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Ok. Ok. So today, what we're gonna be going through is inflammatory bowel disease. So, ulcerative colitis and Crohn's disease, as well as Celiac disease and irritable bowel syndrome. We're also gonna touch on gastroenteritis pretty briefly at the end. Um Yeah. Ok. So have a look at our first case. We have a 33 year old man who presents to the GP with a two month history of diarrhea and abdominal pain. He describes emptying his bowels more than five times a day and sometimes feels the need to pass all with no bowel emptying. So his symptoms are instantly gi symptoms. So IBD IBS maybe CDX CS. Um, those are kind of things when we have thinking about at this point. Does anyone know what it is to have the need to pass stool with no volunteer? Does anyone know what that is, what that's called? So the need to pass stool but not actually having any bowel movements. It's quite a key sign. Yeah. Tenesmus. Exactly. Ok. So Tenesmus and that's also pointing us quite towards one of the IBD conditions. We'll come back to that in a second. So he's also noticed blood and mucus in his stool. So, again, um, quite a key, quite a key symptom. Does anyone have any ideas so far about what this might be? It's a bit of a stretch. We haven't quite done the investigations yet, but just from the symptoms. Does anyone have any ideas? Anything at all? Yeah, exactly. You see. So this is quite a typical picture of, so kind of proving our point. His stool culture is negative so we can rule out any form of gastroenteritis pretty much and his fecal calprotectin is positive. So what that's doing is pretty much ruling out IBS because he's got signs of inflammation in his bowel, it can also point towards other things. But with this symptomatic picture, we're thinking IBD. So now in uh once he's gone for colonoscopy, it shows continuous distal disease, absence of granulomas and crypt abscesses again, very, very stereotypical osteitis. And that basically rules out Crohn's disease. So in terms of investigations, we've already said we want to do a fecal car protectant. So this is just a primary care investigation, easy to do. And it's just ruling out IBS basically showing us that we do need to do further investigations and that includes colonoscopy and biopsy. So the important of colonoscopy and biopsy is two things, disease, extent and severity. So both of these things help us in our management because we can see where exactly the disease is within the colon and also how bad it is. Does he need admission to the hospital, for example. So some of the key features and again, very key SB language is continuous ulceration, limited to the colon, the rectum. So if we're seeing any disease in the small intestine or anywhere else in the gi tract, and that's pointing us away from osteitis and also crypt abscesses and depletion of goblet cells. Again, very key um SBA language that points us away from Crohn's disease. Ok. Now, we also want to do a barium enema. So if we see again, key phrase, drain pipe colon, basically just describing a very short and narrow colon because of the chronic inflammation as well as loss of frustrations on the enema. So again, those are pointing us towards some other investigations that may be mentioned less commonly. So in BA S but CT S abdominal X ray and abdominal ultrasound scan, um there's also some things to bear in mind. So one of the best ways I'm sure most of you have kind of come across is using the acronym close up. So I think that's a really good way to start. So continuous inflammation, like we said, it starts from the rectum and moves approximately in the Gi tract unlike Crohn's, which is very patchy in terms of information. So that's ulcerative colitis. It's also limited to the colon, the rectum. So in terms of um managing this, we do need to know these terms hip proctitis, sigmoiditis, left sided colitis where the descending colon is also involved extensive colitis, which also involves a transverse colitis and pan colitis, which involves the whole colon. So that's gonna come into play a little bit later on when we look at management. Now, it's also important to remember that only the superficial mucosa is affected. So that's talking about our mucosa and our submucosa. It is not through the whole of the bowel wall. So that's something that we'll see on colonoscopy. Smoking is also protective. So this is a big difference between ulcerative colitis and Crohn's. So a typical SBA picture might be someone's um been smoking, then they stop smoking and then they might see these symptoms starting to present. Um in terms of IBD, they, they get these symptoms after they've stopped smoking. It's also very, very common to excrete blood and mucus. That being said, if in a question, everything is pointing towards ulcerative colitis, but they don't excrete blood and mucus don't let that throw you off. It probably still is ulcerative colitis because it's not always present. Now, in terms of management, the U stands for use aminosalicylates. So five A SAS, now we'll