Inflammatory Bowel Disease


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Inflammatory Bowel Disease

  1. 1. Inflammatory Bowel Disease By Dr. Osman Bukhari
  2. 2. <ul><li>-Includes ulcerative colitis (UC) & Crohns disease( CD). </li></ul><ul><li>-There is overlap between or they are spectrum of the same disease. </li></ul><ul><li>-In 10% of colitis it is difficult to differentiate between them. </li></ul><ul><li>-Common in the west. Peak age is20-40 y. M=F. </li></ul><ul><li>-Remission & relapses. </li></ul><ul><li>Aetiology </li></ul><ul><li>-Genetic & enviromental factors. </li></ul><ul><li>-Familial:10% with high concordance in id. twins </li></ul>
  3. 3. <ul><li>-Genetics: HLAB27. Association with autoimmune diseases. </li></ul><ul><li>-High sugar & low residue diet and smoking are associated with CD. </li></ul><ul><li>-Transmissible agent in CD( measles & T.b.) </li></ul><ul><li>-Multiangiitis leading to infarction. </li></ul><ul><li>-Bact. Endotoxins release NO causing damage. </li></ul><ul><li>-Immune response to luminal Ag.( bacterial product or diet) leading to inflammation through cytokins & free O2 radicals with activation & attraction of polymorphs, plasma cells & lymphocytes causing inflmm.& ulcers . </li></ul>
  4. 4. <ul><li>Pathology </li></ul><ul><li>-In CD whole GIT is involved. Terminal ileum & ascending colon being commonly affected. Rectal disease is rare. In UC proctitis is invariable & back wash ileitis is rare. </li></ul><ul><li>-Macroscopically : In CD small bowel is thickened & narrowed. The lesions are skipped deep ulcers with enlarged L.nodes, abscesses, fissures & fistulae. Toxic colonic dilatation can follow fulminant colitis. </li></ul><ul><li>-In UC colitis is continuous with ulceration & is more distally. Pseudopolyps are common. </li></ul>
  5. 5. <ul><li>toxic dilatation can follow fulminant colitis. </li></ul><ul><li>-Microscopically: In CD there is transmural non casiating granuloma with normal goblet cells & infrequent crypt abscesses. In UC inflamm. is superficial with chronic inflamm. infiltrates, loss of goblet cells, frequent crypt abscesses. Displasia & Ca are more common. </li></ul><ul><li>Clinical features of CD </li></ul><ul><li>- presentation is variable depending on the severity & extent of the disease. Mild cases lead normal life with repeated admission in severe cases. </li></ul>
  6. 6. <ul><li>-Major symptoms of abd. Pain, diarrhoea (80%) & weight loss. Abd. Pain is due to peritoneal involvement or obstruction. 10% present wuth acute pain in RIF. Diarrhoea is bloody in colitis & steatorrhoeic in small bowel disease </li></ul><ul><li>-Constitutional symptoms of anorexia, N, V, general illhealth & fatigue ( Anemia due to malabsorption of Fe, FA,& B12). </li></ul><ul><li>-Abdominal ex.=normal or tender or masses in the RIF ( Inflm. Loops of bowel or abscesses). </li></ul>
  7. 7. <ul><li>-PR =perianal abscess, skin tags, fissures & fistulae sp. with colitis. </li></ul><ul><li>-Sigmoidoscopy= rectum may be spared or may be indistinguishable from UC. Take biopsies. </li></ul><ul><li>Clinical feature of UC </li></ul><ul><li>-Presentation is variable depending on the extent & severity of the disease. </li></ul><ul><li>-Bloody diarrhea with mucus & occasionally only blood &mucus. Lower abdominal pain. </li></ul><ul><li>-Urgency & tensmus in proctitis without constitutional symptom. </li></ul>
