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Ulcerative Colitis
Ulcerative Colitis
Ulcerative Colitis
Ulcerative Colitis
Ulcerative Colitis
Ulcerative Colitis
Ulcerative Colitis
Ulcerative Colitis
Ulcerative Colitis
Ulcerative Colitis
Ulcerative Colitis
Ulcerative Colitis
Ulcerative Colitis
Ulcerative Colitis
Ulcerative Colitis
Ulcerative Colitis
Ulcerative Colitis
Ulcerative Colitis
Ulcerative Colitis
Ulcerative Colitis
Ulcerative Colitis
Ulcerative Colitis
Ulcerative Colitis
Ulcerative Colitis
Ulcerative Colitis
Ulcerative Colitis
Ulcerative Colitis
Ulcerative Colitis
Ulcerative Colitis
Ulcerative Colitis
Ulcerative Colitis
Ulcerative Colitis
Ulcerative Colitis
Ulcerative Colitis
Ulcerative Colitis
Ulcerative Colitis
Ulcerative Colitis
Ulcerative Colitis
Ulcerative Colitis
Ulcerative Colitis
Ulcerative Colitis
Ulcerative Colitis
Ulcerative Colitis
Ulcerative Colitis
Ulcerative Colitis
Ulcerative Colitis
Ulcerative Colitis
Ulcerative Colitis
Ulcerative Colitis
Ulcerative Colitis
Ulcerative Colitis
Ulcerative Colitis
Ulcerative Colitis
Ulcerative Colitis
Ulcerative Colitis
Ulcerative Colitis
Ulcerative Colitis
Ulcerative Colitis
Ulcerative Colitis
Ulcerative Colitis
Ulcerative Colitis
Ulcerative Colitis
Ulcerative Colitis
Ulcerative Colitis
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Ulcerative Colitis

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Inflammatory Bowel Diseases are commonly Crohn's disease and Ulcerative Colitis. Both are also grouped under psychosomatic disorders. Ulcerative colitis is a chronic disease that causes bleeding from …

Inflammatory Bowel Diseases are commonly Crohn's disease and Ulcerative Colitis. Both are also grouped under psychosomatic disorders. Ulcerative colitis is a chronic disease that causes bleeding from the anus and it is very difficult to treat.

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  • 1. Ulcerative Colitis
  • 2. INFLAMMATORY BOWEL DISEASE 1. Refers to two chronic diseases that cause inflammation of the intestine: Ulcerative colitis and Crohn's disease. 2. Although the diseases have some features in common, there are some important differences.
  • 3. Epidemiology  Ulcerative Colitis: – High incidence areas: US, UK, northern Europe – Young adults, commoner in females  Crohn's Disease: – 1st peak 15-30 years of age, 2nd peak around 60 y INCIDENCE IS ON THE RISE IN ASIAN (INDIA) POPULATION
  • 4. Rise of Incidence in IBD in India         Familial aggregation Nicotine Consumption Oral Contraceptives Dietary Habits-Refined sugars, Fast food, cereals, bakers yeast etc Physical inactivity Early weaning Hygiene Infectious diseases- TB, Measles
  • 5. Ulcerative Colitis A mucosal disease usually involves rectum and extended proximally to involve all or a part of colon. Small intestine is not involved
  • 6. Ulcerative Colitis 40-50% 30-40% 20% When the whole colon is involved, inflammation extends 1-2 cm in Terminal ileum ( Back wash ileitis)
  • 7. The major symptoms of UC are: - Diarrhea - Rectal bleeding - Tenesmus - Passage of mucus - Crampy abdominal pain - Loss of weight
  • 8. MILD BOWEL MOVEMENTS BLOOD IN STOOL FEVER TACHYCARDIA ANEMIA SEDIMENTATION RATE MODERATE SEVERE < 4 per day 4-6 per day small moderate >6 per day <37,5 C <90 mean pulse >75% > 37,5 C >90 mean pulse <75% >30mm none none mild <30mm Severe
  • 9.  Clinical history  Physical examination  Laboratory tests  Colonoscopy  X-ray findings  Tissue biopsy (pathology)
  • 10. COLONOSCOPY : IBD  Diagnosis of IBD (UC vs. CD)  Allows visualization of large intestine and ileum  Allows biopsies to examine colon tissue  Determines activity of disease  Important for pre-cancer surveillance in UC and CD
  • 11. COLONSCOPY : UC
  • 12. Normal UC
  • 13. Colonic pseudopolyps
  • 14. Microscopic Findings in UC
  • 15. Yes Yes Occasionally Crohn’s disease Occasionally Occasionally Frequently Occasionally Rarely Frequently Yes No Frequently U. Colitis Blood in stool Mucus Systemic symptoms Pain Abdominal mass Perineal disease
  • 16. No No Crohn’s disease Yes Frequently Rarely Frequently No Yes No Yes U. Colitis Fistulas Small intestine obstruction Colonic obstruction Response to antibiotic Recurrence after surgery
