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31 Oct, 14 tweets, 30 min read
@MondayNightIBD @SobiaMujtabaMD @JasonHouMD @DCharabaty 1/ 65 y/o M new dx #Crohns ileitis after he presented w abdo pain,diarrhea, wt loss, anemia. CLN: deep linear ulcers in TI. He has an active lifestyle,stable CAD. Symptoms recur when prednisone<15 mg. What is the LEAST effective strategy to keep this pt in remission? #Back2Basics
@MondayNightIBD @SobiaMujtabaMD @JasonHouMD @DCharabaty 2/ #IBD is not only a disease of the young !

♦️ Typical dx age 20-39, w a second smaller peak >50

♦️ Recently ⬆️ prevalence in elderly> age 60, due to:

🔺Aging of adults w #IBD

🔺⬆️elderly onset IBD > age 60 #EOIBD:
🔹⬆️awareness & dx
🔹Environment/ microbiome changes
@MondayNightIBD @SobiaMujtabaMD @JasonHouMD @DCharabaty 3/ Clinical Features of #IBD in #elderly 🔎?

📌Milder disease course, Fewer #Crohns complications, but

⬆️rates of hospitalizations
⬆️rates of colectomy in EO UC

📌❓Due to disease severity vs poor #IBD control d/t underuse of effective Rx
@MondayNightIBD @SobiaMujtabaMD @JasonHouMD @DCharabaty 4/ Real life data of #IBD Rx in elderly show :

⚠️Overuse of 5ASA even in #Crohns disease

⚠️Up to ⅓ pts kept on chronic corticosteroids

⚠️Limited use of thiopurines or biologic (<6%)

⚠️CS are NOT a maintenance strategy & SE ⬆️⬆️in elderly

link.springer.com/article/10.100…
@MondayNightIBD @SobiaMujtabaMD @JasonHouMD @DCharabaty 5/⬆️Disease burden in elderly; for eg:
⬇️cognitive & functional status → ⬇️anal sphincer tone,⬇️mobility →incontinence,distress, risk of fall from diarrhea
⬇️social support →limit access to scope, infusion..
@DCharabaty @joshsteinbergMD @yaransarkis
doi.org/10.1007/s11938…
@MondayNightIBD @SobiaMujtabaMD @JasonHouMD @DCharabaty @joshsteinbergMD @yaransarkis 6/ Potential barriers to Rx in #EOIBD :

Co-morbidities

⬆️risk of (opportunistic) infection, mainly if frail vs fit pt

❗️Poly💊
❗️Overall frailty
❗️Older pts excluded from biologics RCT👉🏽limited data on efficacy/safety in elderly
@MondayNightIBD @SobiaMujtabaMD @JasonHouMD @DCharabaty @joshsteinbergMD @yaransarkis 7/ Rx options for #IBD in #elderly
#5ASA most prescribed
👉🏽Perceived as safe,but 🛎️

📍Many & large💊in pts w often difficulty swallowing
📍Difficulty using topical form
👉🏽non-adherence

📍⬆️risk of interstitial nephritis in elderly w comorbidities

📍Indicated only in mild UC
@MondayNightIBD @SobiaMujtabaMD @JasonHouMD @DCharabaty @joshsteinbergMD @yaransarkis 8/ Rx options for #IBD in #elderly
#Thiopurines (AZA/MP)/ IMM

⬆️ Risk of lymphoma, specifically in men > age 50

⬆️ Risk of NMSC

📍Need frequent lab monitoring, that can be challenging in elderly
@MondayNightIBD @SobiaMujtabaMD @JasonHouMD @DCharabaty @joshsteinbergMD @yaransarkis 9/ How about biologics for #IBD in #elderly ?

❇️ #TNFi ❇️

🔰⬆️ risk of URI/pneumonia, opportunistic infxn
🔰Avoid use w IMM/CS

🚫diff in efficacy vs young on TNFi

⛔️ Absolute/relative CI: Uncontrolled CHF, neurologic disease, h/o lymphoma, CA..

doi.org/10.1016/j.cgh.…
@MondayNightIBD @SobiaMujtabaMD @JasonHouMD @DCharabaty @joshsteinbergMD @yaransarkis 10 / 🌀VDZ🌀 in #elderly

🔹Perceived as safer option because it’s gut-specific
⬆️ Risk of (non serious) infection elderly vs young on VDZ

🔹Similar efficacy vs adult on VDZ
🔹👍 #IBD w/o EIMs, or h/o lymphoma/ CA/Skin CA

doi.org/10.1177/205064…
@MondayNightIBD @SobiaMujtabaMD @JasonHouMD @DCharabaty @joshsteinbergMD @yaransarkis 11/ ✴️ #UST ✴️ in #elderly

