Inflammatory bowel disease includes Crohn's disease and ulcerative colitis, which cause inflammation in the intestines. Crohn's disease can affect any part of the gastrointestinal tract and causes transmural inflammation, while ulcerative colitis causes inflammation and ulcers only in the inner lining of the colon and rectum. Treatment involves lifestyle changes, medications like 5-ASA agents, glucocorticoids, antibiotics, immunosuppressants, and biological therapies. Surgery may be required for severe cases or complications that do not respond to medical management.

2. Inflammatory bowel disease
intestines.
It includes a group of chronic disorders that
cause inflammation or ulceration in large and
small intestines.

3. TYPES
Crohn’s disease Ulcerative colitis
• Extends into the deeper
layers of the intestinal wall, • causes ulceration and
and may affect the mouth, inflammation of the inner
esophagus, stomach, and lining of the colon and
small intestine. rectum.
• Transmural inflammation
and skip lesions. • It is usually in the form of
• In 50% cases -ileocolic,30% characteristic ulcers or open
ileal and 20% -colic region. sores.
• Regional enteritis

5. Other forms of IBD
• Collagenous colitis
• Lymphocytic colitis
• Ischemic colitis
• Behcet’s syndrome
• Infective colitis
• Intermediate colitis

6. Epidemiology
Ulcerative colitis Crohn’s
Incidence / 1 lac. 2.2-14.3 3.1-14.6
Age of onset 15-30, 60-80
Ethnicity Jewish
Male: Female 1:1 1.1-1.8 : 1
Smoking May prevent Causative
Oral contraceptives No risk 1.4 odds ratio
Appedicectomy Protective Not
Monozygotic 6% 58%
Dizygotic 0% 4%

7. Etiopathogenesis
• Exact cause is unknown.
• Genetic factors
• Immunological factors
• Microbial factors
• Psychosocial factors

8. Genetic factors
• Ulcerative colitis is more common in
DR2-related genes
• Crohn’s disease is more common in
DR5 DQ1 alleles
• 3-20 times higher incidence in first degree
relatives

9. Immunologic factors
• Defective regulation of immunesuppresion
• Activated CD+4 cells activate other
inflammatory cells like macrophages & B-cells
or recruit more inflammatory cells by
stimulation of homing receptor on leucocytes
& vascular epithelium.

11. Pathogenesis of IBD
Tolerance
Acute Injury
Environmental
trigger
Normal Complete Healing
Gut (Infection, NSAID, other)
Genetically
Tolerance- Acute Inflammation Susceptible
controlled Host
↓ Immunoregulation,
inflammation
failure of repair or
bacterial clearance
Chronic Inflammation
American Gastroenterological Association Institute, Bethesda, MD.
Sartor RB. Nat Clin Pract Gastroenterol Hepatol. 2006;3:390-407.

12. Pathology
Macrocopic features
• Ulcerative colitis
 Usually involves rectum & extends proximally to
involve all or part of colon.
 Spread is in continuity.
 May be limited colitis( proctitis &
proctosigmoiditis)
 in total colitis there is back wash ileitis (lumpy-
bumpy appearance)

14. • Mild disease- erythema & sand paper
appearance(fine granularity)
• Moderate-marked erythema,coarse
granularity,contact bleeding & no ulceration
• Severe- spontaneous bleeding, edematous &
ulcerated(collar button ulcer).
• Long standing-epithelial regeneration so
pseudopolyps , mucosal atrophy &
disorientation leads to a precancerous
condition.
• Eventually can lead to shortening and
narrowing of colon.
• Fulminant disease-Toxic colitis/megacolon

15. Ulcerative colitis
pseudopolyps
Ulcer

16. Microscopic features
 Crypts atrophy & irregularity
 Superficial erosion
 Diffuse mixed inflammation
 Basal lymphoplasmacytosis

18. Diffuse
inflammation
Crypt
distortion

19. Macroscopic features
• Crohn’s disease
Can affect any part of GIT
Transmural
Segmental with skip lesions
Cobblestone appearance
Creeping fat- adhesions & fistula

22. Microscopic features
• Aphthous ulcerations
• Focal crypt abscesses
• Granuloma-pathognomic
• Submucosal or subserosal lymphoid
aggregates
• Transmural with fissure formation

23. Aphthous ulcer
Granuloma

24. Clinical features
• Ulcerative colitis
Diarrhea
Rectal bleeding
Tenesmus
Passage of mucus
Crampy abdominal pain

25. • Diarrhea & bleeding blood-intermittent &mild.
do not seek medical attention.
• Patient with proctatis-pass fresh or blood
stained mucus with formed or semi formed
stool. They also have tenesmus , urgency with
feeling of incomplete evacuation.
• With proctosigmoiditis-constipation
• Severe disease-liquid stools with blood , pus &
fecal matter.

26. • Physical signs
Proctitis – Tender anal canal & blood on rectal
examination
Extensive disease-tenderness on palpation of
colon
Toxic colitis-severe pain &bleeding
If perforation-signs of peritonitis

27. Clinical Severity of UC
Mild Moderate Severe Fulminant
Bowel movement <4 >6 >10
Blood in stool Intermittent Frequent Continuous
Temperature Normal >37.5° >37.5°
Pulse Normal >90 bpm >90 bpm
Intermediate
<75% normal Transfusion
Hemoglobin Normal
rate required
ESR <30 mm/hour >30 mm/hour >30 mm/hour
Abdominal
Abdominal
Clinical signs distension and
tenderness
tenderness
1. Truelove SC, et al. Br Med J. 1955;2:1041-1045.
2. Sandborn WJ. Curr Treat Options Gastroenterol.1999;2:113-118.