  8. 8. <ul><li>-Anorexia ;nausea & lethargy in total colitis. </li></ul><ul><li>-Slight abdominal distension & tenderness. </li></ul><ul><li>-PR= normal or tender with blood in the examining finger. </li></ul><ul><li>-Mild colitis=up to 4 motions per day. </li></ul><ul><li>-Mod. Colitis=4-6 motions per day. </li></ul><ul><li>-Severe Colitis = more than 6 motions per day, patient very ill temp. >37.5, pulse >90, Hb <10 g./dl., ser. Albumin <30 g./l. & under nutrition. </li></ul>Anorexia, nausea
  9. 9. <ul><li>* Fulminent colitis may cause toxic mega- colon with perforation or septicemia. </li></ul><ul><li>Extra-intestinal manifestations of IBS </li></ul><ul><li>(Related to disease activity & more in UC.) </li></ul><ul><li>-Clubbing of fingers, E. nodosum, pyoderma gangrenosum & oral aphthus ulcers. </li></ul><ul><li>-Episcleritis, conjunctivitis, iritis & uveitis. </li></ul><ul><li>-Monoarthritis, sacro-ilitis & ankylosing spondylitis. </li></ul><ul><li>-Fatty liver, chronic hep., cirrhosis, autoimmune hep. scl.cholanhitis, cholanioCa. </li></ul>
  10. 10. <ul><li>-Portal pyaemia &liver abscess. </li></ul><ul><li>-Auto-immune hemolytic anemia, vasculitis & thrombosis of portal & mesenteric veins. </li></ul><ul><li>-Amyloidosis. </li></ul><ul><li>* *** Relapses in UC are precipitated by:- Stress, intercurrent infection, G.E, antibiotics & NSAIDs. </li></ul><ul><li>Investigations in IBD. </li></ul><ul><li>-anemia( multifactorial), raised WBC, ESR & CRP. </li></ul><ul><li>-stools ex. To exclude bacterial ,protozal & helmithic infections. </li></ul>
  11. 11. <ul><li>-Low serum albumin & abnormal LFT. </li></ul><ul><li>-Blood culture in suspected septicemia. </li></ul><ul><li>-Stool culture if diarrhea persist despite Tr. </li></ul><ul><li>-Plain abd. X-ray in toxic megacolon. </li></ul><ul><li>-Ba.enema : shortening, narrowing & loss of haustrations of colon, granular appearance of colon, pseudopolyps & filling defects. Avoided in acute cases. </li></ul><ul><li>-Sigmoidoscopy: engorged hyperemic mucosa which bleed spontaneously in severe cases. </li></ul><ul><li>-Colonoscopy: assesses extent & severity of disease </li></ul>
  12. 12. <ul><li>and take multiple biopsies to distinguish between UC & CD. </li></ul><ul><li>-Small bowel Ba. follow- through ( abn. Mucosal pattern, skipped lesions, deep ulcers & narrowing_string sign.) </li></ul><ul><li>- US fore masses & CT for abscesses & bowel thickening. </li></ul><ul><li>Diff. diag : </li></ul><ul><li>- Small bowel disease: chronic diarrhea, malabsorption & malnutrition, ileocecal Tb., </li></ul>
  13. 13. <ul><li>actinomycosis, yersinia, appendicitis & append. Abscess, lymphoma &Ca caecum. </li></ul><ul><li>-Infective diarrhea :salmonella, shigella, campylobacter., E.coli hagic colitis, GN & Chlamydia proctitis, pseudomembraneous, herpes simplex & amebiasis. </li></ul><ul><li>-Noninfecive colitis: ischemic, radiation, diffuse lymphoma, behcet, NSAID, diverticulitis & colonic Ca. </li></ul><ul><li>Management of IBS. </li></ul><ul><li>Medical :well balanced diet with protein and energy. Maintain fluid & elect. balance. </li></ul>
