2. IBD
Definition ,Epidemiology ,Etiology and Pathology .
Diagnosis and Activity Assessment :
1. Clinical .
2. Radiological .
3. Endoscopic .
4. Histological .
Treatment of active IBD
3. (IBD)
It is an idiopathic inflammatory intestinal disease resulting from
an inappropriate immune activation to host intestinal
microflora.
Types of IBD are
Ulcerative colitis
Crohn’s disease
Indeterminate colitis
5. Ulcerative Colitis Crohn’s Disease
Age-Specific Incidence of IBD *
Incidence in both CD and UC have 2 peaks
( in 3 rd and 6 th decades ).
10
0
2
4
6
8
0 20 40 60 80
10
0
2
4
6
8
0 20 40 60 80
Age (yrs) Age (yrs)
7. One model of IBD pathogenesis. Aspects of both CD and UC.
8.
9. Comparison of the distribution patterns, ulcers and wall
thickenings of CD and UC.
10. Pathological Features That Differ between CD and UC
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15. Clinical presentation of IBD
A- symptoms:
- diarrhea
- rectal bleeding
- tenesmus
- passage of mucus
- abdominal pain
- other symptoms: anorexia,
nausea, vomiting, fever,
and weight loss
16. B- Signs
Examination findings in CD
Loss of weight
General ill health
Aphthous ulceration of mouth, glossitis angular stomatitis
Abdominal tenderness and RIF mass
Perianal skin tags, fissures, fistulae
17. Examination findings in UC
Hydration & volume status determined by B.P
Pulse rate
High temperature
Abdominal: Tenderness & evidence
of peritoneal inflammation
Presence of blood on DRE
18. Clinical findings That Differ between CD and UC
CD UC
Defecation Often porridge like
,sometimes steatorrhea
Often mucus-like and
with blood
Tenesmus Less common More common
Fever Common Indicates severe
disease
Fistulae Common Seldom
Weight loss Often More seldom
Malignant
potential
With colonic
involvement
Yes
Toxic megacolon No Yes
after surgery Recurrence is common No recurrence
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20.
21. Complication of UC
Haemorrhage
Perforation
Toxic megacolon (transverse colon with a diameter of
more than 5 cm to 6cm with loss of haustration
Cancer: with active colitis of more than eight year
22. Complication of CD
Strictures with intestinal obstruction
Abscesses
Fistulas
Cancer: Risk related to the severity and duration of the disease.
watering-can perineum secondary to severe
perianal Crohn disease.
23. Clinical Assessment of Activity in IBD
A-Ulcerative colitis Clinical Activity Index(UCCAI)
B-Crohn's Disease clinical Activity Indices:
I - Harvey-Bradshaw index
II - Crohn's Disease Activity Index
24. Criteria Mild
Disease
Severe Disease Fulminant Disease
Stools < 4/day > 6/day > 10/day
Blood in stool Intermittent Frequent Continuous
Temperature Normal > 37.5°C > 37.5°C
Pulse Normal > 90 beats/min > 90 beats/min
Hemoglobin Normal < 75% of normal Transfusion required
ESR ≤30 mm/hr > 30 mm/hr > 30 mm/hr
Colonic
features on
radiography
_ Air, edematous wall,
thumbprinting
Dilatation
Clinical signs _ Abdominal
tenderness
Abdominal distention
and tenderness
A-Ulcerative colitis Clinical Activity Index.
Criteria for Evaluating Severity of Ulcerative Colitis
25. B-Crohn's Disease clinical Activity Indices
I - Harvey-Bradshaw index
A-general well-being (0 = very well, 1 = slightly below
average, 2 = poor, 3 = very poor, 4 = terrible)
B- abdominal pain (0 = none, 1 = mild, 2 = moderate, 3 =
severe) .
C- number of liquid stools per day.
D- abdominal mass (0 = none, 1 = dubious, 2 = definite, 3 =
tender) .
E- Complications, with one point for each.
-----------------------------------------------------------------------------
A score of less than 5 represent clinical remission.
26. II - Crohn's Disease Activity Index(CDAI)
Clinical or laboratory variable Weighting factor
Number of liquid or soft stools each day for seven days x 2
Abdominal pain (graded from 0-3 on severity) each day for seven
days
x 5
General well-being, subjectively assessed from 0 (well) to 4
(terrible) each day for seven days
x 7
Presence of complications* x 20
Taking Lomotil or opiates for diarrhea x 30
Presence of an abdominal mass (0 as none, 2 as questionable, 5 as
definite)
x 10
Hematocrit of <0.47 in men and <0.42 in women x 6
Percentage deviation from standard weight x 1
Crohn's Disease Activity Index.
