeks: Add/switch to high- dose oral aminosalicylate and consider corticosteroids for 4-8 weeks.
For those disliking enemas/suppositories: High-
dose oral aminosalicylate monotherapy.
If aminosalicylates unsuitable: Consider
corticosteroids for 4-8 weeks.
Extensive Ulcerative Colitis:
First-line: Topical aminosalicylate + high-dose oral aminosalicylate.
If no remission in 4 weeks: Stop topical and consider oral corticosteroids for 4-8 weeks.
If aminosalicylates unsuitable: Consider
corticosteroids for 4-8 weeks.
Moderate-to-Severe Ulcerative Colitis:
Under specialist care: Use Janus kinase inhibitors,
sphingosine-1-phosphate receptor modulators,
and biological drugs.
Acute Severe Ulcerative Colitis:
Requires immediate hospitalisation.
* First-line: Intravenous corticosteroids.
* If corticosteroids unsuitable: Intravenous ciclosporin or surgery.
* If no improvement within 72 hours: Intravenous ciclosporin with corticosteroids, or surgery.
* Infliximab: For those where ciclosporin is inappropriate.
* Also, consider stool cultures and cytomegalovirus activation.
maintaining remission
Use aminosalicylate in most patients to reduce relapse chances.
◦ Corticosteroids aren’t suitable for maintenance due to side-effects.
◦ For proctitis/proctosigmoiditis: rectal aminosalicylate alone or with oral aminosalicylate.
◦ For left-sided or extensive ulcerative colitis: low-dose oral aminosalicylate.
◦ Single daily doses of oral aminosalicylates might be more effective but with more side-effects.
◦ Consider oral azathioprine or mercaptopurine if:
▪ Two or more flare-ups in a year requiring corticosteroids.
▪ Aminosalicylates fail to maintain remission.
▪ Following a severe episode.
◦ Methotrexate is commonly used, but there’s no evidence supporting its efficacy.
◦ Biological drugs, Janus kinase inhibitors, and sphingosine-1-phosphate receptor modulators can be continued into the maintenance phase.
