IBD and malnutrition

Today we talked about a young man with acute on chronic diarrhea. We discussed the presentation of Inflammatory Bowel Disease, as well as the extraintestinal manifestations of IBD. We also chatted about the physical examination for malnourishment and splenomegaly.

1. Extraintestinal Manifestations of IBD:

MSK:

Seronegative spondyloarthropathy (oligoarticular, asymmetric, migratory, migratory; mostly peripheral but can be axial. Most often seen in Crohn's and is often associated with other extra-intestinal manifestations, namely ocular, skin, mouth).

Ocular:

Iritis/Uveitis/Episcleritis (from IBD)

Glaucoma/Cataracts (from prednisone)

Dermatologic/Mucosal:

Can be divided into 3 classes: granulomatous, reactive, and secondary to nutritional deficiency

Granulomatous

Perianal/stomal ulcers/fistulas

Abscesses

Reactive

Erythema Nodosum

Pyoderma gangrenosum

Aphthous stomatitis

Sweet's syndrome

Nutritional

Acrodermatitis enteropathica (looks like psoriasis, zinc-related)

Angular cheilitis (from Fe deficiency)

HepatobiIiary:

Primary sclerosing cholangitis (inflammation and fibrosis of intra- and extra-hepatic bile ducts)

Cholelithiasis (from GI loss of bile acids)

Fatty liver (from malnutrition)

Liver abscess (rare)

Heme:

Anemia (blood loss, chronic disease)

Thromboembolic events

Renal:

Acute renal failure (from ++ GI losses)

Nephrolithiasis (from both dehydration and hyperoxaluria)

Metabolic:

Osteoporosis

Drug-Induced:

Too many to list here, but there are many, depending on the agent used.

See here for a useful review.

2. We also discussed how to determine if a patient is malnourished. I don't need to tell you that the reason we worry about this is because malnourished individuals have higher risks of infection, poorer wound healing, poorer outcomes related to other illnesses (ie trouble weaning from ventilators in the ICU), and death.

Key features on history:

• weight loss >10% body weight in past 6 months
• abnormal dietary intake
• daily anorexia/nausea/vomiting/diarrhea for >2 weeks
• functional capacity.

Key features on physical exam:

• Loss of SubQ fat (manifest as skinny triceps, deltoid thinness, midaxillary line @ costal margin, and palmar/interosseous areas of hand)
• Loss of muscle (check the quadriceps and look for squaring of the deltoid muscle)
• Edema (ankle, sacral, ascites)

These findings must be used in combination to avoid false positives.

See here for the JAMA Rational Clinical Examination on this issue.

3. Splenomegaly: You're all very busy and this post is too long already - I am sure it will come up again, and I'll post more then!

Have a great weekend!