Remission of CD below 150.
Severe CD greater than 450
28. A-Routine blood work
CBC: HB, WBCS and platelets.
Nutritional evaluation:
Vitamin B12 , iron studies, folate & other nutritional
markers
29. B - Serological Markers
ESR
In UC, the correlation between ESR and disease activity is good.
In CD, the ESR appears to be a less accurate measure of disease
activity.
CRP
CRP is a valuable marker to detect the activity of IBD Can be
used as a marker to treatment response
Orosomucoid :
The levels of circulating orosomucoid correlate with
disease activity of IBD.
31. D-Fecal Biomarkers
Fecal calprotectin
Measured in stool by ELISA
sensitive marker of inflammation
Fecal lactoferrin
Measured in stool by ELISA
Sensitive marker of inflammation
Fecal S100A12:
Detectable in serum and stool
But the fecal assay is more sensitive and specific for
IBD
40. Magnetic resonance enterography with gadolinium contrast in
CD. shows mural hyperenhancement, mural thickening, and the comb
sign (engorged perienteric vasculature) involving the terminal ileum.
(signs of active disease ).
41. VI - Wireless capsule endoscopy
(WCE)
VII-Double balloon enteroscopy
42. VIII-Nuclear Medicine
Tc-99m (WBC) imaging is superior to contrast
radiology for assessing the extent and activity of
inflammatory bowel disease. can be used to accurately
distinguish CD from UC .
More recently PET/CT and PET-MRI has been
combined with CT enterography or enteroclysis
techniques to further improve localization and reduce
false positives
47. 2- Endoscopic Indices of IBD Activity
A-Endoscopic assessment of disease activity in the UC
I - The Mayo Score.
II- The Baron Score
III - The Ulcerative Colitis Endoscopic Index of Severity (UCEIS).
B - Endoscopic assessment of disease activity in the CD
I - Crohn’s Disease Endoscopic Index of Severity (CDEIS).
II - Endoscopic Crohn’s Disease Index (SES-CD).
III - Rutgeerts’ score .
48. A - Endoscopic assessment of disease activity in
the ulcerative colitis.
score Endoscopic Findings Disease
severity
0 Normal mucosa , Mucosal healing or
inactive UC
Inactive
1 Mild friability, reduced vascular pattern, and
mucosal erythema
Mild disease
2 Friability, erosions, complete loss of
vascular pattern, and significant erythema
Moderate
disease
3 Ulceration and spontaneous bleeding Sever disease
I - The Mayo Score
49. II-The Baron Score
Endoscopic activity is defined as a Baron Score of >1
score Endoscopic findings
0 Normal mucosa with no bleeding and normal
vascular pattern present throughout the colon
1 Abnormal mucosa that is not expressly hemorrhagic
2 Bleeding with light intervention with an instrument
of the mucosa but no spontaneous bleeding
3 Spontaneous bleeding before the instrument is
introduced.
50. III-The Ulcerative Colitis Endoscopic Index of Severity
(UCEIS) (It is a newer scoring system)
Score Endoscopic findings (vascular pattern)
1 normal vascular pattern
2 partial loss of pattern
3 complete obliteration of vascular pattern
Score Endoscopic findings (Bleeding)
1 none
2 mucosal bleeding
3 mild colonic luminal bleeding
4 moderate or severe luminal bleeding
Score Endoscopic findings (Erosions and ulcers )
1 none
2 erosions
3 superficial ulcerations
4 deep ulcers
51. B - Endoscopic assessment of disease activity in the CD
I - Crohn’s Disease Endoscopic Index of Severity (CDEIS)
Rectum Sigmoid and left colon Transverse colon Right colon Ileum
Total
Deep ulcerations (12 if present) Total 1
Superficial ulcerations (12 if present) Total 2
Surface involved by disease (cm) Total 3
Surface involved by ulcerations (cm) Total 4
Total 1 + Total 2 + Total 3 + Total 4 = Total A
Number of segments totally or partially explored n
Total A ⁄ n = Total B
If an ulcerated stenosis is present anywhere add 3 = C
If a non-ulcerated stenosis is present anywhere add 3= D
Total B + C + D = CDEIS
52. II - Rutgeerts’ score
Grade Endoscopic findings
i0 No lesions in the distal ileum
i1 ≤ 5 apthous lesions
i2 >5 apthous lesions with normal mucosa between the
lesions, or skip areas of larger lesions or lesions
confined to ileocolonic anastomosis
i3 Diffuse apthous ileitis with diffusely inflamed mucosa
i4 Diffuse inflammation with already larger ulcers,
nodules, and ⁄ or narrowing
Rutgeerts’ score is the gold standard for
Endoscopical post-surgical recurrence evaluation
54. Grade 0 Structural (architectural change) Subgrades : 0.0 No
abnormality 0.1 Mild abnormality 0.2 Mild or
moderate diffuse ormultifocal abnormalities 0.3 Severe
diffuse or multifocal abnormalities
Grade 1 Chronic inflammatory infiltrate Subgrades 1.0 No increase
1.1 Mild but unequivocal increase 1.2 Moderate increase
1.3 Marked increase
Grade 2 Lamina propria neutrophils and eosinophils
2A Eosinophils 2B Neutrophils
Grade 3 Neutrophils in epithelium
Grade 4 Crypt destruction
Grade 5 Erosion or ulceration.
