Inflammatory Bowel Disease: IBD Dr. Mohammad Shaikhani CABM,FRCP.
1 IBD: Definition Idiopathic chronic inflammatory Ulcerative colitis MACROSCOPIC disease of the GIT Crohn’s disease (regional enteritis).. of 2 distinct clinical entities:Exact pathophysiology: unknown.2-4/100000 IBD: 90% Can be differentiated from Genetic predisposition each other 10% not (indeterminate colitis). + A dysregulated immunologic response to the local microenvironment of luminal bacteria.
Comparison of Features in Ulcerative Colitis and Crohns DiseaseFeature Ulcerative Colitis Crohns DiseaseDepth of inflammation Mucosal TransmuralPattern of disease Contiguous Skip areasLocation Colorectum Mouth to anusRectal involvement Usual Less commonIleal disease Backwash ileitis (15%– Common 20% of patients)Fistulas Rare CommonPerianal disease Rare CommonGranulomas Unlikely 10-30%Overt bleeding Usual Less commonMalnutrition Unlikely More commonCancer risk Colorectal cancer, Colorectal cancer, small cholangiocarcinoma (if bowel cancer (depending primary sclerosing on disease location) cholangitis is present)Tobacco use Protective Harmful
2UC: Clinical features Bloody diarrhea Proctitis causing tenesmus (urgency & sense of incomplete evacuation), sometimes causing constipation.Continuous mucosal Fever disease extends Weight loss( from proximally, may involve Clinical features inflammation / diarrhea) whole colon (pancolitis) Physical exam: Extra-intestinal From mild tenderness to manifestations & Abdominal distension & rebound complications. tenderness( toxic megacolon)
Crohn’s disease: Clinical features 2Skip(discontinous) Affects any part of GIT frommouth-anus. trans-luminal lesions or. Transluminal leading to Diarrhea caused by SI & strictures & fistulas. Colonic disease. Clinical features Hematochesia almost always a sign of colonic disease. Diarrhea from SI inflammation, protein lossing enteropathy,Ileal disease or ileal surgical removal.
Crohn’s disease: Clinical features 2 Abscess. Enterocutanous fistula.perianal rectovaginal Fistulas rectovesical. Psoas abscess prsenting as limping.
Crohn’s disease: Clinical features 2 Mostly in TI. Present as IO .DU or GOO Right iliac fossa mass in ileocecal or ileal disease, strictures Present as fever, abdoninal pain,distension,vomiting. Signs of perianal disease as skin tags & anal fistulas.
3Extra-intestinal manifestations of IBD Arthritis: osteopenia A. Peripheral arthritis, usually paralels the disease activity Cholangio PSC carcinoma B. Ankylosing Spondylitis, 1-6%, sacroiliitis,not paralel disease others activity. RENALOcular lesions: STONES CRC Iritis (uvietis) (0.5-3%), episcleritis, keratitis, Gall stonesSkin / oral cavity: Erythema nodosum 1-3%>CD Pyoderma Gangrenosum 0.6% >UC Aphthus stomatitis, metastatic CD.
4Primary sclerosing cholangitis: 5% of UC Sometimes in CD Present with: 80% Have High SAP underlying Jaundice IBD Biliary obst PHT PSC Higher incidence of CRC Cholangitis/CC UDCA May prevent CRC
4IBD local Complications: strictures fistulas Bleeding local complications CRC Toxic Depending on megacolon Severity/duration CMV Colitis
IBD local Complications: Toxic mega colon Dilation of colon With Fulminant colitis CT scan: For follow-up + Diagnosis: Diagnosis of Clin features+ Complications Plain abd X Ray Most important Serious Complication Toxic Of UC megacolon BE is C/I BZ/O perforation risk CRC Depending on Severity/duration Causes: Management: IBD Close observation Inf colitis To consider surgery Ischemic colitis If trt fails
5IBD: Diagnosis/ assessing severity Anemia leockocytosis thrombocytosis Non-specific markers of inflammation markers of inflammation Increased HYPO High ESR CRP ALBUMINEMIA
5IBD: Diagnosis/ assessing severity Stool In UC 2/3 P-ANCA: Calprotectin < In CD 15% In UC/CD Immunological markers of inflammation Immunological markers of inflammation Omp-C Abs& In CD 50% Cbir1 Abs ASCA < In UC <5% Predict classical CD p-ANCA & ASCA is reasonably reliable for the diagnosis of Crohn disease or ulcerative colitis. Stool calprotectin: predictive of activity in UC similar to colonoscopy.
