Crohn's disease and ulcerative colitis are the two main forms of inflammatory bowel disease. Crohn's can affect any part of the gastrointestinal tract and is characterized by transmural inflammation and granulomas. Ulcerative colitis only affects the colon and causes superficial ulcers. Both conditions are diagnosed based on symptoms, endoscopic findings, and histology. Treatment involves medications to induce and maintain remission as well as surgery for complications.

1. Ghali Abduljalil Abubakar

2. Introduction
 Inflammatory bowel disease or IBD is a chronic,
relapsing inflammation of bowel possibly due to
abnormal immune response to enteric flora.
 The two major forms of IBD are recognized as:-
 Crohn’s disease (CD) which affect any part of the GI
tract from “gum to bum”.
 Ulcerative colitis (UC) which affect only the colon.

3.  There is a degree of overlap between these two
conditions, in there clinical features, histological and
radiological abnormalities. In 10% of cases of IBD
causing colitis a definitive diagnosis is either UC or CD
is not possible and the diagnosis is term as colitis of
undetermined type and etiology (CUTE).
 Its clinical useful to distinguished between these two
conditions because of differences in their
management, although in reality they may represent
two aspect of the same disease.

4. Epidemiology
 The incidence and prevalence of IBD are highest in
westernized nations, the incidence of CD varies from
country to country but is approximately 4-10 per
100000 annually with the prevalence 25-100 per
100000.The incidence of UC is stable at 6-15/10000
annually with a prevalence of 80-150/100000. The
disease is more prevalent in the west, particularly
Caucasian and eastern European Jews.

5. Etiology
 Genetic factors
 Smoking
 NSAIDs
 Hygiene
 Nutritional factors
 Appendectomy
 The intestinal microbiota
 The intestinal immune system

6. CROHN’S
 Crohn’s disease is a chronic inflammatory condition
that affect any part of the GI tract from mouth to anus
but has the tendency to affect the ileum and ascending
colon (ileocolonic disease).
 The disease can involve one small areas with relatively
normal bowel in between (skip lesion). It may also
involve the whole of the colon (total colitis) sometimes
without macroscopic small bowel involvement.

8. Macroscopic features of CD
 The involved bowel is usually thickened and is
narrowed. Deep ulcers and fissures in mucosa produce
a cobblestones appearance. Fistula and abscesses
maybe seen which reflect penetrating disease.

9.  An early features is aphthoid ulceration, usually seen
at colonoscopy; later larger and deeper ulcers appears
in a patchy distribution again producing a cobblestone
appearance.

10. Microscopic features of CD
 The earliest lesions are aphthoid ulceration and focal
crypt abscesses with loose aggregations of
macrophages, which form non-caseating granulomas
in all layers of the bowel wall. Granulomas can be seen
in lymph node, mesentery, peritoneum, liver and
pancreas. Although granulomas are a pathognomic
features of CD, there are rarely found on mucosal
biopsies.

11. Sign and Symptoms of CD
 MAJOR SYMPTOMS:-
 Watery Diarrhea
 Abdominal pain
 Weight loss
 CONSTITUTIONAL SYMPTOMS:-
 Malaise, lethargy, anorexia, nausea, vomiting, and low
great fever maybe present and 15% no gastrointestinal
symptoms.

12. Diagnosis
 How can you diagnose CD?:-
 History and Examination
 Presenting complain:- insidious or acutely abdominal
pain. Non-bloody Diarrhea but sometimes it maybe
bloody and Steatorrhea
 systemic review is very important because of extra GI
manifestations

13.  Family history is important because of genetic
predisposition.
 Drug and social history due to NSAIDs and smoking
which is said to exacerbate CD.

14. Examination:-
 Loss of weight and sign of malnutrition. aphthous
ulcer in the mouth is often seen.

15. Abdominal examination:-
• Maybe normal or shows tenderness and or right iliac
fossa mass are occasionally found.
• The anus should be examined to look for edematous
anal tags, fissures or perianal abscesses.
• And the presence of extra GI features should not be
forgotten.

