Vancouver IM LMR

Natasha Klemm, PGY5 in GI presented a fantastic lecture on the inpatient and outpatient management of IBD. This was an engaging lecture that was relevant for both IM residents and GIM staff.

Please see the didactic lecture slides here.

Key takeaways:

1. Include thorough IBD history in consults

Ulcerative Colitis:

1. Assessing severity of UC
   • Severe UC requires >= 6 bloody BMs per day plus at least one marker of systemic toxicity: HR (>90), temperature (>37.8C), Hb (<105), CRP (>30)
2. Initial management of UC
   • CF diet +/- enteral feeding if malnourished
   • Tylenol; avoid/ minimize opioids
   • Methylprednisolone 30mg IV BID or 20mg IV TID
   • DVT prophylaxis: 2-3x risk of VTE than general public during flare; should be giving DVTp unless significant hemorrhage
   • Stool chart, daily CBC, CRP, lytes, Cr +/- extended lytes, albumin if malnourished
3. Predicting risk of needing colectomy in UC
   • 30% rate of needing colectomy at admission
   • Oxford criteria (used on day 3 of admission):
     • If BMs > 8 over 24h OR CRP > 45 with 3-8 BMs over 24h, then patient now has an 85% colectomy rate!
4. Surgical management (colectomy + ileostomy) for UC
   • Consult surgery early if refractory to med management
   • For IBD patients, 80% reported improved QoL and 80% would have stoma again

Crohn’s disease:

1. Presentation of Crohn’s is variable
   • Inflammatory enteritis/ colitis
   • Stricturing disease/ previous resections (most common presentation to ED for Crohn’s is SBO at 35-59%)
   • Penetrating disease and intraabdominal/ perianal abscess
2. High risk features for surgery/ relapse/ complications:
   • Younger age at diagnosis, smoker, longer disease duration, early use of steroids, fistulizing/ perianal CD, previous resection, PSC
   • Location (rectal, upper GI, small bowel)
   • Labs: low Hb or albumin, high CRP or fecal calprotectin
   • Endoscopy: presence of deep ulceration