This document provides an overview of inflammatory bowel disease (IBD), including ulcerative colitis and Crohn's disease. It discusses risk factors, clinical manifestations, diagnostic testing, and treatment approaches. The main points are: - IBD is characterized by idiopathic inflammation of the gastrointestinal tract. The two main types are ulcerative colitis and Crohn's disease. - Genetic and environmental factors contribute to risk. Smoking increases risk for Crohn's but decreases risk for ulcerative colitis. - Symptoms vary based on disease location but may include abdominal pain, diarrhea, bleeding, weight loss, and nutritional deficiencies. Extraintestinal manifestations are more common with Crohn's.

1. Dr. Mohamed Alshekhani
Professor in Medicine
MBChB-CABM-FRCP-EBGH
2017
1
Inflammatory Bowel Disease(IBD):

2. Inflammatory Bowel Disease(IBD):
• IBD is idiopathic GIT inflammation ( no specific cause of
inflammation as infections,ischemia,radiation, Vasculitis,etc) .
• 2 Main types: macroscopic & microscopic.
• Microscopic: lymphocytic & collagenous.
• Macroscopic: 2 main subclasses:
• Crohn disease (CD)
• Uulcerative colitis (UC)
• Minor subclass; Indeterminate colitis; 10-15%( clinical features &
test that do not allow a definitive sub-classification into above 2
types).

3. Risk Factors:
• Interplay between genetic & environmental factors.
• Genetics:
• Increased risk in family members.
• Monozygotic twins have a higher risk than dizygotics or siblings.
• The risk in an offspring is higher if both parents are affected.
• Certain ethnic groups (Jewish) are at higher risk > others (blacks).
• Genes identified, but contribution to overall population is small.

4. Risk Factors:
• Interplay between genetic & environmental factors.
• Environmental:
• Smoking&appendisectomy is a risk factor for the development of
CD, protective factor for UC.
• Dietary factors inconsistent.
• IBD is more common in developed countries.
• A north-south gradient, ? vitamin D.

5. Clinical Manifestations:Ulcerative Colitis
• Typically presents with bloody diarrhea & abdominal discomfort,
the severity related to the extent / severity of inflammation.
• The distribution:
• Proctitis 25%(involving the rectum only); can present with
constipation owing to rectal spasm & stasis of stool.
• Left-sided colitis 25% (not extend beyond splenic flexure).
• Pancolitis 50% (inflammation extends above the splenic flexure).
• Because UC typically involves the rectum, so tenesmus, urgency,
rectal pain& fecal incontinence are common.
• Fever& weight loss are uncommon, suggest severe disease.

6. Clinical Manifestations:Ulcerative Colitis
• PE:
• With mild disease, physical exam may be normal.
• Severe disease: fever, tachycardia, dehydration, abd tenderness, or
pallor.
• Abdominal distention, hypoactive bowel sounds, & rebound
tenderness suggest fulminant colitis or perforation or toxic
megacolon.
• Lab findings: significant anemia, leukocytosis, hypoalbuminemia&
electrolyte abnormalities, reflect the severity of disease.

8. Severity in UC:
Variable Mild Severe
Stools (number per day) <4 >6
Blood in stool Intermittent Frequent
Temperature Normal >37.5 °C (99.5 °F)
Pulse (beats per minute) Normal >90
Hemoglobin Normal <75% of normal
Erythrocyte sedimentation rate (mm/h) <30 >30

9. Clinical Manifestations:CD
• Common symptoms are abdominal pain, diarrhea, weight loss.
• Fever & overt GIB are less common than is typical in UC.
• Unlike UC,transmural inflammation in CD may predispose to fistula.
• 30% have isolated SB disease.
• 40% ileocolonic disease.
• 25% isolated colonic disease
• 5% isolated upper GI or perianal disease.

10. Clinical Manifestations:CD
• Symptoms correlate with disease location:
• SB disease usually presents with abdominal pain with or without
diarrhea; overt GI bleeding is uncommon.
• Ileocolonic dis: RLQ pain is common, diarrhea & bleeding are less.
• Colonic disease: bloody diarrhea more likely; also associated with
perianal disease, with perineal pain& seepage of stool or mucus
from fistulas.
• Proctitis (very rare):Small-volume diarrhea with urgency&
tenesmus.
• UGI disease: epigastric pain,nausea,vomiting& occasionally GOO.

