Enfermedad Inflamatoria de Intestino ¿Como Diagnosticarla? - www.grupodeapoyoeii.org


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Enfermedad Inflamatoria de Intestino ¿Como Diagnosticarla?
Forma parte del taller del Grupo De Apoyo De Enfermedades Inflamatorias Del Intestino. Para mas informacion visita: www.grupodeapoyoeii.org

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  • Enfermedad Inflamatoria de Intestino ¿Como Diagnosticarla? - www.grupodeapoyoeii.org

    1. 1. IBD Epidemiology and Diagnosis Roberto E. Mera Lastra MD Gastroenterology University of Puerto Rico Medical Sciences Campus
    2. 2. Inflammatory Bowel Disease <ul><li>Definition: Conditions characterized by a tendency for chronic or relapsing immune activation and inflammation within the gastrointestinal tract. </li></ul><ul><li>Crohn’s disease and ulcerative colitis </li></ul>
    3. 3. Crohn’s disease <ul><li>chronic inflammation </li></ul><ul><ul><li>involving any location of the alimentary tract from mouth to anus </li></ul></ul><ul><ul><li>propensity for the distal small bowel and proximal large bowel </li></ul></ul>
    4. 4. Ulcerative Colitis <ul><li>Inflammatory disorder that affects the rectum and extends proximally to affect a variable extent of the colon </li></ul>
    5. 5. Inflammatory Bowel Disease <ul><li>Epidemiology </li></ul><ul><li>Pathogenesis </li></ul><ul><li>Clinical Presentation of Crohn’s disease and Ulcerative Colitis </li></ul><ul><li>Diagnosis </li></ul><ul><li>Extraintestinal Manifestations </li></ul>
    6. 6. Epidemiology of IBD <ul><li>1-2 million IBD patients in the U.S. </li></ul><ul><li>Equal incidence of ulcerative colitis and Crohn’s disease </li></ul><ul><li>Approximately 10,000 new cases diagnosed annually* </li></ul><ul><li>Reassignment 10% in the first 2 years after diagnosis </li></ul>*Hanauer S. Inflammatory Bowel Disease. N Engl J Med. 1996;334(13):841-8
    7. 7. Epidemiology of IBD: Overview Variable Finding Time trends in incidence Increased 1960s – 80s with recent plateau Incidence (per 100,000) 5-7 Peak age at onset (y) 15-30 Female-to-male ratio 1.1 to 1.8:1 Racial/ethnic incidence High in whites, Jews Andres PG et al. Gastroenterol Clin N Am . 1999;28:255.
    8. 8. Pathogenesis
    9. 9. <ul><li>Immune dysregulation </li></ul>IBD – Interaction of Genetic Susceptibility, Immune Dysregulation, and Environmental Triggers IBD Genetic susceptibility Environmental triggers
    10. 10. Normal Intestine Vs. Intestine With IBD Environmental triggers (infection, bacterial products) Moderately inflamed Failure to down- regulate Chronic uncontrolled inflammation = IBD Down-regulate Normal gut controlled inflammation Normal gut controlled inflammation
    11. 11. IBD: Evidence of Genetic Influence <ul><li>Racial differences in incidence: White > Black > Asian </li></ul><ul><li>Ethnic influences: Jewish > non-Jewish; Ashkanazi > Sephardic </li></ul><ul><li>Twin studies: Monozygotic > dizygotic </li></ul><ul><li>Association with specific HLA antigens, ? susceptibility loci on chromosomes 6, 16 </li></ul><ul><li>NOD2 gene explains 20% of Crohn’s disease </li></ul>Sartor RB. Inflammatory Bowel Dis . 1995;24:475.
    12. 12. Familial Patterns of Inheritance <ul><li>Approximately 10% of patients have positive family history </li></ul><ul><li>2%–10% risk if first-degree relatives affected </li></ul><ul><li>20–50-fold increase in prevalence among siblings </li></ul><ul><li>50–100-fold increase in prevalence for children of patients with IBD </li></ul>Yang H, Rotter JI. In: Inflammatory Bowel Disease. From Bench to Bedside. 1993:32.
