Inflammatory bowel disease (IBD)


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  • 1,,,Axial CTE image showing severe inflammatory changes in the terminal ileum: marked mucosal enhancement (solid arrow), wall thickening (arrow head), engorgement of vasa recta or comb sign (broken arrows). Luminal stenosis is also seen. This lesion was scored as CTE inflammation (3), fibrostenosis (1).Surgical specimen from the patient in Figure 1 showing severe inflammation with mild fibrosis (a stiletto is inserted into a fistula tract)…Microscopic view of a section of the specimen in Figure 2 showing severe mucosal and submucosal acute and chronic inflammation with architectural distortion on the left and ulcer on the right.Coronal CTE image of severe fibrostenoticileal disease with mild inflammation. Mild mucosal enhancement, no significant mural stratification, and severe luminal stenosis (solid arrow) are associated with marked prestenotic dilation (broken arrow) and absent comb sign. This lesion was classified as CTE inflammation (1), fibrostenosis (2).Microscopic view of a section of the specimen showed in Figure 4 showing chronic inflammatory infiltrates in the mucosa and submucosa with marked thickening of the bowel wall by fibrous tissue.
  • Inflammatory bowel disease (IBD)

    1. 1. IBD Inflammatory Bowel Disease(IBD) is currently presumed to result from the aggregate effect of inherited variants of genes conferring risk of disease and environmental factors affecting the immune system, which combined lead to an aberrant inflammatory response.
    2. 2. THE INFLAMMATORY CASCADE IN IBD  Inflammatory response is perpetuated by T-cell activation Inflammatory cytokines, such as L-1, IL-6, and TNF, have diverse effects on tissues.  They promote fibrogenesis, collagen production, activation of tissue metalloproteinases, and the production of other inflammatory mediators; they also activate the coagulation cascade in local blood vessels.
    3. 3. REPLICATED GENETIC LOCI IN IBD IBD Locus a Chromosome Gene b Phenotype IBD1 16q CARD15 CD IBD2 12p --- DC,UC IBD3 6p MHC? CD IBD4 14q --- CD IBD5 5q OCTN? CD IBD6 19p --- CD,UC
    4. 4. Defective immune regulation in IBD CROHN’S DISEASE ULCERATIVE COLITIS It is associated with HLA,DR1/DQw5 and NOD2 genes Associate with HLA-DR2 polymorphism and an abnormal T-cell response particularly,CD4+T in IL-10 gene and an abnormal T-cell cell (TH1 cells). response particularly of CD4+ T cells ( TH2cells). It is chronic granulomatous disease which can be affect any part of the gut
    5. 5. DIFFERENT CLINICAL, ENDOSCOPIC, AND RADIOGRAPHIC FEATURES Clinical Ulcerative Colitis Crohn’s Disease Gross blood in stool Yes Occasionally Mucus Yes Occasionally Systemic symptoms Occasionally Frequently Pain Occasionally Frequently Abdominal mass Rarely Yes Significant perineal disease No Frequently Fistulas No Yes Small-intestinal obstruction No Frequently Colonic obstruction Rarely Frequently Response to antibiotics No Yes Recurrence after surgery No Yes ANCA-positive Frequently Rarely ASCA-positive Rarely Frequently
    6. 6. Radiographic Ulcerative Colitis Crohn’s Disease Small bowel significantly abnormal No Yes Abnormal terminal ileum Occasionally Yes Segmental colitis No Yes Asymmetric colitis No Yes Stricture Occasionally Frequently Endoscopic Ulcerative Colitis Crohn’s Disease Rectal sparing Rarely Frequently Continuous disease Yes Occasionally “Cobblestoning” No Yes Granuloma on biopsy No Occasionally
    7. 7. Colonoscopy is the procedure of choice Sigmoidoscopy examines the colon up to the splenic flexure and is currently used to exclude distal colonic inflammation or obstruction in young patients not at significant risk for colon cancer. For elusive capsule endoscopy, or the novel technique of double-balloon enteroscopy.
    8. 8. MORPHOLOGY CD • The earliest lesion in crohn’s is the aphthous ulcer. Many such ulcers may fuse together to form serpentine ulcer arranged longitudinally. • Grossly, involved bowel segment typically has a rigid, strictured or thickened wall with creeping fat. • Full thickness of the intestine is affected in the disease i.e there is transmural inflammation. This causes weakness in the wall there by leading to fissure and fistula formation in Crohn’s disease. Fibrosis is also commoner in this type IBD. Perianal fistula is the most common fistula seen . UC  • • The disease involves the entire colon (pancolitis )starting from the rectum (retrograde involvement). There is presence of regenrating mucosa which projects in the lumen and is called “pseudopolyps”. In extreme cases, there is involvement of the nerve plexus in the muscularis layer resulting in decrese in the motility of the colon and increase in its size over a period of time giving rise to “toxic megacolon” The characteristic feature of the disease is mucosal damage continuously from the rectum and extended proximally. This may also lead to “backwash ileitis”. This type of IBD is more commonly associated with progression of the development of cancer.
    9. 9. • There is patchy involvement of the intestine which is known as presence of “skip lesion”. The intervening area between two affected portions is absolutely normal. So, the mucosa appears to be irregular which is unknown as “cobblestone mucosa.” • There is a presence of non-caseating granulomas. • Clinical features are intermittent attacks of abdominal pain, blood in stools, fever steatorrhoea and megaloblastic anemia (the last two features result because there is impairment in the absorption of bile acids and vitamin B12 respectively from the ileum). Screeing test is presence of ASCA . AB formation is common against cell wall of yeast , sacchromyces cerevisae in patients with crohn’s disease. • There is absence of granulomas. Clinical features are : intermittent attacks of abdominal pain, bloody mucoid stools and fever. There is presence of p-ANCA.
    10. 10. Medical management of IBD.
    11. 11. Medical management of IBD.
    12. 12. Indication for surgery Ulcerative Colitis • • • • • • • • • Intractable disease Fulminant disease Toxic megacolon Colonic perforation Massive colonic hemorrhage Extracolonic disease Abscess Colonic obstruction Colon cancer prophylaxis Colon dysplasia or cancer Crohn’s Disease • Small Intestine • Stricture and obstruction unresponsive to medical therapy. • Massive hemorrhage • Refractory fistula • Colon and Rectum • Intractable disease • Fulminant disease • Perianal disease unresponsive to • medical therapy • Refractory fistula • Colonic obstruction • Cancer prophylaxis • Colon dysplasia or cancer
    13. 13. Novel agents currently under investigation for treating inflammatory bowel disease
    14. 14. Kings college of London (NHS)
    15. 15. Kings college of London (NHS
    16. 16. Kings college of London (NHS
    17. 17. Waiting for your answer ! Blossom Sabi :)