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56
Vol. 66, No. 4 2015
Northeast Florida Medicine
DCMS online
. org
CME
The Role of a Primary Care Physician in the
Management of Inflammatory Bowel Disease
Introduction
The Primary Care Physician (PCP) plays a very import-
ant role in the management of patients with Inflammatory
Bowel Disease (IBD), acting much like a copilot to the
gastroenterologist, and at times taking over the role of a
pilot. Some patients are hesitant to follow up with their
PCP, claiming that they have no other medical problems,
but most gastroenterologists find that the best outcomes
are obtained in patients whose PCP is closely involved
with their care. Gastroenterologists sometimes develop
a tunnel vision in treating these patients and PCPs can
help them in refocusing on the whole patient.
When to suspect IBD and refer patients?
The diagnosis of IBD can be difficult to make. There
is no single or specific test that makes a definitive diag-
nosis of IBD. The diagnosis is based on a combination of
clinical findings, laboratory abnormalities, radiological
abnormalities, endoscopic findings, pathological features
and, more recently, serological markers. The mean delay
in diagnosis of IBD was 3.3 years in the past, but has
recently decreased to about a year.
1
PCPs should be vigilant
Abstract:
Primary Care Physicians (PCPs) play an important role
in the management of patients with IBD. They should know when
to suspect and refer patients with IBD, how to screen and treat for
bone loss, update all vaccinations, screen and treat for depression
and anxiety, when to consider screening for self-image, and how
to monitor and treat nutritional deficiencies. They should also
understand the role of NSAIDs, smoking and Clostridium difficile
infections. PCPs are critical to optimizing patient care and outcomes.
and refer patients who have symptoms, signs, laboratory
or radiological evidence of IBD. The cardinal symptoms
are abdominal pain, diarrhea and rectal bleeding. Some
patients have tenesmus, anorexia and weight loss. Crohn’s
disease patients may present with perianal disease or bowel
obstruction. These symptoms are usually of gradual onset
and may be intermittent. Examination may showmild pal-
lor, non-specific abdominal tenderness, and non-descript
perianal disease. Examination however is usually not very
impressive. A review of systems may reveal symptoms of
extra intestinal involvement. Lab work may be normal
or may reveal anemia, hypoalbuminemia, elevated C
reactive protein (CRP) or deficiencies of iron, folic acid
and vitamin B12. Stool studies may reveal presence of
occult blood, leucocytes, lactoferrin and calprotectin.
Infectious agents should be ruled out by appropriate
stool studies. A family history of IBD may help, but is
usually not present. Serological markers of IBD are not
very reliable or cost effective in the initial diagnosis.
1,2
Osteoporosis screening and treatment
Patients with IBD have a very high prevalence of
osteopenia and osteoporosis, which ranges from 18–42
percent.
3,4
Osteoporosis is more prevalent in Crohn’s
disease as compared to ulcerative colitis. Corticosteroid
treatment is a major risk factor and the risk of osteoporosis
is directly proportional to the lifetime use of corticoste-
roids. IBD-related chronic inflammation also predisposes
to osteoporosis. Hypogonadism, low vitamin D, calcium
malabsorption and malnutrition are also contributing
factors. Other lifestyle risk factors include smoking,
alcoholism, physical inactivity and obesity.
5
Postmeno-
pausal women and men over 50 are at increased risk.
6
The American Gastroenterological Association (AGA)
recommends a Bone Mineral Density (BMD) using a
DXA scan of the spine and hip in patients with IBD
who are at risk for bone loss and fracture.
3
If the BMD
is normal, it should be repeated in two to three years.
If abnormal, patients should be screened for secondary
causes of osteoporosis. Treatment should be initiated
By Bharat K. Misra, MD
Address correspondence to:
Bharat K. Misra, MD
Borland Groover Clinic
3627 University Boulevard South, Suite #705
Jacksonville, Fl 32216