A - Histological Assessment of activity in UC
Histologic scoring system for the assessment of severity in UC.
55. B - Histological Assessment of activity in CD
Histologic findings Score
Epithelial damage 0-2
Architectural changes 0-2
Mononuclear infiltrate in LP 0-2
PMN infiltrate in epithelium 0-3
Erosion / ulcers 0-1
Granulomas 0-1
Proportion of biopsies affected 0-3
Pointes of histologic assessment of disease activity in CD
56. Fig. 14:UC. Mucosal atrophy with loss
of crypts. Neutrophils are still present
in the lumen and wall of one of the
crypts indicating persistent activity.
(H&E x10).
Fig.15: CD Stomach. Gastric mucosal
biopsy containing two characteristic
granulomas. (H&E x10).
66. General Care
Proper resuscitation.
Hospitalization.
Bowel rest to reduces the volume of diarrhea.
Blood products should be administered to treat
significant anemia or coagulopathy.
Pain relievers. Acetaminophen.
Iron supplements.
Nutrition(TPN).
Avoid (Narcotics, antidiarrheal agents and
anticholinergic ) can precipitate toxic dilation of the
colon.
68. Oral
•Varies by agent: may be released in the
distal/terminal ileum, or colon1
Distribution of 5-ASA Preparations
Suppositories
• Reach the upper rectum2,5
(15-20 cm beyond the anal verge)
Liquid Enemas
• May reach the splenic flexure2-4
• Do not frequently concentrate in the rectum3
1. Sandborn WJ, et al. Aliment Pharmacol Ther. 2003;17:29-42; 2. Regueiro M, et al. Inflamm Bowel Dis. 2006;12:972–978; 3. Van Bodegraven AA,
et al. Aliment Pharmacol Ther. 1996; 10:327-332; 4. Chapman NJ, et al. Mayo Clin Proc. 1992;62:245-248; 5. Williams CN, et al. Dig Dis Sci. 1987;32:71S-75S.
1- 5-ASA; Sulfasalazine (Supp. , enemas or Oral)
69.
70. 2 - Hydrocortisone or Methylprednisolone (IV , Oral or
enema)
Fast symptom relief
40 to 60 mg/day in a continuous I.V. infusion
5 to 10 days
Not advised for prolonged use (120 day max)
Does not improve long term surgery rates
3 - Ciprofloxacin +/- Metronidazole
Effectiveness arguable but often seen used anyway
71. 4 - IV Cyclosporine 2-4 mg/kg
Effective for induction of remission but not long-term
maintenance
Patients who did not respond to I.V. steroid
If no improvement within 4 to 5 days or if complete
remission is not achieved by 10 to 14 days, surgical
treatment is advised. (32)
5 - Infliximab is currently approved for use in IBD
Induction- 3 separate infusions of 5 mg/kg for
moderate to severe IBD at weeks 0, 2, and 6
Maintenance- infusions every 8 weeks
75. 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
*Current Surgical Therapy 9th Edition
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77. Artwork is reproduced, with permission, from the Johns Hopkins Gastroenterology and Hepatology Resource
Center,
78. 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
80. Artwork is reproduced, with permission, from the Johns Hopkins Gastroenterology and Hepatology Resource Center,
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