Basic Approach to IBD

1. Clinical Features , Diagnosis and Management
of Inflammatory Bowel Disease
Presented by : Dr. Sanjay
Moderator: Dr. Husaini S. Haider Mehdi
Department of Medicine, JNMC, AMU, Aligarh

2. Introduction
• IBD is an immune mediated chronic intestinal condition.
• UC and Crohn’s disease are two major types
• It has bimodal presentation, one peak at 20-29 years other at 7th to
9th decade

4. Epidemiology of IBD
Ulcerative Colitis Crohn’s Disease
Incidence (North America) per
person-years
0-19.2 per 100,000 0-20.2 per 100,000
Age of onset 2nd to 4th decades and 7th to 9th
decades
2nd to 4th decades and 7th to 9th
decades
Ethnicity Jewish > non-Jewish white > African American > Hispanic > Asian
Female/male ratio 0.51-1.58 0.34-1.65
Smoking May prevent disease (odds ratio
0.58)
May cause disease (odds ratio 1.76)
Oral contraceptives No increased risk Odds ratio 1.4
Appendectomy Protective (risk reduction of
13-26%)
Not protective
Monozygotic twins 6-18% concordance 38-58% concordance
Dizygotic twins 0-2% concordance 4% concordance
Antibiotic use in the first year of life 2.9 x the risk of developing childhood IBD

5. Clinical features
Clinical Ulcerative Colitis Crohn’s Disease
Gross blood in stool Yes Occasionally
Mucus Yes Occasionally
Systematic symptoms Occasionally Frequently
Pain Occasionally Frequently
Abdominal mass Rarely Yes
Significant perineal disease No Frequently
Fistulas No Yes
Small intestinal obstruction No Frequently
Colonic obstruction Rarely Frequently
Response to antibiotics No Yes
Recurrence after surgery No Yes

7. ExtraIntestinal manifestations
1.Constitutional symptoms:- Anorexia, nausea, vomiting, fever,
weight loss.
7. Thromboembolic events (Thrombocytosis, phlebo &
Arterial thrombosis).
2. Arthritis (Sacrolitis) 8. Cholestasis
3. Anterior uveitis 9. Pyoderma gangerosum
4. Ankylosing spondylitis 10. Amyloidosis (CD)
5. Erythema nodosum 11. Pancreatitis
6. Sclerosing cholangitis (ANCA positive). 12. Nephrotic syndrome

9. Complications
Feature Crohn’s Disease Ulcerative Colitis
1. Fistula formation Internal and external fistulae in
10% case
Extremely rare
2. Malignant changes Less common but present May occur in disease of more than
10 years duration (more common)
3. Fibrous strictures Common Never
4. Toxic megacolon - Risk present
5. Named Features Hose pipe appearance
Cobble-stone appearance
Halo sign on CT
String sign of Kantor
Raspberry/rosethron appearance
Garden hose appearance
Pseudopolyps
Pipestem colon ( Ahaustral)
Earliest change in CD : Apthoid Ulceration
Earliest change in UC : Blurring of Mucosal stripe and Granular appearance

10. Macroscopic Features
Feature Crohn’s Disease Ulcerative Colitis
1. Distribution Segmental with skip areas Continuous without skip areas
2. Location Commonly terminal ileum and/or
ascending colon
Commonly rectum , sigmoid colon
and extending upwards
3. Extent Usually involves the entire
thickness of the affected segment
of bowel wall
Usually superficial , confined to
mucosal layers
4. Ulcers Serpiginous ulcers , that may
develop into deep Fissures
Superficial mucosal ulcers without
fissures
5. Pseudopolyps Rarely seen Commonly present
6. Fibrosis Common Rare
7. Shortening Due to fibrosis Due to contraction of muscularis

11. Microscopic Features
Features Crohn’s Disease Ulcerative Colitis
1.Depth of inflammation Typically transmural Mucosal and submucosal
2. Type of inflammation Non-caseating granulomas and
infiltrate of mononuclear cells
(lymphocytes, plasma cells and
macrophages)
Crypt abscess and non- specific
acute and chronic inflammatory
cells (lymphocytes , plasma cells ,
neutrophills , eosinophils , mast
cells)
3. Mucosa Patchy ulceration Hemorrhagic mucosa with
ulceration
4. Submucosa Widened due to edema and
lymphoid aggregates
Normal or reduced in width
5. Muscularis Infiltrated by inflammatory cells Usually spared , except in case of
Toxic Megacolon
6. Fibrosis Present Usually absent

12. Laboratory Features:
Ulcerative Colitis Crohn’s disease
1. Anemia 1. Anemia
2. Raised ESR, CRP levels. 2.Increased ESR, CRP levels.
3. Pancreatic autoantibodies (41%) 3. Pancreatic autoantibodies (30%)
4. Low serum albumin 4. Hypoalbuminemia
5. Leukocytosis 5. Leukocytosis
6. P-ANCA (60-70%) 6.P-ANCA (5-10%)
7. Anti goblet cell antibody (40%) 7.Anti goblet antibodies (30%)
8. Anti-Saccharomyces cerevisiae antibody (10-15%) 8. ASCA antibodies (60-70%)
9. Anti colon antibodies (36%) 9.Anti colon antibodies (13%)
10. Increased platelet count

