IBD
One liner:
Race/Ethnicity:
Ulcerative Colitis:
Extent and location of disease:
Index colonoscopy:
Age at diagnosis:
Current IBD medications:
Crohns Disease:
Extent and location of disease:
Index colonoscopy:
Montreal:
A1: <16 yrs
A2: between 17 and 40 yrs
A3: Over 40yrs
Location:
L1:Ileal
L2:Colonic
L3:Ileocolonic
L4:Isolated upper GI
Phenotype:
B1:Inflammatory (non-stricturing/non-penetrating)
B2:Fibrostenotic (stricturing)
B3: Penetrating
Modifiers:
P: Perianal (anal fissure, anal fistula, perianal abscess)
HISTORY OF PRESENT ILLNESS:
Change in condition since last visit:
Frequency of BMs:
Form of stools: Bristol Stool Scale
Nocturnal BMs:
Blood in BM:
PHQ-2:
1. Lost interest or had little pleasure in doing things:
a. ☐ Not at all (0) ☐ Several days (1) ☐ >50% of days (2) ☐ Nearly every day (3)
2. Felt down, depressed or hopeless:
a. ☐ Not at all (0) ☐ Several days (1) ☐ >50% of days (2) ☐ Nearly every day (3)
BACKGROUND IBD HISTORY:
Prior Ineffective Medications:
Prior Medication Reactions/Side Effects:
EXTRAINTESTINAL MANIFESTATIONS (present if bolded)
☐ Oral lesions/ulcers
☐ Scleritis, episcleritis, uveitis
☐ Arthritis
☐ Ankylosing spondylitis
☐ Erythema nodosum
☐ Pyoderma gangrenosum
☐ PSC
☐ Osteoporosis/osteopenia
☐ Thromboembolism
☐ Anemia
☐ Iron / B12 / Vit D Deficiency
☐ Pancreatitis
☐ NAFLD/NASH
PAST MEDICAL HISTORY:
PAST SURGICAL HISTORY:
ALLERGIES: NKDA
SOCIAL HISTORY:
Tobacco: Lifetime nonsmoker.
EtOH:
Illicit drugs:
Occupation:
FAMILY HISTORY:
Denies FMH of CRC, celiac disease, IBD, liver disease.
Review of systems (negative unless bold)
Fever, chills, fatigue, weight loss/gain, abd pain, bloating, anal pain, rashes, oral ulcers, eye pain, joint pain, anxiety/depression/”low energy”, heartburn, regurgitation, early satiety, dysphagia, nausea/vomiting, hematemesis
Prior endoscopy:
Prior imaging:
IBD HEALTH MAINTENANCE:
Vaccinations:
☐Influenza:
☐COVID-19:
☐Pneumonia:
☐Tdap:
☐HPV (<45yo):
☐HAV:
☐HBV:
☐Varicella (check VZV IgG, >4wk pre-tx):
☐MMR (check titers, give >4wk pre-tx)
☐Shingrix:
☐Meningococcal:
☐RSV:
Annual Labs:
☐CBC:
☐CMP:
☐Vitamin D:
☐Iron/ferritin:
☐B12/folate:
☐Lipids (for JAK inhibitors):
☐Fecal calprotectin:
☐CRP:
Mesalamine:
☐UA (yearly):
☐Cr (yearly):
MTX:
☐LAEs (baseline):
☐LAEs (annual):
☐Birth control (women):
Thiopurines:
☐TPMT (level):
☐EBV:
☐WBC/Hb/Plt (baseline):
☐Cr (baseline):
☐WBC/Hb/Plt (q3 months):
☐Cr (q3 months):
☐6TG/6MMP:
Biologics:
☐HBV sAg/cAb/sAb:
☐Quantiferon/PPD:
☐HCV:
☐Levels:
Bone Health:
☐DEXA (hx steroids>3mo, alb<3, BMI<19):
☐Taking Ca/Vitamin D (on steroids, bone dz):
Cancer Prevention:
☐Dysplasia surveillance:
☐Annual dermatology skin exam (thiopurines, MTX, biologics):
☐Annual pap smear (thiopurines or biologics):
Smoking Cessation:
☐Smoking cessation counseling: Maintain cessation
Miscellaneous:
☐Annual dental exam:
☐Annual eye exam:
☐Fertility concerns/Birth Control:
Plan:
- Medications:
- Labs: CBC, CMP, Vit D, B12/Fol, Iron Panel, Fecal Calprotectin, CRP, Lipids, HCG
- Endoscopy:
- Imaging:
- Immunizations:
- Bone Health:
- Cancer Prevention: (derm/gyn)
- Pt advised to avoid NSAIDs and narcotic pain medications
- Pt to f/u in the GI clinic in 8-12 weeks
Counseling For High Risk Medications:
☐ Steroids: Risk, benefits and alternatives to steroid use were discussed with the patient, to include the possibility but not limited to experiencing mood changes/psychiatric conditions (psychosis, depression), insomnia, infection (including life threatening), swelling/edema, weight gain, osteoporosis, osteonecrosis including avascular necrosis/loss of function of affected joint(s), cataracts, medication induced diabetes.
☐ Azathioprine: Risks, benefits and alternatives to AZA use were discussed with the patient, also to include but not limited to malaise, fatigue, diarrhea, nausea/vomiting, anorexia, possibility of developing pancreatitis, bone marrow suppression, allergic reactions, drug-induced hepatitis, increased liver enzymes, infection (including life-threatening), lymphoma, non-melanoma skin cancer, and cervical cancer.
☐ 6MP: Risk, benefits and alternatives to 6MP were discussed with the patient, to include the possibility but not limited to malaise, hyperuricemia, anorexia, diarrhea, nausea/vomiting, pancreatitis, oligospermia, bone marrow suppression, increased liver enzymes, drug-induced hepatitis, infection (including life threatening), lymphoma, non-melanoma skin cancer, and cervical cancer.
☐ MTX: Risk, benefits and alternatives to methotrexate were discussed with the patient, to include but not limited to: bone marrow suppression including leukopenia, nausea, vomiting, abdominal pain, skin rash, headache, hepatic fibrosis, hypersensitivity pneumonitis, hepatotoxicity (RFs for are obesity, DM, prior history of significant alcohol use, elevated baseline liver associated enzymes, cumulative dose > 1.5 g).
☐ Infliximab: Risk, benefits and alternatives to infliximab were discussed with the patient, also to include the possibility but not limited to headache, nausea, diarrhea, abdominal pain, increased ALT, antibody development, infection (fungal and other intracellular pathogens including life threatening), lymphoma, viral hepatitis reactivation, infusion related reaction, hypertension, fatigue, pain, skin rash, pruritus, dyspepsia, arthralgia, back pain, dyspnea, fever, and disseminated tuberculosis.
☐ Humira: Risk, benefits and alternatives to Humira were discussed with the patient, also to include the possibility but not limited to experiencing headache, skin rash, infection (fungal and other intracellular pathogens including life threatening), disseminated tuberculosis, viral hepatitis reactivation, injection site reaction, nausea/vomiting, hypertension, hyperlipidemia, hypercholesterolemia, flu-like symptoms, lymphoma.
☐ Vedolizumab: Risk, benefits and alternatives to vedolizumab were discussed with the patient, also to include the possibility but not limited to experiencing headache, skin rash, infection (including life threatening), injection site reaction, nausea/vomiting, hypertension, hyperlipidemia, hypercholesterolemia, flu-like symptoms, URI symptoms.
☐ Ustekinumab: Risk, benefits and alternatives to ustekinumab were discussed with the patient, also to include the possibility but not limited to headache, fatigue, diarrhea, antibody development, infection (fungal and other intracellular pathogens), infusion related reaction, injection site reaction, nasopharyngitis, pruritus, back pain, fever, upper respiratory tract infection and disseminated tuberculosis.
