1. S
INFLAMMATORY BOWEL
DISEASE
Dr. Nasir Khokhar MD FACP FACG
Professor of Medicine and
Gastroenterology
Shifa International Hosptal, Islamabad,
Pakistan

3. Crohns and Ulcerative colitis

4. IBD

5. CROHN’S DISEASE

6. Anatomic Distribution

7. Bimodal Distribution

8. Prevalence of Crohn’s Disease

9. Immune Dysregulation in
Crohn’s Disease

10. Potential Risk Factors
S Diet
S NSAIDS
S Smoking
S Infections
S Oral Contraceptives
S Psycho social factors

11. Etiology

12. Gut structure

13. Intestinal defences

14. Pathogenesis

15. Pathogenesis

16. Tumor Necrosis Factor (TNF)

17. TNF induced apoptosis

18. TNF actions

19. Patterns of Crohn’s Disease

20. Chronic abdominal pain

21. Imaging in Crohn’s Disease

22. Aphthoid Ulceration

23. Aphthoid Ulceration

24. Endoscopic view

25. Crohn’s Ileitis

26. Chronic Subserositis

27. Granuloma

28. Post stenotic Dilatation

29. Enteroenteric Fistula

30. Enterocutaneous Fistula

31. Perianal Fistula

32. Mechanism of Perianal Fistula

33. Carcinoma in Crohn’s Disease

34. Acute Inflammatory Presentation

35. Chronic Inflammatory Presentation

36. Scarring and Narrowing

37. Enteroenteric Fistula

38. Enterovesical Fistula

39. Localised Phlegmon

40. Presentation

41. Clinical Presentations
S CHRONIC INFLAMMATORY DISEASE: fever, malaise,
weight loss, abdominal pain, RLQ mass
S INTESTINAL OBSTRUCTION: Post prandial bloating,
cramping, borborygmy
S FISTULIZATION: Internal, external
S ABSCESS: Fever, chills, tender mass
S PERIANAL DISEASE: Fissure, abscess, fistula
S EXTRAINTESTINAL: Oral, skin, joints, eye, gall
stones, nephrolithiasis, liver

42. Laboratory Diagnosis
S CBC
S Albumin
S ESR, CRP
S Stool RE
S P-ANCA: 10% crohns, 70% UC
S ASCA (antibody to yeast S cerevisiae): 70% crohn, 10%
UC

43. Radiological Diagnosis

44. Endoscopic Diagnosis

45. Differential Diagnosis:
Appendiceal Abscess

46. Differential Diagnosis:
Carcinoma

47. Differential Diagnosis:
Carcinoid

48. Differential Diagnosis:
Lymphoma

49. Differential Diagnosis:
Tuberculosis

50. COMPLICATIONS
S ABSCESS
S INTESTINAL OBSTRUCTION
S FISTULAS
S PERIANAL DISEASE
S CARCINOMA
S HEMORRHAGE
S MALABSORPTION

51. TREATMENT:Aminosalicylic acid

53. TREATMENT: Corticosteroids
S Dramatically suppress clinical symptoms
S Do not alter underlying disease process
S Prednisone 40-60 mg/day, taper slowly
S Side effects: Osteoporosis, others
S Ileal release preparation: Budesonide 9mg/day, 50-70%
remission in mild to mod
S Persistent symptoms need ASA, AZA,MTX

55. TREATMENT:Immunosuppressent
s

56. TREATMENT:Immunosuppressents

57. TREATMENT:Immunosuppressents

58. TREATMENT:Immunosuppressents

60. Biologicals

61. Mechanism of action

62. TNF binding

63. Summary of medical treatment of
Crohn’s disease
S Aminosalisylic acid: ASA
S Corticosteroids: Pred, Budesonide
S Immunosuppressents: AZA, MTX, Cyc
S Antibiotics: Metronidazole, Ciproflox
S TNF antibody: Infliximab

64. SURGICAL TREATMENT

65. ENDOSCOPIC TREATMENT
Balloon Dilatation

66. MANAGEMENT
S Life long illness, exacerbations, remissions
S Psych social support: patient education
S No specific therapy exists: supportive care;
diarrhea, steatorrhea, pain
S Nutritional support: enteral, parenteral;
Fiber, iron, B12, low fat, MCT supplements
well balanced diets

69. PROGNOSIS
S Prolonged illness
S Proper medical and surgical care help cope with disease
S Anticipate complications and manage
S Avoid side effects of drugs
S Few die of direct effects of disease

70. ULCERATIVE COLITIS

71. Ulcerative Colitis: Forms

72. Ulcerative Colitis:Gross Appearance

73. Endoscopic Appearance

74. Microscopic Features

75. Crypt Abscess

76. Radiological Features

77. Pakistani scenario

78. Endoscopic extent: KPK
Hameed et al. JCPSP 2001;11:551-4.

79. Severity of disease: KPK
Khan et al. J Med Sci 2010;18:67-70

80. Shifa Experience
S 85 patients with 8 years follow up
S Diarrhea with blood 100%
S Raised ESR 80%
S Mild disease 55%
S Left sided colitis in 60%
S Medical Treatment response nearly 100%
Khokhar N. Rawal Med J 2005;30:12-15

103. THANKS