Post-graduate presentation on Inflammatory Bowel Disease

1. Inflammatory Bowel
Disease
Seminar by:
DR. ABDUL KAREEM
Ist Year DNB Resident
Department of Internal Medicine
Rohini Super-specialty Hospitals

2. INTRODUCTION
• IBD is a chronic condition resulting from inappropriate
mucosal immune activation
• Comprises two main disorders:
• Ulcerative colitis (UC)
• Crohn’s disease (CD)
• Difference mainly based on distribution of disease and
morphology of lesions

5. EPIDEMIOLOGY

6. Jameson, J. L. (2018).
Harrison’s Principles of
Internal Medicine (20th
ed.). New York: McGraw-
Hill Education.

7. EPIDEMIOLOGY
• Highest incidence in Western countries like USA, Canada, less in
Eastern countries like India, China, Japan
• Incidence increasing with Westernisation of Eastern countries
• Higher incidence in immigrant Asians than native Western
population
• Suggests environmental factors like diet

8. EPIDEMIOLOGY
• OCP use associated with Crohn’s (UC only in smokers)
• Infectious gastro-enteritis (pathogens like Salmonella,
Shigella, Campylobacter spp., Clostridium difficile)
increases IBD risk by 2-3 times
• Breastfeeding has protective role.

9. EPIDEMIOLOGY
• Diet:
• Increased risk → High in animal protein, sugars, sweets, oils,
fish and shellfish, and dietary fat, especially ω-6 fatty acids,
and low in ω-3 fatty acids
• Vitamin D is protective

10. EPIDEMIOLOGY
• Genetics:
• Familial in 5-10% cases
• Show early onset
• CD shows genetic association whereas UC has low
association

11. IBD PHENOTYPES
• Racial differences in IBD location & behavior is seen.
• Americans, Hispanics → Ileo-colonic CD
• East Asians → Ileo-colonic CD most common
peri-anal disease more than Caucasians
• African
Americans,
Hispanics,
Asians
→
Pan-colonic UC more common
than left sided or proctitis

12. IBD PHENOTYPES
• Extra-intestinal manifestations
• African Americans → Joint involvement m/c, ocular
• Hispanics → Dermatologic manifestations

13. ETIOLOGY & PATHOGENESIS
• 3 major host components
1. Commensal microbiota
2. Intestinal Epithelial cells (IECs)
3. Immune cells
• Together function as a ‘supra-organism’
• Disruption of this homeostasis leads to a chronic state of
dysregulated inflammation that is IBD

14. Jameson, J. L. (2018).
Harrison’s Principles of
Internal Medicine (20th
ed.). New York: McGraw-
Hill Education.

15. Jameson, J. L. (2018).
Harrison’s Principles of
Internal Medicine (20th
ed.). New York: McGraw-
Hill Education.

16. GENETIC CONSIDERATIONS
• Few IBD phenotypes are associated with genetic
disorders
• Mainly involve genes coding for inflammatory factors

17. Jameson, J. L. (2018).
Harrison’s Principles of
Internal Medicine (20th
ed.). New York: McGraw-
Hill Education.

18. Jameson, J. L. (2018).
Harrison’s Principles of
Internal Medicine (20th
ed.). New York: McGraw-
Hill Education.

19. PATHOLOGY
• Ulcerative Colitis →
• Involves rectum, extends proximally to colon
• 40 – 50% → limited to rectum & recto-sigmoid
• 30 – 40% → beyond sigmoid
• 20% → total colitis
• In total colitis, 10 – 20% have ‘backwash ileitis’, which is mild,
superficial and of little clinical significance

20. Jameson, J. L. (2018). Harrison’s Principles of Internal Medicine (20th ed.). New York: McGraw-Hill Education

21. PATHOLOGY
• Ulcerative Colitis → Only mucosa involved
• Mild → Erythematous, sandpaper appearance
• Severe → Haemorrhagic, edematous, ulcerated
• Long-standing → inflammatory polyps (pseudopolyps)
• Medical therapy may change appearance
• Fulminant disease → toxic colitis/megacolon → perforation

22. PATHOLOGY
• Crohn’s Disease →
• Can affect any part of small or large intestine
• 30 – 40% → only small bowel
• 40 – 55% → both small & large bowel
• 15 – 25% → only colitis
• If small intestine involved, 90% have terminal ileum
involvement

