Inflammatory Bowel Disease


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Inflammatory Bowel Disease

  1. 1. Inflammatory Bowel Disease By Dr. Nousheen Saleem House Officer MU1
  2. 2. Inflammatory bowel disease  Refers to two chronic diseases that cause inflammation of the intestines: ulcerative colitis and Crohn's disease.  Although the diseases have some features in common, there are some important differences.
  3. 3. Etiology  Familial   Common amongst 1st degree relative. Environment    UC: Common in non smoker and in ex smoker. CD: Common in smokers. Appendicetomy protects against UC.
  4. 4. Cont…   Diet :associated with low residue and high refined sugar diet Genetics  Mutations in CARD 15/ NOD-2 Gene on CH16.
  5. 5. Cont…     Current evidence suggests that there's likely a genetic defect that affects how our immune system works and how the inflammation is turned on and off in those people with inflammatory bowel disease, in response to an offending agent, like: Bacteria: Mycobacterium, listeria, H.hepaticus and endogenous bac. Virus: Measeles… or a protein in food
  6. 6. Ulcerative colitis  Is an inflammatory disease of the large intestine. In which the mucosa - of the intestine becomes inflamed and develops ulcers with diffuse friability and erosions with bleeding
  7. 7. Ulcerative colitis –gut involvement    40-50% of patients have disease limited to the rectum and rectosigmoid (proctosigmoiditis) 30-40% of patients have disease extending beyond the sigmoid (left sided colitis) 20% of patients have a total/extensive colitis
  8. 8. Ulcerative colitis – macroscopic features Mucosa is : - erythematous, has a granular surface that looks like a sand paper  In more severe diseases: - hemorrhagic, edematous and ulcerated   In fulminant disease a toxic colitis or a toxic megacolon may develop ( wall become very thin and mucosa is severly ulcerated)
  9. 9. Colonic pseudopolyps
  10. 10. ulcerative colitis:the left side of the colon is affected The image shows confluent superficial ulceration and loss of mucosal architecture.
  11. 11. Ulcerative colitis – microscopic features  Process is limited to the mucosa and submucosa with deeper layer unaffected Two major histologic features: - the crypt architecture of the colon is distorted - some patients have basal plasma cells and multiple basal lymphoid aggregates 
  12. 12. UC
  13. 13. Ulcerative colitis – clinical presentation  The major symptoms of UC are:  Bloody diarrhea(hallmark)  Tenesmus Passage of mucus Crampy abdominal pain  
  14. 14. Ulcerative colitis – clinical presentation  Patients with proctitis usually pass fresh blood or bloodstained mucus either mixed with stool or streaked onto the surface of normal or hard stool  When the disease extends beyond the rectum, blood is usually mixed with stool or grossly bloody diarrhea may be noted  When the disease is severe, patients pass a liquid stool containing blood, pus, fecal matter  Other symptoms in moderate to severe disease include: anorexia, nausea, vomitting, fever, weight loss
  15. 15. EXAMINATION  PHYSICAL:     Hydration & volume status determined by B.P Pulse rate Nutritional status ABDOMINAL:   Tenderness & evidence of peritoneal inflammation Presence of red blood on DRE
  16. 16. UC assessment of disease activity Ulcerative Colitis assessment of disease activity Mild Moderate Severe Stool frequency per day 4> 4-6 (mostly bloody )6> (Pulse (beats/min 90> 90-100 100< )%(Hematocrits Normal 30-40 30> )%(Weight Loss None 1-10 10< (Temperature (*F Normal 99-100 100< (ESR (mm/h 20> 20-30 30< (Albumin (g/dl Normal 3-3.5 3>