13. Endoscopic Ulcerative Colitis Crohn’s Disease
Rectal sparing Rarely Frequently
Continuous disease Yes Occasionally
“Cobblestoning” No Yes
Granuloma on biopsy No occasionally
Endoscopic features

15. Radiographic features
Radiographic Ulcerative Colitis Crohn’s Disease
Small bowel significantly abnormal No Yes
Abnormal terminal ileum No Yes
Segmental colitis No Yes
Asymmetric colitis No Yes
Stricture Occasionally Frequently

16. Ulcerative Colitis: Disease Presentation
Mild Moderate Severe
Bowel movements <4 per day 4-6 per day >6 per day
Blood in stool Small Moderate Severe
Fever None <37.5 °C means (<99.5° F) >37.5° C mean (>99.5° F )
Tachycardia None <90 mean pulse >90 MEAN PULSE
Anemia Mild >75% ≤ 75%
Sedimentation
rate
<30 mm >30 mm
Endoscopic
appearance
Erythema,decreased
vascular pattern,fine
granularity
Marked erythema, coarse
granularity , absent
vascular markings ,
contact bleeding , no
ulcerations
Spontaneous bleeding ,
ulcerations

17. Diseases that mimic IBD
Infectious Etiologies
Bacterial Mycobacterial Viral
Salmonella Tuberculosis Cytomegalovirus
Shigella Mycobacterium Herpes simplex
Toxigenic avium HIV
Escherichia coli Parasitic Fungal
Campylobacter Amebiasis Histoplasmosis
Yersinia Isospora Candida
Clostridium difficile Trichuris trichiura Aspergillus
Gonorrhea Hookworm
Chlamydia trachomatis Strongyloides

18. Noninfectious Etiologies
Inflammatory Neoplastic Drugs and Chemicals
Appendicitis Lymphoma NSAIDs
Diverticulitis Metastatic Phosphosoda
Diversion colitis Carcinoma Cathartic colon
Collagenous/lymphocytic colitis Carcinoma of the ileum Gold
Ischemic colitis Carcinoid Oral contraceptives
Radiation colitis/enteritis Familial polyposis Cocaine
Solitary rectal ulcer syndrome Ipilimumab
Eosinophilic Mycophenolate mofetil
gastroenteritis
Neutropenic colitis
Behcet’s syndrome
Graft-versus-host disease

19. Infliximab/
Adalimumab/
golimumab
6-Mercaptopurine/
azathioprine
Glucocorticoid oral
Glucocorticoid rectal
5-ASA oral and/or rectal
Infliximab/
Adalimumab/
Certolizumab pegol
6-Mercaptopurine/
Azathioprine/methotrexate
Prednisone
Sulfasalazine (colon)
Budesonide(ileal and right colon)
Cyclosporine
Adalimumab/golimumab
6-Mercaptopurine/
azathioprine + infliximab
Glucocorticoid IV
Glucocorticoid oral
Total parenteral nutrition
Glucocorticoid IV
Natalizumab/vedolizumab
6-Mercaptopurine/azathioprine/methotrexate
+
Infliximab/ adalimumab/ certolizumab pegol
Total parental nutrition
Natalizumab/vedolizumab
Anti-TNF(infliximab/adalimumab/
Certolizumab pegol) +/-6-Mercaptopurine/
Azathioprine/methotrexate
Abscess drainage and antibiotics
Mild to Moderate Crohn’s Disease
Mild to Moderate Ulcerative Colitis
Moderate to Severe Crohn’s Disease
Moderate to Severe Ulcerative
Colitis
Moderate to Severe Crohn’s Disease

20. Indications for surgery
Ulcerative Colitis Crohn’s Disease
Intractable disease Small intestine
Fulminant disease Stricture and obstruction
Toxic megacolon Unresponsive to medical therapy
Colonic perforation Massive hemorrhage
Massive colonic hemorrhage Refractory fistula
Extracolonic disease Abscess
Colonic obstruction Colon and rectum
Colon cancer prophylaxis Intractable disease
Colon dysplasia or cancer Fulminant disease
Perianal disease unresponsive to
medical therapy
Refractory fistula
Colonic obstruction
Cancer prophylaxis
Colon dysplasia or cancer

21. Surgical Options for Ulcerative Colitis
• Total proctocolectomy with ileostomy
• Restorative proctocolectomy with IPAAQ
• Total proctocolectomy with a continent ileal reservoir (Kock pouch)
• Total abdominal coleoctomy with end-ileostomy
• Toxic megacolon