23. PATHOLOGY
• Crohn’s Disease →
• Transmural process (unlike UC which is only mucosal)
• Mild → aphthous / superficial ulcerations
• Active → stellate ulcerations fuse longitudinally, with islands
of normal mucosa – ‘cobblestone’ appearance (endoscopy,
barium x-ray)
• Pseudopolyps seen like in UC

24. PATHOLOGY
• Crohn’s Disease →
• Focal inflammation → fistula tracts → fibrosis → strictures
• Bowel wall → thickened, fibrotic → chronic recurrent bowel
obstructions
• Thickened mesentery → projections into bowel (‘creeping fat’)
• Serosa & mesentery inflammation → adhesions, fistulas

25. Jameson, J. L. (2018). Harrison’s Principles of Internal Medicine (20th ed.). New York: McGraw-Hill Education

26. CLINICAL PRESENTATION:
ULCERATIVE COLITIS
• Major symptoms of UC are diarrhea, rectal bleeding, tenesmus,
passage of mucus, and crampy abdominal pain.
• Severity of symptoms correlates with the extent of disease.
• Although UC can present acutely, symptoms usually have been
present for weeks to months.
• Severe pain not a prominent symptom in UC. May have
abdominal discomfort & cramping

27. CLINICAL PRESENTATION:
ULCERATIVE COLITIS
• Diarrhea → usually nocturnal or post-prandial
• Proctitis → tender anal canal & bleeding on PR exam, severe
disease → tenderness directly over colon on palpation
• Megacolon → hepatic tympany
• Signs of peritonitis if perforation has occured

28. Jameson, J. L. (2018).
Harrison’s Principles of
Internal Medicine (20th ed.).
New York: McGraw-Hill
Education.

29. LABORATORY EXAMINATION:
ULCERATIVE COLITIS
• Active disease → ↑ acute phase reactants (↑CRP, ↑ESR), platelet
count, ↓ hemoglobin
• Fecal lactoferrin → highly sensitive & specific marker for intestinal
inflammation
• Fecal calprotectin → correlates with inflammation, predicts relapses,
and detects pouchitis.
• Both important for D/D versus irritable bowel & bacterial overgrowth

30. LABORATORY EXAMINATION:
ULCERATIVE COLITIS
• Proctitis or proctosigmoiditis rarely causes CRP elevation.
• Diagnosis → history, symptoms, negative stool exam for
bacteria, C. diff. toxin, ova, parasites, sigmoidoscopic
appearance & biopsy.
• Sigmoidoscopy done before starting treatment. Colonoscopy is
done if not an acute flare, to assess disease extent & activity

31. Jameson, J. L. (2018). Harrison’s Principles of Internal Medicine (20th ed.). New York: McGraw-Hill Education.

32. ULCERATIVE COLITIS:
COMPLICATIONS
• Only 15% present with catastrophic illness
• Massive bleeding → 1% patients, if > 6-8 units of blood needed within
24-48 hrs., colectomy indicated
• Toxic megacolon → If diameter > 6 cm, seen in 5%, triggered by
electrolyte abnormalities & narcotics
• Perforation → most dangerous complication, symptoms may be
masked by glucocorticoids
• Strictures occur in 5-10% patients, if impassable with colonoscope,
must be assumed malignant until proven otherwise.

33. CLINICAL PRESENTATION:
CROHN DISEASE
• Ileocolitis: m/c site of inflammation is terminal ileum → Rt. Lower
quadrant pain & diarrhea (mimics appendicitis), low grade fever present
(high grade implies abscess formation), weight loss.
• Inflammatory mass may be seen which consists of bowel, mesentery
and lymph nodes.
• ‘String sign’ on barium studies due to severely narrowed bowel lumen
• Bowel obstruction may occur due to chronic inflammation.

34. CLINICAL PRESENTATION:
CROHN DISEASE
• Jejuno-ileitis: Loss of digestive surface causes malabsorption &
steatorrhea, nutritional deficiencies, anemia etc. Patients need daily
multivitamin, calcium & Vit D supplements
• Colitis & peri-anal disease: low grade fever, malaise, diarrhea, crampy
abdominal pain, and sometimes hematochezia. Gross bleeding is not as
common as in UC. Stricturing can occur in the colon in 4–16%. Perianal
disease affects about one-third of patients.
• Gastro-duodenal disease: Nausea, vomiting, epigastric pain. H. pylori
negative gastritis. Fistulas, gastric outlet obstruction may develop. More
common in children.