11. Clinical Manifestations:CD
• PE:
• From normal to significantly abn depending on location& severity.
• Patients may appear pale, malnourished, or chronically ill.
• Fever; if high it suggests an abscess or peritonitis.
• Abd tenderness, sometimes with a mass or fullness, is often located
in RLQ.
• Perianal exam may reveal skin tags, induration, or fistulas.
• As in UC, abnormal lab findings correlate with disease severity:
• Leukocytosis, anemia, hypoalbuminemia, vitamin deficiencies.
• The ESR& CRP are often elevated; if so, can be monitored as signs of
response to therapy & subsequent disease flare.

12. Clinical Manifestations:EIM
• In 10% of patients.
• In both CD or UC, it may precede GI symptoms.
• The most common:
• Oral aphthous ulcers, arthralgia, back pain (ankylosing spondylitis
or sacroiliitis).
• Eye symptoms (redness, pain, swelling) may be due to uveitis,
scleritis, or other causes of ocular inflammation & warrant
immediate examination by an ophthalmologist.
• Skin manifestations are common include pyoderma gangrenosum &
erythema nodosum.
• Liver involvement, most commonly ;primary sclerosing cholangitis.
• In CD, EIMs are more common with colitis than SB disease.
• Some EIMs correlate with IBD activity, whereas others do not.

15. Diagnosis: UC
• Colonoscopy & biopsy of the colon & ileum, is required.
• All should undergo stool &lab exam to exclude infectious colitis,
including C. difficile & CMV & non-infectious colitis as
ischemic&radiation COLITIS.
• Some patients with pancolitis extend into the ileum for a few
centimeters(backwash ileitis) not indicative of CD.
• Mild UC is characterized by mucosal edema, erythema& loss of the
normal vascular pattern.
• More significant disease produces granularity, friability, ulceration&
bleeding.
• Histology shows altered crypt architecture with shortened,
branched crypts, acute &chronic inflammation of the lamina
propria.

18. Diagnosis:CD
• Endoscopic findings vary from superficial aphthous ulcers to
discrete, deep ulcers that can be linear, stellate, or serpiginous &
that may coalesce into a “cobblestone” appearance
• Rectal sparing is typical, as are areas of inflammation separated by
normal mucosa (known as skip lesions).
• The ileum should be inspected during colonoscopy to detect ileal
inflammation characteristic of CD.
• Histology may show patchy transmural inflammation, but more
superficial inflammation does not rule out CD. Aphthous ulcers &
granulomas are characteristic findings but are often not seen.

19. Diagnosis:CD
• CD can affect any part of GIT&in some patients inflammation is
beyond the reach of colonoscopy.
• In these patients, supportive evidence can be obtained with CT or
(MR) enterography, capsule endoscopy, or directly by deep
enteroscopy.
• Enterography also rules out complications such as obstruction,
perforation, fistulas, abscesses.
• Radiographs are more often used in CD than UC owing to the
frequent involvement of the small intestine.
• Plain films can evaluate bowel obstruction & dilatation.
• Small-bowel barium radiographs have largely been replaced by the
more sensitive CT or MR enterography.

20. Diagnosis:IDC
• 10-15% have indeterminate colitis.
• In these patients, serologic tests have been proposed as a way to
distinguish UC from CD,but are expensive,relatively insensitive or
nonspecific&often do not add useful information to standard
diagnostic tests such as colonoscopy & enterography.

25. Treatment:UC
• For mild to moderate UC, the 5-ASA drugs are first-line therapy for
inducing & maintaining remission.
• 5-ASA is delivered topically to the bowel lumen, primarily to the
colon, with the exception of the time-release formulation of
mesalamine, which is able to deliver the drug throughout the small
bowel & the colon.
• Sulfasalazine may cause folate deficiency& supplementation is
recommended.
• More severe UC is often treated with oral glucocorticoids as
prednisone, 40-60 mg/d.

26. Treatment:
• Budesonide is a glucocorticoid with high first-pass metabolism
available in a controlled ileal-release formulation frequently used in
CD, but (multi-matrix [MMX] system) formulation provides release
of the drug throughout the colon useful in treating UC.
• It has similar efficacy as prednisone but has fewer side effects but
high cost.
• Patients whose disease does not respond to oral glucocorticoids
should be hospitalized&given IV glucocorticoids or biologic agent.
• Glucocorticoids are not effective for maintaining remission in UC.
• In patients whose disease responds to glucocorticoids, the dose
should be tapered over 2 - 4 months while transitioning to a
maintenance medication (AZA, 6-MP, or a biologic agent).