  17. 17. MILD DISEASE (UC) Gradual onset Infrequent diarrhoea (<5movements/day) Intermittent rectal bleeding Stool may be formed or too loose in consistency Fecal urgency ,tenesmus,left lower quadrant pain relieved by defecation NO significant abdominal tenderness
  18. 18. MODERATE DISEASE (UC)    More severe diarrhoea with frequent bleeding Abdominal pain & tenderness but not severe Mild fever , anemia & hypoalbuminemia
  19. 19. SEVERE DISEASE (UC)     Severe diarrhoea with >6-10 bloody bowel movements /day Severe anemia , hypovolemia ,imparied nutrition & hypoalbuminemia Abdominal pain & tenderness FULMINANT COLITIS:  Subset of severe disease with rapidly worsening symptoms & signs of toxicity
  20. 20. CHRON’S DISEASE   It is the chronic recurrent disease characterised by patchy transmural inflammation involving any segment of GIT from mouth to anus Cigarette smoking is strongly associated with the development of chrons disease,resistance to medical therapy and early disease relapse
  21. 21. Crohn’s disease – gut involvement  30-40% of patients have small bowel disease alone  40-55% of patients have both small and large intestines disease  15-25% of patients have colitis alone  In 75% of patients with small intestinal disease the terminal ileum in involved in 90%
  22. 22. Distribution of gastrointestinal Crohn's disease. Based on data from American Gastroenterological Association.
  23. 23. Crohn’s disease – macroscopic features  CD is a transmural process  CD is segmental with skip leisions in the diseased intestine.  In one –third of patients with CD perirectal fistulas, fissures, abscesses, anal stenosis are present
  24. 24. Crohn’s disease – macroscopic features  mild disease is characterized by: aphthous or small superficial ulcerations  In more active disease: stellate ulcerations fuse longitudinally and transversely to demarcate island of mucosa that are histologically normal  Cobblestone appearance is characteristic of CD (both endoscopically and by barium radiography)
  25. 25. Cont…  Active CD is characterized by focal inflammation and formation of fistula tracts  The bowel wall thickens and becomes narrowed and fibrotic, leading to chronic, recurrent bowel obstruction
  26. 26. serpiginous ulcer, a classic finding in Crohn's disease
  27. 27. Chrons disease: Microscopic
  28. 28. Crohn’s disease – sign and symptoms Ileocolitis - right lower quadrant pain and non bloody diarrhoea - palpable mass, fever and leucocytosis - pain is colickly and relieved by defecation Right lower quadrant tenderness & a palpable mass  Jejunoileitis - inflammatory disease is associated with loss of digestive and absorptive surface 
  29. 29. Crohn’s disease – sign and symptoms  Colitis and perianal disease - low grade fever, malaise, diarrhea, crampy abdominal pain, sometimes hematochezia - pain is caused by passage of fecal material through narrowed and inflamed segments of large bowel  Gastroduodenal disease - nusea, vomiting, epigastric pain - second portion of duodenum is more commonly involved than the bulb
  30. 30. Cont...  INTESTINAL OBSTRUCTION IN CD: Postprandial bloating,cramping pains & loud borborygmi  (narrowing can occur due to inflammation spasm or fibrosis) FISTULATING DISEASE: Can result in intra abdominal or retroperitoneal abscess menifested by fever chills, a tender abdominal mass & leucocytosis. 
  31. 31. Cont…    Enterocolic fistulas : presents with diarrhoea , weight loss & malnutrition. Enterovesical fistulas/enterovaginal fistulas: presents with recurrent infections. Enterocutaneous fistulas: usually develop at site of surgical scars.
  32. 32. Endoscopic image of Crohn's colitis showing deep ulceration.
  33. 33. Extraintestianal Menifestation  25% of the pts develop a number of extraintestinal menifestations  Almost one-third of the patients have at least one.
