Inflammatory Bowel Disease (old version, with sound) – CRASH! Medical Review Series

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Inflammatory Bowel Disease (old version, with sound) – CRASH! Medical Review Series

so here we’re going to focus on inflammatory bowel disease which if you ever spend some time with the gastroenterologist is one of the most common things that they deal with both in the inpatient and outpatient basis I guarantee you’re going to have a question on inflammatory bowel disease at least one or two on your step two or three exam so inflammatory bowel disease can affect any part of the digestive tract and it can also affect the biliary tract up to the gallbladder so here’s a vignette a 35 year old man presents to the emergency department complaining of bloody diarrhea he says that he’s been having diarrhea for the past two weeks but he was prompted to come in because this afternoon he noticed a maroon color in his stool he says that he has abdominal pain but is unable to point an exact spot he rates it as a plus 6 out of 10 and he’s been trying to control it with pepto-bismol to no avail he’s lost 10 pounds his previous visit to the ER for a broken thumb six months ago his vitals are stable but he’s slightly feverish blood pressure 125 over three heart rate 80 respirations 15 temperature 100.5 so this is a patient with inflammatory bowel disease we don’t know what kind he has but the tip-off to the fact that he has inflammatory bowel disease should be the fact that he has chronic diarrhea diarrhea lasting longer than two weeks and the fact that it’s bloody so inflammatory bowel disease is an idiopathic inflammatory autoimmune disease process so it’s autoimmune because the patient is is producing factors that are attacking the body’s own tissue and it’s inflammatory because there is actual inflammation in the affected tissue and it’s idiopathic because we don’t know what causes it there are genetic factors but but this can happen in anybody and of course it involves the GI tract the most common age of onset is in the 21 and 30s but this can happen in teenagers it’s happening kids and it can happen it can it can show up in 50 or 60 year olds really it can happen to anybody but the most common age where this shows up in a person for the first time is in the third or fourth decade of light so the 20s and 30s you tend to see inflammatory bowel diseases more in Caucasians than in african-americans or in Hispanics but you can of course you can see it in anybody so don’t let that throw you off I’m just telling you some some basic some basic overall factors its more common in caucasians and particularly there’s a preponderance and ashkenazic juice inflammatory bowel disease is increasing in incidents and there’s a higher incidence in developed countries so we don’t really know what to make of that information but we do know it exists people with inflammatory bowel disease if it exists for longer than 10 years they do have an increased risk for colon cancer and of course there’s going to be a reduced quality of life you can imagine having bloody diarrhea and going to the hospital frequently is going to reduce your quality of life and there’s two types of inflammatory bowel diseases that we’re going to talk about not will be Crohn’s disease and ulcerative colitis so the symptoms of inflammatory bowel disease so right now we’re talking about both Crohn’s and ulcerative colitis you’re going to have chronic abdominal pain so this is an abdominal pain that came on recently and romance this is abdominal pain that the patient can when they come into the ER they can say hey this has been going on for you know since last August or since last year it comes and goes or I’ve had this sort of mild pain for the last few weeks and now I’m coming in because I have bloody diarrhea another symptom of course is the bloody diarrhea hematochezia mucus in stool is also another not necessarily common finding but a more specific finding diarrhea of course is is common because the because of the inflammation in the bowel t the large intestine can’t absorb fluid systemic symptoms because this is a an autoimmune disease you’re going to see systemic symptoms so fever weight loss sweats malaise arthralgia nausea and vomiting the systemic symptoms really point towards inflammatory bowel disease whereas you can get bloody diarrhea and chronic abdominal pain from a lot of things the systemic symptoms particularly the fever and weight loss are really what what will point towards inflammatory bowel disease when they’re

accompanied by the abdominal pain in the bloody diarrhea and then also there are extra intestinal manifestations you don’t necessarily see these very often but when they exist again they point towards inflammatory bowel disease so I sort of ordered these symptoms in order of the most common to the most specific so chronic abdominal pain bloody diarrhea those are the most common you’re also going to see fever and weight loss that’s also very common and then the extra intestinal manifestations are a little less common but they are more specific when you see these things along with your you’re more you’re more frequent symptoms that really points towards inflammatory bowel disease so the extra intestinal manifestations can manifest in the skin eyes joint some liver there’s two different kinds of skin manifestations we’re going to see some pictures of those in a little bit erythema nodosum and pyoderma gangrenosum Gingrey know some in the eyes you can get any kind of really any kind