35. LABORATORY EXAMINATION:
CROHN DISEASE
• Elevated CRP, ESR
• Fecal lactoferrin & calprotectin useful in D/D
• Endoscopy: rectal sparing, aphthous ulceration, fistulas, skip
lesions. Biopsy of masses or strictures can be done.
• Wireless capsule endoscopy (WCE) is superior to CT & MRE.
• ‘Cobblestoning’ → early radiographic finding, thickened folds &
aphthous ulcerations

36. CROHN DISEASE: COMPLICATIONS
• Because CD is transmural, serosal adhesions develop which
provide direct pathways for fistula formation & reduce free
perforation.
• Perforation occurs in 1-2% patients. Peritonitis may be fatal.
• Abscesses – Intra-abdominal & pelvic, occur in 10-30% of
patients. CT-guided percutaneous drainage is standard therapy.
• Intestinal obstruction may occur in 40%, hemorrhage,
malabsorption, severe peri-anal disease.

37. CROHN DISEASE:
SEROLOGIC MARKERS
• Increased levels of perinuclear antineutrophil cytoplasmic
antibodies (pANCA) more commonly seen in patients with UC
• Anti-Saccharomyces cerevisiae antibodies (ASCAs) have been
associated with CD
• Low sensitivity & specificity, minimal clinical utility.

38. DIFFERENTIAL DIAGNOSIS
• No key diagnostic test, hence a combination of features is used.
• In 15% cases, UC & CD cannot be differentiated, called
indeterminate colitis. Often becomes clear in later course of the
disease.

39. Jameson, J. L. (2018).
Harrison’s Principles of
Internal Medicine (20th
ed.). New York: McGraw-
Hill Education.

40. Jameson, J. L. (2018).
Harrison’s Principles of
Internal Medicine (20th
ed.). New York: McGraw-
Hill Education.

41. EXTRA-INTESTNAL
MANIFESTATIONS (EIM)
• Up to 1/3rd of patients have extra-intestinal manifestations
• Dermatologic: Erythema nodosum (EN) occurs in 10% of UC &
15% of CD patients, correlate with bowel activity
• Pyoderma gangrenosum (PG) seen in 1-12% of UC & less
commons in Crohn’s
• Psoriasis occurs in 5-10% of IBD, unrelated to bowel activity.
Sweet syndrome, oral mucosal lesions may be seen.

42. EXTRA-INTESTNAL
MANIFESTATIONS (EIM)
• Rheumatologic: 15-20% IBD patients have peripheral
arthritis, related to bowel activity.
• Ankylosing spondylitis occurs in 10% IBD pts. (CD>UC), not
related to bowel activity.
• Ocular: Incidence is 1-10%. Most common are
conjunctivitis, anterior uveitis/iritis, and episcleritis.

43. EXTRA-INTESTNAL
MANIFESTATIONS (EIM)
• Hepato-biliary: Hepatic steatosis & cholelithiasis is common.
• Primary sclerosing cholangitis (PSC): Intra-hepatic &
extrahepatic bile duct inflammation & fibrosis. In 5% UC pts., less
in CD. Both PSC & IBD are usually pANCA (+)ve. Gold standard
is ERCP. MRCP is more sensitive, specific & safer. Gallbladder
polyps have high risk of malignancy. Symptomatic patients
develop liver failure within 5-10 yrs needing transplant.
• Variant of PSC called ‘small duct primary sclerosing cholangitis’
or ‘pericholangitis’ has better prognosis.

44. EXTRA-INTESTNAL
MANIFESTATIONS (EIM)
• Urologic: Calculi, ureteral obstruction & ileal bladder fistulas
common. Calcium oxalate stones develop due to increased
absorption of dietary oxalate.
• Metabolic bone disorders: Low bone mass / osteoporosis
develops in 14-42% pts., risk increased by drugs.
Osteonecrosis may develop within 6 months of starting
glucocorticoids.

45. EXTRA-INTESTNAL
MANIFESTATIONS (EIM)
• Thrombo-embolic: IBD is a hypercoagulable state with
increased risk of arterial & venous thrombosis even in
inactive disease. Small, medium & large vessel vasculitides
have also been observed.
• Others: endocarditis, myocarditis, pleuro-pericarditis,
interstitial lung disease, amyloidosis, pancreatitis may be
seen.