🔸Good safety data in RCT
🔸 Limited data in elderly
🔸⬆️ risk of CV SEs in pts w CVD risk factors

jamanetwork.com/journals/jamad…
@MondayNightIBD @SobiaMujtabaMD @JasonHouMD @DCharabaty @joshsteinbergMD @yaransarkis 12/🔺TOFA/JAK-i🔻in #elderly

🚩Approved after failure of TNFi

🚩⬆️ Risk of HZ with ⬆️age
👉Vaccinate w/Shingrix

🚩⬆️ Potential risk of DVT/PE in pts with VTE risk factors on 10mg bid dosing
@ManasiAgrawalMD

ncbi.nlm.nih.gov/pmc/articles/P…
@MondayNightIBD @SobiaMujtabaMD @JasonHouMD @DCharabaty @joshsteinbergMD @yaransarkis @ManasiAgrawalMD 13/ To Recap #IBD in the #Elderly

🎯Elderly make up ⅓ of all #IBD pts
🎯Tailor Rx based on “Fit” vs “Frail”

🚫Chronic Corticosteroids

⬆️ Risk of lymphoma w IMM
⬆️ Risk of infxn w biologics related to age, frailty & MOA

🔑 Vaccinate for flu/pneumoc. in all & Shingles if TOFA
@MondayNightIBD @SobiaMujtabaMD @JasonHouMD @DCharabaty @joshsteinbergMD @yaransarkis @ManasiAgrawalMD @DrMalSimons @FITWITMD @Waseem_AhmedMD @LaurenFeldMD @MayssanMuftah @JacquelineChuMD @MahamHayatMD @ptandonGI @MishahMD @DVinsard @RuthvikPadival @AlexaWeingarden @VivyTCmd @BilalMohammadMD @DrMohdZein @OmerShahabMD @HarisMD14 @mohammad @purnie_mae

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More from @mjayoushe

Majdoline Jayoushe, MD Profile picture
10 Oct
@MondayNightIBD @ibdnaik @SobiaMujtabaMD @ibdleuven @DCharabaty 1/29 yo M, smoker, presents with RLQ abscess w fistula to the TI; he undergoes abscess drainage & then ileocecal✂️w primary ileocolonic anastomosis. Path c/w #Crohns, margins free of disease. You see him for f/up 2 weeks post-op, What's the next ? #MondayNightIBD #Back2Basics
@MondayNightIBD @ibdnaik @SobiaMujtabaMD @ibdleuven @DCharabaty 2/ Let’s talk #Crohn’s intestinal complications
CD can present w stricturing/perforating complications
50-60% CD will develop strictures, fistulas or abscesses over time
70% require surgical✂️by 15yrs of dx
Surgery not curative, most pts will have endo recurrence 1 yr post-IC✂️
@MondayNightIBD @ibdnaik @SobiaMujtabaMD @ibdleuven @DCharabaty 3/ Natural course of CD recurrence post- IC ✂️

📌Histologic e/o CD within 3 wks post-op !!

📌70-90% pts w endo recurrence at 1 year

📌30-60% pts w clinical recurrence by 3 & 5 yrs

📌50% will need ✂️by 5 yrs

@MRegueiroMD
Read 12 tweets
Majdoline Jayoushe, MD Profile picture
3 Oct
@MondayNightIBD @SobiaMujtabaMD @NabilQuraishi @CholestasisDoc @DCharabaty 1/ 35 y/o M presents with fatigue & generalized pruritus x 6weeks. No skin rash, No abdo pain, diarrhea or 🩸 in stool. AST 62 ALT 64 ALP 435 Tbili 1.3. MRI/MRCP: multifocal strictures & areas of dilatation of intra +extra hepatic ducts. What’s the next step?💡 #Back2Basics #B2B
@MondayNightIBD @SobiaMujtabaMD @NabilQuraishi @CholestasisDoc @DCharabaty 2/ What’s #PSC & phenotypes?

🧩Idiopathic chronic inflam dis. of the biliary tree

🧩90%: Large ducts (LD): "Beads on string appearance” on ERCP/MRCP (pt👆)

🧩5% Small IHD only: nml MRCP, dx by liver bx, slide👇

🧩5% PSC w AIH overlap: abnl MRCP+liver bx w⬆️AST/ALT or IgG ImageImage
@MondayNightIBD @SobiaMujtabaMD @NabilQuraishi @CholestasisDoc @DCharabaty 3/ 💎#B2BPearl #PSC w ⬆️IgG4

📌15% of LD-PSC

📌⬆️IgG4 serum>140mg/dL +/- tissue
💎✅IgG4 at least once w PSC dx

📌Assoc. w AI pancreatitis; other Ig4 dis.

