Ernæringsmangler og IBD Jørgen Jahnsen
Inflammatoriske tarmsykdommer Crohns sykdom Ulcerøs kolitt IBD
Lokalisasjon Endoskopi Histologi Crohns sykdom Ulcerøs kolitt
Komplikasjoner ved IBD Crohns sykdom Fistler Perianal sykdom Strikturer Blødning Vekttap/malnutrisjon Vekst forstyrrelser Anemi Artralgier/arthritt Uveitt Erythema nodosum Metabolsk beinsykdom Ulcerøs kolitt Blødning Anemi Vekttap/malnutrisjon Vekst forstyrrelser Artralgier/arthritt Uveitt Erythema nodosum PSC
Komplikasjoner ved IBD Crohns sykdom Fistler Perianal sykdom Strikturer Blødning Vekttap/malnutrisjon Vekst forstyrrelser Anemi Artralgier/arthritt Uveitt Erythema nodosum Metabolsk beinsykdom Ulcerøs kolitt Blødning Anemi Vekttap/malnutrisjon Vekst forstyrrelser Artralgier/arthritt Uveitt Erythema nodosum PSC
Nutritional deficiencies in patients with IBD Filippi J, et al.. Inflamm Bowel Dis 2006; 12: 185-191 Vagianos K et al. JPEN J Parenter Enteral Nutr 2007; 31: 311-319
Jernmangel hos IBD pasienter Den mest vanlige mangeltilstanden 36-90% Lavt inntak Hemmet opptak fra tarmen Crohns sykdom (L4) Inflammasjonen Kontinuerlig blodtap Synlig (ulcerøs kolitt) Usynlig (Crohns sykdom) Lomer MC, Br J Nutr. 2004 Semrin G, Inflamm Bowel Dis 2006 Kulnigg S, APT 2006
The prevalence of anemia and iron deficiency in IBD outpatients in Scandinavia Overall prevalence: 19% (95% CI: 16-23%) Crohns disease > ulcerative colitis (p=0.01) Aetiology of anaemia Iron deficiency (20%) Chronic inflammation (12%) Both Iron deficiency and chronic inflammation (68%) Folate acid or B12 deficiency (<5%) Iron deficiency: 35 % (95% CI: 31-40%) Bager P et al. Scand J Gastroenterol 2011 Mar;46(3):304-9.
Anemia in IBD - pathophysiological mechanisms Weiss G, Gasche C Haematologica. 2010 Feb;95(2):175-8.
IBD-associated anemia and iron deficiency after intravenous iron sucrose and erythropoietin treatment Objective Evaluate the frequency and timing of anemia and ID recurrence after a successful treatment cycle Methods Medical records of patients who received iv iron sucrose ± EPO within one of three prospective trials Gasche et al, Ann Intern Med 1997, Digestion 1999, and Am J Gastroenterol 2001 studied for a 5-year follow-up period Risk for recurrence of anemia and ID (ferritin < 30 μg/l) was evaluated by Kaplan Meier analysis using the logrank test Kulnigg S et al. Am J Gastroenterol 2009 Jun;104(6):1460-7.
Characteristics of patients sorted by iron dose before + after iron replacement therapy More iron = higher hemoglobin and iron parameters Kulnigg S et al. Am J Gastroenterol 2009 Jun;104(6):1460-7.