  • 17. Rarely Yes Crohn’s disease Frequently Occasionally No Yes No Occasionally U. Colitis Rectal sparing Continuous disease “Cobble stoning” Granuloma on biopsy
  • 18. Serpiginous ulcer, a classic finding in Crohn's disease
  • 19. Pathologic features of Crohn's Disease and Ulcerative Colitis Crohn's Disease Ulcerative Colitis Feature Transmural inflammation Yes Uncommon Granulomas 50-75% No Fissures Common Rare Fibrosis Common No Submucosal inflammation Common Uncommon
  • 20. Clinicopathological comparison of CD,UC and GITB Features % CD UC GITB Diarrhoea 70 100 35 Hematoch. 40 100 0 Rectal Sym 10 100 0 Abd. Pain 55 25 85 Obst.Symt. 0 0 35 Fever 10 15 35 Wt loss 55 40 75 Lump 20 0 45 Fistula 20 0 0 Perianal les 20 5 0 Pallor 55 60 50 Smoking 25 5 25 Past h/o ATT 50 0 0
  • 21. Salient Distinguishing Features of GI TB  Granuloma more than 400 u in maximum dimension  More than 4 sites of granulomaper site  Band of epitheloid histiocytes in ulcer bases  Granuloma located in the caecum
  • 22. Algorithm TB for pts with GI  Pt with suspected TB        Endoscopy with multiple deep biospies Histopathology AFB smear AFB Culture Positive for TB – Start ATT Negative for TB– search for extraintestinal features of CD Laparascopy /Lap assited enteroscopy+BX
  • 23.  Hemorrhage  Perforation  Stricture  Toxic megacolon (transverse colon with a diameter of more than 5.0 cm to 6.0 cm with loss of haustration)  Malabsorbtion  Obstruction  Possibility of malignant transformation?
  • 24. Inflammatory Bowel Disease  CHRONIC DISORDER  INCURABLE  LIFE TIME TREATMENT
  • 25. Goals of Therapy for UC  Inducing remission  Maintaining remission  Restoring and maintaining nutrition  Maintaining patient’s quality of life  Surgical intervention (selection of optimal time for surgery)
  • 26. Medical treatment Aminosalicylates (5-ASA) Glucocorticoids Azathioprine or 6-MP Cyclosporine Infliximab Low roughage diet No milk Sometimes TPN
  • 27. 5-Aminosalicylic Acids Sulfasalazine Olsalazine Balsalazide Asacol Rowasa Enema Pentasa Canasa Suppository
  • 28. 5-Aminosalicylic Acids  The mainstay treatment of mild to moderately active • Ulcerative Colitis and Crohn's Disease 5-ASA may act by - Blocking the production of prostaglandins and leukotrienes  5-ASA absorbed in small intestine - Do not reach colon - Hence need delivery system - 2 types of delivery systems  pH dependent resin or semi permeable membrane  5-ASA +bond (like sulfasalazine)
  • 29. Oral 5-ASA Release Sites Pentasa® Asacol® AZOCOMPOUNDS Stomach Small Intestine Large Intestine Mesalamine in microgranules Mesalamine w/ eudragit-S Azo bond
  • 30. Benefits      Well-tolerated Few side effects Relatively inexpensive Oral or Rectal Safe for all ages & pregnancy Risks   Not helpful in severe disease side effects - skin rashes - Fever - Arthralgia - Agranulocytosis - Pancreatitis - Hepatitis - Male infertility
  • 31.  Topical corticosteroids can be used as an alternative to 5- ASA in ulcerative proctitis or distal Ulcerative Colitis.  Oral prednisone or prednisolone is used for moderately severe Ulcerative Colitis or Crohn's Disease,( for about 1 month) in doses ranging up to 60 mg per day.  IV is warranted for patients who are sufficiently ill to require hospitalization; the majority will have a response within 7 to 10 days.
  • 32. Benefits  Induces remissions in UC and CD  Inexpensive  Oral or rectal Risks  No long-term benefits  Numerous side effects – Cushingoid changes – Hypertension – Diabetes – Osteoporosis – Acne – Cataracts – Depression – Growth retardation
  • 33.  No proven maintenance benefit in the treatment of either Ulcerative Colitis or Crohn's Disease.  Budesonide: – less side effects, – its use is limited to patients with distal ileal and right- sided colonic disease
  • 34. Immunosuppressive Agents  These agents are generally appropriate for patients in whom the dose of corticosteroids cannot be tapered or discontinued.  Azathioprine & 6-MP – The most extensively used immunosuppressive agents. – The mechanisms of action unknown but may include suppressing the generation of a specific subgroup of T cells. – The onset of benefit takes several weeks up to six months.