17. Investigations
 Complete blood count (CBC):- for the presence of
anemia either normocytic normochronic anemia of
chronic diseases. However iron deficiency and or folate
also occur.
 Erythrocyte sedimentation rate (ESR) & C-reactive
protein (CRP) may raised, white cells & platelets count
is also high.
 Hypoalbuminemia is present in severe disease or as
part of an acute phase response to inflammation
associated with raised CRP.

18.  Liver function test (LFT)
 Blood culture for suspected septicemia
 Serologic test:- anti-saccharomyces cerevisiae
antibodies (ASCA) often positive.
 Stool culture for C. difficile toxin assay should always
be performed if diarrhea is present.

19. Endoscopy & radiological imaging
 Colonoscopy/sigmoidoscopy in patient with severe
disease.
 Upper GI endoscopy to exclude esophageal &
gastroduedenal involvement.
 Small bowel imaging is mandatory in patient with CD
 Perianal MRI or endoanal ultrasound.
 Capsule endoscopy in CD with normal radiological
findings.
 Radionuclide scan.

20. MRI shows linear fluid-filled
perianal fistula in the right
ischioanal fossa

21. Capsule endoscopy show ulceration
& narrowing of the intestinal lumen

22. Complications of CD
 Malaborption
 Peritonitis
 Intestinal obstruction in 40%
 Massive hemorrhage
 Skin tags
 Ischiorectal abscess
 Anorectal
 Fistula

23. Medical Management
 The aim of management is to induce and maintain
clinical remission & achieve mucosal healing to
prevent complications.
 Stop smoking
 Induction of remission:- oral or I.V
glucocortic0steriods (e.g. 6 mercaptorine,
methotrexate) and TNF antibodies (e.g. infliximab,
adalimumab)

24.  Maintaince of remission:- Azathioprine, 6-MP,
methotrexate, mycophenolate, mofitil & TNF
antibodies.
 Perianal disease:- ciprofloxacin, metronidazole,
azathioprine & TNF antibodies.

25. Surgical management of CD
 Approximately 80% of patient will required surgery at
some course of the disease.
 INDICATION FOR SURGERY ARE:-
 Failure of medical therapy with acute or chronic
symptoms producing ill-health
 Complications (e.g. toxic dilation, obstructions,
perforation, abscesses and enterocutenous fistula)
 Failure to grow in children despite medical therapy
 Presence of perianal sepsis

26. Surgical intervention
 Colectomy
 Stricturoplasty
 Ileorectal anastomosis
 Panprocolectomy with an end ileostomy (if the whole
colon & rectum is involved)

27. Problems associated with
ileostomies
 Mechanical problem
 Dehydration particularly if there is a short length of
small bowel remaining.
 Psychosexual problems
 Erectile dysfunction in men and reduced fueundity in
women (due to prior surgery)
 Recurrence of CD

28. Ulcerative colitis

29. Ulcerative colitis UC
 Ulcerative colitis (UC) can affect the rectum alone
(proctitis) & can extend to proximally to involved the
sigmoid and descending colon (left sided colitis) or
may involve the whole colon (extensive colitis). In a
few of these patients there is also inflammation of the
distal terminal ileum (backwash ileitis).

31. Macroscopic changes in colitis
 The mucosa looks reddened, inflamed and bleed easily
(friability). In severe disease there is extensive
ulceration with the adjacent mucosa appearing as
inflammatory (pseudo) polyps.

32. Microscopic changes in UC
 The mucosa shows a chronic inflammatory cells
infiltrate in the lamina propria. Crypt abscesses and
goblet cell depletion are also seen.