27. Treatment:
• Patients whose symptoms do not respond to glucocorticoids are
treated with cyclosporine, a biologic agent, or colectomy.
• Cyclosporine is effective for avoiding colectomy in the short term.
• Many patients eventually require colectomy.
• The three anti-TNF antibodies approved for inducing/ maintaining
remission in UC are infliximab, adalimumab&golimumab.
• The integrin-blocking antibody vedolizumab blocks leukocyte
trafficking ,also approved for the treatment of UC.

29. Treatment:CD
• 5-ASA drugs for CD little or no benefit.
• Antimicrobial agents are important in patients with fistulas or
abscesses, but no treating luminal disease.
• Patients with mild to moderate inflammatory CD are often treated
initially with glucocorticoids. Prednisone is often used.
• For ileocolonic CD, controlled-release budesonide is an alternative
to prednisone, with fewer side effects but higher cost.
• As in UC, glucocorticoids are not effective for maintaining remission
in CD,SO patients who responds to glucocorticoids should be
transitioned to an immunomodulator while the glucocorticoid is
tapered.

30. Treatment:CD
• In addition to AZA / 6-MP, methotrexate is an option in CD.
• AZA, 2 -3 mg/kg/d; 6-MP, 1.5 mg/kg/d; methotrexate, 25 mg/week,
are effective for inducing & maintaining remission.
• AZA / 6-MP are effective for closing fistulas.
• Some adverse events from methotrexate minimized by the use of
folic acid,but should not be used in pregnant or lactating women.

31. Treatment:CD
• Patients with more severe disease are treated with a biologic agent.
The three anti-TNF agents approved for CD are infliximab,
adalimumab, and certolizumab.
• These medications are effective for inducing / maintaining
remission & closing fistulas, generally considered to be safe in
pregnancy.
• Anti-TNF efficacy is better when used with an immunomodulator&
risk of developing anti-TNF antibodies is lower.

32. Treatment:CD
• Patients whose disease does not respond to one anti-TNF agent are
often switched to a second or third anti-TNF agent.
• Those with no response to or intolerance of anti-TNF agents should
be treated with either surgery or a leukocyte trafficking blocker
(natalizumab or vedolizumab).
• Natalizumab increases the risk of infections, including progressive
multifocal leukoencephalopathy (PML), specially if JC virus sero +ve
making the risk unacceptably high & should not be used.

33. IBD: Health maintinance
• CRC Surveillance: Patients with long-standing IBD are at increased
risk for CRC & should undergo surveillance colonoscopy every 1- 2
years beginning after 8-10 years of disease.

34. IBD: Health maintinance
• Nutritional support:
• Patients with severely active disease, particularly CD, are at risk for
malnutrition & various vitamin deficiencies & should undergo
screening for these conditions,sp distal ileal disease is associated
with vitamin B12 malabsorption.

35. IBD: Health maintinance
• Osteoporosis screen:
• Steriod use for > 3 mons is a risk factor for osteoporosis &indication
to assess bone density.

36. IBD: Health maintinance
• Vaccination:
• Routine adult vaccines+annual killed influenza vaccine( not
attenuated vaccine) hepatitis A & B virus (if not already immune),
pneumococcus&meningococcal vaccine.

37. IBD: Health maintinance
• TB screen:
• Before starting anti-TNF, patients assessed for TB (with Tuberculin
or IGRA) & for immunity to hepatitis A / B viruses.

38. Microscopic colitis:
• Accounts for 10- 15% of patients with chronic, watery diarrhea.
• > Common in elderly.
• Endoscopically normal.
• The symptoms similar to other chronic causes of non-bloody
diarrhea, such as celiac disease & IBS which should be excluded.
• Colonic mucosal biopsies are required for diagnosis.
• Lymphocytic & collagenous colitis are the two subtypes &
distinguishable only by histology.
• In some patients, certain medications (NSAIDs /PPI).
• MC is associated with other AI diseases as DM & psoriasis.