46. TREATMENT
• 5-ASA agents
• Glucocorticoids
• Antibiotics
• Azathioprine & 6-MP
• Methotrexate
• Cyclosporine
• Tacrolimus
• Biologic therapies
• Anti-TNF therapies
• Anti-integrins
• Therapies in development
• Nutritional therapies
• Surgical therapy

47. Jameson, J. L. (2018).
Harrison’s Principles of
Internal Medicine (20th ed.).
New York: McGraw-Hill
Education.

48. 5-ASA Agents
• Anti-inflammatory agents, related to NSAIDs & salicylates
• Convenient delivery, only partial absorption from gut
• UC → Induces & maintains remission
• CD → Induces but no clear role in maintenance
• High rate of side effects → headache, anorexia, nausea, vomiting,
hepatitis, agranulocytosis, pancreatitis, reversible sperm anomalies.
• Preparations without sulpha have lesser side effects

49. Jameson, J. L. (2018). Harrison’s Principles of Internal Medicine (20th ed.). New York: McGraw-Hill
Education.

50. Glucocorticoids
• UC:
• Prednisone (oral) started at 40 – 60 mg/ day for active UC
unresponsive to 5-ASA therapy
• Parenteral → Hydrocortisone 300 mg / day (or) methyl-
prednisolone 40 – 60 mg / day
• New → Budesonide → released entirely in colon, no side-effects,
dose = 9 mg / day for 8 weeks, no taper required
• Topical route may be used for distal colitis & rectal involvement

51. Glucocorticoids
• Crohn’s:
• 60 – 70% remission rate in moderate to severe CD
• Budesonide 9 mg / day for 2-3 months
• Steroids have no role in maintenance in either UC or CD,
only useful in induction.

52. Antibiotics
• UC:
• No role in active or quiescent UC
• Only pouchitis responds well to metronidazole and/or ciprofloxacin
• CD:
• Metronidazole effective in inflammatory, fistulising & peri-anal CD
• 15 – 20 mg / day in 3 divided doses
• Ciprofloxacin also effective
• Used only for short periods due to side effects

53. Azathioprine & 6-MP
• Used along with biologic therapy
• Azathioprine converted to 6-mercapto-purine, then metabolized to
active product thio-inosinic acid
• Adherence can be monitored by measuring the levels of 6-thioguanine
and 6-methyl-mercaptopurine, end products of 6-MP metabolism
• Side effects → Usually well-tolerated. Pancreatitis (3-4%), bone
marrow depression (dose-related), nausea, fever, rash, hepatitis.
• Few individuals have enzyme deficiency that may lead to toxicity
hence CBP & LFTs must be monitored

54. Methotrexate (MTX)
• Used along with biologic therapy
• DHFR inhibitor → ↓DNA synthesis; also ↓IL-1 production
• IM / SC dose → 15 – 25 mg / week
• Side effects → Leukopenia, hepatic fibrosis (needs CBP &
LFT monitoring), hypersensitivity pneumonitis (rare but
serious)

55. Cyclosporine (CSA)
• Inhibitory effects on both cellular & humoral immunity
• Most effective at 2–4 mg/kg IV in severe UC refractory to IV steroids
• Significant toxicity → Renal function must be monitored, discontinue if
elevated.
• Hypertension, gingival hyperplasia, hypertrichosis, paresthesias,
tremors, headaches, and electrolyte abnormalities. Hypomagnesemia
or low sr. cholesterol may cause seizures.

56. Tacrolimus
• Macrolide antibiotic with immunomodulatory properties
similar to cyclosporine, 100 times more potent
• Not dependant on bile or mucosa for absorption, therefore
good for proximal small bowel involvement in Crohn’s
• Effective in children with refractory IBD, adults with steroid
dependant / resistant UC/CD and refractory fistulising CD

57. BIOLOGIC THERAPIES
• Now given as initial therapy for moderate to severe UC or CD
• Patients who respond show improvement in clinical symptoms; better
quality of life; less disability, fatigue, depression; fewer surgeries and
hospitalizations.
• Include:
• Anti-TNF agents
• Anti-integrin agents

58. Anti-TNF therapies
• Infliximab
• Chimeric IgG1 antibody against TNF-α
• 5 mg/kg infusions every 8 weeks
• Refractory patients to IV steroids, 6-MP, 5-ASA show 65% response and 33%
complete remission, 40% maintain remission for 1 year
• Adalimumab → recombinant human monoclonal IgG1 antibody, containing only
human peptide sequence and S/C route
• Certolizumab pegol → pegylated form of an anti-TNF Fab portion of an antibody
administered SC once monthly
• Golimumab → another fully human IgG1 antibody against TNF-α, S/C route