  14. 14. <ul><li>-Low fat & milk if malabsorption. High fibre avoided in mall bowel disease, it is beneficial in proctitis & constipation. Iron, folic acid, B12,Vit. D & Ca supplements. </li></ul><ul><li>-Drugs: Mild CD treated symptomatically with antidiarrheal.In acute CD admit for induction of remission with Prednsolone 40-60 mg/ day for 2W & reduce to 10-20mg for 6-8 w. Azathioprin for maintenance of steroid induced remission or if Prednsolone fails. Sulphasalasine ( 5ASA) & mesalasine for maintenance of remiss. In colonic CD . Methotrexate, ciclosp & TNF Abs.for those who do not respond to a.m. drugs. </li></ul>
  15. 15. <ul><li>-Antibiotics & Metronidazole bacterial colonization & perianal disease. </li></ul><ul><li>-Surgery is required in 80% CD but should be avoided & conservative with minim. resection ( stricture & fistulae, abscess, perforation , toxic megacolon & severe extensive colonic disease if no response to med . TR..). Unlike UC surgery is not curative. </li></ul><ul><li>-Medical management in UC: In severe active colitis--- fluid & elect. correction, blood & plasma transfusion , nutrition, S/C heparin to prevent DVT, blood culture & antibiotics if septicemia is suspected. </li></ul>
  16. 16. <ul><li>-Parentral methylprednsolone or oral Prednsolone ( 40-60) for 2W to induce remission & maintain on (5ASA) to prevent relapse. If no response use azathioprin. If no response then surgery. Azathioprin is also used for patients who require high dose steroids for Maintaince. </li></ul><ul><li>-Steroid suppositories for proctitis & steroid enema for mild proctocolitis. If no response or if the patient can not retain enema; use systemic steroids. 5ASA can induce remission in mild & mod. colitis but less effective. </li></ul>
  17. 17. <ul><li>- Surgery for UC : Emergency proctocolectomy or colectomy Ist.& later proctosigmoidectomy for toxic dilatation, perforation & hage ,. Acue severe UC failing to med. TR , colonic abscess stricture & long standing total colitis & severe extra-intestinal not responding to med. TR are another indications. </li></ul><ul><li>Complications of IBS: </li></ul><ul><li>-Fistulae, fissures, abscess & local perforation in CD. </li></ul><ul><li>-Toxic colonic dilatation. </li></ul><ul><li>- Perforation in toxic dilt. </li></ul>
  18. 18. <ul><li>-Massive hage is rare. </li></ul><ul><li>-Ca colon (3-5%) specially in extensive colitis of > 10 years. </li></ul><ul><li>-Amyloidosis. </li></ul><ul><li>Course in IBS: </li></ul><ul><li>- R elapses & remiss. Mortality is twice as common as in normals in CD & is associated with surgery. </li></ul><ul><li>-Prognosis is good in proctitis & worse with severe colitis. Mortality 15-25 % in fulmin. colitis </li></ul>
  19. 124. <ul><li>-Low serum albumin & abnormal LFTs. </li></ul><ul><li>-Blood culture in suspected septicemia. </li></ul><ul><li>-Stool culture if diarrhea is persistent. </li></ul><ul><li>=In colitis plain in toxic dilatation of colon, </li></ul><ul><li>Ba enema : avoided in acute cases.There is narrowing, shoryening, loss of haustration , ulceration, pseudo polyps &granular appearance. </li></ul><ul><li>-Sigmoidoscopy :engorged hyperemic mucosa which bleeds spontaneously or or touch </li></ul>
  20. 125. <ul><li>-Colonoscopy: To assess extenty & severity of the disease, to distinguish between UC &CD & take multiple biopsies. </li></ul><ul><li>-Small bowel follow through in CD( skipped lesions, abnormal mucosa, deep ulcerations & narrowing ( string sign) </li></ul><ul><li>-CT for abscesses & bowel thickening & US for masses. </li></ul><ul><li>Diff. Diagnosis: </li></ul><ul><li>-CD of small bowel: chronic diarrhea, malabsorption, malnutrition, ileocecal Tb., </li></ul>