39. Microscopic colitis:treatment
• Based on symptom severity.
• Suspected drugs stopped if possible.
• In mild disease, antidiarrheal as loperamide or diphenoxylate used.
• In moderate disease, bismuth subsalicylate may be beneficial.
• In severe cases or those that do not respond to antidiarrheal agents
or bismuth, budesonide is the treatment of choice,highly effective
(response rates of ≥80%), but the risk of relapse is high once
stopped (70%-80%); many patients require long-term low dose
maintenance or an immunomodulator as AZA.
• The 5-ASA medications are not very effective for MC.
• If not respond or not tolerate budesonide, cholestyramine effective.
• In severe cases, treatment with an anti-TNF agent may be needed.

40. BO5:1
• 1.Inflammatory Bowel disease includes:
• A.Ischemic colitis.
• B.Infectious colitis.
• C.Idiopathic inflammattory colitis.
• D.Radiation colitis.
• E.Behcet-associated colitis.

41. BO5:2
• 2.The following are Inflammatory Bowel
disease except:
• A.Ulcerative colitis.
• B.Crohns disease.
• C.Intdermined colitis.
• D.TB-induced colitis.
• E.Microscopic colitis.

42. BO5:3
• 3.The least common subtype of IBD is:
• A.Ulcerative colitis.
• B.Crohns disease.
• C.Intdermined colitis.
• D.Collagenous colitis.
• E.Lymphocytic colitis.

43. BO5:4
• 4.Hematochesia is more common with:
• A.Ulcerative colitis.
• B.Crohns disease.
• C. Both above.
• D.Collagenous colitis.
• E.Lymphocytic colitis.

44. BO5:5
• 5.Skiped lesions are more characteristic of:
• A.Ulcerative colitis.
• B.Crohns disease.
• C. Both above.
• D.Collagenous colitis.
• E.Lymphocytic colitis.

45. BO5:6
• 6.Transmural colonic involvement is
characteristic of:
• A.Ulcerative colitis.
• B.Crohns disease.
• C. Both above.
• D.Collagenous colitis.
• E.Lymphocytic colitis.

46. BO5:7
• 7.Granuloma on histopathology is
characteristic of:
• A.Ulcerative colitis.
• B.Crohns disease.
• C. Both above.
• D.Collagenous colitis.
• E.Lymphocytic colitis.

47. BO5:8
• 8.Extraintestinal features are characteristic of:
• A.Ulcerative colitis.
• B.Crohns disease.
• C. Both above.
• D.Collagenous colitis.
• E.Lymphocytic colitis.

48. BO5:9
• 9.Standard drug treatment for crohn’s disease
usually include all except:
• A.5 ASAs.
• B. Steroides.
• C. Infliximab.
• D.Azathioprine.
• E.Cyclosporine.

49. BO5:10
• 10.Patients with long-standing IBD require the
following long-term interventions except:
• A.CRC surveillance.
• B. Nutritional support.
• C. Killed vaccine.
• D. Attenuated vaccines.
• E.TB screen.

50. BO5:11
• 11.The standard drug therapies for
microscopic colitis include all except:
• A.Anti-diarrheals.
• B. Bismuth.
• C. Budosonide.
• D. 5 ASA.
• E.Cholecytramine.

51. BO5:12
• 12.The biological agent that increase the risk
of CJD in IBD treated patients is:
• A.Infliximab.
• B. Adalimumab.
• C. Golizumab.
• D. Natalizumab.
• E. None of the above.

52. BO5:13
• 13.The IBD subtype that has a more
complicated course is:
• A.Crohn’s disease.
• B. Ulcerative colitis.
• C. Indetermined colitis.
• D. Lymphocytic colitis.
• E. Collagenous colitis.

53. BO5:14
• 14.patients with long-standing active
extensive disease should start surveillance
colonoscopy after how many years:
• A. 15.
• B. 5.
• C. 7.
• D. 20.
• E. 8.

54. BO5:15
• 15.Important differential diagnosis of
Microscopic colitis include:
• A. UC.
• B. IBS.
• C. Celiac disease.
• D. Crohn’s disease.
• E. The last 3.

55. BO5:16
• 16.Common extra-intestinal features of IBD
involve the following organs except:
• A. Skin.
• B. Eye.
• C. Hepatobiliary system.
• D. Heart.
• E. Joints.