59. Anti-TNF therapies
• Side effects:
• Development of antibodies: hence periodic infusions are given (every
8 wks) compared to on-demand infusions, Aza, 6-MP or MTX added
to prevent this.
• Lymphomas: NHL, Hepatosplenic T-cell lymphoma (HSTCL,
universally fatal)
• Skin lesions: psoriasiform skin lesions, 2x melanoma risk
• Infections: latent TB reactivation, fungal inf.
• Hep B reactivation, liver injury

60. Anti-integrins
• Natalizumab:
• Recombinant humanized IgG4 antibody against α4-integrin
• Effective in induction & maintenance in CD patients
• 300 mg every 4 weeks IV
• No longer widely used due to risk of leuko-encephalopathy (PMLE) due to JC
virus (virus screening can be done using antibody)
• Vedolizumab: Specific α4β7 integrin antibody, gut-selective, can be given in JC virus
antibody positive patients
• Ustekinumab: fully human IgG1 monoclonal antibody, blocks IL-12 and IL-23 through
common p40 subunit

61. THERAPIES IN DEVELOPMENT
• Tofacitinib: Oral inhibitor of Janus kinase 1, 3, and lesser extent 2,
effective in moderate to severe UC in trials
• Biosimilars: Have lower cost than the original drug with same activity,
many are in development.
• Ozanimod: Oral agonist of sphingosine-1-phosphate receptor types 1
& 5. Decreases activated lymphocytes in the GIT, in Phase III trial.

62. NUTRITIONAL THERAPY
• UC:
• No reduction in inflammation with dietary intervention.
• CD:
• Bowel rest & TPN as effective as glucocorticoids for inducing remission
on CD (not effective in maintenance).
• Enteral diets (elemental or peptide-based) are equally effective, without
side-effects of TPN, but not palatable.

63. Jameson, J. L. (2018).
Harrison’s Principles of
Internal Medicine (20th ed.).
New York: McGraw-Hill
Education.

64. SURGICAL THERAPY
• UC:
• Nearly 50% undergo surgery in first 10 yrs.
• Operation of choice → IPAA (Ileal pouch-anal anastomosis)
• m/c complication → pouchitis, responds to antibiotics, probiotics
• CD:
• Most patients require surgery once in a lifetime
• Small bowel disease → resection & anastomosis, strictureplasty
• Colorectal disease → diverting colostomy

65. Jameson, J. L. (2018).
Harrison’s Principles of
Internal Medicine (20th ed.).
New York: McGraw-Hill
Education.

66. IBD IN PREGNANCY
• Quiescent UC & CD → Normal fertility rates
• Post-IPAA → Fertility reduced to 50 – 80% of normal
• Patients must be in 6 months remission before conception
• 5-ASA, steroids, azathioprine, 6-MP safe in pregnancy. CSA has
insufficient data hence must be avoided. MTX in contra-indicated.
• Most biological agents are safe, but live vaccines must be avoided in
the infant.
• Surgery in UC must be performed only for emergency indications.

67. CANCER IN IBD: ULCERATIVE COLITIS
• 1.5 – 2 times higher risk of colon cancer
• Colonoscopic surveillance is the standard of care
• Annual or biennial colonoscopy with multiple biopsies
recommended for > 8-10 yrs. of extensive colitis or 12-15 yrs. of
procto-sigmoiditis
• Risk factors → long duration, extensive disease, family hx. of ca.
colon, pri. sclerosing cholangitis, strictures & pseudopolyps

68. CANCER IN IBD: CROHN DISEASE
• Same colonoscopic surveillance strategy is recommended
• Risk factors → duration, extent of disease, family history, pri.
sclerosing cholangitis & bypassed colon segments
• Other malignancies:
• IBD patients also at high risk for NHL, leukemias & MDS.
• Perianal CD increases rectum & anal squamous cell ca. risk

69. MANAGEMENT OF DYSPLASIA &
CANCER
• Dysplasia may be flat or polypoid
• Flat dysplasia
• High grade → colectomy for UC, segmental resection for CD
• Low grade → colectomy recommended by most
• Adenomas → r/o surrounding dysplasia, endoscopic resection

70. SUMMARY
• IBD is a chronic debilitating disease that needs long term therapy
and support. Incidence is on the rise.
• Diagnosis is based on a combination of clinical & investigative
findings.
• Differential diagnosis from various related and unrelated
conditions is important.

71. Thank you
Sources:
Harrison’s Principles of InternalMedicine, 20th ed.
Robbins & Cotran Pathologic Basis of Disease, 9th ed.