Rutgeerts Endoscopic Scoring System – neoterminal ileumI,1 I,3 I,4
Actuarial analysis of symptomatic recurrence in patients stratified accordingto severity of endoscopic lesions
5IBD: Diagnosis/ assessing severity Plain abdomen for toxic ENTEROCLYSIS BARIUM Megacolon FOR CD & IO Radiological findings Radiological findings VCE for SI CT MRI CD enterography In Pelvic CD
Management:Medical: immune-modulating drugs.Surgical:Surgery needed for :25-35% UC; total colectomy with ileal pouch anastomosis.& 70% CD (local resections of local complications) with 40-50% requiring recurrent intervention.
Surgery for UC : Indications Urgent Surgery Elective Surgery Ongoing hemorrhage Failure of medical therapy Toxic megacolon Intolerable side effect of medical therapy Colonic perforation Development of dysplasia Fulminant ulcerative colitis Carcinoma Colonic stricture Growth retardation in children Emergency Operation Elective Operation ±Subtotal colectomy with end ileostomy Panproctocolectomy with permanent end ileostomy (simple and curative) Panproctocolectomy with permanent end Subtotal colectomy with ileorectal ileostomy Anastomosis (rarely performed) Proctocolectomy with continent ileostomy (Kock pouch) - Rarely performed Panproctocolectomy with IPAA with or without diverting ileostomy (CI in Crohn’s disease)
Surgery for CD:Indications Urgent Surgery Elective Surgery Perforation Stricture Abscess Fistula Uncontrollable hemorrhage Malignancy Toxic megacolon Malnutrition Bowel obstruction Poorly controlled despite management Extra-intestinal manifestations
Therapeutic Pyramid for Active UCSevere Surgery Cyclosporine InfliximabModerate Systemic Corticosteroids AZA/6-MP Oral SteroidsMild Aminosalicylates
Ulcerative Colitis: Mild to Moderate Acute flare Exclude enteric pathogen L sided ExtensivePatient unwilling Patient willing to Oral 5-ASA to take rectal take rectal therapy therapy Response Response adequate inadequate Consider rectal therapy Response (5-ASA and/or steroid) Maintain adequateConsider oral 5-ASA increased dose Oral 5-ASA Response inadequate Response Response inadequate adequate Response inadequate Maintain Oral steroid
Ulcerative Colitis: Moderate to Severe Moderate Severe Inadequate response Inadequate response Consider CyA Oral steroid IV Steroid Adequate response Response Unsuccessful Taper 6MP/AZA No Failure response No response Successful Success Infliximab Response Colectomy Maintain on Maintain5-ASA and observe 6-MP/AZA Maintain infliximab
Biologic era in IBD management:Healing of refractory ulceration/fistula with InfliximabPretreatment 4 Weeks posttreatment Pretreatment 2 Weeks 10 Weeks 18 weeks van Dullemen HM et al. Gastroenterology. 1995;109:129. Present DH, et al. N Engl J Med. 1999;34
New Approaches to Therapeutic Intervention in Crohn’s Disease?The “Step-up” vs “Top-down” Trial + IFX IFX + AZA + AZA/MTX + (episodic) IFX Corticosteroids Corticosteroids Corticosteroids AZA, azathioprine; IFX, infliximab; MTX, methotrexate.