If you are a medical student in your general surgery rotation, this will help you, Good Luck All.

3. Inflammatory Bowel Disease (IBD) is a term for a group of disorders
characterized by chronic, idiopathic (of unknown cause) inflammation of
the gastrointestinal tract. It is considered an immune-mediated
inflammatory disease (IMID), where repetitive episodes of inflammation
are triggered by an abnormal immune response to the gut microflora.
The two primary and most common subtypes of IBD are Ulcerative Colitis
and Crohn's Disease. Other, far less frequent, entities have also been
identified, including Microscopic Colitis and Indeterminate Colitis
(Rudbaek et al., 2024).

4. • Crohn’s disease: transmural inflammation and skip areas of involvement (ie, segments of normal
appearing bowel interrupted by areas of disease).
• Ulcerative colitis: chronic inflammatory condition characterized by relapsing and remitting episodes
of inflammation limited to the mucosal & Submucosal layers of the colon.
• Indeterminate colitis: difficulty distinguishing UC from CD in the colon.This occurs in approximately
10% of patients.
• Microscopic colitis: type of (IBD) characterized by inflammation that it can only be seen
microscopically on colonic biopsy with normal colonoscopy. It is subdivided into: collagenous and
lymphocytic colitis, mainly presented as chronic, watery, non-bloody diarrhea.

5. -The number of individuals affected by IBD across the globe increased from 3.7 million in 1990 to 6.8 million
in 2017 and Between 1990 and 2017, ("The global, regional, and national burden of inflammatory bowel
disease in 195 countries and territories, 1990-2017: a systematic analysis for the Global Burden of Disease Study
2017," 2020)
-In 2019, there were (282,534) cases of IBD in the MENA region. Incidence rates were highest in Jordan, at 6.9
per 100,000, and lowest in Morocco, at 1.6 per 100,000. https://pmc.ncbi.nlm.nih.gov/articles/PMC11372542/
1. Age:
-Crohns disease: highest incidence between 20- to 29-year-old age group.(Shivashankar et al., 2017)
-”pediatric-onset IBD has been increasing over time”(Kuenzig et al., 2022)
2. Sex: Adult-onset CD slighty F>M ,UC slighty M>F (Shivashankar et al., 2017)(Loftus et al., 2000)
3. Race and ethnicity:
-Both UC and CD are more common in Jewish (Mayberry et al., 1986)(Karlinger et al., 2000)
-The prevalence of IBD is higher in White populations than in Black. (Sonnenberg, A.,1991)

6. Crohn’s Disease (CD)
Ulcerative Colitis (UC)
I. Genetic predisposition
1) HLA-B27 association for both CD & UC.
2) In crohn disease (NOD2 confers the greatest risk of developing Crohn
disease) -49 studies with 8893 Crohn disease patients found that patients
with NOD2 mutations were at increased risk for the susceptibility to
developing CD at an earlier age, more complicated and fibrostenosing
disease, and worse outcomes following surgery compared with those
without mutations.
II. An altered, dysregulated immune response or epithelium.
III. An altered response to gut microorganisms.
IV. Environmental factors.
o Despite extensive research, its cause remains poorly understood.

7. The layers of wall of intestine
Crohn’s Disease

8. A. Smoking
➢Smokers are more likely to develop CD and increase the risk of complications from CD
(eg, strictures, fistula) and the need for surgery. (Higuchi et al., 2012)(Louis, E.,2003)
➢Smoking not a risk factor for UC and may lower the risk of developing ulcerative colitis.
➢Smoking cessation in patients with ulcerative colitis is associated with an increase in disease
activity and risk of hospitalization. (Beaugerie, L., 2001)
B. Obesity
➢patients with obesity were more likely to develop active disease and may require
hospitalization. (Blain, A.,2002)
Lifestyle
Factors
Protective Factors of UC:
1.Smoking
2.Appendectomy