of inflammation on the front part of the eye so I write a square itís and epi scleritis in the joints and get an inflammatory arthritis so patients will come in when they have inflammatory arthritis that could be the only symptom for instance and they’ll have a redness and pain in their joint and when you do an aspiration of the joint you’ll find white blood cells in the liver you can get primary sclerosing coal jadis a lot of times you hear that that only comes with Crohn’s this primary sclerosing cholangitis can come with crohn’s or ulcerative colitis so it can come with any inflammatory bowel disease and then gallstones are an actual actually a common manifestation of inflammatory bowel disease what I put here in italics are the more common extra intestinal manifestations so the history in any patient with inflammatory bowel disease a lot of times it’s going to be non-contributory but a lot of patients with inflammatory bowel disease definitely a minority but but a good chunk of them will have a family history of inflammatory bowel disease or rheumatoid arthritis and for diagnosis the gold standard is going to be a colonoscopy with biopsy that’s the only way you can diagnose inflammatory bowel disease it is a diagnosis on biopsy that’s the only way you’re going to be able to differentiate Crohn’s from ulcerative colitis okay so this is we’re just going to take a look at some of these skin manifestations this is erythema nodosum so what these kind of look like are just sort of bruises redness so erythema nodosum erythema comes from the Latin word for redness and nodosum is just a note so it’s little red notes and that’s what these kind of look like they look like kind of like bruises or or read notes if you want to go by the name so this is erythema nodosum most commonly it occurs on the shins and and on the calves this is one on the fingers that’s not as common so here is pyoderma gangrenosum clearly this is much different pyoderma meaning fire skin gangrenosum meaning gangrene or dead tissue so this is an ulcerating disease I’m get again I’m going to say you don’t see this very commonly but this can happen in patients with Crohn’s are all sort of colitis so this is just ulceration of the skin and it can really have anywhere so for for erythema nodosum general you’re not going to have to do anything about that for pyoderma gangrenosum in addition to treating the Crohn’s disease or ulcerative colitis you’re going to have to consult with a surgeon or dermatologist so this can be either scleritis or epi scleritis the difference between scleritis and epi scleritis they look the same you’ve got inflammation of the cornea but with epi scleritis the difference is you don’t have pain with square itís you do have pain so that’s how you separate the two okay so how do we differentiate Crohn’s disease versus all sort of colitis what’s unique until now we’ve been talking about things that are common to the two of them which are a pretty significant amount of things so what makes Crohn’s disease and ulcerative colitis separate for Crohn’s disease this affects the entire thickness of the GI tissue so it affects all the way from the inside close to the close to the lumen and then all the way to the outside so this is transmural the entire thickness of the tissue and it also affects the entire GI tract so all the way from the oral mouth tissue all the way to the anus so entire tissue entire

GI tract with crohn’s disease one of the most prominent things that make this unique are fistula and fistula are just due to inflammation and it’s a communication between one lumen to another luminor one lumen to to another cavity so this only occurs in crohn’s disease and some examples of this would be enteral enteric so entro enteric would be would be bowel lumen to bowel lumen entro cystic so be vowel lumen to bladder antro vaginal to be bowel lumen to the vagina and perianal which would be bowel lumen to the anus and a lot of these fistula can manifest in if it’s perianal it can manifest in anal leakage the the other kinds can manifest as infections if this ulcers or canker sores do occur and increase incidents and patients with Crohn’s disease it can occur in the esophagus and stomach as well so these are going to this could manifest as as dysphagia or as odynophagia and these are just patients with what looked like regular old canker sores that you’ve probably had but they’re more severe of course not all patients with Crohn’s disease have these these are just unique to Crohn’s disease and then Crohn’s ill ìitís is an inflammation or ulceration of the terminal ileum so remember that we talked like Crohn’s disease infects the entire GI tract whereas ulcerative colitis only affects the large bowel so if you have disease in your terminal ileum which is part of the small bowel then you know this is Crohn’s disease for all sort of colitis we know that this is limited to the large bowel and primarily this affects the rectum you can have ulcerative colitis of the entire large bowel that’s certainly possible but ulcerative colitis in most cases tends to only affect the rectum in the sig point but it can affect the entire large bowel it never affects the rest of the GI tract though just the large bowel and with all sort of colitis what you can’t see what comes up in the USMLE NSA it happens so much in real life but you get this what they call 10 SMS which is an urge to defecate but there’s no stool and then a passage of mucus that tends to be more common and also have colitis but it’s not exclusive with ulcerative