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2. Inflammatory bowel disease (IBD)

3. Inflammatory bowel disease (IBD)
• Inflammatory bowel disease (IBD) is an idiopathic
disease caused by a dysregulated immune
response to host intestinal microflora.
• The two major types of inflammatory bowel
disease are ulcerative colitis (UC), which is
limited to the colonic mucosa, and Crohn disease
(CD), which can affect any segment of the
gastrointestinal tract from the mouth to the anus,
involves "skip lesions," and is transmural.
• There is a genetic predisposition for IBD, and
patients with this condition are more prone to the
development of malignancy.

4. Inflammatory bowel disease
(IBD)
• Crohn disease
• Ulcerative colitis
• Inflammatory bowel disease (IBD) of
undetermined type.

5. Introduction & History.

6. Introduction & History.
• Ulcerative colitis (UC) is idiopatic
inflammatory disease potentially affecting
the entire large bowel (colon and rectum).
• The inflammation is confined to mucosa.
• UC can go into remission and recur.
• Extraintestinal manifestations.

7. Aetiology

8. Aetiology
• Idiopathic
• Congenital/ Genetic
• Nutritional Deficiency/excess
• Traumatic
• Infections /Infestation
• Autoimmune
• Neoplastic (Benign/Malignant)
• Degenerative
• Iatrogenic
• Psychosomatic

9. Aetiology
• Certain types of food composition
• Oral contraceptives
• Protective effect of tobacco seen in
ulcerative colitis
• Disturbed intestinal flora.

10. Pathology

11. Pathology
• Ulcerative colitis characteristically involves the
large bowel.
• Starts in rectum and proceeds proximally upto
terminal ileum (backwater ileitis).
• No skip lesions.
• Ulcerative colitis is a lifelong illness.
• Mucosal disease.

12. Pathology
• Rectum 95%
• Terminal ileum 10%
• Extraintestinal manifestations.

13. Gross
•

14. Microscopic Pathology

15. Microscopic Pathology
• Acute and chronic inflammatory infiltrate of
the lamina propria, crypt branching, and
villous atrophy are present in ulcerative
colitis.
• Inflammation of the crypts of lieberkühn
and abscesses.
• Granulomas are also seen in tuberculosis,
yersiniosis, and can even be seen in
ulcerative colitis

16. Microscopic Pathology
• The ulcerated areas are soon covered by
granulation tissue
• Inflammatory polyps or pseudopolyps.
• Excessive fibrosis is not a feature of the
disease

17. Grading

18. Grading
• Mild: Bleeding per rectum, fewer than four
bowel motions per day
• Moderate: Bleeding per rectum, more than
four bowel motions per day
• Severe: Bleeding per rectum, more than
four bowel motions per day, and a systemic
illness with hypoalbuminemia (< 30 g/L)

19. Clinical Features

20. Clinical Features
• Demography
• Symptoms
• Signs
• Prognosis
• Complications

21. Demography

22. Demography
• The annual incidence is 10.4-12 cases per
100,000 people, and the prevalence rate is
35-100 cases per 100,000 people.
• Three times more common than Crohn
disease
• White individuals living in Western
industrialized nations
• 2-4 times higher in Ashkenazi Jews.

23. Demography
• Bimodal pattern, with a peak at 15-25 years
and a smaller one at 55-65 years, although
the disease can occur in people of any age.
• Slightly more common in women than in
men.

24. Demography:Geographical
distribution
• Ulcerative colitis is more common in the
Western and Northern hemispheres; the
incidence is low in Asia and the Far East.
• As new regions assume Western cultural
practices, an increased prevalence of
ulcerative colitis is usually found
approximately 1 decade before the observed
increase in Crohn disease.

25. Symptoms

26. Symptoms
• Rectal bleeding
• Frequent stools
• Mucous discharge from the rectum
• Tenesmus (occasionally)
• Lower abdominal pain and severe
dehydration from purulent rectal discharge
(in severe cases, especially in the elderly).

27. Symptoms
In some cases, UC has a fulminant course
marked by the following:
• Severe diarrhea and cramps
• Fever
• Leukocytosis
• Abdominal distention

28. Symptoms
• Colonic Crohn disease may be clinically
indistinguishable from ulcerative colitis,
with symptoms of bloody mucopurulent
diarrhea, cramping abdominal pain, and
urgency to defecate.

29. Symptoms:ExtraGI manifestations
• Uveitis
• Pyoderma gangrenosum
• Pleuritis
• Erythema nodosum
• Ankylosing spondylitis
• Spondyloarthropathies
• Primary sclerosing cholangitis (PSC)
• Recurrent subcutaneous abscesses unrelated to
pyoderma gangrenosum
• Multiple sclerosis
• Immunobullous disease of the skin

30. Signs

31. Signs
• Normal in mild disease
• Mild tenderness in the lower left abdominal
quadrant
Severe cases-
• Fever
• Tachycardia
• Significant abdominal tenderness
• Weight loss

32. Prognosis: IBD

33. Prognosis: IBD
• Both are lifelong diseases.
• For both conditions, the overall mortality
has decreased steadily, and currently is less
than 5%.
• Both follow a more severe course in
children and adolescents
• Both are at increased risk for the later
development of cancer.
• The excess risk is limited to colorectal
cancer

34. Prognosis
• Most patients with these diseases are able to
maintain normal occupations and enjoy
reasonably stable social and economic
situations.
• Ulcerative colitis is curable with
proctocolectomy and ileostomy.