take a little break from our acronym and we'll talk about the treatment at this point. So in terms of management, one of the first things we need to do is determine the severity of the disease and I think it's best to start at the severe side of things. So if there's any signs of systemic upset, if there's substantial blood in the stool or if there's very high number of stools per day that is severe and that's quite important. And we'll look at that in a little in a little bit and then mild is less than four stools with no blood in the stool and no systemic upset and moderate is 4 to 6 stools with a little bit of blood in the stools and no systemic upset again. So basically, one of the key things to look out for is systemic upset because that indicates whether it's severe or not, we also need to know about the extent of the disease. So, like I said, where is the disease in the colon? Um because that's also going to influence the management. So our patient that we were looking at with a case that he had, I think five stools per day. Um So that would be moderate, moderate for him because he also had no signs of systemic upset from the inflammation that we had. So this would be relevant to him. Um Obviously, we don't know whether it's proctitis, proctosigmoiditis or left sided. But if that was the case, then our first step for treatment to induce remission. So he's having a flare, we want to calm down the flare um and treat his symptoms at the moment is to topical aminosalicylic. So usually mesalazine. Now the reason why it's important to know exactly where the disease is is because if it's not extensive disease, then topical treatment should suffice because you can actually physically reach the areas of inflammation. Now, if after around four weeks, this doesn't work, it doesn't induce remission, then you want to add an oral aminosalicylate and again, high dose depending on where it is. Um And whether it's mild or moderate, then again, if this hasn't worked, then we want to add a topical or an oral oral corticosteroid. So basically we go from topical a aminosalicylate to oral and then to corticosteroids. Any questions so far? Yeah. Ok. So now that was um not extensive disease like in these pictures, but if we do have extensive disease, so including the transverse colon or the ascending colon, then our number one is gonna be topical aminosalicylates and high dose oral aminosalicylates. Ok. So that's gonna be our number one and then if that doesn't work. So again, after four weeks, then we're gonna stop our topical treatments. We're gonna start oral high dose aminosalicylates and oral corticosteroids. So you move away from the topical treatments and you start the oral treatments. Ok. Ok. So now in sative colitis, if you want to induce remission, but it's severe, our number one step is gonna be to admit to hospital. So if they have any signs of systemic upset hemody hemodynamic instability, you're gonna admit to hospital immediately. Ok. Now, if the number one treatment is gonna be IV steroids, now, if that's contraindicated you're gonna go to IV cycloSPORINE and then if that doesn't work after two, at 72 hours, the IV steroids don't work after 72 hours, then you're gonna add IV cycloSPORINE or consider surgery because a severe colitis can be very, very life threatening. Ok. Sorry, I'm just reading the comments at the moment. Ok, I'll come back to your question at the end if that's ok. Just because it's quite a long one. Will that be ok? Ok. So we're gonna keep going with this for now. So just a reminder if it's severe colitis, we're looking for stomach upset, substantial blood in the stools and more than six stools a day. Ok. So now that we've actually induced remission, we've treated the inflammation, um, during this flare, how are we going to maintain this remission? So again, we're looking at the same, same two things, the severity and the extent of the disease. So if you've had a mild to moderate flare and there's proctitis or proctosigmoiditis, so pretty, you know, near the rectum, then you're gonna have one of three options. So either just a topical aminosalicylate alone or oral and topical or oral amino salicide alone. Now, ideally, it's one of the top two, those are shown to be um, ideal in terms of how, how well they work. But the num num but C is also an option. Ok. Now, if it's left sided and extensive disease, then you're gonna be looking for a low maintenance dose of oral aminosalicylate. Cos obviously, if you go topical, then it's not gonna reach the entirety of the inflammation. Ok. Now, if you've had a severe flare or you've had two or more exacerbations in the past year, and I would bear in mind because again, this comes up a lot in SBA S, this kind of um alternative management, you're gonna go for oral azaTHIOprine or oral mercaptopurine. Ok? Now again, something that's important to bear in mind for SBA S is you need to assess TPMT activity before you start. Either of these two mean, essentially, we're trying to check will the body be able to break down the these drugs or