IBD SEVERITY, SYMPTOMS, MEDICAL AND SURGICAL MANAGEMENT

1. Inflammatory bowel
disease (IBD)
• PRESENTOR:- Dr. Rohan Kumar
(DrNB Resident
Fortis Hospital Jaipur)

2. Inflammatory bowel disease
(IBD)
• Crohn disease
• Ulcerative colitis
• Inflammatory bowel disease (IBD) of
undetermined type.

3. Introduction & History.
Ulcerative Colitis
• Ulcerative colitis (UC) is
idiopatic inflammatory
disease potentially affecting
the entire large bowel (colon
and rectum).
• The inflammation is
confined to mucosa.
• UC can go into remission
and recur.
• extraintestinal
manifestations.
Crohn's Disease
• Is an idiopathic, chronic
regional enteritis that most
commonly affects the
terminal ileum but has the
potential to affect any part
of the gastrointestinal tract
from mouth to anus.
• Periods of symptomatic
relapse and remission.

5. Aetiology
• Idiopathic
• Congenital/ Genetic
• Nutritional Deficiency/excess
• Traumatic
• Infections /Infestation
• Autoimmune
• Neoplastic (Benign/Malignant)
• Degenerative
• Iatrogenic
• Psychosomatic

6. Aetiology
Ulcerative Colitis
• Idiopathic
• genetic factors,
• immune system reactions,
environmental factors,
• NSAID) use,
• low levels of antioxidants,
• psychological stress factors,
• consumption of milk
products
Crohn's Disease
• Idiopathic
• Risk factors-
– family history
– Smoking
– oral contraceptives
– Diet
– ethnicity.
• aberrant mucosal immune
responses
• intestinal epithelial dysfunction
• defects of host interactions with
intestinal microbes

7. Aetiology
Ulcerative Colitis
• Certain types of food
composition
• oral contraceptives
• protective effect of tobacco
seen in ulcerative colitis
• Disturbed intestinal flora.
Crohn's Disease
• polygenic basis- clear
genetic predisposition-
– First-degree relatives have a
13-18% increase in incidence.
– concordance rates of 50% in
monozygotic twins
• hygiene hypothesis

8. Pathology
Ulcerative Colitis
• ulcerative colitis
characteristically involves
the large bowel.
• Starts in rectum and
proceeds proximally upto
terminal ileum (backwash
ileitis).
• No skip lesions.
• Ulcerative colitis is a
lifelong illness.
• Mucosal disease.
Crohn's Disease
• Can affect any part of GI
tract.
• skip lesions +nt.
• transmural (full-thickness)
inflammation, involvement
of discontinuous segments
of the intestine (skip areas),
and, in a proportion of
cases, by non-necrotizing
granulomas composed of
epithelioid histiocytes.

9. Pathology
Ulcerative Colitis
• Rectum 95%
• Terminal ileum 10%
• extraintestinal
manifestations.
Crohn's Disease
• limited to the small intestine in
approximately 40-50% of cases, whereas
another 30-40% of cases involve both the
small intestine and the colon. The
remaining cases involve only the colon.
• Aphthoid ulcers in the mouth and anal
fissures, skin tags, and abscesses are
frequently seen,
• cobblestoned" appearance of the
mucosa,.

10. Pathology
•
Crohn's Disease
• Mucosal pseudopolyps (inflammatory pseudopolyps) of the
terminal ileum in a patient with Crohn disease. These polyps
can reach giant proportions, up to 5 cm in maximum
dimension, and are often seen on the proximal side of an
ulcerated stricture (a "sentinel" inflammatory polyp).
• Deep ulcers, vertical fissures, and fistula tracts are commonly
seen. In particular, vertical fissuring can be especially helpful
in the distinction between Crohn disease and ulcerative
colitis. In addition, small, pinpoint hemorrhages and shallow
ulcers with white bases (aphthoid ulcers) are frequent along the
periphery of the involved segments of mucosa.

