Inflammatory bowel disease (IBD) encompasses chronic intestinal conditions like Crohn's disease and ulcerative colitis, characterized by inflammation with distinct clinical features. Ulcerative colitis primarily affects the colon with varying presentations and complications, while Crohn's disease can involve any part of the gastrointestinal tract with transmural inflammation. Management includes dietary adjustments, medication for inducing and maintaining remission, and surgical intervention in severe cases or complications.

1. Inflammatory bowel disease
Franck K. SIKAKULYA, MD,MMED
Surgeon and Researcher

2. Inflammatory Bowel Disease
IBD is a group of idiopathic chronic inflammatory
intestinal conditions.
The two main disease categories are Crohn’s disease
(CD) and ulcerative colitis (UC), which have both
overlapping and distinct clinical and pathological
features.
The pathogenesis of IBD is incompletely understood.
Genetic and environmental factors such as altered
luminal bacteria and enhanced intestinal permeability
play a role in the dysregulation of intestinal immunity,
leading to gastrointestinal injury.

3. Ulcerative Colitis- Definition
• Chronic Inflammatory bowel Disease
• Unknown etiology
• Only Large bowel
• Mucosal inflammation
• Classification:
– Distal Disease,
– More extensive disease
– Pancolitis

4. Ulcerative Colitis- Epidemiology
• More common than Crohn’s disease
• Incidence: 10 per 100,000
• The sex ratio is equal in the first four decades
of life.
• From 40 years, the incidence in females falls
whereas it remains the same in males.
• Uncommon before the age of 10

5. Aetiological Factors
• Westernized diet, red meat; less common in vegetarians.
• Defective mucin production in the colonic mucosa and
mucosal immunological reaction.
• Autoimmune factors—cytotoxic T lymphocytes against
colonic epithelial cells and presence of anticolon antibodies.
• Appendicectomy and smoking protects ulcerative colitis
especially from extraintestinal features and from
postoperative complications.
• Familial in nature.
• Allergy to milk (cow milk) and other dietary factors.
• Excess reactive oxidative metabolism in ulcerative colitis.
• Psychological aspects, stress, life style, personality disorders.

6. Pathology
• It is a disease confined to mucosa and submucosa
(only in severe disease are the deeper layers
affected).
• There is no bowel wall thickening and no
granuloma formation.
• There is no skip lesions
• Rectum is always involved.

7. Multiple pseudopolyposis involving entire colon in
ulcerative colitis.
Disease involves only mucosa and submucosa.

8. Clinical Features
Disease usually begins in rectum as proctitis
later becomes left sided colitis and eventually
causes severe total proctocolitis.
• Watery diarrhoea, mucus or blood stained
discharge per rectum.
• Colicky pain, spasms.
• Decreased appetite and loss of weight.
• Relapses and remissions at regular intervals.

9. Two types of presentations:
a. Fulminant type, 5% common:
• It is a severe form, with continuous diarrhoea with
passage of blood, mucus and pus.
• Patient is ill and dehydrated.
• Mimics fulminant amoebic colitis; severe typhoid
and dysentery.
• Fever, hypokalaemia, acidosis, dehydration and
shock.
• Abdominal distension occurs.
• Acute toxic dilatation of transverse colon may occur
where the diameter of transverse colon > 6 cm.

10. b. Chronic type (95%):
• Lasts for months to years with diarrhoea, blood
loss, anaemia, invalidism, abdominal discomfort
and pain.
• Severe malnutrition and hypoproteinaemia.

11. Investigations
• Barium enema—shows loss of haustrations,
narrow contracted colon (hose pipe colon),
mucosal changes, pseudo-polyps.
• Colonoscopy and biopsy.
• Plain X-ray abdomen is useful in obstruction,
toxic megacolon, perforation.