33. Sign & symptoms of UC
 Bloody Diarrhea with mucus
 Lower abdominal discomfort
 Malaise
 Lethargy
 Anorexia
 Weight loss more often in UC than CD

34. Diagnosis
 History and examination:-
 History:- patient usually complain about frequent
passage of blood and mucus in his stool with urgency
and tenesmus. And frequency of defecation. About 10-
20 liquid of stool per day. Diarrhea mainly occurs at
night with incontinence and urgency.
 In system review extra GI symptoms, +/- family history

35. Examinations
 In general there are no specific sign in UC but the
abdomen maybe slightly distended or tender to
palpation.
 Pyrexia, tachycardia, are sign of severe colitis and
require urgent admission.
 Rectal examination will show presence blood.
 Rigid sigmoidoscopy is usually abnormal, showing an
inflamed, bleeding, friable mucosa.

36. Sigmoidoscopy

37. Investigations
 Complete blood count (CBC):- iron deficiency and
raised WBC & platelet.
 ESR & CRP are often raised
 Liver function test (LFT)
 Serologic test:- perinuclear anti-neutrophil
cytoplasmic antibodies (pANCA) often positive
 Stool culture for C.difficile toxin.
 Colonoscopy with mucosal biopsy is the gold standard
 X-ray

38. Pseudopolyps Ulcerative colitis

39. Complications of UC
 Short term complication:-
 Toxic megacolon
 Hemorrhage
 Perforation
 Long term complication:-
 Stricture leading to obstruction
 Dysplasia leading to cancer.

42. Medical Management
 Multidisplinary term
 Aminosalicyclic acid (5-ASA)(e.g. sulfasalazine,
balsaladize & olsalazine)
 Suppositories and enemas of 5-ASA can be use
 Oral prednisolone
 In severe cases admission give I.V hydrocortisone
100mg 6 hourly with subcutaneous low molecular
weight heparin to prevent thromboembolism

43. Salvage therapy
 To avoid Colectomy is required for patient with
CRP>40mg/L or more than eight bowel motions after 3
days of hydrocortisone.
 Oral cyclosporine 2mg/kg/day
 Infliximab 5mg/kg as an Infusion
SMOKING?

44. Surgical Management
 While the treatment of UC remains primarily
medical, surgery continues to have a central role
because it maybe life saving is curative and eliminated
the long term risk of cancer.
 Acute disease:- subtotal Colectomy with end ileostomy
 Severe disease:- proctectomy with permanent
ileostomy.

45. Indications for surgery
 Fulminate acute attack:-
 failure of medical therapy
 Toxic dilation
 Hemorrhage
 Imminent perforation
 Chronic disease:-
 Incomplete response to medical treatment
 Dysplasia on surveillance colonoscopy

48. Differential diagnosis of IBD
 Causes of infectious diarrhea such as:-
 Clostridium difficile ,Amoebiasis, Ileocolonic
tuberculosis.
 Others:-
 Celiac disease
 Microscopic colitis
 Lactose intolerance
 Irritable bowel syndrome (IBS)
 Functional diarrhea

49.  Behcet disease
 AIDS
 Colorectal malignancy (e.g. adenocarcinoma and
lymphoma)
 C1 esterase deficiency, hereditary angioedema
 Ischemic colitis e.t.c

51. Features that distinguished CD
from UC
 Crohn's gives GIFTS:-
 Granulomas
 Ileum
 Fistula and fissure
 Transmural
 Skip lesions

52. Cancer in inflammatory bowel
diseases
 Patients with UC and extensive Crohn’s colitis have
an increased incidence of developing dysplasia and
subsequent colon cancer. The risk of dysplasia is
related to the extent and duration of disease as well as
the presence of untreated mucosal inflammation.

53. Pregnancy and inflammatory
bowel disease
 Women with inactive IBD have normal fertility.
Fertility, however, may be reduced in those with active
disease, and patients with active disease are twice
more likely to suffer spontaneous abortion than
those with inactive disease.

54.  Listen to your patient he is telling you the diagnosis.
Dr. Williams Osler

55. Thank You