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inflammatory bowel disease
This document discusses inflammatory bowel disease (IBD), including ulcerative colitis and Crohn's disease. IBD is characterized by chronic inflammation of the gastrointestinal tract due to an inappropriate immune response. Ulcerative colitis only involves the colon, while Crohn's disease can involve any part of the GI tract. Risk factors include genetics, smoking status, and an altered gut microbiome. Symptoms vary depending on the location of inflammation. Treatment involves medications to induce and maintain remission, as well as surgery for complications or non-responsive cases.
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inflammatory bowel disease
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- 2. INTRODUCTION It is achronic inflammatory disorder of the GIT due to inappropriate immune response characterized by a relapsing and remitting course. Types of IBD • Crohn’s disease – involves any part of the GIT from mouth to anus • Ulcerative colitis – involves only colon
- 3. FACTORS ASSOCIATED WITHDEVELOPMENT OF IBD ENVIRONMENTAL: • Ulcerative colitis is more common in non smoker and ex-smokers • Crohn’s disease is more common in smoker • Crohn’s disease is associated with a low-residue, high-refined sugar diet • Commensal gut microbiota are altered in UC and CD • Appendicectomy protects against UC
- 4. GENETICS: • Common inAshkenazi Jews • 10% have first degree relatives • High concordance in identical twins • CD is associated with genetic defects in innate and autophagy • HLA-DR 103 is associated with severe UC
- 5. PATHOPHYSIOLOGY • environmental triggersabnormal host response in genetically susceptible individuals. • inflammation of the intestine occurs due to innate and adaptive immune cell response leading to tissue damage. • association between microbial dysbiosis and IBD present • In both disease the intestinal wall is infiltrated with acute and chronic inflammatory cells
- 7. ULCERATIVE COLITIS • Inflammationinvolves the rectum and spreads proximally in some cases(pancolitis). • In long standing pancolitis , the bowel become shortened and develop post inflammatory pseudopolyps ( hypertrophied residual mucosa within areas of atrophy) • Limited to mucosa and spare deep layers of bowel wall • Both acute and chronic cell infiltrate lamina propria and crypts • Dysplasia, nuclear atypia and increased mitotic rate, may predispose the development of colon cancer
- 9. CROHN’S DISEASE • Themost common sites are terminal ileum and right side of colon, colon alone, terminal ileum alone, ileum and jejunum. • Entire wall of the bowel is oedematous and thickened • Deep ulcers often appear as linear fissure; thus the mucosa between them is described as cobblestone. • Patchy distribution and inflammatory process is interrupted by normal mucosa
- 11. CLINICAL FEATURES ULCERATIVE COLITIS: •Rectal bleeding with passage of mucus and bloody diarrhoea • Tenesmus • First attack is the most severe and is followed by relapses and remission • Some patient pass frequent, small-volume fluid stool while others pass pellety stools due to constipation upstream of the inflamed rectum • In severe cases, anorexia, malaise, weight loss and abdominal pain occur and the patient is toxic , with fever , tachycardia and signs of peritoneal inflammation.
- 12. CLINICAL FEATURES CROHN’S DISEASE: •The major symptoms are abdominal pain,diarrhoea and weight loss • Ileal crohn’s disease may cause subacute or acute intestinal obstruction • Watery stool and does not contain blood or mucus • Eating provokes pain • Abdominal tenderness
- 13. DIFFERENTIAL DIAGNOSIS INFECTIVE: Bacterial: • Salmonella •Shigella • Campylobacter jejuni • Escherichia coli Viral: • Herpes simplex proctitis • Cytomegalovirus Protozoal; • Amoebiasis
- 14. NON-INFECTIVE • Ischaemic colitis •Collagenous colitis • Diverticulitis • Radiation proctitis • behcet’s disease • Colonic carinoma
- 15. COMPLICATION • Life threateningcolonic inflammation • Haemorrhage • Fistulas • Cancers • Extra intestinal complications
- 17. INVESTIGATION • Complete bloodcount-anaemia, leukocytosis • ESR and CRP increased Stool examination: • Stool microscopy, culture, examination for ova and parasite. Sigmoidoscopy : • UC-Loss of vascular pattern, granularity, friability and contact bleeding with or without ulceration. • Cd-patchy inflammation,discrete deep ulcers, strictures perianal disease Mucosal biopsy-confirm the diagnosis
- 19. Barium enema • Contraindicatedin megacolon • In UC-loss of haustration, ulceration, pseudopolyp,shortening of bowel • In CD-linear fissures throughout bowel, cobble stone appearance ,concentric lesions are seen. Plain abdominal x-ray Colonoscopy-assessing the progression of proctitis and colitis Upper GI endoscopy-differentiating cohn’s disease of duodenum fom peptic ulcer
- 21. MANAGEMENT The key aimsare • Treat acute attacks • Prevent relapses • Detect carcinoma at an early stage • Select appropriate patient for surgery
- 22. MANAGEMENT OF ULCERATIVECOLITIS • Active proctitis: 1g mesalazine suppository +/- oral 5- aminosalicylate.(Topical glucocorticoids are reserved ) • Extensive ulcerative colitis: Oral 5-ASA+topical 5-ASA. • Topical is withdrawn after 1 month but oral 5-ASA is continued. • If unresponsive then oral prednisolone 40mg daily tampered 5mg/week over 8weeks is indicated
- 23. Severe ulcerative colitis: •I.V fluids +enteral nutritional support . • I.V methylprednisolone 60 mg or hydrocortisone 400mg/day • Ciclosporin or infliximab if unresponsive to glucocorticoids. • Coloctomy –who do not respond to medical therapy
- 24. Maintenance therapy: • lifelong maintenance therapy is required in extensive ulcerative colitis. • oral 5-ASA OD are preferred first line agents. • Sulfasalazine is effective but higher incidence of side effects • Biologic therapy with anti TNF or anti-α4ᵦ7 integrin antibodies
- 25. MANAGEMENT OF CROHN’SDISEASE principle of treatment: • To induce remission and maintain glucocorticoid-free remission with normal quality of life Induction of remission: • Glucocorticoids - mainstay of treatment • Drug of choice in patient with ileal disease is budesonide (regimen is 9mg once daily for 6weeks with gradual reduction in dose. ) • If no response - switched to prednisolone 40mg daily • Calcium and vitamin d
- 26. Maintenance therapy: • Immunosuppressivetreatment with azathioprine or mercaptopurine • Methotrexate orally or S.C is also effective • Combination therapy with anti TNF antibodies is effective but costly
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- 28. Ulcerative colitis: • 60%patients with extensive ulcerative colitis eventually require surgery • Surgery involves removal of entire colon and rectum • The choice of procedure is either panproctocolectomy with ileostomy, or proctocolectomy with ileal-anal pouch anastomosis
- 29. Crohn’s disease: • Operationare often necessary to deal with fistulae, abscesses and peri anal disease and also to relieve bowel obstruction. • Localized segments of crohn’s disease are managed by segmental resection and multiple stricturoplasties, in which stricture is not resected but instead incised in its longitudinal axis and sutured transversely.
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