13. Colonoscopic view of ulcerative colitis and
multiple ulcers.

14. Due to very high incidence of malignant transformation
in ulcerative colitis (10-20%), multiple biopsies should
be taken from suspected areas of the colon.
Sigmoidoscopic grading of ulcerative colitis
0—Normal mucosa
1—Loss of vascular pattern
2—Granular, non-friable mucosa
3—Friability on rubbing
4—Spontaneous bleeding, ulcerations

15. Differential diagnosis
• Crohn’s disease
• Ischaemic colitis
• Irritable bowel syndrome
• Amoebic colitis
• Bacillary dysentery
• Carcinoma colon

16. Complications
GIT
• Pseudopolyposis
• Turning into malignancy
• Stricture formation, commonly in recto sigmoid and anal
canal
• Toxic megacolon in transverse colon
• Massive haemorrhage—1%
• Fistula in ano—20%
• Perforation—10-20%
Extraintestinal
• Severe malnutrition
• Liver cirrhosis (50%)
• Skin lesions—pyoderma, erythema nodosum
• Arthritis, iritis, ankylosing spondylitis
• Sclerosing cholangitis, carcinoma of bile duct

17. Treatment
General
• Correction of anaemia.
• Fluid and electrolyte supplimentation.
• Nutrition (high protein, carbohydrate,
vitamin, but low fat diet), TPN.
• Sedatives
• Psychological counselling.

18. Drugs
In active disease, drugs are used to induce remission.
Later drugs also should be given for maintenance of remission
and to prevent relapses.
• Salazopyrine/sulfasalazine splits into 5 amino-salicylic acid and
sulphapyridine in colon. It is used as first line therapy.
• 5 ASA (Mesalamine) is also used in active disease as first line
therapy.
• Steroids are used in cases where salazopyrine fail to induce
remission.
• Immunomodulators are used often to induce remission and for
maintenance. Azathioprine and 6-mercaptopurine are used.
•Cyclosporin is used in refractory, fulminant severe ulcerative
colitis as a reserve drug. Dose is 4 mg/kg/day IV.

19. Management of severe
ulcerative colitis
• It is more than 6 stools per day, with cramping pain,
toxicity, fever, raised ESR, anaemia, tachycardia, more than
10% weight loss, hypoalbuminaemia less than 3.5 gm%
• It always needs hospitalisation
• IV corticosteroids [hydrocortisone] 300 mg/day/oral
prednisolone/5 ASA orally or as enema
• IV cyclosporine with azathioprine or 6 mercaptopurine
• Fluid and electrolyte management
• TPN/enteral nutrition
• Proper monitoring of the patient for complications
• Surgery

20. Indications for Surgery—30% Cases
• Intractability—commonest indication
• Toxic dilatation
• Perforation, Haemorrhage
• Risk of malignant transformation
• Progressive disease with stricture, abscess,
fistulae
• Steroid dependency, persistent active
disease
• Malignancy

21. Surgeries
1. Total proctocolectomy with ileo-anal
anastomosis
2. Total proctocolectomy with ileostomy
3. Total colectomy with ileorectal anastomosis
4. Total colectomy with rectal mucosectomy and
anastomosis above the dentate line on
posterior aspect is also occasionally used.

22. Different pouches are used after proctocolectomy and during
ileoanal anastomosis.
Pouch acts as reservoir and reduces the frequency of stool.

23. Total proctocolectomy with ileostomy

24. Complications of Surgery for Ulcerative Colitis
♦ Pouchitis (20%) with pain, diarrhoea, fever, bleeding,
toxicity, pouch—vaginal fistula, foecal incontinence (5%).
♦ Stenosis, pelvic abscess formation.
♦ Leak, fistula formation.
♦ Problems with ileostomy—psychological trauma, skin
excoriation, retraction, stenosis, prolapse, bleeding,
enteritis, ileal necrosis, ileal volvulus, paraileostomy
hernia, paraileostomy abscess.
♦ Sexual dysfunction following proctocolectomy by nerve
injury.

25. Crohn’s Disease
Crohn’s disease is a chronic transmural
inflammatory disorder of
the alimentary tract.

26. Aetiology
♦ Unknown, but a familial and infective nature
is thought of.
♦ Increased autoantibodies.
♦ Diet and food allergy.
♦ It is slightly more common in females.
♦ Focal ischaemia as a vasculitis may be the
cause.
♦ Smoking is related to Crohn‘s disease.

27. Pathology
• May affect any part of the alimentary tract.
• Skip lesions in bowel (affected bowel wall and
mesentery are thickened and oedematous,
frequent fistulae).
• Perianal disease characterized by perianal
induration and sepsis with fissure, and fistula
formation.
• Mesentery is thickened, oedematous, with
enlarged lymph glands.