35. Complications

36. Complications
• Colonic perforation.
• Carcinoma.
• Benign strictures.

37. Investigations

38. Investigations
• Laboratory Studies
– Routine
– Special
• Imaging Studies
• Tissue diagnosis
– Cytology
• FNAC
– Histology

39. Diagnostic Studies

40. Diagnostic Studies
Imaging Studies
• X-Ray
• USG
• CT
• Angiography
• MRI
• Endoscopy
• Nuclear scan

41. Investigations

42. Investigations
• Serologic markers (eg, antineutrophil
cytoplasmic antibodies [ANCA], anti–
Saccharomyces cerevisiae antibodies
[ASCA])
• Complete blood cell (CBC) count
• Comprehensive metabolic panel
• Inflammation markers (eg, erythrocyte
sedimentation rate [ESR], C-reactive
protein [CRP])
• Stool assays
•

43. Imaging Studies
1. Endoscopy and biopsy-Abnormal
erythematous mucosa, with or without
ulceration, extending from the rectum to a
part or all of the colon
2. Uniform inflammation, without intervening
areas of normal mucosa (skip lesions tend
to characterize Crohn disease)
3. Contact bleeding may also be observed,
with mucus identified in the lumen of the
bowel

44. Colonscopy
Mucosa hyperemic loss of the normal vascular pattern
Normal colon Ulcerative Colitis

45. Imaging Studies
• Plain abdominal radiography
• Double-contrast barium enema examination
• Cross-sectional imaging studies (eg,
ultrasonography, magnetic resonance
imaging, computed tomography scanning)
• Radionuclide studies
• Angiography

46. UC: Barium enema
strictures in the transverse and
descending colon Mucosal ulcers

47. Radiography

48. Radiography
• Pseudopolyposis
• Deep ulcers
• The colon may appear shortened
• Loss of colonic haustra
• Toxic megacolon -massive colonic dilatation
associated with an abnormal mucosal contour.
• Colonic perforation
• Thumbprinting
• Long stricture/spasm of the ascending
colon/cecum
• Increased postrectal space

49. Barium enema findings

50. Barium enema findings
• Colon may appear narrow , short and loose.
• Granular mucosa.
• Pseudopolyposis
• Mucosal ulcers
– Collar-button ulcers
– Double-tracking ulcers
• Burnt-out ulcerative colitis
• Similar radiographic signs may be seen in cases of
infective diarrhea, crohn disease, ischemic colitis,
drug-induced colitis, and amebic colitis

51. Computed Tomography

52. Computed Tomography
• Difuse , circumferential, symmetrical wall
thickening with fold enlargement.
• Submucosal fat deposition
• Target sign
• The halo sign typically occurs in ulcerative
colitis.

53. Differential Diagnosis

54. Differential Diagnosis
• Crohn's Disease
• Cathartic colon.
• Collagenous colitis
• Lymphocytic colitis
• Infectious colitis
• Ischemic colitis

55. Summary

56. Summary
Ulcerative Colitis Crohn Disease
Only colon involved Panintestinal
Continuous inflammation
extending proximally from
rectum
Skip-lesions with intervening normal
mucosa
Inflammation in mucosa and
submucosa only
Transmural inflammation
Perianal lesions
No granulomas Noncaseating granulomas
Perinuclear ANCA (pANCA)
positive
ASCA positive
Bleeding (common) Bleeding (uncommon)
Fistulae (rare) Fistulae (common)

57. Non Operative Therapy

58. Non Operative Therapy
• Mild disease confined to the rectum: Topical
mesalazine via suppository (preferred) or
budesonide rectal foam
• Left-side colonic disease: Mesalazine suppository
and oral aminosalicylate (oral mesalazine is
preferred to oral sulfasalazine)
• Systemic steroids, when disease does not quickly
respond to aminosalicylates
• Oral budesonide
• After remission, long-term maintenance therapy
(eg, once-daily mesalazine)

59. Non Operative Therapy
• Medical treatment of acute, severe UC
• Hospitalization
• Intravenous high-dose corticosteroids
• Alternative induction medications:
Cyclosporine, Tofacitinib
• tacrolimus, infliximab, adalimumab,
golimumab

60. Operative Therapy

61. Operative Therapy
• Indications for urgent surgery include the
following:
1. Toxic megacolon refractory to medical
management
2. Fulminant attack refractory to medical
management
3. Uncontrolled colonic bleeding

62. Operative Therapy
• Indications for elective surgery -
1. Long-term steroid dependence
2. Dysplasia or adenocarcinoma found on
screening biopsy
3. Disease being present for 7-10 years

63. Operative Therapy
Surgical options -
• Total colectomy (panproctocolectomy) and
ileostomy
• Total colectomy Ileoanal pouch
reconstruction or ileorectal anastomosis
• In an emergency, subtotal colectomy with
end-ileostomy

64. Operative Therapy
• UC is generally limited to the colon, apart
from minimal distal "back-wash" ileitis;
• ulcerative colitis usually involves only the
mucosal layer of the bowel, and, in some
cases, superficial submucosa, unless there is
fulminant colitis
• may also manifest cecal or appendiceal
patches of involvement that can simulate
the "skip" lesions of CD
•

65. Prevention

66. Prevention

67. Take Home Messages

68. Take Home Messages
• UC is generally limited to the colon, apart
from minimal distal "back-wash" ileitis;
• ulcerative colitis usually involves only the
mucosal layer of the bowel, and, in some
cases, superficial submucosa, unless there is
fulminant colitis
• may also manifest cecal or appendiceal
patches of involvement that can simulate
the "skip" lesions of CD
•

69. Take Home Messages
• risk of neoplastic transformation, the risk
is higher
• continuous process, worse distally, with
increased span of involvement distal to
proximal, as the disease progresses
• Surgical intervention is better tolerated in
UC

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