Inflammatory Bowel Diseases

1. INFLAMMATORY
BOWEL DISEASES
DR. DURGESH MAHAJAN
MD MEDICINE
ASSISTANT PROFESSOR
SVNGMC, YAVATMAL

2. Inflammatory bowel disease
It includes a group of chronic disorders that
cause inflammation or ulceration in large and
small intestines.

3. TYPES
Ulcerative colitis
• causes ulceration and
inflammation of the
inner lining of the colon
and rectum.
• It is usually in the form of
characteristic ulcers or
open sores.
Crohn’s disease
• Extends into the deeper layers
of the intestinal wall, and may
affect the mouth, esophagus,
stomach, and small intestine.
• Transmural inflammation
and skip lesions.
• In 50% cases -ileocolic,30%
ileal and 20% -colic region.
• Regional enteritis

4. Ulcerative colitisCrohn’s disease

5. OTHER FORMS OF IBD
• Collagenous colitis
• Lymphocytic colitis
• Ischemic colitis
• Behcet’s syndrome
• Infective colitis
• Intermediate colitis

6. Epidemiology

7. Etiopathogenesis
• Exact cause is unknown.
• Genetic factors
• Immunological factors
• Microbial factors
• Psychosocial factors

8. Genetic factors
• Ulcerative colitis is more common in
DR2-related genes
• Crohn’s disease is more common in
DR5 DQ1 alleles
• 3-20 times higher incidence in first degree
relatives

9. Immunologic factors
• Defective regulation of immunesuppresion
• Activated CD+4 cells activate other
inflammatory cells like macrophages & B-cells
or recruit more inflammatory cells by
stimulation of homing receptor on leucocytes
& vascular epithelium.

11. Pathogenesis of IBD
American Gastroenterological Association Institute, Bethesda, MD.
Sartor RB. Nat Clin Pract Gastroenterol Hepatol. 2006;3:390-407.
Normal
Gut
Tolerance-
controlled
inflammation
Tolerance
Acute Injury
Environmental
trigger
(Infection, NSAID, other)
Complete Healing
Chronic Inflammation
Genetically
Susceptible
Host
Acute Inflammation
↓ Immunoregulation,
failure of repair or
bacterial clearance

12. Ulcerative colitis

13. Pathology
Macrocopic features
Usually involves rectum & extends proximally to involve all
or part of colon.
Spread is in continuity.
May be limited colitis( proctitis &
proctosigmoiditis)
in total colitis there is back wash ileitis (lumpy- bumpy
appearance)

15. • Mild disease- erythema & sand paper
appearance(fine granularity)
• Moderate-marked erythema,coarse granularity,contact
bleeding & no ulceration
• Severe- spontaneous bleeding, edematous &
ulcerated(collar button ulcer).
• Long standing-epithelial regeneration so
pseudopolyps , mucosal atrophy &
disorientation leads to a precancerous condition.
• Eventually can lead to shortening and narrowing
of colon.
• Fulminant disease-Toxic colitis/megacolon

16. Ulcerative colitis
Ulcer
pseudopolyps

17. Microscopic features
 Crypts atrophy & irregularity
 Superficial erosion
 Diffuse mixed inflammation
 Basal lymphoplasmacytosis

18. Clinical features
Ulcerative colitis
Diarrhea
Rectal bleeding
Tenesmus
Passage of mucus
Crampy abdominal pain

19. • Diarrhea & bleeding blood-intermittent &mild.
do not seek medical attention.
• Patient with proctatis-pass fresh or blood
stained mucus with formed or semi formed
stool. They also have tenesmus , urgency with
feeling of incomplete evacuation.
• With proctosigmoiditis-constipation
• Severe disease-liquid stools with blood , pus &
fecal matter.

20. Physical signs
Proctitis – Tender anal canal & blood on rectal
examination
Extensive disease-tenderness on palpation of
colon
Toxic colitis-severe pain &bleeding
If perforation-signs of peritonitis

21. Clinical Severity of UC

23. Diagnosis
• Laboratory tests
• Endoscopy
• Radiography
• Biopsy

24. Laboratory tests
• Hemogram
C-reactive protein is increased
ESR is increased
Platelet count-increased
Hemoglobin-decreased
 Fecal Calponectin levels correlate with
histological inflammation,predict relapses
&detect pouchitis

25. Barium
enema

26. BARIUM ENEMA
• Fine mucosal granularity
• Superficial ulcers seen
• Collar button ulcers
• Pipe stem appearance-
loss of haustrations
• Narrow & short colon-
ribbon contour colon

