Inflammatory Bowel Disease – 7/31/18

Thanks to Connie for presenting a case of a young man with chronic bloody diarrhea, abdominal pain, and fever, found to have a new diagnosis of severe Ulcerative Colitis.


Clinical Pearls

  • Acute diarrhea requires work up in anyone >65, immunocompromised, blood in stools, fever, severe abdominal pain, recent antibiotics, known or suspected IBD, risky jobs like food handler, or recent travel.
  • Fecal calprotectin can help distinguish inflammatory from non-inflammatory diarrhea and is a more sensitive and specific marker than fecal leukocytes.
  • 5-ASA based drugs are generally more effective in the colon so their primary role is in the treatment of Ulcerative Colitis or Crohn’s Colitis.

Capture

Disease severity in IBD:

  • Mild: <4 stools/day, no systemic toxicity
  • Moderate: 4-6 stools/day, no systemic toxicity
  • Severe: >6 stools per day, systemic toxicity
  • Fulminant: >10 BMs per day, continuous bleed, systemic toxicity

Key distinctions between UC and CD:

Capture 2

Items in red in the table above correlate with disease activity.

Before initiating immunosuppression:

  • Check PPD/quantiferon
  • Hepatitis serologies
  • Administer routine live vaccines
  • Check TPMT level (to assess phenotype for bone marrow suppression secondary to 6MP).¬† If TPMT level low, do not give 6MP!

Hereditary angioedema – 1/10/18

Epidemiology

  • Autosomal dominant – look for a positive family history
  • Usually diagnosed early in life

Mediators

  • Caused by elevations in bradykinin
  • No effect by histamine or mast cells

Clinical Presentation

  • Recurrent angioedema¬†without hives or pruritis
  • Skin and GI tract most commonly affected
  • Colicky abdominal pain of unexplained etiology
  • Hypokalemia due to bradykinin elevation leading to high levels of ACE which activate the RAA system

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Treatment

  • Usually self-limited within 2-5 days
  • Can use FFP as FFP contained C1 inhibitor and ACE
  • Can use C1 inhibitor analogues, kallikrein antagonists, or bradykinin receptor antagonists for treatment if concern for rapidly progressive angioedema