colitis primarily what you should know is that it’s limited to the large bowel and primarily the rectum so as far as diagnosing Crohn’s disease for us versus all sort of colitis the only way you can make the definitive diagnosis is colonoscopy with a biopsy so you put in the colonoscope to look at the tissue get your impression and then you get a biopsy and that biopsy will give you a specific result that will tell you if it’s Crohn’s disease versus ulcerative colitis remember back to step one you had to know what as crohn’s disease look like versus what is ulcerative colitis look like under the microscope for step two or three you don’t need to know that but you do have to know that you need a biopsy to make the definitive diagnosis so for crohn’s disease some of the things that can help you diagnose this is patients with Crohn’s disease will tend to be asked a positive so what asca stands for is anti saccharomyces or vca antibody we I can’t say that we do these that much in real life but on the USMLE this is very prone to come up on colonoscopy macroscopically you’ll see skip lesions so it’s skip lesions are basically what it says lesions that skip so you’ll see healthy tissue and then diseased inflamed tissue and then healthy tissue alternating and a lot of times this is going to encompass the entire large intestine all the way to the ileum chromis disease is not very commonly going to just be in the sigmoid and rectum and then the rest of large intestine is fine patients with symptomatic Crohn’s disease are going to have diseased tissue throughout their entire large bowel and frequently you’ll see diseased tissue in the terminal ileum as far as all sort of colitis they’ll also have a marker for their disease but that there’s a beat anca so remember ANCA is what we signed wegener’s granulomatosis ANCA has also seen an ulcerative colitis so ANCA is antineutrophil cytoplasmic antibody and on colonoscopy in these patients you’ll see confluent inflammation so rather than the skip lesions where you see some healthy tissue some diseased tissue I’m colonoscopy for all sort of colitis you’re going to see a confluent inflammation all that all the tissue is going to look relatively similar and then you get to your healthy tissue so

you’ll have inflamed tissue and then healthy tissue you’re not going to have you’re not going to have alternating regions you’re not going to have your skip lesions of course if the ulcerative colitis occurs in the entire large bowel then you would see the large bowel entirely and fly so you can see why we really do need to get a biopsy our macroscopic impression can only give us an idea biopsy is what we need to make a definitive diagnosis so here’s a colonoscopy so this is on the left here this is a normal patient so this is I think this would be the transverse colon here usually no transverse because you have triangles that’s what would my attending taught me but this is healthy tissue it’s pink you can see capillaries here so this is healthy tissue this looks like it’s the sigmoid so this is healthy tissue this is clearly not healthy tissue so this in the middle here you can see that there’s some healthy tissue right here this pink tissue and then you got some red inflamed tissue with lot of polyps this is the this is also transverse or ascending colon so this is Crohn’s disease you have polyps and inflamed tissue along with normal tissue here polyps can occur in either them and then this is also Crohn’s disease this looks like the sigmoid colon and here you have healthy tissue and then little spots of inflamed tissue here so this is Crohn’s disease and these were both these are all confirmed so they look like even you still have to get the biopsy but these are these are confirmed with biopsy I wouldn’t show you these otherwise but these are good good examples of what Crohn’s disease and ulcerative colitis look like I’m colonoscopy so this is ulcerative colitis this is the rectum here are sigmoid I’m not exactly sure I think this is a rectum down again this Sigma it doesn’t really matter this is you can see confluent inflammation so you don’t have any regions of healthy tissue it’s all inflamed tissue this is all inflamed down here too so this is ulcerative colitis confluent inflammation so when you’re doing colonoscopy your you’re sending it from the rectum all the way over if you can to the to the cecum which is the first part of the large intestine if you can you want a retrograde your valve into the through the ileocecal valve so you can get a look at the ileal pouch which is the last part of the small intestine because you want to see is there any diseased tissue in the ileum if there is then you’re going to know that this is crumbs because with ulcerative colitis you will never have diseased tissue in the small intestine so this is Crohn’s illy itís this is a ulceration inflammation of the ileal pouch so this is the ileum here and you know you hit ileum because this is nice shiny mucosal tissue so this is Crohn’s it is much shinier and glimmering than your large bottle okay so how do we treat inflammatory bowel disease Crohn’s disease and ulcerative colitis are very very similar in how they present their very different disease processes but again they’re very similar and how you treat them so that’s a good thing because it means less things to memorized so the first line of therapy are going to be the mesalamine derivatives or commonly known as the ASA’s the first these are the first line of therapy for long-term treatment so when the test question