Inflammatory bowel disease (IBD) refers to chronic inflammatory disorders of the gastrointestinal tract including ulcerative colitis (UC) and Crohn's disease. The causes are unknown but may involve genetic and immune factors. UC primarily involves the colonic mucosa while Crohn's disease can involve all layers of the intestinal wall. Treatment involves medications to suppress inflammation such as aminosalicylates, corticosteroids, immunosuppressants, antibiotics, and antispasmodics. While some patients can be managed medically, many will require surgery for complications or refractory disease. The prognosis is generally better for UC than Crohn's disease.
1- Defines inflammatory bowel disease.
2-Recall pathological changes associated with ulcerative colitis and Crohn's disease
Inflammatory bowel disease (IBD) is an idiopathic disease caused by a dysregulated immune response to host intestinal microflora.
The two major types of inflammatory bowel disease are:
ulcerative colitis (UC), which is limited to the colon.
Crohn disease (CD), which can affect any segment of the gastrointestinal tract from the mouth to the anus, involves skip lesions
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It discusses investigations useful in diagnosis of inflammatory bowel disease and their important findings e.g Barium enema, histopathology, a word about indeterminate colitis and followed by discussion of possible etiologies to be ruled out before diagnosing IBD
UC is an idiopathic IBD that affects the colonic mucosa.
Hallmark of UC is bloody diarrhea often with prominent symptoms of rectal urgency and tenesmus.
The clinical course is marked by exacerbations and remissions.
The diagnosis of UC is suspected on clinical grounds and supported by the appropriate findings on
Proctosigmoidoscopy or colonoscopy
Biopsy
By negative stool examination for infectious causes
1- Defines inflammatory bowel disease.
2-Recall pathological changes associated with ulcerative colitis and Crohn's disease
Inflammatory bowel disease (IBD) is an idiopathic disease caused by a dysregulated immune response to host intestinal microflora.
The two major types of inflammatory bowel disease are:
ulcerative colitis (UC), which is limited to the colon.
Crohn disease (CD), which can affect any segment of the gastrointestinal tract from the mouth to the anus, involves skip lesions
Med_students0
Follow us:
Instagram
slideshare
It discusses investigations useful in diagnosis of inflammatory bowel disease and their important findings e.g Barium enema, histopathology, a word about indeterminate colitis and followed by discussion of possible etiologies to be ruled out before diagnosing IBD
UC is an idiopathic IBD that affects the colonic mucosa.
Hallmark of UC is bloody diarrhea often with prominent symptoms of rectal urgency and tenesmus.
The clinical course is marked by exacerbations and remissions.
The diagnosis of UC is suspected on clinical grounds and supported by the appropriate findings on
Proctosigmoidoscopy or colonoscopy
Biopsy
By negative stool examination for infectious causes
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Stewardship is the act of taking good care of something.
Antimicrobial stewardship is a coordinated program that promotes the appropriate use of antimicrobials (including antibiotics), improves patient outcomes, reduces microbial resistance, and decreases the spread of infections caused by multidrug-resistant organisms.
WHO launched the Global Antimicrobial Resistance and Use Surveillance System (GLASS) in 2015 to fill knowledge gaps and inform strategies at all levels.
ACCORDING TO apic.org,
Antimicrobial stewardship is a coordinated program that promotes the appropriate use of antimicrobials (including antibiotics), improves patient outcomes, reduces microbial resistance, and decreases the spread of infections caused by multidrug-resistant organisms.
ACCORDING TO pewtrusts.org,
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According to WHO,
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VISION
Being proactive
Supporting optimal animal and human health
Exploring ways to reduce overall use of antimicrobials
Using the drugs that prevent and treat disease by killing microscopic organisms in a responsible way
GOAL
to prevent the generation and spread of antimicrobial resistance (AMR). Doing so will preserve the effectiveness of these drugs in animals and humans for years to come.
being to preserve human and animal health and the effectiveness of antimicrobial medications.
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to prevent antimicrobial overuse, misuse and abuse.
to minimize the developme
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5. Causes of IBD
• Genetic predisposition?
• Infectious organisms?
• Immune mechanisms
o Immunosuppressive agents used in treatment
o Autoimmune phenomena accompany IBD
• Psychological mechanisms
o IBD may flare in association with stress
o Characteristic personality
8. Ulcerative Colitis
• Inflammatory reaction involving primarily
colonic mucosa
• Colon appears ulcerated, hyperemic
• Inflammation is uniform and continuous, with
no intervening areas of normal mucosa.
• Rectum usually involved (95%) and extends
proximally
9. UC Clinical Features
• Major symptoms:
o Bloody diarrhea/constipation
o Abdominal pain
o Weight loss
o Fever
10. UC Manifestations/Complications
• Physical findings (nonspecific)
o Tenderness along colon
• Extracolonic manifestations
o Anemia of chronic disease + Fe deficiency
o Leukocytosis, left shift
o Electrolyte abnormalities
o Hypoalbuminemia
• Colon CA
• Toxic megacolon
• Hemorrhage
11. UC Clinical Course
• > 50% will relapse within 1 year (may be
prolonged remissions)
• Severity of symptoms reflects intensity of
inflammation
• Rectal involvement-major symptoms rectal
bleeding, tenesmus
• 85% have mild to moderate disease
• 15% disease involves entire colon
12. UC Characteristic Appearance of
Colon
• Smooth “lead pipe” appearance
radiographically
• “Pseudopolyps”: Inflammatory, not neoplastic
resulting from regenerating mucosa
surrounded by ulceration
• Dysplasia may influence decision for
colectomy
13. Crohn's Disease
• Inflammation extending through all layers of
intestinal wall
• Involves entire digestive tract, especially distal
ileum, colon, anorectal area
14. Crohn's Disease Clinical
Presentation
• (Depends on anatomic location of disease)
• Fever
• Abdominal pain (with colonic involvement)
• Diarrhea often w/blood (with colonic
involvement)
• Generalized fatigability
• Weight loss
15. Crohn's Disease Bowel Appearance
• Bowel appears greatly thickened, lumen
narrows (associated with varying degrees of
obstruction.)