9. C. Physical activity
➢associated with a decrease in risk of Crohn disease, but not ulcerative colitis.(Wanner et
al., 2016)
D. Dietary factors
➢Western diet (↓ fibers, ↑animal fat) increases the incidence of both UC and CD.
➢Vitamin D : Vit. D intake is inversely associated with the risk of CD and that vitamin D
deficiency is common among patients with IBD. (Del Pinto, R., 2015)
E. Sleep duration
➢Sleep deprivation has been associated with an increased risk of incident ulcerative colitis
and of disease flares in patients with IBD.(Ananthakrishnan et al., 2014)
Lifestyle
Factors

10. Infection and the immune response:
➢Infection and the immune response have been implicated in the pathogenesis of IBD and
risk of IBD was higher in patients with a prior episode of acute gastroenteritis.(Cho,
2008)(Porter et al., 2008)
Medications:
➢ NSAIDs and OCPs seem to ↑ the risk for developing IBD.
➢ NSAIDs may exacerbate ulcerative colitis.
➢antibiotic exposure increase risk of Crohn disease (https://pubmed.ncbi.nlm.nih.gov/39927188/)
(2024/Oct)
Familial aggregation:
➢A positive family history remains the strongest recognizable risk factor for the
development of IBD and is reported in around (10-25%) of IBD patients.
Other
Factors

11. The “hygiene hypothesis” :
➢It proposes that reduced exposure to enteric bacteria and high levels of sanitation during early
life may affect our immune responses later in life, predisposing us to a higher risk of developing
autoimmune diseases.
Appendectomy:
➢CD : ✓ Risk of CD is increased after appendectomy.(Andersson et al., 2003)
➢UC: ✓ May lower the risk of developing UC esp. before the age of 20 years,
(López-Serrano et al., 2010)
-Appendicectomy before UC diagnosis reduces the risk of future colectomy .
Other
Factors

12. Crohn’s Disease (CD) Ulcerative Colitis (UC)
- Confined to the large intestine
- Mucosal inflammation.
- Continuous
- Less genetic predisposition
- Rarely in childhood
- NOD 2 rare
- Less in smoker
- Pain usually at the LLQ.
- More frequent colorectal Ca.
- Less extra intestinal manifestation.
- Proctocolectomy is curative
- affect any portion and mainly terminal ileum
- transmural inflammation.
- Skip lesions
- More genetic predisposition
- Can occur in childhood
- NOD 2 mutation common
- More in smoker
- Pain usually at the RLQ.
- Less frequent colorectal ca.
- More extra intestinal manifestations
- Surgery not curative

13. Ulcerative colitis (UC) is a chronic inflammatory disease of the large intestine that is
limited to the innermost layer of the bowel wall—the mucosa. A hallmark of the
condition is that it always involves the rectum and spreads upward (proximally) into
the colon in a continuous, uninterrupted fashion. The inflammation is characterized
by recurring episodes and is often circumferential, affecting the entire inner lining of
the bowel. Additionally, ulcerative colitis can be associated with extraintestinal
manifestations, meaning it may affect other parts of the body outside of the digestive
tract.

14. • Different terms have been used to describe the degree of
involvement (Montreal Classification E1,E2,E3):
-Ulcerative proctitis (E1): limited to the rectum.
-Ulcerative proctosigmoiditis: limited to the rectum and sigmoid
colon.
-Left-sided colitis (E2): extends beyond the rectum, from the
sigmoid colon and as far proximally as the splenic flexure.
-Extensive colitis (E3): extending proximal to the splenic flexure.
- pancolitis: colon and rectum are involved.
Ulcerative Procitis
Ulcerative Proctosigmoiditis
Left Sided Colitis
Extensive Colitis
Pancolitis

15. The assessment of severity of UC is determined by frequency of bowel action
and the presence of systemic signs of illness:
● Mild disease is characterized <4 stools daily, with or without
bleeding. There are no systemic signs of toxicity.
● Moderate disease corresponds to more than four stools daily, but
with few signs of systemic illness. There may be mild anemia.
Abdominal pain may occur. Inflammatory markers, including
erythrocyte sedimentation rate “ESR” and C-reactive protein “CRP” are
Often raised.