asks you in a patient gives you a vignette patient with Crohn’s disease or ulcerative colitis it asks you which of the following is the best pharmacologic therapy in this patient best initial pharmacologic therapy your answer is going to be a SAS these ameliorate your symptoms these are going to be the long-term therapy for patients with inflammatory bowel disease there’s three different ones that are most commonly most commonly come up in well in real life and on the boards pentasa works on the entire GI tract so the way you can think of it is pent meaning five parts so you can think of your esophagus your stomach your small bowel your large bowel and your rectum so these work on the entire GI tract well whose disease affects the entire GI tract that would be Crohn’s disease so pentasa is best for Crohn’s disease aiza kalindra wassa these both primarily work on the rectum and anal rectal area aiza call is I believe in

oral medication row wazza is an enema so these are both good for ulcerative colitis but they can also be given to patients with Crohn’s disease too so so those are the ASA’s um I think I heard I heard it once read in a book once is a call is like ass a call and so that’s how you know it works in the rectum and then robbaz it starts with R and that’s how you know that works in the rectum so anyway ah whatever helps you remember okay steroids bearing agents are used in conjunctive therapy when the ASA’s alone are not sufficient so what the steroids bearing agents do is they inhibit inflammation by cytotoxicity so these are like chemotherapeutic agents and and their cytotoxic so they prevent inflammation bye bye just their inherent cytotoxic properties so the two that we use our 6-mercaptopurine and a zath iframe so they’re called steroids bearing agent because a lot of times in the patients who don’t respond to a SAS we’re going to have to have to put them on steroids to get there to get their disease process under control over time we don’t want these patients to be on steroids long term so we put them on these drugs and steroids bearing agents long term so steroid sparing agents are also long-term treatment biologics are monoclonal antibodies and so these are newer drugs and they selectively block tumor necrosis factor alpha again these are conjunctive therapy you’re always going to have these patients on a SAS first and particularly these drugs are used for Crohn’s that come with fistulas so infliximab is the one you’re going to see on the USMLE but there’s other ones at a living lab and so for so the steroids are used primarily for flares and acute therapy only they’re not used for long-term you don’t want to use these for longer than six months if you can avoid it the ones you’ll commonly crb desonide which is a p.o you’ll see prednisone which is also p 0 and methylprednisolone which is IP so some of the adverse effects primarily the ASAS are relatively well tolerated so you’re not going to see you should see adverse effects from those at least on the USMLE 46 MP and asa thyferran that steroid sparing agents drug induced pancreatitis is I’m not going to say comment but it’s it does happen if you do get drug induced pancreatitis you’re going to stop these drugs if the patient is on them my low toxicity is another thing it’s reducing in frequency because we have a way of preventing it and that is to get a TPMT phenotype test so don’t ask me what TPMT stands for because I don’t know look it up ah TPMT what this is is basically an enzyme that breaks down or the byproducts of these drugs so six MP and a SF I apron are cytotoxic which is fine but if it lingers around in the body long enough you can get my old toxicity and that would be bad so you want to make sure that this patient has TPMT enzyme and so what you get is a TPMT phenotype ten percent of patients approximately are going to be TPMT negative which normally would be fine but if you give these patients 6mp raiseth aya prime they’re not going to be able to metabolize the drug as fast and so they can get my low toxicity so in a patient that’s TPMT negative if they don’t have TPMT enzyme you don’t start these drugs ever you can’t use these drugs but most patients should be TPMT positive meaning they do have the enzyme i will say that Asians or and Pacific Islanders do have an increased well they have a they’re more likely to be TPMT negative so that does happen infliximab with any of the anti TNF alpha drugs any of the biologics that we use one of the adverse effects can be reactivation of latent TB so in any patient before we start and flex some ab or any of the anti TNF alpha drugs we want to get a PPD before starting on a patient with steroids you see all the very typical adverse effects of long-term steroid use and this is a reason why we don’t want to use steroids long term and why we would rather use 6mph the thyferran long term and the adverse effects of steroids are waking Buffalo Hump hypernatremia hypokalemia metabolic syndrome and so forth now if a patient has an act of perrier no mask or fistula we want to treat that mass that

