Inflammatory Bowel Diseases (IBD) Lecture

1. Ajdabya University – Medical College
General Surgery Department
Dr. Abdulgadir M. Abdulrahman, MD
Inflammatory Bowel Disease (IBD)
Crohn's disease(CD) & Ulcerative colitis(UC)

2. Crohn’s Disease
• Definition : is an idiopathic chronic ,
granulomatous disease that can affect any
part of the GI tract from Mouth -to -Anus .
• This incurable, slowly progressive disease is
characterized by episodes of Exacerbation and
Remissions.
• The incidence is 4/100.000 , with a Bimodal
age distribution at :
• (15 to 29) and (55 to 70)years old .

3. Etiology of Crohn’s Disease
• The cause of CD. is Unknown .
• (Genetic vs. Environmental ) factors .
• Genetic : CD. is 25 times more common with
Family History+ 60 % in monozygotic twins .
• Environmental: Smoking ?

4. Bowel involvement in Crohn’s Disease
• NB: the Terminal ileum is the most common
site of disease and is involved in 75% of the
cases
• Patterns of CD ;Three patterns :
• 1- Ileo-colic disease (40%) of patients
• 2-Small- bowel Only (30%) of patients
• 3-Colonic disease (30%) of patients

5. Patterns of CD ;Three patterns :
1-Ileo-colic disease (40%)
2-Small- bowel Only (30%)
3-Colonic disease (30%)

6. Histology of CD.
• Grossly: the diseased bowel is
• thickened , Creeping fat ,Corkscrew vessels
and Shortened fibrotic mesentery containing
Enlarged Lymph Nodes
1- Bowel Thickening
2- Creeping fat ,
3- Shortened fibrotic mesentery

7. Histology of CD.
• Mucosal changes :
1-Pinpoint Hges , 2- Apthous ulcerations , 3- Deep linear fissures
4- Cobble stoning . 5- Segmental - Skip lesions ,
6- Full thickness bowel involvement ( Transmural inflammation )
= sinuses –fistulas ,7-Granulomas (40-60%)

8. Clinical Presentation of CD
Intestinal :
1-Diarrhea*(not bloody )
2-Abdominal pain
3-Weight loss
4-Anorectal=Fissure/fistulas
5- Constitutional:
malaise/ fever
Extra-intestinal
 Eyes =Conjunctivitis, Iritis,
Uveitis
 Skin= Pyoderma
ganrenosum , Erythema
nodosum , Aphtuos stomatitis
 M.sk = Arthritis
 Hepato-Biliry : sclerosing
cholangitis , Cirrhosis, liver
failure
Highly variable
No Pathognomonic phys. signs to CD

9. Examination of CD case
General Exam: Aphtuos stomatitis (ulcer)
Clubbing , Legs Pyoderma ganrenosum ,
Erythema nodosum ,
Abdominal Exam: A Palpable Mass =thick
edematous bowel, phlegmon, or abscess
Rectal exam : Multiple lesions, lateral anal
fissures ,deep ulcers of the Perianal skin and
anal canal and anal strictures

10. A.. Erythema nodosum:: characteristic red nodular areas on the shins
B.. Pyoderma ganrenosum:: early lesion presents as a pustular and
violaceous plaque with incipient breakdown
C.. Multiple active and healing lesions of Pyoderma ganrenosum

11. Imaging of CD
• 1-Contrast study:
• SBFT, SBE, Water –souluble 2- Endoscopy
• 3-CT-Scan Abdomen with Enteroclysis or
Enterography ( Oral contrast )
• 4- MRI .

12. Differential Diagnosis of CD
• 1-Ulcerative Colitis (UC)
• 2-Appendicitis
• 3-infection ileitis
• 4-others

13. Complications of Crohn’s disease
1-Instetinal Obstruction
2-Bleeding (GI Bleeding )
3- Intractability (failure of medical treatment )
4- Abscess, Fistulas / Stricture ( inflamm. vs
Fibrotic )
5- Perforation / Peritonitis / Acute Toxic colitis

15. Management of Crohn’s disease
1- Adequate Nutrition
2- Medical treatment
3-Surgery , indications : 1- Medical intractability
2- intestinal obstruction
3- Perforation / peritonitis
4- Bleeding
5-Acute toxic colitis

