Inflammatory bowel disease
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Lecture on inflammatory bowel diseases for medical student. Encompasses basic sciences, classifications, pathophysiology and principles of management.
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Inflammatory bowel disease
- 1. Inflammatory bowel disease Chea Chan Hooi Surgeon Sibu Hospital
- 2. Content • Definition • Epidemiology • Classification • Investigations • Pertinent differences – Clinical features – Diagnostic criteria – Principles of management
- 3. Definition • Genetically predisposed idiopathic disease caused by a dysregulated immune response to host intestinal microflora
- 4. Epidemiology • Developed countries • Increasing over time • Historically UC > CD but CD is fast catching up • Malaysia – Low incidence but rising – Indians > Chinese > Malays
- 5. Classification • Ulcerative colitis – Limited to colon • Crohn disease – Any where along the GI tract • Indeterminate IBD – 10 – 15%
- 6. Etiology UC CD Epidemiology More common On the rise Genetic predisposition Less More Specific gene pANCA ASCA, CARD15 Mechanism Mucosal immunological dysregulation Weakend mucosal barrier Defective mucosal metabolism of butyrates Abnormal T helper cell response Correlation with TB? Nicotine Protective Aggravate
- 7. Clinical presentation UC CD Presentation Toxic megacolon ± perforation Fulminating colitis ± perforation Severe haemorrhage Severity (Truelove & Witt) – mild, moderate, severe Perforation, abdominal abscess, fistula Stricture, chronic pain MRO TB Vienna classification – based on age, location & disease behaviour) Perineal involvement Relatively common Associated colorectal cancer Higher risk Lower risk Extra-colonic manifestations Eye – iritis Joint – arthritis, ankylosing spondylitis, sacroilitis HPB – PSC, cholangiocarcinoma Uro - calculi Skin – erythema nodosum, pyoderma gangrenosum
- 8. Endoscopic features UC CD Site Almost always involve rectum Perineal involvement relatively common Rectum often spared Most common in ileo-caecal region Extent Continuous Pancolitis 10% Backwash ileitis Skip lesions Mucosal appearance Pseudopolyps d/t areas of hyperplastic growth with swollen mucosa surrounded by ulcers Cobblestone appearance d/t deep longitudinal ulcerations interlaced with normal mucosal
- 9. Colonoscopy
- 11. Histological features UC CD Wall involvement Mucosa Trans-mural Hallmark Crypt abscess Reduced crypt numbers Non-caseating granuloma
- 12. Radiological features • Barium enema contraindicated in patients with moderate – severe colitis – Risk of perforation – Precipitate toxic megacolon UC CD Barium Lead pipe appearance String sign on Barium follow thru (narrowed terminal ileum) Radiograph Thumb print sign (mucosal thickening)
- 13. Lead pipe appearance on Barium enema • Lead pipe-like: narrowed, ahaustral & shortened • Mucosal inflammation • Regeneration leads to hypertrophy & muscularis mucosae thickening • Chronically contracted
- 14. String sign
- 15. Treatment • Medical – Sulfasalazine, azathioprine – Infliximab – Steroids – Antibiotics – acute flare – Dietary modification – high fibre, bulking
- 16. Surgery UC CD Principles Unresected colon has high risk to develop colorectal carcinoma, especially so after 10 years of disease activity Role of surgery is to control acute disease that failed medical therapy, definitively cure UC and to prevent occurrence of carcinoma CD is a chronic, remitting disease that may involve any segment(s) of the whole GI tract Surgery is limited to symptomatic control and to correct any arising complications; resection is limited to minimise risk of short bowel syndrome Emergency setting Total colectomy + end ileostomy Drainage procedures (percutaneous is preferred) Limited segmental bowel resection with end stoma ala Hartmann’s procedure or mucus fistula exteriorisation Elective setting Total proctocolectomy + restorative ileo pouch-anal anastomosis (IPAA) Total proctocolectomy + ileoanal anastomosis Total proctocolectomy + end ileostomy (±Kock continence modification) Stricturoplasty Limited segmental bowel resection with primary reanastomosis whenever feasible
- 18. Restorative ileal pouch anal anastomosis (IPAA)
- 19. Stricturoplasty
- 20. TQ! Q&A?