11. Gross
Psedopolyps UC
Creeping fat in Crohn
disease

12. Microscopic Pathology
Ulcerative Colitis
• acute and chronic
inflammatory infiltrate of
the lamina propria, crypt
branching, and villous
atrophy are present in
ulcerative colitis.
• inflammation of the crypts
of Lieberkühn and
abscesses.
• granulomas are also seen in
tuberculosis, yersiniosis,
and can even be seen in
ulcerative colitis
Crohn's Disease
• Areas of chronic inflammation
• Skip lesions comprising focal,
patchy erosions or ulcers, vertical
fissures, and fistulas
• Transmural inflammation
• Granulomas
• Submucosal fibrosis and
neuromuscular hyperplasia of
submucosa

13. Microscopic Pathology
Ulcerative Colitis
• The ulcerated areas are soon
covered by granulation
tissue
• inflammatory polyps or
pseudopolyps.
• Excessive fibrosis is not a
feature of the disease
Crohn's Disease
• Microscopically, the
inflammation in ulcerative
colitis and Crohn disease
can appear similar, but
noncaseating granulomas
are present only in Crohn
disease
•

14. Grading
Ulcerative Colitis
• Mild: Bleeding per rectum,
fewer than four bowel
motions per day
• Moderate: Bleeding per
rectum, more than four
bowel motions per day
• Severe: Bleeding per
rectum, more than four
bowel motions per day, and
a systemic illness with
hypoalbuminemia (< 30
g/L)

15. Clinical Features
• Demography
• Symptoms
• Signs
• Prognosis
• Complications

16. Demography
Ulcerative Colitis
• The annual incidence is
10.4-12 cases per 100,000
people, and the prevalence
rate is 35-100 cases per
100,000 people.
• Three times more common
than Crohn disease
• white individuals living in
Western industrialized
nations
• 2-4 times higher in
Ashkenazi Jews.
Crohn's Disease
• Incidence in Europe is
about 5.6 per 100,000
inhabitants
• white individuals living in
Western industrialized
nations
• European (Ashkenazi)
Jewish heritage have a 2-4
times higher prevalence than
members of the general
population.

17. Demography
Ulcerative Colitis
• Bimodal pattern, with a
peak at 15-25 years and a
smaller one at 55-65 years,
although the disease can
occur in people of any age.
• slightly more common in
women than in men.
Crohn's Disease
• The incidence and
prevalence of the disease
(especially colonic CD) are
steadily increasing
• peaks of incidence, one in
early adulthood (range,
teens–20s) and another in
the 60-70 year age group.
• slight female predilection
for the disease.

18. Geographical distribution
Ulcerative Colitis
• Ulcerative colitis is more
common in the Western and
Northern hemispheres; the
incidence is low in Asia and
the Far East.
Crohn's Disease
• Highest in North America
• Incidence in Asia0.5 to 4.2
cases per 100,000 persons
• The lowest rates in South
Africa (0.3-2.6 cases per
100,000 persons) and Latin
America (0-0.03 cases per
100,000 persons). .

19. Demography
• As new regions assume Western cultural
practices, an increased prevalence of
ulcerative colitis is usually found
approximately 1 decade before the observed
increase in Crohn disease.

20. Symptoms
Ulcerative Colitis
• Rectal bleeding
• Frequent stools
• Mucous discharge from the
rectum
• Tenesmus (occasionally)
• Lower abdominal pain and
severe dehydration from
purulent rectal discharge (in
severe cases, especially in
the elderly).
Crohn's Disease
• crampy abdominal pain
• Prolonged nonbloody
diarrhea ,
• which may be complicated
by intestinal fistulas,
particularly after surgical
intervention,
• intramural abscesses
• bowel obstruction.
• diarrhea may contain blood,
mucus, and pus