• Mucosa appearance variable; may appear
normal, in contrast to UC
• "Cobblestone" appearance of mucosa
• Discontinuous "skip lesions" present
• Rectum spared in 50% of cases (never in UC)
16. Crohn's Disease Complications
• Severe complications include fistulas, fissures,
abscesses
• Toxic megacolon: less than with UC
• Colonic cancer: less than with UC
17. Systemic Complications of IBD
• Joint manifestations (25% incidence)
• Arthralgias to acute arthritis
• Skin manifestations (15% incidence)
• Severity reflects activity of bowel disease
• More common with colonic disease
• Erythema nodosum: and eruption of painful red
nodules of legs
• Pyoderma gangrenosum: ulcerating lesion often
occurring on the trunk
• Aphthous ulcers: resemble canker sores of mouth
• Treat symptomatically only
18. Systemic Complications of IBD
• Ocular manifestations (5% incidence)
• May represent severe manifestation of disease
• Episcleritis, recurrent iritis may occur
• Activity parallels course of bowel disease
• Lesion may respond when colectomy
performed
19. Local complications of IBD
• UC
o toxic megacolon
o colonic perforation
o hemorrhage
o colonic carcinoma
• Crohn’s Disease
o fistulas
o sepsis
o intestinal obstruction
o B12 malabsorption
20. Treatment of UC and Crohn's
Disease
• Similarities: Initial treatment is medical
• Surgery reserved for specific complications,
intractable disease
• Differences: Response to drug therapy may
differ
• Complications often different
• Prognosis following surgery different
21. Goals of Pharmacotherapy for IBD
• Control inflammatory process
• Replace nutritional losses
• Improvements following IV fluid and
electrolyte replacement
• Blood transfusions may be necessary
• Agents to control diarrhea should be used with
caution
22. Drug Therapy in IBD
• Aminosalicylates
• Sulfasalazine-reaches colon intact where diazo
bond is cleaved by flora to mesalamine
(active) and sulfapyridine.
• Proposed mechanisms of action:
o Inhibit NKC's
o Inhibit cyclooxygenase and lipoxygenase
pathways
o Repair neutrophil function
o Scavenge oxygen radicals
23. Problems with sulfasalazine
• Many patients allergic or intolerant
(sulfapyridine portion)
• May be possible to "desensitize" patients
• Other adverse effects:
o fever, rash, hepatic dysfunction, agranulocytosis,
hemolytic anemia, thrombocytopenia, pancreatitis,
adverse sperm effects in males
24. • Corticosteroids:
o exact mechanism unknown
• Enemas:
o Decrease tenesmus by suppressing rectal inflammation
• IV:
o appropriate in severely ill patients to avoid uncertainty of
oral absorption
• PO:
o After 7-10 days, if improvement (dec. fever, diarrhea,
increased appetite), start oral feedings and taper steroids
• To decrease side effects: Use rapid tapering
schedules
• Every other day schedules
• AM dosing
26. • Azathiaprine-Discouraging results
• 6-Mercaptopurine-Active metabolite of azathiaprine
• Role in refractory Crohn's
o Studies have shown reductions in steroid use, healing of
fistulas and abscesses.
• Toxicities: pancreatitis 3.3%
• BM suppression 2%
• Allergy 2%
• Hepatitis 0.3%
• Should be considered in treatment of patients with
refractory Crohn's, or in patients intolerant of steroids
or sulfasalazine
27. Methotrexate in IBD
• Interferes with IL-1's inflammatory actions
• Study results:
o In patients with refractory IBD, given MTX 25 mg
IM weekly x12 weeks, then oral taper:
o 5/7 with UC, 11/14 Crohn's improved allowing
decreased steroid doses
28. Cyclosporine in IBD
• Study results:
o In patients with resistant Crohn's, cyclosporine 5-
7.5 mg /kg/d x3 months
o 59% cyclosporine vs 32% placebo showed
improvement.
o No long term improvement
o Side effects need to be assessed (renal impairment)
29. Antibiotics in IBD
• Role:
o As treatment for intercurrent infections
o As primary treatment for IBD
• Considerations:
o Infections can cause flares in IBD
o C. jejuni infections can mimic IBD
• Uncontrolled study:
o Continuous treatment with ATB's resulted in
symptomatic improvement in 41/44 patients with
Crohn's
30. Metronidazole in IBD
• Only antimicrobial with firm rationale for use
in Crohn's
• May work through mechanism independent of
antimicrobial properties
• No evidence in UC, except in treating C.dif
infections
• Study results:
o Patients with unremitting Crohn's, 21/21 had
improvements in drainage, erythema, induration.
10/18 had complete healing.
31. Anticholinergics/Antispasmodics
• Symptomatic treatment
• Use should be discouraged in acute symptoms;
• May ppt. ileus, toxic megacolon
• Major usefulness:
o control of diarrhea in patients with well
established, chronic symptoms
32. Prognosis for IBD
• UC:
o 20-25% will require colectomy
o Indication for colectomy:
• failure to respond to medical management
o Long term prognosis- variable
o 10 year mortality for severe first attacks=5-10%
o 75% relapse rate
33. Prognosis for IBD
• Crohn's:
o prognosis less favorable than for UC
o disease responds less favorably to medical therapy
o 2/3 develop complications requiring surgery
o mortality increases with duration of disease (5-
10%)
o surgery not a primary form of therapy-high rate of
recurrence