16. ● Severe disease corresponds to more than six bloody stools a day and evidence of
systemic illness, with fever, tachycardia, anaemia and raised inflammatory markers.
Hypoalbuminaemia is common and an ominous finding.
● Fulminant disease is associated with more than 10 bowel movements daily, fever,
tachycardia, continuous bleeding, anaemia, hypoalbuminaemia, abdominal tenderness
and distension, the need for blood transfusion and, in the most severe cases,
progressive colonic dilation (toxic megacolon).This is a very significant finding,
suggestive of disintegrative colitis, and an indication for emergency surgery if colonic
perforation is to be avoided.

17. American College of Gastroenterology: Ulcerative
Colitis Activity Index

18. • Bloody diarrhea with mucus
• Fecal urgency
• Fecal incontinance
• Abdominal pain and cramps
• Tenesmus (The sense of incomplete evacuation despite an empty rectum)

19. • General: fatigue and fever
• Skeletal manifestations (most common):
Osteoarthritis, Ankylosing Spondylitis, and Sacroiliitis
• Ocular: Uveitis, Episcleritis, and Iritis.
• Primary sclerosing cholangitis (PSC): rare “Jaundice & Bloody diarrhea”
• Cutaneous:
-Erythema Nodosum, Pyoderma Gangrenosum
-Aphthous Stomatitis
-Pyostomatitis vegetans: a very rare condition that is associated with
other cutaneous diseases and Inflammatory Bowel Disease, particularly
Ulcerative Colitis.
-Manifests with multiple aphthae and pustules of the oral mucosa.
-In children and adolescent:
Growth retardation and delayed puberty
Osteoarthritis
Ankylosing
Spondylitis
Pyostomatitis
vegetans
Erythema Nodosum
Apthous Stomatitis
Pyoderma Gangrenosum

20. Chronic Intermittent Chronic Continuous Acute Fulminant
-Most common course
-Exacerbated is followed by complete
remission
-Complete remission doesn’t occur
-Disease severity varies
-Sudden onset
-Severe diarrhea, dehydration and shock

21. How to approach the UC:
1.Hx and PE
(If there Hematochezia & Fecal Urgency)
< 1 month … Think about gastroenteritis …. Consult gastroenterologist … Stool testing
> 1 month … Think about UC … perform ileocolonscopy … if contraindicated order abdominal CT/ MRI.
DRE: May yield mucus and bloody stools
Typical age, 2 peaks 15-30 y.o and > 55 y.o
2.Laboratory Studies
• Blood tests ➤ CBC:anemia, leukocytosis, thrombocytosis ESR, CRP: Elevated levels may indicate active ulcerative colitis and often
correlates with disease severity.
• Hypoalbuminemia
• ALP, GGT: elevated in patients with concurrent PSC
• Perinuclear ANCA (PANCA)Not routinely recommended Elevated in up to 70% of patients with ulcerative colitis
• Stool testing:
• It is mandatory in all patients to rule out gastroenteritis.
• Gross or Occult bloodTest
• for C.Difficile

22. 3.Endoscopy:
• Ileocolonoscopy
• Recommended method for diagnosis and disease monitoring
• Severe disease is a relative contraindication.
• The endoscopist should document the macroscopic findings and perform biopsies throughout the gastrointestinal tract
to confirm the diagnosis through histopathology
• In early diseases:
• Video Capsule Endoscopy (VCE): used for diagnosing and assessing severity of the disease, it's the best option for
children; FDA approved for children over 2 years.
• In chronic disease:
Inflamed, erythmatous, edematous
friable mucosa with bleeding Fibrin covered ulcer Small mucosal ulcerations Loss of superficial vascular pattern
Loss of mucosal folds and hamstring Stricture (Very unusual, more in CD) Deep Ulceration Pseudo polyps