    13. 13. Immune dysregulation <ul><li>Sustained exaggerated inflammatory reaction may result from an ineffective immune response </li></ul><ul><ul><li>over-responsiveness to a persistent stimulus </li></ul></ul>
    14. 14. Enviroment <ul><li>Breast Feeding </li></ul><ul><li>Smoking </li></ul><ul><li>Nsaids </li></ul><ul><li>OCP’S </li></ul>
    15. 15. Clinical Findings
    16. 17. Presentation of UC <ul><li>Diarrhea </li></ul><ul><li>Bleeding </li></ul><ul><li>NO abdominal pain (cramps) </li></ul><ul><li>Extraintestinal manifestations </li></ul>
    17. 19. Presentation of CD <ul><li>Diarrhea </li></ul><ul><li>Chronic abdominal pain and tenderness </li></ul><ul><li>Loss of appetite and weight loss </li></ul><ul><li>Fever </li></ul><ul><li>Perianal disease </li></ul><ul><li>Complications such as fistulas </li></ul><ul><li>Extraintestinal manifestations </li></ul>
    18. 22. Complications of CD <ul><li>Fistulas </li></ul><ul><li>Abscess </li></ul><ul><li>Strictures </li></ul><ul><li>Growth failure (pediatrics) </li></ul><ul><li>Malnutrition </li></ul><ul><li>Extraintestinal disorders </li></ul>
    19. 24. Crohn’s Disease Complications: Fistulas <ul><li>A tunnel between two sections of the intestines or between the intestines and other organs, including the skin </li></ul>Small Intestine Large Intestine (Colon) Fistula Fistula
    20. 25. Crohn’s Disease Complications: Abscesses <ul><li>A localized collection of pus within the tissue of the GI tract </li></ul>Stomach Small Intestine Large Intestine (Colon) Abscess from a fissure in the small intestine into the peritoneal cavity
    21. 26. Complications of CD: Fistulas Abdominal Fistula Perianal Fistula
    22. 27. Differential Diagnosis of IBD <ul><li>Lymphoma </li></ul><ul><li>Infectious etiologies </li></ul><ul><li>Appendicitis </li></ul><ul><li>Diverticulitis </li></ul><ul><li>Carcinoma </li></ul><ul><li>Ischemic Colitis </li></ul><ul><li>Celiac disease </li></ul>
    23. 28. Severity of UC
    24. 29. Diagnostic algorithm for IBD Intestinal symptoms Rectal bleeding, diarrhea, vomiting, anorexia, abdominal pain Extraintestinal symptoms Fever, perianal lesions, growth failure, mouth ulcers, erythema nodosum, etc. Differential diagnosis Gastroenteritis, appendicitis, IBD, antibiotic-associated colitis, etc Laboratory findings Anaemia, leukocytosis, thrombocytosis, elevated CRP, hypalbuminaemia, low vitamin levels, p-ANCA, ASCA Radiologic studies Plain abdominal x-ray, upper GI barium series Echo Endoscopy and biopsy Crohn disease Ulcerative colitis
    25. 30. Differentiating Crohn’s Disease from Ulcerative Colitis Feature Crohn’s Disease Ulcerative Colitis Abdominal pain Frequent and prominent Primarily cramping associated complaint but may not be present with bowel movement Diarrhea Watery or voluminous stools Usually; occasionally constipation with complaint but may not be present proctitis Gross blood in stool Occasionally; primarily with colonic disease Frequently Mucus in stool Occasionally Frequently Abdominal mass Frequently, particularly with ileocecal disease Rarely Abdominal tenderness Frequently Rarely Intestinal obstruction Frequently Rarely Perianal disease Frequently Rarely Perianal fistulas Frequently No
    26. 31. Rectal involvement 25–50% 95–100% (before treatment) Continuous colitis Rarely Yes Symmetry of inflammation Eccentric inflammation Circumferential inflammation Bowel wall thickening Marked None to moderate Cobblestone appearance Frequent Rare Background mucosa Normal Abnormal Fistula Often Rarely (rectovaginal) Mesenteric inflammation Frequent Rare, except with toxic megacolon Segmental inflammation Yes, skip areas frequently seen No, except for cecal Inflammation adjacent to appendiceal orifice Stricture Often Rarely Ulceration Depth: aphthous to deep Superficial Shape: linear, serpiginous, stellate Mesenteric proliferation of fat Frequent No
    27. 32. Feature Crohn’s Disease Ulcerative Colitis Rectovaginal fistulas Occasionally Rarely Abscess Occasionally No Recurrence after surgery Yes No recurrence after total proctocolectomy, though pouchitis may occur in ileal pouch Toxic megacolon Rare Infrequent Current smoker Frequently Rarely Former smoker Rarely Frequently Previous appendectomy Occasionally Rarely Macrocytic anemia Occasionally Rarely Perinuclear antineutrophil 20% 70% cytoplasmic antibodies (pANCA) Anti- Saccharomyces 65% 15% cerevisiae antibodies (ASCA) Distribution of disease May involve any segment of GI Contiguous involvement of colon from rectum proximally Abn prox to terminal ileum Sometimes No Abnormal terminal ileum Frequently Occasionally, from backwash ileitis Ileocecal valve Often narrowed Normal or gaping
    28. 33. <ul><li>Significant factors UC CD </li></ul><ul><li>Anatomic location Colon/rectum Any part of GI tract </li></ul><ul><li>Distribution Diffuse Focal with “skip” areas </li></ul><ul><li>Fistula or abscess Rare Common </li></ul><ul><li>Strictures Uncommon Common </li></ul><ul><li>Current smoker Rare Common </li></ul><ul><li>Bloody diarrhea Common Rare </li></ul>Differential Diagnosis Adapted from Surawicz CM. Contemp Intern Med. 1991;3:17 .
