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Inflammatory Bowel Disease

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Presentation covering the key points of the pathology and surgical management of inflammatory bowel disease.

Presentation covering the key points of the pathology and surgical management of inflammatory bowel disease.

Published in: Education, Health & Medicine

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  • Excellent presentation
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  • very nice presentation
    also the hyponatremia presentation.
    I like to have from you a presentation on other electrolyte disorders.
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  • Crohn?s disease, a disease belonging to the larger group of inflammatory bowel diseases (IBD), is named after an American gastroenterologist, Dr. Burrill B. Crohn. Crohn's disease initially came to be known as a medical entity when it was referred to by Dr. Crohn, Dr. Leon Ginzburg, and Dr. Gordon D. Oppenheimer in 1932. The first description of this condition was earlier made by the Italian physician Giovanni Battista Morgagni (1682?1771) in 1769, when he diagnosed a young man with a chronic, debilitating illness and diarrhea.

    Successive cases were reported in 1898 by John Berg and by Polish surgeon Antoni Lesniowski in 1904. In 1913, Scottish physician T. Kennedy Dalziel, at the meeting of the British Medical Association, described nine cases in which the patients suffered from intestinal obstruction. On close examination of the inflamed bowel, the transmural inflammation that is characteristic of the disease was clearly evident. Abdominal cramps, fever, diarrhea and weight loss were observed in most patients, particularly young adults, in the 1920s and 1930s. In 1923, surgeons at the Mt Sinai Hospital in New York identified 12 patients with similar symptoms. Dr. Burrill B. Crohn, in 1930, pointed out similar findings in two patients whom he was treating.

    On May 13, 1932, Dr. Crohn and his colleagues, Oppenheimer and Ginzburg, presented a paper on ?Terminal Ileitis?, describing the features of Crohn?s disease to the American Medical Association. This was published later that year as a landmark article in the Journal of the American Medical Association with the title "Regional Ileitis: A Pathologic and Chronic Entity." The JAMA article was published at a time when the medical community was interested in new findings. The findings were given significant recognition, while the Dalziel article in the British Medical Journal of 1913 was not. It is by virtue of alphabetization rather than contribution that Crohn's name appeared as the first author. This was the first time the condition was reported in a widely-read journal, and the disease came to be known as Crohn's disease.
  • This inhibition can be achieved with a monoclonal antibody such as infliximab (Remicade), adalimumab (Humira), certolizumab pegol (Cimzia), and golimumab (Simponi), or with a circulating receptor fusion protein such as etanercept (Enbrel).
    While most clinically useful TNF inhibitors are monoclonal antibodies, some are simple molecules such as xanthine derivatives [3] (e.g. pentoxifylline [4]) and Bupropion .[5] Bupropion is the active ingredient in the smoking cessation aid Zyban and the antidepressant Wellbutrin.
  • Figure 22.  Ulcerative colitis in a 27-year-old man. Contrast-enhanced CT scan shows minimal diffuse thickening of the sigmoid colon with minimal inflammatory stranding. The remainder of the colon was normal (not shown).
  • Figure 21.  Crohn disease. CT scan obtained with oral contrast material shows moderate thickening of the terminal ileum (curved arrow) and cecum (straight arrow) with adjacent inflammatory changes in the pericolic fat.
  • Transcript