21. Symptoms
Ulcerative Colitis
In some cases, UC has a
fulminant course marked by
the following:
• Severe diarrhea and cramps
• Fever
• Leukocytosis
• Abdominal distention
Crohn's Disease
• weight loss and possible
malabsorption syndromes
• Low-grade fever and feeling
of general fatigue and
malaise
• Nausea, vomiting
• In pediatric patients,
unexplained growth failure
in addition

22. Types of UC and symptoms:-
• Proctitis: Rectal bleeding & mucous discharge some
times with tenesmus ,no constitutional symptoms.
• Proctosigmoiditis: bloody diarrhea with mucous Small
no. of patients with v. active limited disease develop
fever, lethargy & abdominal discomfort.
• Extensive colitis: bloody diarrhea with passage of
mucous, in sever cases anorexia , nausea ,weight loss
& abdominal pain ,patient is toxic with fever &
tachycardia & signs of peritoneal inflammation.

23. Symptoms
• colonic Crohn disease may be clinically
indistinguishable from ulcerative colitis,
with symptoms of bloody mucopurulent
diarrhea, cramping abdominal pain, and
urgency to defecate.

24. Symptoms:extraGI manifestations
• Unrelated to IBD activity:-
ŸAutoimmune hepatitis
ŸPrimary Sclerosing Cholangitis &
Cholangiocarcinoma
ŸGallstones.
ŸAmyloidosis & oxalate calculi.
ŸSacroiliitis/ankylosing spondylitis.
ŸMetabolic bone disease.

25. Occur during the active phase of IBD:
ŸConjunctivitis.
ŸEpiscleritis.
ŸMouth ulcers.
ŸFatty liver.
ŸLiver abscess / Portal pyaemia.
ŸMesenteric or portal vein thrombosis.
ŸVenous thrombosis.
ŸArthralgia of large joints.
ŸErythema nodosum.
ŸPyoderma gangrenosum

26. Signs
Ulcerative Colitis
• normal in mild disease
• mild tenderness in the lower
left abdominal quadrant
Severe cases-
• Fever
• Tachycardia
• Significant abdominal
tenderness
• Weight loss
Crohn's Disease
• Chronic intermittent fever is a
common presenting sign.
• Abdominal findings may vary
from normal to those of an
acute abdomen
• Fullness or a discrete mass
may be appreciated, typically
in the right lower quadrant of
the abdomen
• perianal region can reveal skin
tags, fistulae, ulcers, abscesses,
and scarring

27. Prognosis
• Both are lifelong diseases.
• For both conditions, the overall mortality has
decreased steadily, and currently is less than 5%.
• Both follow a more severe course in children and
adolescents
• Both are at increased risk for the later
development of cancer.
• most patients with these diseases are able to
maintain normal occupations and enjoy reasonably
stable social and economic situations.

28. Prognosis
Ulcerative Colitis
• Ulcerative colitis is curable
with proctocolectomy and
ileostomy.
• The excess risk is limited to
colorectal cancer
Crohn's Disease
• The recurrence rate after
proctocolectomy and
ileostomy for Crohn's
disease of the colon also is
considerable,
• increased cancer rates for
both the small and large
bowel.

29. Complications
Ulcerative Colitis
• Colonic perforation.
• Carcinoma.
• Benign strictures.
Crohn's Disease
• Intestinal fistulas,
particularly after surgical
intervention,
• Strictures
• intramural abscesses
• bowel obstruction.
• colonic adenocarcinoma.

