IBD includes Crohn's disease and ulcerative colitis. Crohn's disease is a chronic inflammatory condition that can affect any part of the gastrointestinal tract and is characterized by transmural inflammation and skip lesions. Ulcerative colitis causes inflammation and ulcers in the innermost lining of the large intestine. Both conditions involve relapsing inflammation and have no known causes but are associated with genetic and environmental factors. Treatment depends on severity but may include medications to reduce inflammation, immunosuppressants, antibiotics, surgery for complications, and potentially colectomy for ulcerative colitis.

1. Rayyan Mkahal
Dana Nour Eddine

2. IBD
Crohn’s disease Ulcerative colitis

3. •Known as regional enteritis or granulomatous colitis
•Relapsing & remitting course
•High rate of recurrence
•Chronic inflammatory GI disease characterized by
transmural granulomatous inflammation.
It affects any part of the gut from the mouth to the anus
•Favors the terminal ilieum (in 50%) and proximal colon
•Unlike UC, there is unaffected bowel areas in between
areas of active disease(skip lesions)

4. Cause: unknown,
• enviromental agents are implicated
• genetics-colon involvement goes with increased
NOD2/CARD15 gene expression in macrophages and
epithelial cells
•Dysregulated immune responses might be primary or
from infection as mycobacterium avium paratuberculosis ,
Ecoli may have a role
•More common in Ashkenazi Jews
•Associated with autoimmune thyroiditis and SLE

6. Sites(inorder of
frquecy)
-terminal ileum
& right side of
colon
-colon alone
-terminal ileum
alone
-ileum &
jejunum

7. Incidence: 5-10 per 100000/yr
Association: altered cell-mediated immunity,
smoking increase *3-4 ,high refined sugar diet, NSAIDs
may exacerbate disesase

8. Pathology:

9. Non-caseating granuloma
Fissuring ulceration extendimg to
submucosa

10. •Entire wall is edematous and thikened
•Deep ulcers which appear as linear fissures, thus mucosa in
between is cobblestone
•Deep ulcers invade the wall to initiate abscess or fistula
•Fistula may develop betweeen adjacent loop of bowel , or between
affected segments of bowel and the bladder, uterus, or vagina & may
appear in perineum
•The changes are patchy
•Skip lesions
•The mesnteric LNs are enlarged & the mesentry is thickened

13. Symptoms:
Major symptoms are: -abdominal pain
-watery diarrhea
- weight loss (failure to thrive in
children)
fever ,anorexia, malaise, vomiting from jejunal
strictures can occur
*crohns colitis presents in an identical manner to
UC, with bloody diarrhea, passage of mucus &
constisutional symptoms including lethargy, malaise,
anorexia, weight loss
*oral ulceration

14. Signs:
Rectal sparring & the presence of perianal disease are features
which favor a diagnosis of CD rather than UC
•Apthhous ulcer
•Abdominal tenderness
•Right iliac fossa pain
•Perianal abscess, fistulae, skin tags, rectal strictures,fissures
(present in more than 50% of patients)
Extra-intestinal signs,
•Clubbing
•Erythema nodosum
•Fatty liver ,gall stones
•Ankylosing spondylitis
•Renal stones
•Malnutrition,hypocalcemia th vit D malabsorption, B12 def
•amyloidosis

16. Aphthous ulcers
Erythema nodusum, non GI symptom of
CD & UC. These painful purplish nodules
occur over the shins. They regress after a
few weeks, leaving a bruised
appearance.other causes include TB,
drugs, streptococcal infection,sarcoidosis

18. Anal fistula in crohns disease
Perianal abscess

19. Comlpcations:
1. Small bowel obstruction
2. Toxic dilation (colonic dilatation is commen in UC)*
3. Abscess formation (abdominal, pelvic, ishiorectal)
4. Fistula(fistulovesical, colovaginal, perianal, enterocutaneous)
5. Perforation
6. Rectal Hge (erosion of a major artery)
7. Colonic carcinoma ,small bowel adenocarcinoma (low incidence in
CD, more common in UC )

20. Investigation:
•CBC( may show anemia dt bleeding, malabsorption of iron
,folic acid, or vitamin B12)
•ESR is raised in exacerbation or bcz of abscess
•CRP is helpful in monitoring CD activity
•Serum albumin cocentration falls a consequence of protein
losing enteropathy, reflecting active & extensive disease , or
bcz of poor nutrition
•LFT
•U&E
MARKERS OF ACTIVITY: Hb , ESR ,CRP ,WCC ,ALBUMIN

21. bacteriology-
•Stool culture ,to exclude infectious diarrhea
•Blood culture,
Endoscopy-
•Sigmoidoscopy with biopsies
In CD patchy inflammation with discrete ,deep ulcers , perianal
disease(fissures, fistulae & skin tag) or rectal sparing occurs
•Colonoscopy
It may show active active inflammation with pseudopolyps or a
complicating carcinoma
Biopsies are taken to define disease extent & to seek dysplasia in
patients with long-standing colitis
Patchy appearance
Aphthoid or deeper ulcers & strictures are common

