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CC: Inflammatory Bowel Disease

IBD includes Crohn's, UC, and Celiac disease


IBD OVERVIEW
probably vastly underdiagnosed
peak incidence 15-40 years of age
Crohn's more in women, men get more UC
most in whites esp Ashkenazi Jews
Family History is big player but not determinate
some genes not methylated, not turned off-->more susceptibility to IBD, allergies
autoimmune response: aberrant T-cell activation
approx 500 species of microbes in colon
lots of immune tissue there, enhanced antibody production
"most AI dz starts by age 7" or by time of conception according to Dr T
genetic?: concordance in monozygotic twins, more in offspring
Q: relationship to ABX use? probably so

CROHN'S
acute and chronic inflam
waxing and waning, different parts may flare at different times
any part of GI: mouth to anus
lesions mb discontinuous
full thickness of intestinal wall involved
5-10 incidence, 50-100 prevalence (per 100,000)
onset bimodal: 15-25, 55-65
hereditary: 15% have 1st degree relative with IBD
80% small bowel, 1/3 just ileitis, 50% ileocolitis, 20% colon only
most difficult to manage: both ends, dt malabsorption and discomfort

RISK FACTORS
OCPs
smoking
diet-->determines flora
NSAIDS
Jew/white
upper income/clean

ETIO
unclear
genetics
bact/virus
Mycobacterium avium paratuberculosis
AI

CROHN'S SX
depends on where in GI the dz is
if in the SI:
abdominal discomfort
wt loss
def: B12, iron, fat soluble vits, calcium
fatigue
low grade fever, lymphadenitis
peak for men is teen years
if in LI:
diarrhea or normal or alt
perianal disease, ulcers, fissures, fistulae

SX
mb extra-intestinal:
apthous ulcers (mc cause of chronic apthae: citrus/tomato/strawberry allergy, then consider zinc def, celiac, etc)
gallstones, cholecystitis, pancreatitis
arthritis

DX

LABS
fecal lysozyme
alpha anti-chymotrypsin
if these two pos it is suggestive
best: GI health panel (to rule out many other things, gluten issue)
lactase def?
carb sensit? (sorbitol)
stool chymotrypsin/stool fat
anemia
leukocytosis
incr ESR

IMAGING
diagnostic
longitudinal lesions, patches of chronic inflammation
xray classic: string sign: narrowing of lumen
upper GI with small bowel follow through
cobblestone appearance
double contract
bx
CT's not ordered so often anymore dt awareness of radiation
one abdominal CT = 500 chest x-rays

CROHN'S TREATMENT AT ACUTE STATE
goals: comfort, hydration, nutrition (palliative and long term)
make them feel better: IV nutrition, vinegar pack for acute pain, demulcents, acupx, homeop
glutamine (soothing)
sea-cure (predigested fish protein, easy nutrition)(keep in freezer, take 2/meal, 6/day)(stinky)
diet: SIMPLIFY
anti-inflam may not be enough, must be stricter: no carbs whatsoever (both UC and Crohn's)
eat easy meat: chicken, turkey, fish
if eat legumes cook them very well
Biehler broth and bone broth very helpful
do this however long it takes to stop acute
longterm should be able to eat some grains
avoid food intol
anti-ox
stress management

CROHN'S TREATMENT LONGTERM:
nutrients that may be needed: lacto, A, beta carotene, B12, C, E, folate, Mg, Zinc, quercetin, EFAs, arginine, gluatmine, n-acetylated glucosmamine sugars 800mg tid, liquid chlorophyll, alfalfa tabs, chlorella
he's not a fan of multi-vitamins, says figure out what they need and target with bigger doses
always gives glutamine, fuel source for enterocytes, 2/meal tid
always gives B vits and probiotics
Q: rxns to probiotics? some pts do have trouble for various reasons, not rxn to microbes
Q: rxn to FOS? not react to garlic, onion? it wasn't the FOS.
pts attribute rxns to whatever they don't want to take
butyrate enemas for colitis only
cod liver oil enema
castor oil packs
constitutional hydrotherapy: heating compress, wet sheet pack
homeop: acon, alth, bell, bry, cnic, ech, bell, bry, iris tenax, changed slide

ALLO TX
NPO sometimes ordered but Dr T disagrees, not for routine use,
Gastroenertology 2001, Oct 121(4):966
MED: sulfasalazine mc given, pro-drug, broken down by bact into 5ASA and sulfapyridine, efficacy dose dependent
dose over 4g/d and serum sulfapyridine---he changed slide, lots more to know about this drug

ULCERATIVE COLITIS

inflam begins at rectum and extends proximally thru colon
may involve entire colon
involves just mucosa and lamina propria
10-20/100,000 new dx/year (incidence)
100-200/100,000 prevalent
severe dz-->decr colonic motility
mean age at dx: 32
complic: hemorrhage, toxic colitis
loc of dz: 37% whole colon, 17% descending, 46% sigmoid

SX
urgency, incr defecation, tenesmus are top 3 sx
frequent D: fulminant is 10+/day, he's seen 26/day
stool with ucus, blood, pus
urgency, tensemus
colickly abdominal cramps, distnetion
low grade fever
fluid and electrolyte imbalance
wt loss, anorexia
weakness, cachexia
psych: adolescents, young adults, Jews
depression, anger, frustration
stress exacerbates

EXTRAINTESTINAL
erythema nodosus
pyoderma granulosum
iritis
fatty liver
kidney stones
amyloidosis
more primary sclerosing cholangitis

DX
dx: hx, stool studies, endoscope, bx
bloody mucousy frequent stool
urgency

DDX: Crohn's radiation coliits, ischemic coliits, infx (salmon, shig, campy, ecoli, cdiff), drugs (nsaids, retinoic acid, gold, ocps)

IMAGING
double barium contrast tells most
barium enema: late stage-->lead pipe appearance
halo sign

TREATMENT
goals: feel better, stop bleeding
butyrate enema
implant of herbs, suppository with vasoconstrictors to stop bleed
10 grams/day fish oil (2 TBS)

ALLO TX
IV steroids in acute
oral and rectal 5ASA
oral steroids
sulfasalazine
asacol/mesalamine
pentasa/mesalamine as suppository, 4x250mg qid total ddaily dose 4g
new: tnf alpha inhibitors?
surgery
infrared coag
staples
remicade/infliximab is anti tnf drug, is a monoclonal ab

DIET
high complex carb, high fiber
same supps as Crohns

MORE TX
same hydro tx
charcoal slurry water
herbs: achillea, althea, bosewellia
homeop: ars, canth, caps, coch, merc, etc
EBM: diet doesn't help (yeah, um hm)
EBM: wheat grass helps
EBM: stop milk
EBM: don't eat so much meat and alc

LOOK UP
IBD paper by TV Rajan
"maladaptation of the vigiliant genoty in a hyper-clean world"
on Indian children growing up in very rich/hygienic environs
rich kids get far more IBD and poor kids
some genes not methylated, not turned off-->more susceptibility to IBD, allergies

Bacteriotherapy using Fecal Flora: Toying with Human Motions
trying to treat Clostridium difficile
Thomas J Borody, EF Warrne, SM Leis, more

Treatment of UC using Fecal Bacteriotherapy
TJ Borody
infusing bugs can reverse UC, suggests fecal flora is reason

Dr T says fecal flora will be the new "in thing"

Dr T argues against using totally evidence based medicine: common sense trumps a study or two

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