  34. 34. Extraintestinal manifestation •Eyes: Uveitis, Episcleritis, Conjuctivitis •Joints: Peripheral arthropathy, arthralgia, ankylosing spondylits, inflammatory Back pain •Skin: Erythema nodosum, pyoderma gangrenosum •Liver and Biliary tree: Sclerosing cholangitis [UC] •Nephrolithiasis [Oxalate Stone in pt with small bowel disease or after resection] (CD) •Oral apthous leisions (CD) •Gall stone(CD) •Venous thrombosis
  35. 35. Patients with IBD have an increased prevelance of osteoporosis secondary to vitamin D deficiency, calcium malabsorbtion, malnutrition, corticosteroid use More common cardiopulmonary manifestations include endocarditis, myocarditis, pleuropericarditis and interstitial lung disease.
  36. 36. Examination findings_in CD      Loss of weight General ill health Aphthous ulceration of mouth, glossitis angular stomatitis Abdominal tenderness and RIF mass Perianal skin tags, fissures, fistulae
  37. 37. ?       Extraintestinal menifestations common to chrons disease & UC include all except A) amyloidosis B) gall stones C) pyoderma gangreonosum D) uveitis E) ankylosing spondylitis
  38. 38.  Answer is B
  39. 39. Investigations CD UC Blood Test •CP with morphology: Normocytic normocromic anemia of chronic disease •Serum B12 level may be low. •Raised ESR, CRP and raised WBC count. •Hypo albuminaemia. •Blood culture in septicaemia. •Fe deficiency anemia •Raised white cell and platelet count •Raised ESR, CRP •Hypo albuminaemia Serological Test •Saccharamyces cerevisiae antibody is usually present •P-ANCA negative •P-ANCA may be positive Stool culture •Should always be performed in both to rule out infective cause
  40. 40. Cont….. CD UC Radiology Plain ABD. X-ray: •Intestinal obstruction or displacement of bowel loops by a mass. Ultrasound: •Thickened small bowel loops and mesentery or abscess Barium follow through: •Asymmetrical alteration mucosal pattern with narrowing or stricturing. •Skip lesions •Extent of the disease can be judge by air distribution in the colon and the presence of colonic dialatation •Thickening of colonic wall and presence of free fluid in abdominal cavity •Fine mucosal granularity •Mucosa become thickenned and superficial ulcers are seen (collar-button ulcers) •Loss of haustration
  41. 41. Cont….. CD UC Instant Barium enema •Patchy sup. Ulceration to wide spread deep (rose thorn ulcer) •Cobble stone appearance and narrowing •Superficial ulcers •Shortened and narrowed colon in long standing disease Colonoscopy •Fissures and fistulae High resolution USG. And spiral CT •Radionuclide scan with gallium labeled polymorphs or indium or technetium labeled leucocytes •Capsule imaging of the gut. •Pseudopolyps •Mucosal granularity and hyperemia •Radionuclide scan used to assess colonic inflammation
  43. 43. Complication IN UC: Haemorrage  Perforation  Toxic megacolon (transverse colon with a diameter of more than 5 cm to 6cm with loss of haustration  Cancer: in patient with active colitis of more than eight year
  44. 44. Cont…  IN CD:    Strictures with intestinal obstruction Abscesses Fistulas
  45. 45. Treatment  Medical treatment         Amino salicylates Cortico steroid Thiopurines Methotrexate Ciclosporin Infliximab Antibiotic Antidiarrhoeal agents
  46. 46. T/M OF UC  ACTIVE PROCTITIS: 1st line   Pt NOT RESPONDING:   Mesalazine enemas/suppositries+ oral mesalazine Oral prednisolone 40mg daily ACTIVE LEFT SIDED OR EXTENSIVE UC:  High dose aminosalicylates
  47. 47. Cont....   With topical aminosalicylates + corticosteroids SEVERE/FULMINANT UC: SUPPORTIVE T/M:  I/V fluids,nutritional support,blood transfusion if HB <100g/l MEDICAL T/M: I/V steroids,prophylaxis for venous thrombosis, I/V cyclosporin or infliximab for non responders to steroids 