Iron dosage Hemoglobin < normal Ferritin < 30µg/L TfS < 16% Iron re-treatment
Post-treatment ferritin level Hemoglobin < normal Ferritin < 30µg/L TfS < 16% Iron re-treatment
Conclusions The higher the initial iron dose, the better was the initial treatment outcome IBD-associated iron deficiency and anemia recurs fast Appropriate dosing is not well established Recurrence of anemia did not relate to iron dose or post-treatment ferritin
Conclusions Post-treatment ferritin levels predict recurrence of iron deficiency but not anemia Ferritin level of at least 400 μg/l after iv iron treatment (with an upper safety limit of 800 μg/l to avoid iron overload) Iron (and/or EPO) maintenance therapy may be needed to prevent anemia recurrence
American Journal of Gastroenterology 2008 May;103(5):1182-92. Conclusion Ferinject Trial: FeCarb (Ferinject) is non-inferior to FeSulf FeCarb is safe Faster hemoglobin increase Convenient administration of high doses of iron
Bone Remodeling Osteoclasts followed by osteoblasts Act on the same bone surface
Osteoporose Definisjon Osteoporose er en sykdom karakterisert ved reduksjon i beinmasse og ødelagt mikroarkitektur, hvilket medfører økt skjørhet av skjelettet og derfor større risiko for brudd
Kompresjonsfrakturer
Trabekulært bein Normalt Osteoporose
Osteoporosis
Osteoporose vs. osteomalaci Normalt ben Osteoporose Osteomalaci Ben mengde Normal Redusert Normal % Mineral Normal Normal Redusert
Benmineraltetthetsmåling DXA QUS
Definition of osteoporosis BMD Normal - 1 SD Topp ben masse Lav benmasse (Osteopeni) - 2.5 SD Ingen brudd Med brudd Osteporose Alvorlig osteoporose
Possible causes Corticosteroids Vitamin D deficiency and disturbances of calcium metabolism Sex hormone deficiency Smoking Poor nutritional status Disease activity
Bone Mineral Density and Bone Metabolism in Patients with Inflammatory Bowel Disease: A population-based Study J.Jahnsen, J.A.Falch*, P.Mowinckel**, E.Aadland Medical Department and *Hormone Laboratory, Aker University Hospital, **Foundation for Healthservices Research, Central hospital of Akershus, Norway. AKER UNIVERSITY HOSPITAL UNIVERSITY OF OSLO
Aims Compare bone mineral density (BMD) in patients with Crohn s disease with patients with ulcerative colitis and healthy subjects Evaluate possible risk factors for bone loss in inflammatory bowel disease
Materiale HS UC CD Antall personer 60 60 60 Menn/Kvinner 24/36 24/36 24/36 Post/premenopause 7/29 7/29 7/29 Alder (median og 36(21-75) 38(21-75) 36(21-75) spredning)
80 År Alder Kvinner Menn 70 60 50 40 30 20 10 HS UC CD
Utbredning CD UC 11 11 16 33 13 28 8 Tynntarm Tynn- og tykktarm Tykktarm Proctitt Proctosigmoiditt Ve. sidig Pan- /substantial Tynntarmsreseksjon hos 27 pasienter
BMI (Mean, 95% Konfidensintervall) kg/m 2 27.0 p=0.021 0.031 26.0 25.0 p=0.900 24.0 23.0 22.0 HS UC CD
Resultater UC CD PTH (pmol/l) 4.1 4.8 25-OHVitD3 (nmol/l) a 56 47 Ca (mmol/l) a 2.27 2.24 Osteocalcin (nmol/l) 1.5 1.3 ALP (U/l) b 159 214 Albumin (g/l) c 43 41 U-Pyridinoline 52.3 57.6 a p<0.05 b p<0.01 c p<0.001
25-hydroksyvitamin D nmol/l 140 Vitamin D status 120 100 Kvinner Menn 80 60 40 20 0 CD UC
PTH (pmol/l) 22.5 22 15.5 p=0.0007 PTH in CD 15 patients 12.5 10 7.5 5 2.5 0 + Small bowel - Small bowel resections resections (n= 27) (n= 33)
PTH Relationship between Vitamin D and PTH in CD patients pmol/l 22.5 + small bowel res. - small bowel res. 20 17.5 15 12.5 10 7.5 5 2.5 0 0 20 40 60 80 100 120 25-hydroxyvitamin D nmol/l
Konklusjon Pasienter med Crohn s sykdom har økt prevalens av osteopeni og osteoporose Årsaken synes å være multifaktoriell Redusert BMD hos pasienter med Crohn s sykdom, er knyttet til bruk av corticosteroider
Konklusjon Vitamin D mangel er vanlig hos pasienter med Crohn s sykdom Crohn pasienter operert med tynntarmsreseksjon har økt risiko for å utvikle sekundær hyperparathyreoidisme og lav BMD