💎⬆️severity of UC, colectomy
📌More rapid progression to cirhhosis

💎Steroid responsive: ️ ⬇️AlPhos, TBili, IgG4
Read 15 tweets
Majdoline Jayoushe, MD Profile picture
19 Sep
@MondayNightIBD @SobiaMujtabaMD @FezaRemziMD @DCharabaty 1/ 35 yo F panUC on IFX 10mg q4wk, admitted with abdo pain, hematochezia, malaise. T 39 BP 95/63 HR 110 FCP 900 mcg/g. Abdo distended, TTP; CT: colonic wall thickening+edematous mucosa. Cdiff neg; WBC 15, Hb 6. No improvement despite IVCS+Abx. Which surgery is indicated #B2BPoll
@MondayNightIBD @SobiaMujtabaMD @FezaRemziMD @DCharabaty 2/ Indications for colectomy in UC:

📌Elective:

📍UC refractory to medical Rx

📍Steroid-dependant UC

📍Unresectable dysplasia, CA

📍Complications from medical Rx

📌Emergency:

📍Toxic megacolon

📍Fulminant colitis

📍Perforation

📍Severe Bleeding
@MondayNightIBD @SobiaMujtabaMD @FezaRemziMD @DCharabaty 3/ What is a toxic megacolon?

🔺Transverse colon > 6cm

🔺AND one:
T>101.5° F
HR> 120
WBC>10.5
anemia

🔺AND one:
Dehydration
altered mental status
electrolyte abnormality
hypotension

💡Recall our #B2B tweetorial on ASUC👇🏽👇🏽👇🏽
Read 14 tweets
Majdoline Jayoushe, MD Profile picture
22 Aug
@MondayNightIBD @SobiaMujtabaMD @SchwartzbergMD @DCharabaty 1/ 27 yo F, crohns colitis on AZA, presents w 2wk perianal pain. One week ago a “boil” developed adjacent to the anus, painful to touch and draining cloudy fluid. PE: Perianal fistulous opening tender & draining pus on palpation. What is the next best step ? #B2B
@MondayNightIBD @SobiaMujtabaMD @SchwartzbergMD @DCharabaty 2/Recap #Crohns:
📌Transmural inflammation involving any part of GIT
📌B for Phenotypes: inflammatory/stricturing/penetrating
📌L for location: UGI,SB,Colon
📌Penetrating Behaviors:
Fistulae
Perforations
Intra-abdominal abscesses(IAA)

recall this #B2B MTL classification table👇🏼 Image
@MondayNightIBD @SobiaMujtabaMD @SchwartzbergMD @DCharabaty 3/♦️p->Perianal ds in CD
♦️Can occur w any B&L
♦️May be initial manif in ~10%
♦️Can be isolated(no luminal dis)
♦️Affect up to 1/3 of CD pts
♦️Incidence cld be ⬇️w⬆️use of biologics @sang_hyoung @EdwardLoftus2 pubmed.ncbi.nlm.nih.gov/30346531/

♦️One of most challenging manif for pts+MDs
Read 8 tweets
Majdoline Jayoushe, MD Profile picture
25 Jul
@MondayNightIBD @SobiaMujtabaMD @DuekerJeffrey @DCharabaty 25y/oM quit🚬3 mos ago, now 3🩸loose BM/day,mild abdo cramps;Cousin w Crohns;Stool➖for infection;CLN: erythematous granular mucosa rectum+sigmoid, superficial ulcers;BX:Acute cryptitis,crypt abscess,crypt architecture distortion. What helps most dx UC vs Crohn’s?
#B2B #IBDPoll
@MondayNightIBD @SobiaMujtabaMD @DuekerJeffrey @DCharabaty UC and CD:

🔻Chronic inflammation of the GI tract

🔻Affects all ages: Typically starts between age 20-39

🔻Second peak of incidence age >50

🔻Flares of GI symptoms +/-systemic symptoms +/- EIM
@MondayNightIBD @SobiaMujtabaMD @DuekerJeffrey @DCharabaty 3/ CD:

💡Skipped lesion, any part of GI tract

💡Most common:Colon+ileum
Hallmark➡️ulcers: aphthous,deep large/linear/serpiginous

💡Transmural inflamm -> stricturing, perforating dis.

🚩#B2BPearl
👉🏼Rectum can be involved in CD;➕anorectal ulcers → ⬆️risk of perianal disease
Read 16 tweets
Majdoline Jayoushe, MD Profile picture
16 Jan
Endotherapy of postcholecystectomy biliary strictures (PCBS) with multiple plastic stents (MPSs): Long-term results in a large cohort of patients @GIE_Journal sciencedirect.com/science/articl…
Methods & Design: 196 pts with benign biliary stricture (BBS) treated with endoscopic MPS identified retrospectively from ERCP database with a 7 year follow-up period. Image
Results: in 154 patients, MPS treatment success rate was 96.7%
Early ERCP-related AEs occurred in 6/151 pts. PCBS recurrence rate was 9.4% after a mean follow-up time of 11.2 yrs. 16.5% of pts repeated ERCP due to cholangitis There was no procedure related mortality
Read 4 tweets

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