fluctuant maths usually it even looks like an abscess with metronidazole and ciprofloxacin so we’re going to drain the mass if there’s ever a mass should consider that you do need to drain it but if there’s a fistula present you would want to start antibiotics so active perianal mass or fistula you’ve got to start antibiotics but if it’s if there’s a perianal mass you want to drain it to surgical therapy is curative for ulcerative colitis but not for Crohn’s and of course that is because ulcerative colitis only affects the bowel the lawyer the large bowel and so if you take out the large bowel what you can do and you would just have a you just have your small bowel going into into a bag you can do that and that’s fine and if you take if you take out the large bowel then you’re all sort of colitis will be cured because I only affects the large bowel but for Crohn’s it’s pointless to take out the large bowel because you can get to crohn’s disease anywhere so surgical therapies curative for elster Politis but not for Crohn’s that doesn’t mean that there aren’t surgical therapies that can be used for Crohn’s that can ameliorate the symptom but it wouldn’t be curative patients with Crohn’s can get strictures in their large bowel and that can be so surgical therapy can be used in patients with Crohn’s but it will never be curative for patients with Crohn’s because Crohn’s affects the entire GI tract so long term complications of inflammatory bowel disease so this is again now we’re talking in general so this is all sort of colitis or or Crohn’s disease one of the major long-term complications is colon cancer and so there is an increased risk for colon cancer when the disease has been present for greater than 10 years so starting at around ten years after diagnosis you’re going to want to start routine surveillance for colon cancer and so the symptoms of colon cancer include bloody stools change in stool caliber constitutional symptoms and pallor you can see here that these are very similar symptoms to what you would get an inflammatory bowel disease itself so it’s going to be really important that you get surveillance colonoscopy every one to two years or as indicated in patients with inflammatory bowel disease and of course you’re going to get it even more often if there’s polyps present so very important that patients with IBD are getting colonoscopies on a somewhat regular basis toxic megacolon is primarily a complication of ulcerative colitis and what you would see here is is a very large colon on on abdominal film but the symptoms when they come in they’re going to have an abdominal pain but it’s going to be not the abdominal pain that you see in IBD it’s going to be a very very very severe abdominal pain it’s going to be a generalized abdominal pain but it’s going to be the type of abdominal pain where they’re not going to let you touch them these patients also have fever and they will also be distended so patients with just regular old inflammatory bowel disease flares they don’t have distension they may have fever they may have done I’ll pain but it won’t be incredibly severe abdominal pain they won’t write it out of 10 out of 10 and then of course never have distension and they’ll never have shock with toxic megacolon you can perforate and so you have to keep an eye out for shock so severe abdominal pain distension shock fever those are all part of toxic megacolon and this can be diagnosed on abdominal plain film in what you see of course is colonic dilatation the treatment is going to be surgical resection you resect the entire large bowel and then you will treat with antibiotics accordingly another thing that can happen with a rather than toxic megacolon as you can get just a general perforation of the bowel that will look pretty similar clinically but it’ll get a look different on your point film I’ll show you pictures of that strictures our sig mental narrowing of the large bowel so this will present as an obstruction so you’re not going to have a fever you’re not going to have extremely severe abdominal pain you can’t have distension but this isn’t going to present as a surgical as much of a surgical emergency as toxic megacolon this is going to be more obstructive picture so you’re going to have a patient that’s got nausea and vomiting they haven’t passed stool in a long time they haven’t passed gas in a long time that’s a sign of obstruction you can diagnose this with barium enema and this

can be treated with I’m sorry actually you would not want to do a barium enema on this patient scratch I doubt if you wrote it down you will diagnose them with just regular old barium study so you’ll give them a barium meal and you’ll you’ll be able to see if there’s a stricture don’t do a barium enema so barium studies and this can be treated actually with endoscopic dilatation but it may require surgery so as far as I know Scott mcdo tation what you would do is you take your kelana scope you would go in and you would essentially do the same thing as what you do for the esophagus when you have strictures in the esophagus you the balloon dilated out of course this can require surgical resection of the strictured segment for fistulas and abscesses fistulas our communications from the bowel to another cavity abscesses are just focal infections for these you’re going to just use vigorous medical therapy primarily you’re going to use the biologics for abscesses you’re going to drain them and you’d also use biologics there too and a lot of times these are going to result in surgery for so for the abscesses you’re going to drain them for the fistulas you’re going to do some kind of surgery I don’t know I’m not an anal rectal surgeon just no official and abscesses may result in surgery what I put here in red our surgical things so colon cancer not so much surgical issue as much as the medical issue or an oncological but toxic megacolon strictures efficient abscesses you’re going to want to have your surgeon on call so this is toxic megacolon you can see here that