will it stay at high level and possibly lead to toxicity? Because in that case, you wouldn't go for azaTHIOprine on the catch period. OK. So just remember to check TPMT activity before starting one of these two drugs. OK. So going back to our uh acronym. So on our last, our last letters. So P primary sclerosing cholangitis. So this is essentially just inflammation of the bile ducts inside and outside of the liver. Um and that leads to narrowing of, of these ducts and therefore a cholestatic picture. So just to put this into perspective for patients of with UC have PSE. So fairly, fairly substantial percentage um in terms of how common it comes up in BS and 80% of patients with PS C have UC. OK. So this does come up quite a bit. So some key features to notice are cholestatic jaundice, pruritus, raised bilirubin and ALP and right upper quadrant pain. Also, if they say the phrase beaded appearance or E RCP or M RCP, again, that's PSC, you also might find that they piana positive and the risk of cholangiocarcinoma and colorectal cancer goes up significantly. Ok. So those are some features to be looking out for. So if you see this alongside a picture of IBD, then you can in SBA land pretty much guarantee that it's gonna be, you see that they're pointing towards. Ok. Ok. So that is it for ulcerative colitis. So let's move on to the next condition. So here we have a 27 year old woman who presents the GP with a six week history of diarrhea and abdominal pain. So she describes emptying her bowels more than four times a day and has unintentionally lost 6 kg. Ok. So again, diarrhea, abdominal pain, lots of um bowel movements and she's lost weight. Ok. Now, she has not noticed mucus and blood in her stool and she also has multiple ulcers in her mouth. Does anyone have any idea about what that could be the ulcers? Well, what do we normally call them in this IBD type picture or, or what, what IBD is this pointing towards any ideas with the weight loss, lack of blood and mucus and apthous ulcers. What IBD are we pointing towards Crohn's. Yeah. Perfect. OK. And again, her stool culture is negative and her fecal hyper protectant is positive. Again, suggesting away from IBS and on colonoscopy, she shows skipped lesions, increased goblet cells and transmural inflammation in the colon and the ileum. So um all of these features are very specific to Crohn's and also ileum. So that means it cannot be um osteitis. So again, another acronym C Crohn's Nest for Crohn's um I think I'm sure a lot of you again have seen this one before. So there's no blood or mucus. Now, that being said, if there is blood or mucus, but it's a very Crohn's type picture, it still can be Crohn's, it's just much less common than you see. It also affects the entire gi tract. Now, this being said it's most commonly in the ileum and the colon. So that tends to be where the disease is mostly the ileum actually, but there can be um disease throughout the entire gi tract, including the ulcers, for example, in the mouth. Now, you can also see skipped lesions on endoscopy. So if they use the phrase a cobblestone appearance, that's because if you can see in this image, you have an area of ulceration, then you have an area without ulceration. Then again, more inflammation. So this kind of patchy inflammation leads to a Cobblestone appearance. OK? You also have increased goblet cells and granulomas. Again, key SBA phrases that suggest is Crohn's rather than using and like we said, it's a terminal ileum that is most affected and you have transmural thickness. So, transmural inflammation. So the full thickness of the bowel wall is affected now, that also can um lead to more complications that we'll have a look at in a second. So, whereas in smoking was protective, smoking is actually a risk factor with Crohn's. Um the phrase don't set the nest on fire can help you remember that. And in terms of more features to do with Crohn's, so you see weight loss. So again, if the small bowels affect us, you're more likely to see weight loss. Unlike you see where the small bowel is not affected at all. And weight loss isn't as much of a a symptom and then you also have strictures. So, Cantor's string sign, you're more likely to get strictures um in the small bowel. So again, key SBA phrase also fistulas because you have transmural inflammation. So it's more likely to fistulate through the bowel wall at this ulcer perianal disease because the entire gi tract can be affected. You also can see abdominal mass in the right, inferior quadrant, um right iliac fossa and gallstones and renal stones as well. Ok. So in terms of management with Crohn's disease to induce remission, your first stage is topical, oral or IV glucocorticoids. Um again, depending on essentially the severity. And our second stage, if that doesn't work is aminosalicylates. These are not as effective um as they are in UC and also not as effective as steroids are. But this is our second line treatment and our third stage is to add on azaTHIOprine or mercaptopurine. Again, you want to be checking TPN T um