23. •Barium studies,
Affected areas are narrowed & ulcerated
Rare used , may show cobblestoning , ’rose thorn’ ulcers
& colon strictures with rectal sparring
Barium enema showing N. rectum &
sigmoid colon,typical aphthous
ulceration in dec.
colon,ulceration(arrow)and lack of
haustra in transverse colon.the asc.
Colon & cecum are N & there is
typical crohn’s disease affecting the
terminal ileum, with coarse
ulceration, & lack of mucsal folds

24. •MRI scans are accurate in delineating pelvic or perianal
involvement by crohn’s disease
ASCA(anti-sacchaomyces antibody) is associated with CD
Don’t forget to screen CD patients for
osteoprosis .about 70% have
abnormal bone density dt chronic
disease & steroids

26. Management & Treatment:
*Treatment depends upon a team approach involving
-physicians
-surgeons
Radiologists
-dietitians
*The key aims are to,
-treat acute attacks
-prevent relapses
-detect carcinoma at any early stage
-select patients for surgery

27. severity mild moderate Severe/
fulminant
Post-op remission
treatment Oral amino-
salycilates,
Metronidazole
Oral
coticosteroids
(short term
less than 3
months),azath
ioprine,6-
mercaptopuri
ne,or
metotrexate,
IV
corticosteroids
,IV infliximab,
elemental diet
or TPN
=transient
benefit
Metro-
nidazole
(delays
anastomotic
recurrence-
cuz
irreversible
neuropathy)
Oral
aminosalicylat
e,azathioprine
,6-mp
especially if
steroid
depenent
Note that,6-
mp or
azathioprine
is now
standard
maintenance
therapy
Infliximab heal enterocutaneous fistula
& perianal disease

28. In severe attacks,
-IV steroids, nil by mouth,& IV hydration then,
-hydrocortisone(100mg/6h IV)
-treat rectal diseases :steroids
- metronidazole helps esp. in perianal disease or
superadded inf
-monitor temperature, pulse, BP, record stool
frequency & character,consider parenteral nutrition
- monitor daily FBC, ESR, CRP, U&E& plain abdominal x-
ray
-if improving after 5 days, give oral prednisolone
-if not improving, surgery is needed

29. Surgical treatment,
•Indication for surgery:
Failure to respond to drugs,obstruction, masssive bleeding, fistula,
perforation, suspicion of cancer, abscess, toxic megacolon. Stricture,
dysplasia
So surgery is only for intractable disease & specific serious complications
•Colectomy & ileostomy provide the best results for crohn’s colitis
•The incidence of recurrence after surgery depends on
-site, ileocolic is highest
-nature of complication ,obstruction & abscess have higher incidence
and rates of recurrence
Surgery is never curative
•Surgery should be conservative as possible to minimize loss of viable
intestine & to avoid creation of short bowel syndrome

30. Surgical procedure contraindicated is illeo-anal pouch formation because of
high risk of disease recurrence within the pouch & subsequent fistula,
abscess formation

32. Ulcerative Colitis

33. Ulcerative Colitis
Incidence per person-years 2.2–14.3/100,000
Age of onset 15–30 & 60–80
Male:female ratio 1:1
Smoking May prevent disease
Oral contraceptives No increased risk
Appendectomy Protective (70%)
CD: higher incidence
smoking and appendectomy increase risk

34.  It increases the adherent surface mucus in the large
intestine which is reduced in UC.
 The mucus acts as a protective barrier to the mucosa
which may be damaged by bacteria and breakdown
products in the intestine.
 It may have an inhibiting effect on the inflammatory
response of the body.
 It may relieve proximal constipation
Studies have shown an improvement in
symptoms of patients using nicotine patches
Smoking may prevent UC!!!

35. Risk factors of UC:
High intake of:
unsaturated fat
vitamin B6
Meat proteins
Alcoholic beverages
Associated with genes:
HLA-DR103 (sever UC)
HLA-B27 commonly develop
ankylosing spondulitis

36.  Ulcerative colitis is long-lasting disease that inflames the
lining of the large intestine (the colon) and rectum

37.  Process limited to the mucosa and superficial submucosa,
with deeper layers unaffected
 Inflammatory cells infiltrate the lamina propria and the crypts
(cryptitis & crypt abscesses)

38. Clinical Features:
• Bloody Diarrhea
• Urgency
• Mucus discharge
• Abdominal pain (left-sided)
• Fever
• Nocturnal diarrhea
• Constipation
• Loss of appetite (anorexia)
• Weight losss
• Malaise
The first attack is
the most sever
The disease is
followed by relapse
“flare” and
“remission”

39. Toxic severe cases:
Tachecardia
Fever
Signs of peritoneal
inflammation
Anemia

41. Complications of UC:
A- LOCAL :
1- Pseudo polyposis (15%).
2- Carcinoma (3.5%) ,increase to (12%)after 20 year.
3- Fibrous stricture .
4- Toxic mega colon (3.5%).
5 – Massive bleeding (3%).
B – GENERAL :
1 – Muco cutaneous lesions (erythema nodosum -
stomatites - pyoderma gangrenosum ) .
2 – Eye complications (iritis, uveitis , conjunctivitis ).
3 – Joint complications ( arthritis ) .
4 – Liver changes (hepatitis –cirrhosis )
5 – Biliary ducts (2ry sclerosing cholangitis )
6 – Renal stones
7 – D.V.T.

