Management of Inflammatory Bowel Disease

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Management of Inflammatory Bowel Disease

  1. 1. S INFLAMMATORY BOWEL DISEASE Dr. Nasir Khokhar MD FACP FACG Professor of Medicine and Gastroenterology Shifa International Hosptal, Islamabad, Pakistan
  2. 2. Crohns and Ulcerative colitis
  3. 3. IBD
  4. 4. CROHN’S DISEASE
  5. 5. Anatomic Distribution
  6. 6. Bimodal Distribution
  7. 7. Prevalence of Crohn’s Disease
  8. 8. Immune Dysregulation in Crohn’s Disease
  9. 9. Potential Risk Factors S Diet S NSAIDS S Smoking S Infections S Oral Contraceptives S Psycho social factors
  10. 10. Etiology
  11. 11. Gut structure
  12. 12. Intestinal defences
  13. 13. Pathogenesis
  14. 14. Pathogenesis
  15. 15. Tumor Necrosis Factor (TNF)
  16. 16. TNF induced apoptosis
  17. 17. TNF actions
  18. 18. Patterns of Crohn’s Disease
  19. 19. Chronic abdominal pain
  20. 20. Imaging in Crohn’s Disease
  21. 21. Aphthoid Ulceration
  22. 22. Aphthoid Ulceration
  23. 23. Endoscopic view
  24. 24. Crohn’s Ileitis
  25. 25. Chronic Subserositis
  26. 26. Granuloma
  27. 27. Post stenotic Dilatation
  28. 28. Enteroenteric Fistula
  29. 29. Enterocutaneous Fistula
  30. 30. Perianal Fistula
  31. 31. Mechanism of Perianal Fistula
  32. 32. Carcinoma in Crohn’s Disease
  33. 33. Acute Inflammatory Presentation
  34. 34. Chronic Inflammatory Presentation
  35. 35. Scarring and Narrowing
  36. 36. Enteroenteric Fistula
  37. 37. Enterovesical Fistula
  38. 38. Localised Phlegmon
  39. 39. Presentation
  40. 40. Clinical Presentations S CHRONIC INFLAMMATORY DISEASE: fever, malaise, weight loss, abdominal pain, RLQ mass S INTESTINAL OBSTRUCTION: Post prandial bloating, cramping, borborygmy S FISTULIZATION: Internal, external S ABSCESS: Fever, chills, tender mass S PERIANAL DISEASE: Fissure, abscess, fistula S EXTRAINTESTINAL: Oral, skin, joints, eye, gall stones, nephrolithiasis, liver
  41. 41. Laboratory Diagnosis S CBC S Albumin S ESR, CRP S Stool RE S P-ANCA: 10% crohns, 70% UC S ASCA (antibody to yeast S cerevisiae): 70% crohn, 10% UC
  42. 42. Radiological Diagnosis
  43. 43. Endoscopic Diagnosis
  44. 44. Differential Diagnosis: Appendiceal Abscess
  45. 45. Differential Diagnosis: Carcinoma
  46. 46. Differential Diagnosis: Carcinoid
  47. 47. Differential Diagnosis: Lymphoma
  48. 48. Differential Diagnosis: Tuberculosis
  49. 49. COMPLICATIONS S ABSCESS S INTESTINAL OBSTRUCTION S FISTULAS S PERIANAL DISEASE S CARCINOMA S HEMORRHAGE S MALABSORPTION
  50. 50. TREATMENT:Aminosalicylic acid
  51. 51. TREATMENT: Corticosteroids S Dramatically suppress clinical symptoms S Do not alter underlying disease process S Prednisone 40-60 mg/day, taper slowly S Side effects: Osteoporosis, others S Ileal release preparation: Budesonide 9mg/day, 50-70% remission in mild to mod S Persistent symptoms need ASA, AZA,MTX
  52. 52. TREATMENT:Immunosuppressent s
  53. 53. TREATMENT:Immunosuppressents
  54. 54. TREATMENT:Immunosuppressents
  55. 55. TREATMENT:Immunosuppressents
  56. 56. Biologicals
  57. 57. Mechanism of action
  58. 58. TNF binding
  59. 59. Summary of medical treatment of Crohn’s disease S Aminosalisylic acid: ASA S Corticosteroids: Pred, Budesonide S Immunosuppressents: AZA, MTX, Cyc S Antibiotics: Metronidazole, Ciproflox S TNF antibody: Infliximab
  60. 60. SURGICAL TREATMENT
  61. 61. ENDOSCOPIC TREATMENT Balloon Dilatation
  62. 62. MANAGEMENT S Life long illness, exacerbations, remissions S Psych social support: patient education S No specific therapy exists: supportive care; diarrhea, steatorrhea, pain S Nutritional support: enteral, parenteral; Fiber, iron, B12, low fat, MCT supplements well balanced diets
  63. 63. PROGNOSIS S Prolonged illness S Proper medical and surgical care help cope with disease S Anticipate complications and manage S Avoid side effects of drugs S Few die of direct effects of disease
  64. 64. ULCERATIVE COLITIS
  65. 65. Ulcerative Colitis: Forms
  66. 66. Ulcerative Colitis:Gross Appearance
  67. 67. Endoscopic Appearance
  68. 68. Microscopic Features
  69. 69. Crypt Abscess
  70. 70. Radiological Features
  71. 71. Pakistani scenario
  72. 72. Endoscopic extent: KPK Hameed et al. JCPSP 2001;11:551-4.
  73. 73. Severity of disease: KPK Khan et al. J Med Sci 2010;18:67-70
  74. 74. Shifa Experience S 85 patients with 8 years follow up S Diarrhea with blood 100% S Raised ESR 80% S Mild disease 55% S Left sided colitis in 60% S Medical Treatment response nearly 100% Khokhar N. Rawal Med J 2005;30:12-15
  75. 75. THANKS

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