    29. 34. Crohn’s Disease – Extra-luminal dx <ul><li>(1) Anemia </li></ul><ul><li>(2) Hepatobiliary disorders: - Fatty liver - Hepatitis - Cirrhosis - Sclerosing cholangitis - diffuse inflammation, leading to patchy stricturing of bile duct. </li></ul><ul><li>(3) Rheumatic: - Arthritis - peripheral occurs in 10% - Ankylosing spondylitis - occurs in 5% </li></ul><ul><li>(4) Dermatologic: - Erythema Nodosum (rashes), most commonly over tibia - Pyoderma gangrenosum - necrotic ulcer over skin </li></ul><ul><li>(5) Ocular: - Uveitis - inflammation of uveal tract (iris, ciliary body, choroid) - Episcleritis - inflammation of connective tissue between sclera and conjunctiva </li></ul>
    30. 35. Ulcerative Colitis – Extra-luminal dx <ul><li>(1) Hematologic </li></ul><ul><li>- Anemia, thromboembolic disease </li></ul><ul><li>(2) Hepatobiliary disorders: - Fatty liver, hepatomegaly, Pericholangitis - Cirrhosis (1-5%), Primary Sclerosing cholangitis (1-4%) - Bile duct carcinoma </li></ul><ul><li>(3) Rheumatic: - Arthritis - peripheral occurs in 15-20% - Ankylosing spondylitis - occurs in 3-6% </li></ul><ul><li>(4) Dermatologic: - Aphthous ulcers in oral mucosa - Erythema Nodosum (rashes), most commonly over tibia - Pyoderma gangrenosum - necrotic ulcer over skin </li></ul><ul><li>(5) Ocular (4-10%): - Uveitis, Episcleritis, Marginal ulcerations of cornea, Cataracts, Keratopathy, Central Serous Retinopathy </li></ul>
    31. 36. Endoscopic, Radiographic, and Histologic Findings Diagnosis of Crohn’s Disease and Ulcerative Colitis
    32. 37. Ulcerative Colitis: Bleeding 101402.7 Lindenbaum - On-screen
    33. 38. Severe Crohn’s Colitis Reprinted by permission of Blackwell Science, Inc. Marion JF et al. In: Di Marino AJ, Benjamin SB (eds). Gastrointestinal Disease: An Endoscopic Approach. 1997:511.
    34. 39. Pseudopolyps in CD Reprinted by permission of Blackwell Science, Inc. Marion JF et al. In: Di Marino AJ, Benjamin SB (eds). Gastrointestinal Disease: An Endoscopic Approach . 1997:511.
    35. 40. Perianalis fistula
    36. 41. Normal endoscopic finding
    37. 42. Ulcerative colitis endoscopic finding
    38. 43. Crohn colitis
    39. 44. Crohn disease Enterography: String-sign (arrow) is demonstrated. Sac-formation may be observed on the antimesenteric side (double arrow).
    40. 45. Ulcerative colitis pseudopolyps
    41. 46. Crohn’s Dx – String Sign
    42. 47. Ulcerative Colitis - Ulcerations
    43. 48. Ulcerative Colitis – “Lead Pipe”
    44. 49. Fibrostenosis in CD Courtesy of J-F Colombel, MD.
    45. 50. Intestinal Complications of Ulcerative Colitis Toxicity 101402.7 Lindenbaum - On-screen
    46. 51. Extraintestinal Manifestations
    47. 53. Extraintestinal Manifestations of IBD <ul><li>Skin disorders </li></ul><ul><ul><li>Erythema nodosum </li></ul></ul><ul><ul><li>Pyoderma gangrenosum </li></ul></ul><ul><li>Joint disorders </li></ul><ul><ul><li>Peripheral arthritis </li></ul></ul><ul><ul><li>Sacroiliitis </li></ul></ul><ul><ul><li>Ankylosing spondylitis </li></ul></ul><ul><li>Ocular disorders </li></ul><ul><ul><li>Iritis, uveitis, and episcleritis </li></ul></ul>
    48. 54. Extraintestinal Manifestations of IBD <ul><li>Hepatobiliary </li></ul><ul><ul><li>Gallstones </li></ul></ul><ul><ul><li>Sclerosing cholangitis </li></ul></ul><ul><ul><li>Cholangiocarcinoma </li></ul></ul><ul><li>Renal </li></ul><ul><ul><li>Renal stones </li></ul></ul><ul><ul><li>Amyloidosis </li></ul></ul><ul><li>Other manifestations </li></ul><ul><ul><li>Aphthous stomatitis </li></ul></ul><ul><ul><li>Hypercoagulable state </li></ul></ul>
    49. 55. Erythema Nodosum in IBD Courtesy of J-F Colombel, MD.
    50. 56. Pyoderma Gangrenosum in CD
    51. 57. Sacroiliitis in IBD Courtesy of J-F Colombel, MD.
    52. 58. Ankylosing Spondylitis Reprinted from the Clinical Slide Collection on the Rheumatic Diseases, copyright 1991, 1995, 1997. Used by permission of the American College of Rheumatology.
    53. 59. Scleritis in IBD Courtesy of J-F Colombel, MD.
    54. 60. Aphthous Stomatitis in IBD Courtesy of J-F Colombel, MD.