29. Diagnosis
• Laboratory tests
• Endoscopy
• Radiography
• Biopsy

30. Laboratory tests
• Hemogram
C-reactive protein is increased
ESR is increased
Platelet count-increased
Hemoglobin-decreased
 Fecal Calponectin levels correlate with
histological inflammation,predict relapses
&detect pouchitis

31. Barium
enema

32. Barium enema
• Fine mucosal granularity
• Superficial ulcers seen
• Collar button ulcers
• Pipe stem appearance-
loss of haustrations
• Narrow & short colon-
ribbon contour colon

33. Sigmoidoscopy
• Always abnormal
• Loss of vascular patterns
• Granularity
• Friability
• ulceration

37. Extra intestinal manifestations

39. Clinical features
• Ileal Crohn’s Disease
Abdominal pain
 Diarrhea
 Weight loss
Low grade fever
• Jejunoileitis disease
 Malabsorption
 Steatorrhea

40. Colitis and perianal disease
• Bloody diarrohea
• Passage of mucus
• Lethargy
• Malaise
• Anorexia
• Weight loss

41. Diagnosis
• Laboratory tests
• Endoscopy
• Radiography
• Biopsy
• CT enterography

42. Laboratory tests
• CRP-elevated
• ESR-elevated
• Anemia
• Leukocytosis
• hypoalbuminemia

43. Barium enema
String
sign

44. Colonoscopy

46. CT enterography
• Mural hyperenhancement
• Stratification
• Engorged vasa recta
• Perienteric inflammatory
changes

48. Treatment

49. Treatment

50. Lifestyle changes

51. Drugs
• 5-ASA agents
• Glucocorticoids
• Antibiotics
• Immunosuppresants
• Biological therapy

52. 5-ASA Agents
•Sulfasalazine (5-aminosalicylic
acid and sulfapyridine as carrier
substance)
•Mesalazine (5-ASA), e.g. Asacol,
Pentasa
•Balsalazide (prodrug of 5-ASA)
• Olsalazine (5-ASA dimer cleaves
in colon)

53. Topical Action of 5-ASA: Extent of Disease
Impacts Formulation Choice
Distribution of 5-ASA Preparations
Oral
• Varies by agent: may be released in the distal/terminal
ileum, or colon1
Liquid Enemas
• May reach the splenic flexure2-4
• Do not frequently concentrate in the rectum3
Suppositories
• Reach the upper rectum2,5
(15-20 cm beyond the anal verge)
1. Sandborn WJ, et al. Aliment Pharmacol Ther. 2003;17:29-42; 2. Regueiro M, et al. Inflamm Bowel Dis. 2006;12:972–978; 3. Van Bodegraven AA,
et al. Aliment Pharmacol Ther. 1996; 10:327-332; 4. Chapman NJ, et al. Mayo Clin Proc. 1992;62:245-248; 5. Williams CN, et al. Dig Dis Sci. 1987;32:71S-75S.

54. • Use
 In mild to moderate UC & crohn’s colitis
 Maintaining remission
 May reduce risk of colorectal cancer
• Adverse effects
 Nausea, headache, epigastric pain, diarrhoea,
hypersensitivity, pancreatitis
 Caution in renal impairment, pregnancy, breast feeding

55. Glucocorticoids
• Anti inflammatory agents for moderate to
severe relapses.
• Inhibition of inflammatory pathways
• Budesonide- 9mg/dl used for 2-3 months &
then tapered.
• Prednisone-40-60mg/day
• No role in maintainence therapy

56. Antibiotics
• No role in active/quienscent UC
• Metronidazole is effective in active
inflammatory,fistulous & perianal CD.
• Dose-15-20mg/kg/day in 3 divided doses.
• Ciprofloxacin
• Rifaximin

57. Immunosuppresants
• Thiopurines
Azathioprine
6-mercaptopurin
• Methotrexate
• Cyclosporine

58. Cyclosporine
• Preventing clonal expansion of T cell subsets
• Use
Steroid sparing
Active and chronic disease
• Side effects
Tremor, paraesthesiae, malaise, headache, gingival
hyperplasia, hirsutism Major: renal impairment,
infections, neurotoxicity

59. Biological therapy
• Infliximab
Anti TNF monoclonal antibody
Infliximab binds to TNF trimers with high affinity, preventing cytokine
from binding to its receptors
It also binds to membrane-bound TNF- a and neutralizes its activity &
also reduces serum TNF levels.
• Use
Fistulizing CD
Severe active CD
Refractory/intolerant of steroids or immunosuppression
• Side effects
Infusion reactions, Sepsis, Reactivation of Tb, Increased risk of Tb

60. Other medications
Anti- diarrheals - Loperamide (Imodium)
Laxatives - senna, bisacodyl
Pain relievers. acetaminophen (Tylenol).
Iron supplements
 Nutrition

61. Surgery
Ulcerative colitis
Indications:
• Fulminating disease
• Chronic disease with anemia, frequent stools,
urgency & tenesmus
• Steriod dependant disease
• Risk of neoplastic change
• Extraintestinal manifestations
• Severe hemorrhage or stenosis

63. Others
• Proctocolectomy & ileostomy
• Rectal &anal dissection
• Colectomy with ileorectal anastomosis
• Ileostomy with intraabdominal pouch

64. Crohn’s disease
• Ileocaecal resection
• Segmental resection
• Colectomy & ileorectal anastamosis
• Temporary loop ileostomy
• Proctocolectomy
• Stricturoplasty

65. Strictureplasty