activity before you're giving any of these two drugs. Now, if you have refractory disease, so it nothing's helping or you have fistulated disease, um, you're gonna be looking towards infliximab, but that's quite, quite, um quite a later stage uh medication that you're looking at. Now, one of the biggest things is to stop smoking because we said smoking can be a really, really big trigger for Crohn's disease and it can just make a flare much, much, much worse. And we've also said this already. So TPMT activity has to be assessed before starting. And if it is, if there's basically no activity, then you would want to do methotrexate instead at stage three instead of azaTHIOprine or mercaptopurine. Ok. So that was inducing remission. Now, if we move on to maintaining remission, so our first step is azaTHIOprine or mercaptopurine and stopping smoking. So, Aza azaTHIOprine and meur are pretty much our mainstay of maintaining remission. But smoking, stopping smoking is again, very, very important as is checking your TPMT activity before starting. Ok. So that's pretty much it for Crohn's apart from the fact of surgery, so we don't have enough time to get into the whole details of this at this point. But if you have any signs of strictures, fistula, toxic megacolon or abscesses. Again, these are all things that, you know, um, really clearly differentiate it from. You don't tend to see, um, apart from toxic mega colon, you don't tend to see everything else in. But if you have any of these things, it is quite likely that surgery will be indicated. Ok. Ok. So now we're gonna move on to celiac disease. So, any questions so far? Ok. So Celiac disease is an autoimmune condition. It has a, it's because of a sensitivity to gluten. So what happens is that repeated exposure to gluten causes vous atrophy and therefore malabsorption. Now, all of these uh changes are actually reversible if gluten is removed from the diet. So that's why we'll actually to, we'll touch on it a little bit later. Now, it's also got associations with dermatitis, hepatis and autoimmune disorders. Um So that's just some key things to be looking out for in the history. So, if they have uh type one diabetes, for example, then you're gonna be thinking so that disease might be more likely than IBS for example. Um and this is just a picture of dermatitis a better for us as well. OK. It's also associated with HLA DQ two and HLD Q eight. So again, things to look out for in your SBA S. So in terms of signs and symptoms that you might see, you're gonna see chronic or intermittent diarrhea, a failure to thrive and faltering growth. Now, this is very specific to Children. You're unlikely to see this in adults. Instead, you might see sudden or unexpected weight loss in adults. Um in the history, you also have persistent and unexplained gi symptoms, like feeling nauseous, maybe vomiting, um as well as you know, just prolonged fatigue. So more of a generalized symptom and abdominal pain and cramping as well as bloating. So this is pretty much what you might see. You also might have unexplained anemia. So either b12 iron or folate, those are your key anemias that can crop up in terms of CAC disease. And that's mainly due to, well, that is due to the malabsorption that can take place because of the chronic exposure to gluten. Ok. So in terms of diagnosis, so what needs to be done because the changes that you see in celiac disease can be reversed. If you remove gluten from the diet, you have to reintroduce gluten to the diet for six weeks before testing. And you're gonna look at serology. So you're gonna be testing for tissue transglutine glutaminase. So T TG antibodies and because it is IG, you also want to check for your total IGA because if they have a um IG a deficiency, then you're gonna get a false negative cac result because your TCG antibodies will also be low. So that's really, really important. They ask that a lot in um SB that does come up, you have to check for a total IG as well as your T TG AN. Now, you also need an endoscopy. So you, because you need a biopsy, this is your gold standard. It's normally done in the duodenum can also be done in the jin. So what you might see again, keywords for SBA S, you're looking for villous, atrophy, crypt hyperplasia, an increase in intraepithelial lymphocytes and lamina prior infiltration with lymphocytes. Ok. Now, I'd say the first two come up a lot and they're much easier to recognize. So just keep an eye out for these in terms of SBA S. Ok? Ok. So in terms of management for celiac disease, it's pretty straightforward. It is a gluten free diet. So, gluten free diets are um interaction with a nutritionist in terms of explaining what in what has gluten, what doesn't. And that's quite a strict, quite a strict gluten free diet. Um Any sort of gluten even in the smallest amounts can uh cause those symptoms to reemerge. And there's changes in, in uh in the gi system to, to reemerge as well. You also want to be um checking if anything's needing supplementation. For example, if they're iron deficient, you want