23. 4.Sigmoidscopy
• Indications:
• Initially used as an alternative to colonoscopy in ASUC (acute severe ulcerative colitis). Findings are
similar to colonoscopy findings.
• EGD:
• Recommended for patients with upper gastrointestinal symptoms to rule out Crohn disease. Patients with
severe ulcerative colitis have a high risk for colonic perforation; therefore, caution should be used when
performing biopsies.
5.Imaging Study
Not routinely recommended, but done as an adjunct to endoscopy; especially for the detection of
complications or if endoscopy is not available.
• AbdominalX-Ray:
• Typically normal in mild-to-moderate disease, Loss of colonic haustra.May show signs of complications:
1. Toxic Megacolon: massive distention Ulceration: segmental dilation with
2.irregular edges outlined by gas
3. Perforation:Pneumoperitoneum
Toxic Megacolon
Lead pipe appearance
Loss of colonic haustration
Pneumoperitoneum

24. 5.Imaging Study
CT or MRI Abdomen:
• Indications:
• Abdominal symptoms that can't be explained by disease activity seen on endoscopy
• Proximal disease evaluation
• Complications
• Evaluation to rule out Crohn’s Disease
• Finding:
• Loss of haustra (Pouches or Sacculations)
• Increased bowel wall thickness
• Mural hyperenhancement (Active Inflammation)
• Signs of complications
• Barium Enema Radiography:
• Indications:Could be used if colonoscopy is contraindicated
• Findings: •Granular appearance of the mucosa •Deep ulcerations •Loss of haustra; "lead pipe" sign*Pseudo
polyps that appear as a filling defect
• The role of barium enemas is extremely limited and we rarely use them nowadays since we have better
modalities; it is an absolute contraindication in perforation and obstruction.
Granular Appearnce
Lead Pipe Sign
Due to loss of normal smooth
mucosal pattern

25. 6.Histopathological Findings
• Early stages:
• Granulocyte infiltration; limited to the mucosa and submucosa
• Crypt Abscesses; an infiltration of neutrophils into the lumen of intestinal crypts due to a
breakdown of the crypt epithelium.
• Chronic stages:
•Lymphocyte infiltration •Mucosal atrophy •Altered crypt architecture:branching of crypts,
and irregularities in size and shape Epithelial dysplasia.
• Crypt abscess:
• This crypt shows many segmented granulocytes in the lumen and is known as a “crypt
abscess.” This term can easily be misleading because purulent inflammation in a preformed
cavity (e.g a crypt) is usually called empyema
• In ulcerative colitis, the extent of intestinal inflammation is limited to the mucosa and
submucosa. In contrast, Crohn’s disease shows a transmural pattern of intestinal
involvement.Non caseating granulomas all seen in Crohn’s disease but are not a feature of
ulcelative colitis.

26. Patients with severe disease should be admitted to hospital for intensive treatment. This occurs in
5-10% of patients.
• Complications of UC:
• Acute:
Toxic dilatation ,Perforation,Haemorrhage
• Chronic:
Cancer ,Extra-alimentary manifestations: skin lesions, eye problems, liver disease
• Perforation:
Colonic perforation in UC is a grave complication with a mortality rate of 50% or more. Steroids may
mask the physical signs.
Perforation can sometimes occur without toxic dilatation. Generally, patients with severe attacks should
be managed so that they do not develop these complications.
• The cancer risk:
In colitis, although this is an important complication, the overall risk is only about 3.5%. It is much less
in early cases but increases with duration of disease. At 10 years, the risk of cancer in all patients.

28. The FDA approved Subcutaneous administration of Vedolizumab, following induction therapy of the IV drug
in 2 doses, as maintenance therapy on adults with moderately severe active UC.
October 13, 2023: FDA has approved Etrasimod (Velsipity, Pfizer) for treating moderate to severe active
ulcerative colitis (UC) in adults.
The approved recommended dose is 2 mg once daily orally. Etrasimod is an oral sphingosine-1-phosphate
(S1P) receptor agonist.