  48. 48. Cont….  MAINTAINANCE OF REMISSION:   Oral salicylates Thiopurines should be considered for frequent relapsers
  49. 49. Ulcerative Colitis  Nursing care  Report S/S of problems  Provide emotional support  Skin care  Record # of stools and type  Monitor bowel sounds  Vitals and I/O      Watch for dehydration Monitor Electrolytes Weigh daily Dietary consult Watch for complications
  50. 50. T/M OF CD  INDUCTION OF REMISSION     Enteral nutrition Oral or I/V steroids Aminosalicylates MAINTAINANCE OF REMISSION      Cessation of smoking Aminosalicylates Thiopurines MTX with folic acid(resistant to thiopurines) infliximab
  51. 51. Cont….  FISTULATING AND PERIANAL DISEASE    Metronidazole and ciprofloxacin Thiopurines in chronic disease infliximab
  52. 52. Crohn’s Disease  Nursing care    Identical to colitis Watch for internal bleeding Dietary changes   Restricted fiber diet with no raw fruit or vegetables and no nuts or whole grains Low fat diet to reduce fatty stools
  53. 53. Surgical Treatment   UC IND:  Perforation  Toxic megacolon Uncontrolled hemorrhage Possibility of malignancy (surgery is indicated if dysplastic change is present) Intractability (Acute; fulminant colitis or chronic illness) Extraintestinal manifestations      Panproctocolectomy with ileostmy or proctocolectmy with ilealanal pouch anastomosis
  54. 54. Cont…  CD    IND: fistulae, abscesses, perianal disease, small or large bowel obstruction For localized segment: segmental resection or multiple stricturoplasties For extensive colitis: total colectomy (ileoanal pouch should be avoided)
  55. 55. Probiotic use in IBD (lactobacilli, bifidobacterium, nonpathogenic E.coli,) They maintain remission in inflammation of pouch which is created by surgrey;possibly by increasing tissue levels of IL-10 May also be useful in maintaining remission in UC
  56. 56. ESSENTIALS OF DIAGNOSIS in UC      Bloody diarrhoea Lower abdominal cramps & fecal urgency Anemia and low serum albumin Negative stool cultures Sigmoidoscopy is the key to diagnosis
  57. 57. ESSENTIALS OF DIAGNOSIS in CD      Insidious onset Intermittent bouts of low grade fever diarrhoea & right lower quadrant pain Right lower quadrant mass & tenderness Perianal disease with fistulas Radiographic evidence of ulceration stricturing or fistulas of the small intestine & colon
  58. 58. MCQs
  59. 59. Scenerio  A 23yr old women has chronic diarrhoea with blood & mucus accompanied by lower abdominal discomfort.she has about 8 stools/day,albumin is 29g/l,hb 9g/l,& ESR is 60mm/l.colonoscopy reveals left sided proctocolitis.biopsy shows a chronic inflammatory cell infiltrate in lamina propria crypt abscess & goblet cell depeletion are seen.
  60. 60. Select the best medication for this patient. A) Oral aminosalicylates only B) Parentral aminosalicylates C) Oral aminosalicylates with predisolone 20mg enema D) Oral aminosalicylates with oral prednisolone E) Oral sulphapyridine
  61. 61. Answer is D
  62. 62. What is not true regarding azathioprine use in IBD A) May be useful in pt of chronic IBD B) Helps to lower the dose of corticosteroids C) Used more frequently in UC than CD D) Bone marrow suppression with fetal neutropenia may occur E) Usual dose is 2.5mg/kg/day
  63. 63. Answer is C
  64. 64. Initial investigation of choice to diagnose ulcerative colitis is A) Sigmoidoscopy B) Colonoscopy C) Barium enema D) Barium follow through
  65. 65. Answer is A
  66. 66. Lab investigations in IBD shows all except A) Anemia B) Raised ESR C) Leucocytosis D) Raised amylase E) Abnormal LFTs
  67. 67. Answer is D
  68. 68. Thank you