16. Medical Mx of CD
• 1-Mild-to-Moderate disease :
• Oral Aminosalisylate (Sulfasalzine 3-6gms/dayor
Mesalamine1 gm 1x4/day )
• For Ileal/ colonic & perianal disease add
Metronidazole 500 mg 1x3 /day .
• 2- Severe disease = Exclude active infection or
Abscess + Steroid therapy :
• Oral Prednisolone 40-60 mg /day( OPD) or IV-
Hydrocortisone 50-100mg - 6 hourly / day
(Admission in patients )
Disease location
Severity
Complications
Response to ttt. should be within 7 days
Infliximab( Remicade ):monoclonal Ab against TNF is effective in CD with flares & fistulas

17. Surgical therapy of CD.
• The most common indication for surgery iis disease activity that has
• been intractable (which is hard to define) to medical therapy..
• – persistent/progression of symptoms despite adequate medical therapy
• – dependence upon high dose steroids to maintain remission
• – significant treatment-related complications and side effects
• • Colitis/ileo--colitis/ileitis not responding to therapy
• • Obstruction (( e.g.: small bowel strictures))
• • Unequivocal dyspllasiia iin pattiientts wiitth llong--sttandiing colliittiis
• • Suspicion of a malliignantt sttriictture
• • Fistula nott responding to medical therapy
• • Toxic colliittiis/megacolon
• • Intra--abdominal abscesses ((which are most likely due to severe
• disease or ‘‘walled off’’ perforation)
• • Perianal disease (may require surgical drainage)

18. Prognosis of Crohn’s disease
• CD. is a chronic, relapsing, pan –intestinal
disease has No Cure and requires chronic,
• life –long treatment with operation( surgery )
reserved for the severe complications .
• Recently genetic ( NOD2/CARD15) has been
identified inpatients with CD.

21. UC
• Ulcerative colitis (UC) is a mucosal
inflammatory condition of the GI tract
confined to the colon and rectum.
• UC. is an inflammatory disease of the rectum
extending for a variable degree proximally in
the Colon .
• Females > males
• Age of incidence : 20 to 40 years
• Etiology : Unknown ; HLA-27 ass.

22. UC Pathology
• Site : Rectum & Sigmoid colon +/_ Whole colon =
Pan-colitis .
• Gross: Edematous mucosa / Bleeding petechial
Hges. / Extensive Ulcerations/ Pseudo polyps
• Microscopic :
• 1- Crypt abscesses
• 2- Ulcers lined with granulation tissues
• 3-smooth, thin atrophic bowel wall .

23. UC Presentation
Common symptoms associated with UC include
urgency, diarrhea, tenesmus and hematochezia
(Blood) and Mucous
+/- Cramping Abdominal pain
Constipation in 15–20% of patients
Examination :
Tender Left Iliac Fossa
Rectal Exam: Blood on Exam gloves /Edematous
Rectal mucosa
Fever/ Toxemia.

24. The extra-intestinal manifestations:
ass with UC

25. Diagnosis of UC
1- Sigmoidoscopy ( Diagnostic)/ +/_Biopsy
2- Colonoscopy ( Contra-indicated in acute toxic
colitis )= Surveillance T/O Colon cancer (8-10)
yrs
3- Barium Enema ( Contra-indicated in acute
toxic colitis )

26. Imaging in UC
Barium enema radiograph
from a young girl with
chronic ulcerative colitis.
Note the
– shortening of the colon
– loss of haustral markings,
– gives the colon a
characteristic “ lead-pipe”
appearance..

27. Case Challenge
• 55 years old male Patient with history of
ulcerative colitis presented with abdominal
pain and bloody diarrhea.
• The looked sick , Febrile (39) , PR:110/min,
BP:90/60mmHg .
• The abdominal examination: revealed a
distended and mildly tender abdomen with
hypoactive bowel sounds.

28. Abdomen X-ray

29. TOXIC MEGACOLON
• Plain films of the abdomen
showed:
two characteristic features of
ulcerative colitis:
1-megacolon, with the transverse
colon (normal diameter up to 6
cm) dilated to the height of 2.5
vertebrae (vertical arrows)
2– burned-out chronic colitis, with the
left side of the colon showing
foreshortening and a loss of
haustra (arrowheads).

30. Indications for Surgery in UC

32. Thank You