29. *To induce remission:
crohn’s -> oral prednisolone or Budesonide
UC->mesalamine (5-ASA), in severe cases: IV hydrocortisone
*To maintain remission:
crohn’s -> oral azathioprine or mercaptopurine
UC -> oral mesalamine, if no response: oral azathioprine or mercaptopurine

30. • Indications:
1.Severe or fulminating disease failing to respond to medical therapy.
2. Chronic disease with anaemia, frequent stools, urgency and tenesmus.
3. Steroid-dependent disease - here, the disease is not severe but remission
cannot be maintained without substantial doses of steroids.
4.The risk of neoplastic change: patients who have severe dysplasia on review
colonoscopy.
5.Extraintestinal manifestations; rarely, severe hemorrhage or stenosis causing
obstruction.
a simple reversed
‘J’
‘S’ pouch
‘W’ pouch

31. • UC is surgically curable. However, surgical resection is not curative in CD, with recurrence
being the normal.
• Consider early consultation with a surgeon in the setting of severe colitis or bowel obstruction
and in cases of suspected toxic megacolon (in order to inform the patient or assist them for
possible proctocolectomy).
• Surgical intervention of IBD includes the following:
• restorative proctocolectomy with an ileal pouch-anal anastomosis (IPAA or J pouch)
• >Resection of the entire colon and rectal mucosa while sparing the anal sphincters.
• Loops of small intestine (serving as the pouch) are used to create an artificial rectum, resulting
in a continence-conserving connection between the ileum and anus.
• Indications for urgent surgery:
• Patients who have ulcerative colitis may develop acute fulminant colitis characterized by more
than 10 stools per day; continuous bleeding; abdominal pain; distension; and acute, severe toxic
symptoms including fever and anorexia [4]. Patients with acute fulminant colitis require urgent
surgery (ie, during the same hospital admission) if they fail medical therapy. ‘W’ pouch
a simple reversed
‘J’
‘S’ pouch

32. Ileostomy with ileostomy bag
Complete Resection
Proctocolectomy with ileoanal anastmosis

33. • Complications of surgery:
• Early (≤ 30 days): anastomotic leak, pelvic sepsis
• Late: bowel stricture, bowel obstruction, fertility issues,
sexual dysfunction (Due to adhesions in pelvis/ hypo gastric
plexus and pelvic splanchnic damage)
• Most common late postoperative issue: pouchitis (increased
stool frequency, malaise, and possibly incontinence caused by
bacterial overgrowth) ‘W’ pouch
a simple reversed
‘J’
‘S’ pouch

34. This guideline covers using colonoscopy to check for signs of bowel cancer in people aged 18
and over with ulcerative colitis or Crohn’s disease (types of inflammatory bowel disease) or adenomas (also
known as polyps). It aims to prevent cancer and prolong life by offering advice on identifying early bowel
cancer in adults most at risk.
1.1.1
Offer colonoscopic surveillance to people with inflammatory bowel disease (IBD) whose symptoms started 10
years ago and who have: ulcerative colitis (but not proctitis alone) or Crohn's colitis involving more than one
segment of colon.
1.1.2
Offer a baseline colonoscopy with chromoscopy and targeted biopsy of any abnormal areas to people with IBD
who are being considered for colonoscopic surveillance to determine their risk of developing colorectal cancer
NICE guidelines Colorectal cancer prevention:
colonoscopic surveillance in adults with ulcerative
colitis, Crohn's disease or adenomas
Colon Cancer
Screening

35. 1.1.3
Offer colonoscopic surveillance to people with IBD as defined in recommendation 1.1.1 based
on their risk of developing colorectal cancer (see box 1), determined at the last complete
colonoscopy:
Low risk: offer colonoscopy at 5 years.
Intermediate risk: offer colonoscopy at 3 years.
High risk: offer colonoscopy at 1 year.
1.1.4
For people with IBD who have been offered colonoscopic surveillance, continue to use
colonoscopy with chromoscopy as the method of surveillance.
1.1.5
Offer a repeat colonoscopy with chromoscopy if any colonoscopy is incomplete. Consider
whether a more experienced colonoscopist is needed.
NICE guidelines Colorectal cancer prevention:
colonoscopic surveillance in adults with ulcerative
colitis, Crohn's disease or adenomas
Colon Cancer
Screening

36. Crohn's disease is a chronic inflammatory condition of the gastrointestinal (GI) tract for which the
cause is unknown. A key characteristic of the disease is its transmural nature, meaning the
inflammation penetrates the full thickness of the intestinal wall.
Location and Characteristics
It can affect any part of the alimentary tract, from the mouth to the anus, and is often characterized by
"skip lesions," where segments of inflamed bowel are separated by areas of healthy tissue.