  • 35.  Long-term (maintenance) treatments for UC or CD  Can treat fistulas in CD over long-term  Primarily for patients unable to get off steroids  Requires continuous monitoring of blood tests
  • 36. Benefits  “Steroid-sparing” in UC and CD  Long-term maintenance  Relatively inexpensive Risks  Can lower blood counts and “immunity”  Requires long-term monitoring  Occasional allergies – Pancreatitis – Fever
  • 37. Maintenance Therapies for Ulcerative Colitis  Aminosalicylates  Azathioprine/6-MP
  • 38. Immunosuppressive Agents  Methotrexate – Effective in steroid-dependent active Crohn's Disease and in maintaining remission. – Potential side effects and risks include nausea, vomiting, infections, bone marrow suppression, liver inflammation,.  Cyclosporine – Severe Ulcerative Colitis not responding to IV steroid &need urgent proctocolectomy. – 50% of the responders will need surgery within a year.
  • 39. Benefits  Effective in severe UC  Works rapidly Risks  Renal insufficiency  Seizures  Hypertension  Electrolytes abnormalities
  • 40. Cyclosporine in Patients with Severe Ulcerative Colitis 20 Patients 11 Cyclosporine 9 2 Response No Response: surgery 1 8 Elective colectomy Oral Cyclosporine Lichtiger S et al. NEJM 1994
  • 41. Anti-TNF Therapy: Infliximab  Monoclonal antibody, binds soluble TNF.  Prompt onset, effects takes 6 weeks to max of 6m.  Indicated in fistulizing Crohns, refractory Crohn's Disease and refractory Ulcerative Colitis
  • 42. Benefits     Induces and maintains remissions in CD Rapidly relieves symptoms & fistula drainage Steroid-sparing Effective even when other therapies fail Risks     Reactions to intravenous infusions Development of antibodies and loss of response Reactivation of TB Expensive
  • 43. Other therapies in UC  Probiotics  Nicotine (immunomodulation & increase free oxygen radicals  Heparin (antiinflammatory & immunomodulatory) • Natalizumab (anti-adhesion molecule) • Daclizumab (monoclonal antibody) • Basiliximab (monoclonal antibody) • Visilizumab (monoclonal antibody) • Leukocytapheresis • Porcine whipworm (Trichuri – suis) • Nutritional therapy (short chain fatty acid butyrate and fish oil containing eicosapentanoic acid)
  • 44. Treatment of Active UP  Topical therapy preferred treatment  Corticosteroids and 5-ASAs available in many forms – suppositories reach the upper rectum – enemas reach splenic flexure and the distal transverse colon Proximal distribution of topical preparations Adapted with permission from: Marshall JK, Irvine EJ. Am J Gastroenterol 2000; 95: 1628-1636.
  • 45. Therapeutic Pyramid for Active UC Severe Surgery Cyclosporine Moderate Infliximab Systemic Corticosteroids Oral Steroids Mild Aminosalicylates AZA/6-MP
  • 46. Ulcerative Colitis  Surgery (colectomy), is curative  Colectomy & ileostomy  Colectomy & ileo-anal Anastomosis (J-pouch) Crohn’s Disease  Surgery does not cure  Disease recurs after a resection  Resection of inflamed segments to treat complications or “refractory” disease
  • 47. Surgery in UC : why & when?  Uncontrollable colonic hemorrhage  Failure to control severe attacks or toxic megacolon  Colonic perforation  Chronic symptoms despite medical therapy  Medication side effects without disease control  Dysplasia or Cancer  Growth retardation
  • 48. Surgery in UC : why & when? Intractability: - Colitis refractory to medical management - Often due to side effects of medical treatments - Most common indication for operation Dysplasia/Carcinoma: - high-grade dysplasia : absolute indication Massive Colonic Bleeding: - very infrequent; less than 5% of urgent UC colectomies Toxic Megacolon: - acute colitis accompanied by significant colonic dilatation - high fever, severe abdominal pain,tachycardia, leukocytosis - predisposed to perforation - treatment: IVF resuscitation, antibiotics, steroids, immunosuppressives - clinical deterioration despite above : urgent operation
  • 49. Total Proctocolectomy with End-Ileostomy: - removes entire colon, rectum, and anus - performed in one stage; avoids problems of multiple operations - disadvantages: permanent stoma, problems with healing perineal wound Total Abdominal Colectomy with Hartmann’s Closure or Mucous Fistula: - used in acutely sick patients (fulminant colitis, toxic megacolon) Total Proctocolectomy with Ileal Pouch-Anal Anastomosis: - gold standard - requires good anorectal function and sphincter tone - generally performed on patients younger than 65
  • 50. Complications of UC Surgery  Mortality (<0.5%)  3-10 stools/24 hrs so bowel pattern not normal  Impotence (1.5%)  Pouchitis (10-60%)  Small bowel obstruction (20%)  Decrease in female fertility (56-98%)  Pouch-vaginal fistula (4%)
  • 51. Restore quality of life
  • 52. Herbal Food Supplements Holarhena Antidysentrica Oroxylum Indicum Bombax Malabarica Myristica Fragrance Punica Granatum
  • 53.  It is a chronic disorders  Need to exclude other possibilities  Need to differentiate between the two  Need long term management with primary goal to induce then maintain remission and prevent complications of both the disease and drugs.

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