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![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](https://image.slidesharecdn.com/inflammatoryboweldiseaseclinicalrevised-240510164851-433585aa/75/Inflammatory-bowel-disease-clinical-revised-pptx-32-2048.jpg)
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Inflammatory bowel disease clinical revised.pptx
- 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. UlcerativeColitis • 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 • Certaintypes 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 • ulcerativecolitis 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 • Rectum95% • 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 • Mucosalpseudopolyps (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 fatin 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 • Theannual 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 • Bimodalpattern, 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 newregions 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 • Rectalbleeding • 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 somecases, 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 UCand 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 Crohndisease may be clinically indistinguishable from ulcerative colitis, with symptoms of bloody mucopurulent diarrhea, cramping abdominal pain, and urgency to defecate.
- 24. Symptoms:extraGI manifestations • Unrelatedto IBD activity:- ŸAutoimmune hepatitis ŸPrimary Sclerosing Cholangitis & Cholangiocarcinoma ŸGallstones. ŸAmyloidosis & oxalate calculi. ŸSacroiliitis/ankylosing spondylitis. ŸMetabolic bone disease.
- 25. Occur during theactive 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 • normalin 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 arelifelong 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 • Ulcerativecolitis 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 • Colonicperforation. • 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 • Serologicmarkers (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 lossof the normal vascular pattern Normal colon Ulcerative Colitis
- 35. Colonscopy Ulcer in Crohndiseasee
- 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 stricturesin the transverse and descending colon Mucosal ulcers
- 38. Crohn Disease Cobblestone appearance stringsign, with narrowing and stricturing.
- 39. Plain abdominal radiography UlcerativeColitis • 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 UlcerativeColitis • 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'sDisease • 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'sDisease • 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 Generalgoals 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 intreatment 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 canbe 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 maintenancebenefit 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 in10-18%. 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 Tcell 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.SideEffects: 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 UlcerativeColitis • 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 UlcerativeColitis 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 Surgicaloptions - • 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 • UCis 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 • riskof 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 CrohnDisease 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 • CDcan 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.