Title SCA- Gastro. IMA. Dr A.Ibrahim_watermark.pdf ✅

SCA- GASTROENTEROLOGY Dr.Amr Ibrahim MB ChB, MD, Alexandria University, Egypt MSc, University of Tsukuba, Japan
How to explain: Chronic gut /bowel inflammation that tends to flare up from time to time, it can affect anywhere Crohn’s Disease from mouth to the bottom/back passage. It can affect other organs like liver, eye, skin and joints. Qs to ask • Ask about how sever is the diarrheal, any blood ? Any mucous ? How many episode in the day? • Abd pain (SOCRATES), Fever , vomiting • Bowel cancer Qs • Skin, Joint, eye problem • Did it happen before? • UTI, passing stools from vagina (Fistula) • OTC including NSAIDS • Any recent GE. • FH • SH and Impact on life & Impact on mental health RFs: FH smoking, previous infectious GE Drugs like NSAIDs. NB: Cause is not fully understood but could be immunologic reaction to environmental triggers Complications: psychosocial impact abscesses, strictures, Fistulas Anaemia malnutrition, faltering growth and delayed puberty (in children) cancer of the small and large intestine. Symptoms (when to suspect) in kids/adults Persistent diarrhoea ± nocturnal diarrhoea, blood or mucus. Abdominal pain or discomfort. Weight loss, faltering growth or delayed puberty (in children). Non-specific: fatigue, malaise, anorexia, or fever. Signs on examination Abdominal tenderness or mass, eg RLQ. Perianal pain/ tenderness, perianal skin tags, fissure, fistula, or abscess. Signs of malnutrition and malabsorption. Abnormalities of the joints, eyes, liver, and skin. Mx of flare up (already known to have Crohn's) Emergency hospital admission if systemically unwell with severe symptoms like: If admission to hospital is not indicated ▪ Severe diarrhoea (more than 6–8 stools a day). ▪ Fever, dehydration, tachycardia, or hypotension. Very high CRP. ▪ Suspected intestinal obstruction or abscess. ▪ BMI < than 18.5 kg/m2 , or unintended sudden weight loss. ▪ Persistent symptoms despite optimal management in primary care. ▪ Refer Urgent to gastro, give steroids while awaiting referral. ➢ Prednisolone,40mg OD, ↓ by 5mg per week ▪ Check compliance to Rx and triggers (eg NSAIDs) ▪ If recurrent flares => refer for Rx r/v and alternative rx options. ▪ Bloods with CRP and Vitamin levels.
Different case scenarios: Suspected Crohn's Confirmed Crohn's Fertility, preg and breast feeding • Urgent Referral to secondary care to confirm Dx and start Rx. • If systemically unwell => emergency hospital admission. Things pt can do: • Avoid triggers like smoking, stress, NSAIDs. • Crohn's and Colitis UK (national charity service). • If Kids: CICRA (Crohn's in Childhood Research Association). • Vaccines: flu, covid and Pneumococcal. • If on Immuno↓ or biological Rx => avoid LAV. Things we can do: • Assess risk of osteoporosis. • Meds for flare up. • Regular bloods esp to r/o vit ↓. • Regular FU. Make sure seen by specialist. • Refer to appropriate specialist (such as rheumatology, dermatology, or ophthalmology) if needed. • Refer If complications happen. • If male/female wanting pregnancy => Refer First. • Crohn's disease management should be optimized by the specialist before preg. • Some meds needs to be changed as they are teratogenic. • Please remember: Crohn's can cause mal absorption and osteoporosis which will affect the choice of effective contraception. • If unplanned pregnancy while on Methotrexate, infliximab, or adalimumab => Immediate specialist advice. If on other Rx => Urgent advice. • If wants breastfeeding => Urgent specialist advice. Secondary care option: under specialist: For AKT mainly not SCA: 1. Immunosuppressive drugs — the thiopurines (azathioprine, mercaptopurine) or methotrexate (second-line). 2. Steroids. 3. Biologic therapy — the anti-tumour necrosis factor alpha monoclonal antibody agents infliximab and adalimumab 4. Aminosalicylates — mesalazine and sulfasalazine may be considered for a first presentation, or a single inflammatory exacerbation in a 12-month period, if corticosteroids are contraindicated or not tolerated.
How to explain: Chronic gut /bowel inflammation that tends to flare up from time to time, usually affects the U large bowels but can affect other organs apart from the bowels. lcerative Colitis Qs to ask • Ask about how sever is the diarrheal, any blood ? Any mucous ? How many episode? • Abd pain (SOCRATES), Faecal urgency and/or incontinence. • Any Tenesmus (a persistent, painful urge to pass stool even when the rectum is empty). • Any Fever , vomiting • Skin, Joint, eye problem • Did it happen before? • Bowel cancer symptoms. • OTC including NSAIDS • FH • SH and Impact on life & Impact on mental health RFs: FH No smoking, No appendicectomy Drugs like NSAIDs. Complications: ▪ psychosocial impact ▪ Anaemia ▪ malnutrition, faltering growth and delayed puberty (in children) ▪ cancer of large intestine. ▪ Toxic megacolon, bowel obstruction, bowel perforation Symptoms (when to suspect) in kids/adults Bloody diarrhoea persisting for more than 6 weeks, or rectal bleeding. Pre-defecation pain, which is relieved on passage of stool. Tenesmus , Abdominal pain, particularly in the left lower quadrant. Non-specific symptoms such as fatigue, malaise, anorexia, or fever (may suggest severe disease). Weight loss, faltering growth or delayed puberty (in children). Signs on examination (physical examination may be normal in people with mild or moderate disease). Pallor, clubbing, or aphthous mouth ulcers. Abdominal distension, tenderness or mass, eg in the left lower quadrant. Signs of malnutrition or malabsorption Signs of malnutrition and malabsorption. Abnormalities of the joints, eyes, liver, and skin. Invx ▪ FBC, CRP, ESR, LFTs, U&Es, TFT, Serum ferritin, vitamin B12, folate, and vitamin D levels, Coeliac serology. ▪ Stool tests: Microscopy, culture, Clostridioides difficile toxin, calprotectin Extra-intestinal manifestations ( 30% of patients) Arthritis(axial or peripheral), Erythema nodosum, Aphthous mouth ulcers, Episcleritis, Uveitis, osteoporosis, VTE, Pyoderma gangrenosum, Hepatobiliary conditions such as primary sclerosing cholangitis, pericholangitis, steatosis, autoimmune hepatitis, cirrhosis, and gallstones.