30. Investigations
• Laboratory Studies
– Routine
– Special
• Imaging Studies
• Tissue diagnosis
– Cytology
• FNAC
– Histology

31. Diagnostic Studies
Imaging Studies
• X-Ray
• USG
• CT
• Angiography
• MRI
• Endoscopy
• Nuclear scan

32. Investigations
Ulcerative Colitis
• Serologic markers (eg,
antineutrophil cytoplasmic
antibodies [ANCA], anti–
Saccharomyces
cerevisiae antibodies [ASCA])
• Complete blood cell (CBC)
count
• Comprehensive metabolic
panel
• Inflammation markers (eg,
erythrocyte sedimentation rate
[ESR], C-reactive protein
[CRP])
• Stool assays
Crohn's Disease
• C-reactive protein (CRP)
and erythrocyte
sedimentation rate (ESR

33. Imaging Studies
Ulcerative Colitis
1. endoscopy and biopsy-
Abnormal erythematous mucosa,
with or without ulceration,
extending from the rectum to a
part or all of the colon
2. Uniform inflammation, without
intervening areas of normal
mucosa (skip lesions tend to
characterize Crohn disease)
3. Contact bleeding may also be
observed, with mucus identified
in the lumen of the bowel
Crohn's Disease
• Upper gastrointestinal (GI)
endoscopy and histologic
examination
• Colonoscopy
• Capsule endoscopy
• CT enterography or
magnetic resonance (MR)
enterography

34. Colonscopy
Mucosa hyperemic loss of the normal vascular pattern
Normal colon Ulcerative Colitis

35. Colonscopy
Ulcer in Crohn diseasee

36. Imaging Studies
Ulcerative Colitis
• Plain abdominal radiography
• Double-contrast barium enema
examination
• Cross-sectional imaging studies
(eg, ultrasonography, magnetic
resonance imaging, computed
tomography scanning)
• Radionuclide studies
• Angiography
Crohn's Disease

37. UC: Barium enema
strictures in the transverse and
descending colon Mucosal ulcers

38. Crohn Disease
Cobblestone appearance
string sign, with narrowing
and stricturing.

39. Plain abdominal radiography
Ulcerative Colitis
• pseudopolyposis
• deep ulcers
• The colon may appear shortened
• loss of colonic haustra
• Toxic megacolon -massive
colonic dilatation associated with
an abnormal mucosal contour.
• Colonic perforation
• Thumbprinting
• long stricture/spasm of the
ascending colon/cecum
• Increased postrectal space
Crohn's Disease

40. Barium enema findings
Ulcerative Colitis
• Colon may appear narrow , short and
loose.
• granular mucosa.
• Pseudopolyposis
• mucosal ulcers
– collar-button ulcers
– double-tracking ulcers
• burnt-out ulcerative colitis
• Similar radiographic signs may be seen
in cases of infective diarrhea, Crohn
disease, ischemic colitis, drug-induced
colitis, and amebic colitis
Crohn's Disease

41. Computed Tomography
Ulcerative Colitis
• Difuse , circumferential,
symmetrical wall thickening
with fold enlargement.
• Submucosal fat deposition
• target sign
• The halo sign typically
occurs in ulcerative colitis.
Crohn's Disease
• CT has become the
procedure of choice not only
for helping diagnose Crohn
disease but also for
managing abscesses.

42. Computed Tomography
Ulcerative Colitis
•
Crohn's Disease
• wall thickening is eccentric
and segmental thickening
with homogeneous
attenuation, fistula and
abscess formation,
pseudodiverticula and
mesenteric abnormalities.
• target sign
• string sign of Kantor on
computed tomography

43. Differential Diagnosis
Ulcerative Colitis
• Crohn's Disease
• cathartic colon.
• collagenous colitis
• lymphocytic colitis
• infectious colitis
• ischemic colitis
Crohn's Disease
• Ulcerative colitis
• Acute appenicitis
• Fistula in ano
• Infectious disease
– yersiniosis and tuberculosis
• Drugs-induced colitis
– NSAID, methyldopa, gold, and
penicillins
• Conditions with small bowel fissuring
ulcers-Behçet disease, malignant
lymphoma, and "ulcerative jejunitis
• Diverticular disease
• Ischemic changes

44. Differential Diagnosis
Ulcerative Colitis
•
Crohn's Disease
• About 7% of large bowel
strictures in patients with
long-standing Crohn disease
are malignant; these should
be surveyed with multiple
biopsies and cytologic
brushing for neoplastic
transformation.