29. Clinical Features
♦ Abdominal pain and diarrhoea is the initial slow
insidious presentation.
♦ Mild fever, weight loss, lassitude
♦ It may present as tender, firm, mass in the right
iliac fossa
♦ Obstruction, fistula formation, often perforation.
♦ Bleeding which is usually chronic but occasionally
massive can occur.
♦ Perianal disease with fissure, fistula, and abscess
♦ Extraintestinal manifestations can occur.

30. Multiple ulcers in the jejunum

31. Crohn’s disease in small bowel. It is transmural full thickness disease.
It can involve any part of GIT occasionally.

32. Clinical Presentations
a. Acute presentations (5%):
It mimics acute appendicitis with severe diarrhoea. Often there will
be localised or diffuse peritonitis.
b. Chronic Crohn’s:
First stage—Mild diarrhoea, colicky pain, fever, anaemia, mass in
right iliac fossa which is tender, firm, nonmobile along with
recurrent perianal abscess.
Second stage—either acute or chronic intestinal obstruction due
to cicatrisation with narrowing.
Third stage—Fistula formation: enterocolic, enteroenteric,
enterovesical, enterocutaneous, etc.
It is precancerous condition but not as much as ulcerative colitis.

33. Extraintestinal manifestations of Crohn’s disease

34. Investigations
♦ Plain X-ray abdomen, ultrasound abdomen
♦ Barium meal follow through or small bowel
enema
♦ CT scan and CT fistulogram
♦ Colonoscopy
♦ Blood tests
♦ Capsule endoscopy is useful investigation.
♦ MRI to diagnose anal disease

35. Small bowel enema examination showing a narrowed
terminal ileum involved with Crohn’s disease – the ‘string’
sign of Kantor.

37. Differential Diagnosis
♦ Radiation enteritis
♦ Ulcerative colitis.
♦ Intestinal tuberculosis
♦ Carcinoma ileum or caecum.
♦ Differential diagnosis for mass in the right iliac
fossa (carcinoma caecum, appendicular mass,
ileocaecal TB, ectopic kidney, mesenteric
lymphadenitis).

38. Treatment

39. Surgery
Indications
♦ Failure of medical treatment.
♦ Intestinal obstruction—most common indication.
♦ Fistula formation, bleeding, malignant change.
♦ Perforation, fulminant colitis.
♦ Perianal problems.
♦ Crohn’s disease children with growth retardation.
Note:
Surgery is not to cure the disease, but to correct complications.
Recurrence of complications and relapse of disease can occur
even after surgery.
Patient should be on postoperative azathioprine/6 MP/5ASA.

40. Surgeries
♦ Ileocaecal resection (common procedure done because
commonly ileocaecal region is involved).
♦ Segmental resection—conservative resection is better.
♦ Total colectomy and ileorectal anastomosis.
It is only done in extensive colonic Crohn’s.
♦ Stricturoplasty.
♦ Temporary ileostomy.
♦ Right hemicolectomy is done occasionally.
♦ Laparoscopic resection is good alternative.
♦ Occasionally if rectum is diseased or anal disease is severe then
total proctocolectomy with ileostomy is done.
♦ Corrective surgery for anal diseases like fissure, abscess and
fistula.

41. ♦ In free perforation and peritonitis ileostomy is
needed.
♦ Enterocutaneous fistula is treated with excision of
fistula with resection and anastomosis of that
particular segment. Organ fistulas are also treated
with resection of adherent bowel and closure of
organ like urinary bladder wall.
♦ Small bowel Crohn’s causes chronic bleeding;
colonic Crohn’s often may cause massive bleed. In
massive bleed angiographic control or colonoscopy
is needed.

42. Small bowel strictures in Crohn’s
disease with dilatation
between strictures.

43. Heineke–Mikulicz strictureplasty. (1) A strictured length of
intestine is incised along its length. (2) The bowel is opened
and the walls are retracted as shown. (3) The bowel is
resutured transversely to widen the narrowed segment.

45. References
• Bailey and Love’s Short Practice of
Surgery 27th
Ed
• SRB’S Manual for surgery, 4th
Ed

46. THANK YOU