  21. 126. <ul><li>actinomycosis, appendicitis &abscess, Yesinia ielitis, lymphoma & Ca cecum. </li></ul><ul><li>-Colitis: infective colitis ( salmonella, shigella, campylobacter, E. coli hemorrhagic colitis, G.N.& Chlamydia proctitis, pseudomembr.colitis & amebiasis.) AND noninfective colitis ( ischemic, radiation, Behcets, NSAIDs, Ca colon & diverticulitis ) </li></ul>
  22. 134. <ul><ul><li>IBD includes UC & CD: </li></ul></ul><ul><ul><li>-There is overlap between them & could be spectrum of the same disease & in 10% of colitis it is difficult to say which is which. </li></ul></ul><ul><ul><li>-Common in the west .F=M. 20-40 ys. </li></ul></ul><ul><ul><li>-Relapses & remissions. </li></ul></ul><ul><ul><li>Aetiology </li></ul></ul><ul><ul><li>Genetic & enviromental factors are implicated </li></ul></ul><ul><ul><li>-Familial </li></ul></ul><ul><ul><li>-Genetic associated with HLAB27. </li></ul></ul><ul><ul><li>- Dietary: low residue & high sugar diet. </li></ul></ul>
  23. 135. <ul><li>- Smoking in CD. UC more common in non smokers. </li></ul><ul><li>-Transmissible agent e.g. measels-mycob.Tb. </li></ul><ul><li>-Multifocal angiitis—infarction. </li></ul><ul><li>-Bacterial endotoxins liberating NO3 causing damage. </li></ul><ul><li>-Luminal Ag. Evocing immune response causing inflammatory response through cytokins & free O2 radicals. </li></ul>
  24. 136. <ul><li>Pathogenesis </li></ul><ul><li>Involves activation of macrophages in response to dietary element or bacterial product with release of inflammatory cytokins with activation & attraction of polymorphs, plasma cells & lymphocytes leading to inflammation & ulceration. </li></ul><ul><li>Pathology </li></ul><ul><li>General: </li></ul><ul><li>-In CD whole GIT is involved sp. Terminal ileum & </li></ul>
  25. 137. <ul><li>ascending colon are commonly affected while proctitis is rare. In UC proctitis is invariable & backwash ileitis is rare. </li></ul><ul><li>Macroscopic: </li></ul><ul><li>-In CD small bowel is thickened with skipped lesions & deep ulcers. Aphthus ulcers, abscesses & fistulae are common. Fulminant colitis & toxic diltation can occur. In UC there is confluent colitis with extensive ulceration and pseudopolyps. </li></ul>
  26. 138. <ul><li>Microscopy </li></ul><ul><li>In CD there is transmural non casiating granuloma of the bowl &L. nodes with infrequent crypts abscesses & normal goblet cells. In UC there is superficial chronic inflammatory infiltrate, no granuloma with loss of goblet cells & crypt abscesses. </li></ul><ul><li>Clinical picture </li></ul><ul><li>In UC clinical picture is variable depending on the site, extent & severity of the disease. </li></ul>
  27. 139. <ul><li>-bloody diarrhoea with mucus. Occasionally only mucus & blood. There is lower abdominal pain, distension & tenderness. </li></ul><ul><li>-Urgency & tensmus without constitutional symptoms in proctitis. </li></ul><ul><li>-Anorexia, malaise & lethergy in total colitis with aphthoid ulcers. </li></ul><ul><li>*Mild colitis =Up to 4 motions/day. </li></ul><ul><li>*Mod. Colitis = 4-6 motions/day. </li></ul><ul><li>*Severe colitis=More than 6 motions/day. Pat. Is very ill , febrile, Hb < 10gm, pulse >90, albumin <30 gm & undernutrition. Fulminant colitis with diltation, perforation & septicaemia can occur. PR= tender with blood. </li></ul>