to be giving them iron and so forth. You also can check your TTG antibodies for compliance to see how well they are actually managing to stay um to stick with a gluten free diet and then what they're changing if that's working for them now a really key thing that comes up is immunization because it causes functional hyposplenism. So the pneumococcal vaccine is recommended for everyone with Celac disease as well as the booster every five years. And that, that comes up. Ok. That's quite important to remember. And then the flu vaccine is done on an individual basis. It's not a requirement for everyone but it can be given as well. So that's pretty much it for C disease and now on to IBS. So IBS is a diagnosis of exclusion. There's no real known cause or cure for this. And it's thought to be a combination of genetics of environmental triggers and motility issues of the bowel. So in terms of looking towards an IBS picture, you're looking at symptoms for more than six months of one off abdominal pain, bloating or change in bowel habits. So ABC quite nice and easy to remember. So if you've had more than six months, months of these, you're gonna be looking towards an IBS picture. Now again, really, really important when you diagnose IB IBS, you want to do um exclude everything else. So IBD and Celiac and we'll come to a few more in a little bit, but you want to be making sure that none of those are the cause cos you don't want to misdiagnose it. So in terms of diagnosis, you can diagnose IBS if and this is really key. So if they experience abdominal pain, that's relieved by defecation or it's associated with altered bowel frequency or stool form. So, for example, if they have abdominal pain that makes them go to the toilet more frequently or gives them, um, results in them having diarrhea constipation, um, and two of the following. So, alter stool passage. So if they're experiencing straining urgency, so, urgency is just talking about if they feel the need to go and they absolutely have to go as soon as they feel the need to go, they're unable to really control it. Um, incomplete evacuation is so they're going and it doesn't feel like it's going or it hasn't all gone or abdominal bloating, distension, tension or hardness symptoms made worse by eating and again, relieved by defecation or the passage of mucus. So they need to have abdominal pain, relieved by defecation and at least two of the following um symptoms. Ok. Some other symptoms that can also kind of crop up in your SBA S are lethargy, nausea, backache and bladder symptoms um by bladder symptoms talking about. So if they feel like when they urinate, they're not um completely emptying their bladder, for example. Uh So those are some other symptoms that can crop up. But like I said, these are the main ones that you need for diagnosis. So some red flag symptoms. So ones that if this is present in their story, you absolutely should not be diagnosing ibs. You want to be looking at alternative diagnoses and taking them along that pathway. So, rectal bleeding, you should not be having any rectal bleeding in IBS at all. You want to be pointing towards something else, unexplained, unintentional weight loss. So again, if they have all the same symptoms, then they could be actually, instead of having, um, some form of IBD or celiac disease. If they have a family history of bowel or ova ovarian cancer or onset after 60 years old, then again, you could be looking at some sort of malignancy. So you don't want to be diagnosing IBS if any of these red flags come up. Ok. Ok. So in terms of investigations, so like we said, a lot of it is ruling things out. So in terms of bloods, you're gonna take FBC S. So you want to make sure there's no signs of infection, chronic or acute or chronic in this case, ESR and CRP because you want to make sure there's no signs of inflammation which would point towards IBD instead, um, thyroid function test. So again, is there any thyroid dysfunction because that can lead to constipation, diarrhea, you also want to do a celiac screen. So like we said, the T TG to T TGI da and the total IG A cos you want to again, make sure it's not celiac and fecal car protectant because like we said, if it's IBS, you do not expect a raised fecal car protectant. Ok. Ok. So in terms of management for IBS you're looking at dietary and lifestyle changes first. So that number one is a low FODMAP diet. I'm not going to go into that. You can talk about that for ages, but you want to let them talk to a nutritionist about that, identify, um which foods to avoid which ones might be inflammatory, irritable to their, um their digestive system. And you also want to manage stress, anxiety and depression, regular meals with a healthy balanced diet, adequate fluids and regular physical activity. So, these are just some general dietary changes um that can help ibs. Now, if that isn't sufficient, then you're gonna be looking at pharmacological management. So first line, you have to control the pain. You're gonna be looking towards antispasmodics to control the