27. SIGMOIDOSCOPY
• Always abnormal
• Loss of vascular patterns
• Granularity
• Friability
• ulceration

31. Extra intestinal manifestations

33. Crohn’s disease

34. Macroscopic features
Can affect any part of GIT
Transmural
Segmental with skip lesions
Cobblestone appearance
Creeping fat- adhesions & fistula

37. Microscopic features
• Aphthous ulcerations
• Focal crypt abscesses
• Granuloma-pathognomic
• Submucosal or subserosal lymphoid aggregates
• Transmural with fissure formation

38. Clinical features
Ileal Crohn’s Disease
Abdominal pain
 Diarrhea
 Weight loss
Low grade fever
Jejunoileitis disease
 Malabsorption
 Steatorrhea
Colitis and perianal disease
 Bloody diarrohea
 Passage of mucus
 Lethargy
 Malaise
 Anorexia
 Weight loss

39. Diagnosis
• Laboratory tests
• Endoscopy
• Radiography
• Biopsy
• CT enterography

40. Laboratory tests
• CRP-elevated
• ESR-elevated
• Anemia
• Leukocytosis
• hypoalbuminemia

41. Barium enema
String
sign

42. Colonoscopy

43. CT enterography
• Mural hyperenhancement
• Stratification
• Engorged vasa recta
• Perienteric inflammatory
changes

45. DIFFERENTIAL
DIAGNOSIS

47. Treatment

48. Treatment

49. Lifestyle changes

50. Drugs
• 5-ASA agents
• Glucocorticoids
• Antibiotics
• Immunosuppresants
• Biological therapy

52. 5-ASA Agents
•Sulfasalazine (5-aminosalicylic
acid and sulfapyridine as carrier
substance)
•Mesalazine (5-ASA), e.g. Asacol,
Pentasa
•Balsalazide (prodrug of 5-ASA)
• Olsalazine (5-ASA dimer cleaves
in colon)

53. Distribution of 5-ASA Preparations
Oral
• Varies by agent: may be released in the distal/terminal
ileum, or colon1
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
Topical Action of 5-ASA: Extent of Disease
Impacts Formulation Choice
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.

54. • Use
 In mild to moderate UC & crohn’s colitis
 Maintaining remission
 May reduce risk of colorectal cancer
• Adverse effects
 Nausea, headache, epigastric pain, diarrhoea,
hypersensitivity, pancreatitis
 Caution in renal impairment, pregnancy, breast feeding

55. Glucocorticoids
• Anti inflammatory agents for moderate to
severe relapses.
• Inhibition of inflammatory pathways
• Budesonide- 9mg/dl used for 2-3 months &
then tapered.
• Prednisone-40-60mg/day
• No role in maintainence therapy

56. Antibiotics
• No role in active/quienscent UC
• Metronidazole is effective in active
inflammatory,fistulous & perianal CD.
• Dose-15-20mg/kg/day in 3 divided doses.
• Ciprofloxacin
• Rifaximin

57. Immunosuppresants
 Thiopurines
Azathioprine
6-mercaptopurin
 Methotrexate
 Cyclosporine

58. Cyclosporine
• Preventing clonal expansion of T cell subsets
• Used in Steroid sparing Active and chronic disease
• Side effects
Tremor, paraesthesiae, malaise, headache, gingival
hyperplasia, hirsutism Major: renal impairment,
infections, neurotoxicity

59. Biological therapy
• Infliximab
Anti TNF monoclonal antibody
Infliximab binds to TNF trimers with high affinity, preventing cytokine
from binding to its receptors
It also binds to membrane-bound TNF- a and neutralizes its activity &
also reduces serum TNF levels.
• Use
Fistulizing CD
Severe active CD
Refractory/intolerant of steroids or immunosuppression
• Side effects
Infusion reactions, Sepsis, Reactivation of Tb, Increased risk of Tb

60. Other medications
Anti- diarrheals - Loperamide (Imodium)
Laxatives - senna, bisacodyl
Pain relievers. acetaminophen (Tylenol).
Iron supplements
 Nutrition

61. Surgery

62. • Reconstructive proctocolectomy with illeoanal pouch
• Proctocolectomy & ileostomy
• Rectal &anal dissection
• Colectomy with ileorectal anastomosis
• Ileostomy with intraabdominal pouch
SURGERIES IN ULCERATIVE COLITIS

64. SURGERIES IN Crohn’s disease
 Ileocaecal resection
 Segmental resection
 Colectomy & ileorectal anastamosis
 Temporary loop ileostomy
 Proctocolectomy
 Stricturoplasty

65. Strictureplasty

66. THANK YOU