you’ve got a very very very large bowel here extending from the descending colon all the way down to the beginning of I think this is the appendix right here actually so you’ve got a very very very large colon very dilated colon so this is toxic megacolon and this is a patient that it’s going to they’re going to need their entire colon resecting this is an intestinal perforation so how you know this is an intestinal perforation versus toxic megacolon is one you don’t see the dramatic dilation of the colon of course you don’t you don’t have a megacolon because all you have is a perforation but what you do have is you have air coming out of the large bowel and into the peritoneal space and so what you’ll get is air underneath underneath the diaphragm sub diaphragmatic air would indicate an intestinal perforation so you see that here i need abdominal plain film it’s more prominent on the chest x-ray because you can see the diaphragm going way up into the chest space so this is an intestinal perforation can also happen with inflammatory bowel disease so toxic megacolon and intestinal perforation okay so what do we do then we talked about the therapy what do we do in general let’s sum it all down for patients with inflammatory bowel disease as far as we treat them the initial drug of choice is an a SI so we want to have these patients on long-term therapy with a SI generally it’s going to be pentasa but you can also use you can also use row as ax or asa call if there’s an adequate response to the a-si you can start the patient on an oral corticosteroid generally you don’t want a patient on an oral corticosteroid for more than six months you desonide and prednisone are your oral corticosteroids once the symptoms remit and generally the symptoms will remove within a couple weeks once the symptoms remit you’re going to taper your steroids down you can’t just stop stories right right right away you have to taper them down so you’ll taper your store steroids once the symptoms remit if this if the symptoms persist so you started the patient on an oral corticosteroid but the symptoms have persisted for four months then you’re going to want to start the patient on a steroid sparing agent now I said that we don’t want to keep the patient on a steroid for more than six months so why do we stop why do we start tapering them at four months because it takes the steroids bearing agents 6-mercaptopurine and aiza theatre in about two months to reach levels stuff that will be effective that so we want to start tapering the corticosteroids at four months and starting the steroid sparing agents at that point so that by six months they’re on only steroids bearing agent if the patient has refractory disease you can consider using biologic remember for steroids bearing agents you want to get a TPMT phenotype and for biologics like infliximab you’re going to want to get a PPD for TV for the flares so this is when the patient comes into the ED because they’ve got significant disease bloody diarrhea and so forth you want to start IV fluids on these patients and

get routine labs you’re going to also want to get a CDF talks NSA because can be another cause of bloody diarrhea another cause of fever something that looks just like colitis + 2 + 3 d Clostridium difficile colitis see difficulties so you’re going to want to give toxin essay on patients that come in like this and you’re going to want to get a pregnancy test women of childbearing age of course you’re always going to want to be vigilant for acute complications so obstruction perforation toxic megacolon and you’ll investigate in Cordingley so if there’s toxic megacolon or perforation symptoms present then you’re going to want to have surgery consult and and you’re going to want to consider immediate surgery so those are things you have to be vigilant for not saying that they’re common though once the patient is stabilized and you’ve got anees you start the IV fluids you’ve got in your labs you’re going to admit them you’re going to start IV corticosteroids so I’d be steroids because this is a more acute problem and so you’re going to use methylprednisolone and their diet can be as tolerated if they’re vomiting frequently which can happen in patients with Crohn’s flares if they’re having severe diarrhea you’re going to want to have them possibly on on IV nutrition hyper alimentation is is okay so in in these patients that are having severe symptoms you’re going to want to have them over the normal amount of calories that’s fine too but just their diet can be as tolerated you don’t have to you don’t have to give you don’t have to worry about NPO you don’t have to worry about a specific diet regular old normal diet the only the only exception to that is of course if they are candidate for surgery then you are going to want to have them NPO so particularly if they have an obstruction then NPO as in any any time when you’ve got a patient that’s pre up we’re going to assess the progress in these patients so after about two to three days on IV steroids the symptoms should begin to remit and at that point you’re going to gradually switch them to p.o corticosteroids in anticipation of discharge you guys so now you can prednisone are your corticosteroids that you would use and if the symptoms are persisting then you would want to consider possibly surgical options and i’ll do a some slides on on surgical therapy of bowel disease at a later point so we’re not talking about everything with inflammatory bowel disease just primarily the medical therapy and that is it