constipation, laxatives and to control the diarrhea, li li lipoamide. So again, you'd go down the normal routes. It's basically just symptomatic control. There is no cure for IBS. Ok. Ok. So it's second line. So this doesn't work and you'll be going for tricyclic antidepressants. So, amitriptyline is the one of choice. Ok. Any questions about IBS? Ok. Ok. So gastroenteritis. So I'm not gonna go into this into too much detail just because there's so many different um pathogens that can cause this. But we're gonna look at it again from an SBA perspective. So presenting symptoms are gonna be diarrhea, abdominal cramping fever, nausea, vomiting, and potentially blood in the stool. Um Now, this can be either at home or traveling abroad, traveling abroad, you're gonna classify it as traveler's diarrhea. Now you're gonna have different pre presentations, again, dependent on the pathogen that's causing this. So you might have more of an acute food poisoning, uh gastroenteritis. So, nausea and vomiting within 24 hours or you might have a longer incubation period and therefore different set of symptoms. So, here is a table I will let give you guys a few, um, a few minutes to have a read through this or take a screenshot of something. So, what I've tried to do here is basically just say, what are the key words you won't be looking out for. So if you hear rice, water, diarrhea, you're thinking cholera, for example. Um And then if you're seeing steatorrhea, you're thinking, then if you see um GBS, you're thinking Campylobacter et cetera or reheated, right? You're thinking bacillus. So these are just some key facts in terms of how to identify which um pathogens. So would H pylori be part of which investigation you saying I IBS because yes, it, it probably would be um H pylori might be producing more of a um dyspepsia picture. But yeah, I'm sure GPS wouldn't, wouldn't protest to that. Ok. So anyone have any questions about this, about the gastroenteritis stuff? Ok. Let's keep going. So we are almost at the end. We have two S VA S. So have a read of this. You have a 40 year old woman complaining of recurrent constipation. She's had problems since her teenage years, but they're worse now. And she also experiences abdominal bloating and abdominal pain. The discomfort is only better on defecation. She's tried more fiber in her diet including fresh fruits and leafy vegetables, but that has only made the boating worse. And physical examination is entirely normal. Rectal examination reveals normal consistency, stools and fecal car protection is not raised. So, basically going to decide what is the diagnosis from, from this. Yes, good IBS. Exactly. So what's pointing towards it is recurrent constipation. So, change of bowel habit issues and then abdominal bloating and pain. And I think one of the most key parts of this history is the fact that it's better on defecation. Um That's, that's very, very, um very common in IBS and the making the bloating worse. Again, we're looking at for ma there with the fresh fruits and leafy vegetables. Then again, what is kind of allowing us to exclude other things is that the fecal carrot protectant is not raised and that she has um normal consistency stool in the rectal exam and her physical examination is entirely normal. Ok. Ok. So have a read of this. Now. So we have a 28 year old woman who presents to the general practitioner with a reported exacerbation of her ulcerative colitis. She describes passing three stools per day for the last two days and has noticed some blood in her stools since yesterday morning, she also reports feeling like she needs to open her bowels frequently and her temperature is 36.7. Her pulse is 78 and her BP is 100 and 28/86 disease limited to the rectum. So, what is the most appropriate initial? Does anyone have any ideas before I put the options on the screen? Yeah. Really good. Topical mesalazine. Ok. So, looking at reasons why, so we've got, we already know oitis that helps us out a lot. And then three stools per day is a mild, um, mild flare and then some blood, again, some blood is still a mild flare. Um She feels like she needs to open her bowels frequently. So that's probably um, 10th and then she has no signs of systemic upset. So we know that it's mild and then disease is limited to rectum. So that gives it away that it's not extensive disease. It doesn't involve the whole colon and so we can use topical treatments. Ok. So that is it for today? I finish a little bit early. Does anyone have any questions at all? And I will get back to you on your question as well. But any other questions, um, about anything you want me to flip back to any slides at all? Um Anything like that? Um Please, please do fill out the feedback form. It's really useful for us to know, you know, how to improve for the next few sessions or if you want any other topic, uh, any other sessions coming up. Um, this is really, really helpful for us. Also. You'll have access to your certificates and your s, and these slides and a recording of today with the feedback board. Yeah.