    • 1. Brian Wells, MS-3, MSM, MPH St. George’s University School of Medicine
    • 2. I have finally come to the conclusion that a good set of bowels is worth more to a man than any quantity of brains. - Josh Billings (4/20/1818 – 10/14/1885) © 2010 Brian Wells
    • 3. IBD Informative Beneficial Deployable Inflammatory Bowel Disease © 2010 Brian Wells Today’s Goals
    • 4. Mathematical Description of Transmural Involvement (+) Informative (-) Beneficial (-) Deployable © 2010 Brian Wells
    • 5. Infammatory Bowel Disease Ulcerative Colitis Crohn’s Disease (Leśniowski-Crohn’s Diease in Poland) © 2010 Brian Wells
    • 6. Infammatory Bowel Disease © 2010 Brian Wells
    • 7. Crohn’s Disease - How did we get here? Giovanni Battista Morgagni 2/25/1682 – 12/6/1771 First description: 1769 Burrill B. Crohn, MD 6/13/1884 – 7/29/1983 1932 - “Regional ilitius” thought due to Mycobacterium paratuberculosis Similar to Johne’s Disease Thomas Kennedy Dalziel 1861–1924 Chronic interstial enteritis. Br Med J 1913; 2: 1068– 1070 Antoni Leśniowski 1/28/1867–4/4/1940 Annals of the Warsaw Medical Association 1903- 1905 – “a chronic inflammatory process in the wall of the gut.” © 2010 Brian Wells
    • 8. Epidemiology Ulcerative Colitis Crohn’s Disease Incidence (per 100,000) 10 (0.5–24.5) 5.8 (0.1-16) Prevalence (per 100,000) 229 (=) 133 (↑) At-risk population High in Jewish, low in African-American, +FHx in 20% High in Jewish, low in African-American, ~equal in Caucasian and AA Sex Male > Female (slightly) Female > Male (slightly) Distribution Bimodal: 20-35, 50-65 Bimodal: 25-40, 50-65 Factors More common with ex- smokers and nonsmokers More common with smokers *Centers for Disease Control and Prevention U.S. Population estimate (July 2009): 307,006,550 Overall prevalence (2006): 396/100,000 persons Total estimated cases (July 2009): ~1.2-1.4 M cases *Lakatos PL. Recent trends in the epidemiology of inflammatory bowel diseases: up or down? World J Gastroenterol 2006;12(38):6102–08. © 2010 Brian Wells
    • 9. Comparative Summary Ulcerative Colitis Crohn’s Disease Type of Involvement Diffuse, No skip areas Skip areas Depth of Involvement Mucosa & submucosa Transmural Rectal Involvement 95% 50% Perianal disease - + Fistulas - + © 2010 Brian Wells
    • 10. Comparative Summary Ulcerative Colitis Crohn’s Disease Ileal involvement - + Aphthous ulcers & linear ulcers - + Cobblestone appearance - + Ulceration Fine, superficial Deep with submucosal extension P-ANCA 70% Occasional © 2010 Brian Wells
    • 11. Comparative Summary Ulcerative Colitis Crohn’s Disease Anti-saccharomyces Occasional >50% Risk of colon CA ++ + Granulomas - Non-caseating Extraintestinal manifestations Arthritis, iritis, erythema nodosum, pyoderma gangrenosum © 2010 Brian Wells
    • 12. Comparative Summary Ulcerative Colitis Crohn’s Disease Medical Treatment Ulcerative proctitis 5-ASA suppositories Consider adding: rectal steroid enema, steroid foam, 5-ASA enemas Ulcerative colitis Oral 5-ASA and/or rectal 5-ASA enemas or steroid foam For severe disease consider adding enema or IV steroids, or TNF-α inhibitors Mild to moderate disease Oral 5-ASA or sulfasalazine. Consider adding: antibiotics flagyl +/- cipro Severe IV steroids, immunosuppressive drugs, TNF-α inhibitors Fistulas TNF-α inhibitors © 2010 Brian Wells
    • 13. © 2010 Brian Wells Horton K M et al. Radiographics 2000;20:399-418 ©2000 by Radiological Society of North America Contrast-enhanced CT scan shows minimal diffuse thickening of the sigmoid colon with minimal inflammatory stranding. Ulcerative colitis in a 27-year-old man
    • 14. © 2010 Brian Wells Horton K M et al. Radiographics 2000;20:399-418 ©2000 by Radiological Society of North America CT scan obtained with oral contrast material shows moderate thickening of the terminal ileum (curved arrow) and cecum (straight arrow) with adjacent inflammatory changes in the pericolic fat. Crohn’s Disease
    • 15. Medical Management • Drug selection – 5-ASA – Sulfasalazine, mesalamine – Steroids – TNF-α inhibitors • Dosing • Role of technology © 2010 Brian Wells
    • 16. Surgical Management • Indications for surgery in ulcerative colitis Urgent Surgery Elective Surgery Ongoing hemorrhage Failure of medical therapy Toxic megacolon Intolerable side effect of medical therapy Colonic perforation Development of dysplasia Fulminant ulcerative colitis Carcinoma Colonic stricture Growth retardation in children © 2010 Brian Wells *Current Surgical Therapy 9th Edition
    • 17. Surgical Management • Surgical alternatives for ulcerative colitis Emergency Operation Elective Operation ±Subtotal colectomy with end ileostomy Panproctocolectomy with permanent end ileostomy (simple and curative) Panproctocolectomy with permanent end ileostomy Subtotal colectomy with ileorectal Anastomosis (rarely performed) Proctocolectomy with continent ileostomy (Kock pouch) - Rarely performed Panproctocolectomy with IPAA with or without diverting ileostomy (CI in Crohn’s disease) ± Standard procedure *Construction of a pouch is avoided in the emergency setting © 2010 Brian Wells
    • 18. Surgical Management • Indications for surgery in Crohn’s Disease Urgent Surgery Elective Surgery Perforation Stricture Abscess Fistula Uncontrollable hemorrhage Malignancy Toxic megacolon Malnutrition Bowel obstruction Poorly controlled despite management Extra-intestinal manifestations *Medical Management of the Surgical Patient: A Textbook of Perioperative Medicine *ASCRS – American Society of Colon and Rectal Surgeons Most patients with Crohn's disease ultimately require one or more operations in their lifetime. Operative indications are the same no matter where the disease manifests itself. © 2010 Brian Wells
    • 19. Thank you! Any questions? © 2010 Brian Wells