45. Management
Ulcerative Colitis
•
Crohn's Disease
General goals of treatment:
• To achieve the best possible clinical, laboratory, and histologic
control of the inflammatory disease with the least adverse
effects from medication
• To permit the patient to function as normally as possible
• In children, to promote growth with adequate nutrition

46. Drugs used in treatment of IBDs
Aminosalysilates:(( Mesalasine, Olsalazine , Balsalazide))
ŸModulate cytokine release from mucosa
ŸDelivered to the colon by:
1-PH-dependent ( Asacol )
2-Time-dependent ( Pentasa )
3-Bacterial breakdown by colonic bacteria from carrier
molecule ( Sulfasalazine, Olsalazine,Balsalized ).

47. Corticosteroids
ŸTopical corticosteroids can be used as an
alternative to 5-ASA in ulcerative
proctitis or distal UC.
ŸOral prednisone or prednisolone is used
for moderately severe UC or CD, in
doses ranging up to 60 mg per day.
ŸIV is warranted for patients who are
sufficiently ill to require hospitalization;
the majority will have a response within
7 to 10 days.

48. ŸNo proven maintenance benefit in the
treatment of either UC or CD.
ŸMany and serious side effects.
ŸBudesonide: less side effects, its use is
limited to patients with distal ileal and
right-sided colonic disease

50. Methotrexate:-
Anti-inflammatory
Side Effect:
Intolerance in 10-18%.
nausea
stomatitis
hepatotoxicity
pneumonitis.

51. Anti-TNF antibodies (Infliximab &
adalimumab)
Given as I.V infusion 4-8 weekly.
Induce apoptosis of inflammatory cells
Uses: Moderately-severely active CD
especially fistulating & in sever active UC.
Anaphylactic reaction after multiple
infusions.
Contraindicated in presence of infection ,
reactivation of TB.
Increased risk of infection & malignancy.

52. Ciclosporin
Suppression of T cell expansion.
As rescue therapy to prevent surgery in UC
responding poorly to corticosteroid.
No value in CD.
ŸSide Effects:-
Nephrotoxicity.
Neurotoxicity.
Hirsutism.

53. Antibacterial.Useful in perianal
CD.Side Effects: Peripheral
neuropathy in long term
metronidazole.
Antidiarrheal agents:( Codeine
phosphate , Loperamide , lomotil)
Avoided in moderately or severe
active UC may precipitate colonic
dilatation.

54. Non Operative Therapy
Ulcerative Colitis
• Mild disease confined to the
rectum: Topical mesalamine via
suppository (preferred) or
budesonide rectal foam
• Left-side colonic disease:
Mesalazine suppository and oral
aminosalicylate (oral mesalamine
is preferred to oral sulfasalazine)
• Systemic steroids, when disease
does not quickly respond to
aminosalicylates
• Oral budesonide
• After remission, long-term
maintenance therapy (eg, once-
daily mesalazine)
Crohn's Disease
• Sulfasalazine is useful
mainly in colonic disease
• mesalamine,in small bowel
Crohn disease
• Corticosteroids
• Budesonide
• immunosuppressants
azathioprine
– Methotrexate

55. Non Operative Therapy
Ulcerative Colitis
Medical treatment of acute,
severe UC
• Hospitalization
• Intravenous high-dose
corticosteroids
• Alternative induction
medications: Cyclosporine,
tacrolimus, infliximab,
adalimumab, golimumab
Crohn's Disease
• Anti–tumor necrosis factor (anti-
TNF) agents (eg, infliximab,
adalimumab, certolizumab pegol,
and natalizumab)
• Antibiotics
• Nutritional Therapy
• Partial small bowel obstruction or
intra-abdominal abscess may
sometimes be treated
conservatively
• granulocyte monocyte apheresis*

