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

1. IBD Epidemiology and Diagnosis Roberto E. Mera Lastra MD Gastroenterology University of Puerto Rico Medical Sciences Campus

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. Pathogenesis

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

15. Clinical Findings

26. Complications of CD: Fistulas Abdominal Fistula Perianal Fistula

28. Severity of UC

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

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

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

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

36. Endoscopic, Radiographic, and Histologic Findings Diagnosis of Crohn’s Disease and Ulcerative Colitis

37. Ulcerative Colitis: Bleeding 101402.7 Lindenbaum - On-screen

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.

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.

40. Perianalis fistula

41. Normal endoscopic finding

42. Ulcerative colitis endoscopic finding

43. Crohn colitis

44. Crohn disease Enterography: String-sign (arrow) is demonstrated. Sac-formation may be observed on the antimesenteric side (double arrow).

45. Ulcerative colitis pseudopolyps

46. Crohn’s Dx – String Sign

47. Ulcerative Colitis - Ulcerations

48. Ulcerative Colitis – “Lead Pipe”

49. Fibrostenosis in CD Courtesy of J-F Colombel, MD.

50. Intestinal Complications of Ulcerative Colitis Toxicity 101402.7 Lindenbaum - On-screen

51. Extraintestinal Manifestations

55. Erythema Nodosum in IBD Courtesy of J-F Colombel, MD.

56. Pyoderma Gangrenosum in CD

57. Sacroiliitis in IBD Courtesy of J-F Colombel, MD.

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.

59. Scleritis in IBD Courtesy of J-F Colombel, MD.

60. Aphthous Stomatitis in IBD Courtesy of J-F Colombel, MD.