37. While it can manifest anywhere, the most common sites are the small intestine and colon:
• 55% of cases involve both the small and large intestines.
• 30% of cases are limited to the small intestine.
• 15% of cases affect only the large intestine.
Affected Populations and Risk Factors
Crohn's disease primarily affects young adults, typically in their second and third decades of life.
Several risk factors and associations have been identified:
• Strong familial association.
• More common in smokers.
• Higher prevalence among urban dwellers.
• Associated with females taking oral contraceptive pills (OCPs).

38. • MC symptom is intermittent & colicky abdominal pain, most commonly noted in lower abdomen
• Diarrhea is the next most frequent symptom and is present, at least intermittently, in about 85% of patients.
• In contrast to ulcerative colitis, patients with Crohn's disease typically have fewer bowel movements, & stools
rarely contain mucus, pus, or blood.
• Main intestinal complications of Crohn's disease include obstruction & perforation
• Fistulas occur between the sites of perforation & adjacent organs, usually at the site of a previous laparotomy.
• Long-standing Crohn's disease predisposes to cancer of small intestine & colon.
• Perianal disease (fissure, fistula, stricture, or abscess) is common
• In Crohn's disease, ileum is MC site of fistula (enterocutaneous & enterovesical), MC site of perforation and
MC site of carcinoma Crohn's disease Inflammation.

39. Skin: Erythema multiform, Erythema Nodosum, Pyoderma Gangrenosum
Eyes: Iritis, Uveitis, Conjunctivitis
Blood: Anemia, Thrombocytosis, Arterial thrombosis, Phlebothrombosis
Joints: Peripheral Arthritis, Ankylosing Spondylitis
Liver: Sclerosing Cholangitis, Non-Specific triaditis
Kidney: Nephrotic Syndrome
Pancreas: Pancreatitis
General: Amyloidosis

40. -Diagnosis of Crohn’s: CT Enteroclysis
-Serology: Anti-Sccharomyces cerevisiae (ASCAQ)
autoantibodies have specificity of 92% for Crohn’s disease

41. -Small bowel evaluation is an essential part of the initial diagnostic
workup of CD. Almost 1/3 of patients with CD have only small bowel
disease and this may not be visible on ileocolonoscopy.
-Indications:
1.All patients with suspected CD.
2.Assesses the distribution and the severity of the disease.
3.Aids to differentiate CD from UC.
4.Monitors disease activity and remission.
5.Can be used therapeutically in cases of stricture dilatation
Cobble
Stone
appearance

42. the bowel wall is thickened with a chronic inflammatory
infiltrate throughout all layers, presence of granuloma.
Characteristic endoscopic features & evidence of
chronic intestinal inflammation on histology are the
most important factors to establish a diagnosis of CD.
Noncaseating granulomas
• Giant cells
• Distinct lymphoid aggregates of the lamina propria
• Creeping fat
• Hypertrophic lymph nodes

43. - Radiological Findings of CD:
• Aphthous ulceration: Earliest radiographic findings in enteroclysis
• Deep ulcers
• Cobble stone appearance
• Fat halo sign on CT: Low attenuation of submucosal fat around bowel
• Creeping fat sign
• Hose-pipe like appearance: Long stricture extending up to ileocecal
valve with thickened wall; corresponds to "String sign of Kantor“
• Raspberry thorn or rosethorn appearance: Linear fissures throughout
the bowel
• Comb sign: Vascular jejunization of ileum Fat halo sign
String sign of Kantor
Apthous Ulceration