42. Investigations:
1 – Stool analysis : to exclude bacillary and amebic dysentery
2- C.B.C. and urine analysis : anemia, inflammation, or malnutrition and
leukocytosis (ESR, CRP, LFT, serum albumin concentration)
3 – Barium enema:
1- Pipe stem colon
2 – pseudo polyps
4 – Endoscopy: Sigmoidoscopy with biopsy
Colonoscopy
5 – RECTAL BIOPSY
6 – Abdominal X-ray
7 – CT and MRI
Shortened
Loss of naustrea
Tubular
Pseudo-polyps
Loss of vascular
pattern
Granularity
Friability
Ulceration
Disease extent
Seek dysplasia
Dilatation of colon
Mucosal edema
Evidence of
perforation

43. Barium enema
Double-contrast barium enema study
shows changes of early disease.

44. Barium enema
Single-contrast enema study in
a patient with total colitis
shows mucosal ulcers with a
variety of shapes.
Postevacuation image obtained after a
single-contrast barium enema study shows
extensive mucosal ulceration resulting
from Shigella colitis.

45. Endoscopy
 Multiple ulcers
 Edema
 Erythema
 Friability
 Focal areas of scaring
 Multiple pseudo polyps
 Pseudo diverticula

46. Mayo Endoscopic Scoring of UC

47.  3-5 mild {score 1}
 6-10 moderate {score 2}
 11-12 severe {score 3}

50. Treatment:
• Depend on severity of disease and its spread
1. Anti inflammatory drugs:
• Sulfasalazine (Salazopyrin)
• Mesalazine ( Pentasa, Asacol, Colazide, Salofalk)
• Olsalazine (Dipentum)
These are all 5-aminosalicylic acid related drugs (ASA)
2. Corticosteroids
Steroid preparations given by mouth, injection, suppository or enema,
such as:
• Prednisolone
• Budesonide
• Hydrocortisone
• Predsol
• Predfoam

51. 3. Immunosuppressants
• Azathioprine
• Methotrexate
• Cyclosporin
• Mycophenolate
4. Antibiotics
• Metronidazole
• Ciprofloxacin
• Clarithromycin
5. Heparin (DVT)
6. Correction of dehydration
8. Diet
A high calorie, high protein diet can help replace lost nutrients
and regain energy
9. Supplements (vitamins, minerals, iron)
10. Rest (to conserve energy and allow healing to take place)

53. Surgical treatment:
Ulcerative colitis differs from
Crohn’s disease in that it can
be cured by surgery

54. Surgery is indicated for a number of
reasons in UC
• Failure to respond satisfactorily to
medical treatment
• Repeated side-effects caused by drugs
such as prednisolone and azathioprine.
• Fulminant colitis
• Cancer development
• Pre-malignant changes such as dysplasia
or the presence of a dysplasia-associated
lesion or mass (DALM) revealed by
colonoscopic screening

55. The surgical choices are:
1.Proctocolectomy and Brooke ileostomy.
2.Abdominal colectomy and ilcorectal
anastomosis.
3.Proctocolectomy and Kock pouch.
4.Restorative proctocolectomy with ileal pouch-
anal anastomosis (IPAA)

58. A to D, Two stages of restorative proctocolectomy
Ileal pouch with anal
anastomosis

61. Ulcerative Colitis Vs Crohn’s Disease

62. Ulcerative colitis Crohn’s disease
Age group Any Any
Gender M=F M=F
Genetic factors HLA-DR103 associated with severe
disease
CARD 15/NOD-2 mutations
predispose
Risk factors More common in non-/ex-smokers More common in smokers
Most common
site
Rectum Terminal ileum
Distribution Rectum to colon “backwash” ileitis Mouth to anus
Spread Continuous Discontinuity “skip” lesions

63. Ulcerative colitis Crohn’s disease
Gross features •Extensive ulceration
•Pseudo-polyps
•Focal aphthous ulcers with
intervening normal mucosa
•Linear fissures
•Cobblestone appearance
•Thickened bowel wall
“linitis plastic”
•Creeping fat
Micro Crypt abscess Noncaseating granulomas
Inflammation Limited to mucosa and submucosa Transmural
Presentation Bloody diarrhea Variable; pain, diarrhoea,
weight loss all common

64. Ulcerative colitis Crohn’s disease
Extra-intestinal
manifestation
Common Uncommon
Complication •Toxic megacolon •Strictures
•String sign on barium study
•Obstruction
•Abscess
•Fistula
•Sinus tract
Cancer risk 5-25% Slight 1-3%
Management 5-ASA; corticosteroids; azathioprine;
colectomy is curative
Corticosteroids;
azathioprine; methotrexate;
infliximab; nutritional
therapy; surgery for
complications is not
curative