☐ Tofacitinib/upadacitinib: Risk, benefits and alternatives to tofacitinib were discussed with the patient, also to include the possibility but not limited to headache, nausea, diarrhea, abdominal pain, bladder pain, blurred vision, infection (fungal and other intracellular pathogens), lymphoma, skin cancer, GI perforation, fatigue, pruritus, fever, upper respiratory tract, disseminated tuberculosis and increased risk for VTE.
☐ Ozanimod: Risk, benefits and alternatives to ozanimod were discussed with the patient, also to include the possibility but not limited to URI, infection (fungal and other intracellular pathogens), abnormal liver enzymes, headaches, nausea, arthralgia, herpes zoster, varicella zoster, bradyarrhythmia, atrioventricular conduction delays, macular edema, and high blood pressure.
#ulcerative proctitis
Patients with ulcerative proctitis should receive topical therapy with 5-aminosalicylate suppositories; once remission is achieved, 5-aminosalicylates are effective in maintaining it.
Combined 5-ASA therapy (oral and topical) is superior for inducing remission in patients with left-sided or extensive ulcerative colitis compared with oral or topical therapies alone.
#PSC
Primary sclerosing cholangitis (PSC) is associated with inflammatory bowel disease (IBD) in approximately 85% of cases; therefore, all patients with PSC without known IBD should have colonoscopy with biopsies at the time of PSC diagnosis.
Patients with PSC have a 15% lifetime risk for cholangiocarcinoma; annual or biannual magnetic resonance cholangiopancreatography and carbohydrate antigen 19-9 measurement is recommended for cholangiocarcinoma surveillance
There is also an increased risk for gallbladder cancer in PSC, and regular annual screening with ultrasonography is recommended
Liver transplantation (Option D) should be considered for patients with PSC and decompensated cirrhosis, recurrent bacterial cholangitis, and hilar cholangiocarcinoma
Transplant outcomes for patients with PSC are excellent, with 1-year survival rates of at least 90% and recurrence rates of approximately 20% at 5 years after liver transplantation
#crohn disease
An anti–tumor necrosis factor agent is most likely to induce and maintain remission of moderate to severe ileocolonic Crohn disease resistant to glucocorticoids or immunomodulators.
Combination therapy with an anti–tumor necrosis factor and an immunomodulator is more efficacious than monotherapy with either agent alone in achieving glucocorticoid-free remission and mucosal healing in moderate to severe Crohn disease
#ulcerative colitis
Combination therapy with infliximab and azathioprine is more efficacious than monotherapy with either agent alone in achieving glucocorticoid-free remission and mucosal healing in ulcerative colitis.
Before initiation of anti–tumor necrosis factor agents, patients should undergo testing for latent tuberculosis and hepatitis B virus infection
#UC flare
Labwork ordered: CMP, CBC, Pre-albumin, ESR, CRP, Total cholesterol, TPMT Enzyme, Quantiferon, Stool culture, C. Diff PCR, CMV PCR, GI PCR, Iron saturation
- Abdominal series ordered
- GI consult in AM to schedule flexible sigmoidoscopy. Greatly appreciate recs
- Record: # stools, # with stool blood, urgency time, signs of toxicity
- IV fluids to produce clear urine, goal output >50 cc/hr x > 8 hours: goal >5L in 1st 24 hours
- patient will be made NPO
- IV steroids
- can consider rectal Messalamine if appropriate
#left sided UC
5-Aminosalicylate enemas are an appropriate and effective treatment for mild, left-sided ulcerative colitis.
5-Aminosalicylate suppositories are an appropriate and effective treatment for mild to moderate ulcerative proctitis
#elevated LFTs in UC
Cholestatic? Get an MRCP. Normal? Get a liver biopsy for small duct PSC