44. Cross-sectional imaging (MRI and CT) is preferred as it permits
evaluation of the entire gastrointestinal tract, including the small
bowel, can identify complications; like bowel obstruction, fistulas,
and abscesses, and can assess for differential diagnoses of CD.
• Indications:
• A. Suspected CD.
• B. Localization of inflammation and assessment of severity
• C. Evaluation of suspected acute flare ups or complications
• D. Serial imaging to assess response to therapy
-Findings of CTE/ MRE
• A. Edematous thickining of the wall
• B. Mucosal enhancement
• C. Creeping fat
• D.Can also identify complications andextraintestinal
manifestations; Strictires,fistulas, and abscesses urolithiasis
Cholilithiasis
• E. Can follow response to therapy; healing of ulcers
Terminal Ileitis (Inflammed mucosa)

45. • Fistulizing CD:
• It occurs in one third of patients and typically involves the perianal region
Internal fistulas may involve the bladder, the vagina, and/or another portion of
the intestine High risk of recurrence.
• Colorectal cancer
• Short bowel syndrome after surgery
• Stenosis and strictures
• Perforation
• Impaired bile acid reabsorption
• Abscess formation

46. Pharmacotherapy
1. Induction phase
✓ Used to manage acute flares.
✓ Agents that have a rapid onset of action (e.g., corticosteroids, biologics) are used.
2. Maintenance phase
✓ Used to maintain remission, typically in patients with moderate or severe CD and those at
high risk of progression of CD.
✓ Biologics and immunomodulators are the principal agents of maintenance therapy.

47. • Symptoms do not accurately correlate with disease activity. Use objective markers of
disease severity (e.g., biomarkers, imaging, endoscopy) to assess the severity of CD, guide
treatment, and verify remission.
➢ Corticosteroids
✓ Primarily used to induce remission.
✓ Agents used (depending on severity of CD): Controlled ileal release budesonide, Oral
prednisolone, IV methylprednisolone.

48. ➢Immunomodulators
✓ Primarily used to induce remission and can be used as a steroid-sparing regimen to induce
remission.
✓ Thiopurine analogs (azathioprine, 6- mercaptopurine), methotrexate.
✓ Immunomodulators should not be used as a monotherapy for induction of remission as the
onset of clinical effect is too slow.
➢ Biologics
✓ Anti-TNF-α antibodies: e.g., adalimumab, infliximab, certolizumab
✓ Increasingly used as a primary agent to induce remission.
✓ Also used to maintain remission and manage CD refractory to immunomodulators

49. As of June 2023:
✓ Upadacitinib induction and maintenance treatment Used in patients with moderate to severe Crohn’s
have shown increased remission and endoscopic response.
• 5-aminosalicylic acid derivative
✓ sulfasalazine (mesalamine is not routinely recommended).
✓ May be considered to induce remission of mild to moderate colonic or ileocolonic CD.
✓ Not effective in isolated small bowel disease.
• Immunomodulators and biologics are the mainstays of maintenance therapy but can also be
used to induce remission.
• Do not use corticosteroids for maintenance therapy in CD. They do not promote
mucosal healing and potentially increase the risk of complications

50. In Crohn’s disease, it is impossible to remove all the at-risk intestine; therefore, surgical
therapy is reserve for complications of the disease.
• Most intra-abdominal abscesses can be drained percutaneously with the use of CT scan
guidance
• Chronic fibrosis may result in strictures in any part of the gastrointestinal tract. Strictures
may be treated with resection or stricturoplasty. Distal ileal strictures are sometimes
amenable to colonoscopic balloon dilatation.
Procedures in CD:
• ✓ Surgical drainage of abscess.
• ✓ Laparoscopic or open resection of the diseased bowel segment (small bowel resection,
segmental colectomy).
• ✓ Strictureplasty (bowel-sparing technique)
Stricturoplasty

51. • Anal and Perianal Crohn’s Disease:
• Anal and perianal manifestations of Crohn’s disease are very common
and occur in 35% of all patients with Crohn’s disease, The most common
perianal lesions in Crohn’s disease are skin tags that are minimally
symptomatic, Fissures are also common. Typically, a fissure from
Crohn’s disease is particularly deep or broad and perhaps better
described as an anal ulcer, Perianal abscess and fistulas are common
and can be particularly challenging
Draining Seton

52. Crohn’s Disease
Ulcerative Colitis

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