  28. 140. <ul><li>In CD clinical picture is variable depending on the extent & severity of disease ranging from mild disease to severe disease with repeated admission. </li></ul><ul><li>-Acute or chronic onset with abd. Pain & diarrhoea(80%) with constitutional symptoms of fever, fever,A, N,V, weight loss & fatigue. Colicky pain suggests obstruction. Pain RIF like acute appendicitis. </li></ul><ul><li>-Features of malabsorption with anaemia, weihgt loss & vitamin deficiency. Aphth. Ulcer </li></ul><ul><li>-Abd. Ex. Normal or tender with masses </li></ul><ul><li>-Colitis in CD is similar to UC. </li></ul><ul><li>-PR: skin tags, perianal abscesses, fissures & fistulae sp. In CD with colitis. </li></ul>
  29. 141. <ul><li>Extraintestinal manifestations of IBD. </li></ul><ul><li>-Clubbing ,E. nodosum, Py. Gangrenosum, Aphthus ulcers & amyloidosis. </li></ul><ul><li>-A spondylitis, S/ Ilitis & monoarthritis. </li></ul><ul><li>-Conjunctivitis, episcleritis, iritis & uveitis. </li></ul><ul><li>-Fatty liver ,chronic hepatitis, cirrhosis, Scler cholangitis, cholangioCa, autoimmune hepatitis, portal pyemia &liver abscess. </li></ul><ul><li>-Autoimmune hemolytic anemia, vasculitis, thrombosis including portal mesen. Thrombosis. </li></ul>
  30. 142. <ul><li>Investigations </li></ul><ul><li>Aimed at confirming diagnosis, defining disease extent & activity and identifying complications. </li></ul><ul><li>-Anemia: multifactorial, high ESR & CRP. </li></ul><ul><li>-Low serum albumin & abn. Liver biochemst. </li></ul><ul><li>-Stool culture to exclude infections & biood cultures in patients with IBD who develop fever. </li></ul><ul><li>-Plain abdominal XR if toxic dilatation & perforation are suspected. </li></ul>
  31. 143. <ul><li>-BA. E nema: narrow & short colon, loss of haustrations, granular appearance, pseudopolyps & filling defects. Ba. Avoided in active disease. </li></ul><ul><li>-Sigmoidoscopy: ranges from abnormal vascular pattern in mild colitis to engorged mucosa which may bleeds spontaneously or on touch. Take biopsies. Rectal sparing in CD. </li></ul><ul><li>-Colonoscopy: In UC the pathology is continuous, while in CD it I patchy, ulcers are deep & strictures are common. Take multiple biopsies </li></ul>
  32. 144. <ul><li>-Small bowel follow-through in CD shows skipped lesions, deep ulcers & narrow segments ( string sign). </li></ul><ul><li>-CT for bowel thickening & abscesses. </li></ul><ul><li>-US to detect masses. </li></ul><ul><li>Differential diagnosis </li></ul><ul><li>-CD should be differentiated from other causes of chronic diarrhoea, malabsosption & malnutrition, ileocaecal Tb., actinomycosis, yersinia, appendicitis & append. Abscess, lymphomas & Ca caecum. </li></ul>
  33. 145. <ul><li>-Colitis in UC & CD should be differentiated from infective colitis ( bacterial or amoebic, & pseudomembraneous colitis ) Or non infective colitis ( ischemic, radiation, lymphoma, behcet, Ca & diverticulitis,). </li></ul><ul><li>Management </li></ul><ul><li>A-Medical of CD: </li></ul><ul><li>-Fluid & electrolyte balance. Maintenance of nutrition with low fat & milk diet if there is malabsorption. Iron, folic acid, B12, vit. D & calcium supplements. </li></ul>
  34. 395. <ul><li>-Symptomatic treatment with antidiarrhoeals in mild cases. </li></ul><ul><li>-For severe acute attacks, Prednsolone 40-60 mg. for 1-2 weeks reduced to 10-20 mg. for 6-8 weeks ( Budesonide has less S.E.). </li></ul>