56. • DEFINITIONS - The following definitions of
ulcerative colitis have been proposed:
• Steroid-responsive disease - Clinical response to high-dose
glucocorticoids (prednisone 40 to 60 mg/day or equivalent) within
30 days for oral therapy or 7 to 10 days for intravenous therapy.
• Steroid-dependent disease - Ulcerative colitis is defined as steroid-
dependent if glucocorticoids cannot be tapered to less than 10
mg/day within three months of starting steroids, without recurrent
disease, or if relapse occurs within three months of stopping
glucocorticoids.
• Steroid-refractory disease - Lack of a meaningful clinical response
to glucocorticoids up to doses of prednisone 40 to 60 mg/day (or
equivalent) within 30 days for oral therapy or 7 to 10 days for
intravenous therapy.

57. Operative Therapy
Ulcerative Colitis
• Indications for urgent
surgery include the
following:
1. Toxic megacolon refractory
to medical management
2. Fulminant attack refractory
to medical management
3. Uncontrolled colonic
bleeding
Crohn's Disease
• If medical therapy for active
Crohn disease fails, surgical
resection of the inflamed
bowel, with restoration of
continuity,
• Urgent surgery may be
required in rare cases of
sustained or recurrent
hemorrhage, perforation,
abscess, and toxic
megacolon.
• Stem cell transplantation

58. Operative Therapy
Ulcerative Colitis
• Indications for elective
surgery -
1. Long-term steroid
dependence
2. Dysplasia or
adenocarcinoma found on
screening biopsy
3. Disease being present for
7-10 years
Crohn's Disease

59. Operative Therapy
Ulcerative Colitis
Surgical options -
• Total colectomy
(panproctocolectomy) and
ileostomy
• Total colectomy Ileoanal
pouch reconstruction or
ileorectal anastomosis
• In an emergency, subtotal
colectomy with end-
ileostomy
Crohn's Disease
• Resection is generally
performed when strictures
cannot be appropriately
surveyed, if neoplastic
changes are observed, or
obstruction is persistent.

60. Summary
Ulcerative Colitis
• UC is generally limited to the
colon, apart from minimal distal
"back-wash" ileitis;
• ulcerative colitis usually involves
only the mucosal layer of the
bowel, and, in some cases,
superficial submucosa, unless
there is fulminant colitis
• may also manifest cecal or
appendiceal patches of
involvement that can simulate the
"skip" lesions of CD
•
Crohn's Disease
• presence of skip lesions
• Granulomas
• transmural inflammation
• Fissures,
• involvement of any part of
the gastrointestinal tract
• aphthous ulceration is
considered unique to Crohn
disease.

61. Summary
Ulcerative Colitis
• risk of neoplastic
transformation, the risk is
higher
• continuous process, worse
distally, with increased span
of involvement distal to
proximal, as the disease
progresses
• Surgical intervention is
better tolerated in UC
Crohn's Disease
• risk of neoplastic
transformation,is lower.
• Higher risk of recurrence
and ulceration, fissure, and
fistula formation at sites of
reanastomosis or stoma
formation.
• creeping fat
• aphthous ulceration is
considered unique to Crohn
disease.

62. Summary
Ulcerative Colitis Crohn Disease
Only colon involved Panintestinal
Continuous inflammation
extending proximally from
rectum
Skip-lesions with intervening normal
mucosa
Inflammation in mucosa and
submucosa only
Transmural inflammation
Perianal lesions
No granulomas Noncaseating granulomas
Perinuclear ANCA (pANCA)
positive
ASCA positive
Bleeding (common) Bleeding (uncommon)
Fistulae (rare) Fistulae (common)

63. Grey Areas
• CD can occasionally affect only the distal colon.
• granulomas may be present in UC (although
typically adjacent to ruptured crypts, whereas CD
granulomas have no necessary spatial relationship
to injured crypts).
• regional involvement/skip lesions of CD may not
be apparent endoscopically or in small mucosal
biopsies.
• approximately 15% may remain indeterminate-
”indeterminate colitis”

64. Thank you.