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1. Inflammatory Bowel Disease
Presenter : Dr. Sujan Khadka(2nd
year)
Moderator :Dr. Sushil Subedi
Date :2081/01/23
Pokhara Academy of Health Sciences

2. Table of Contents:
Introduction
Types
Aetiology and pathology
Distinguishing features of ulcerative colitis and Chron’s disease
Principles of medical management
Role of surgery in acute and elective settings
Management of post operative complications
Long term outcomes

3. Definition and Types:
The term Inflammatory Bowel Disease (IBD) refers to a
conditions characterized by presence of idiopathic intestinal
inflammation.
Types:
• Crohn disease (CD)
• Ulcerative colitis (UC)

4. Epidemiology
The incidence and prevalence of IBD is highest in Europe and North
America
Affects around 3 in 1000 people.
Overall incidence is steadily increasing worldwide
Linked to improved public hygiene, dietary changes, and
industrialization.

5. Crohn’s disease:
Chronic ,Idiopathic transmural
inflammatory disease of GIT for
which definitive cause is unknown.
Involve any part of GIT from
mouth to anus, most commonly
small intestine and colon.

6. Crohn’s disease:
History:
• 1st
documented case described by Morgagni in 1761
• 1913 Scottish surgeon Dalziel described 9 cases of intestinal
inflammatory disease
• 1932,Landmark paper by Crohn and collogues provided the
pathologic and clinical findings of this inflammatory disease in young
adults.
Incidence: Male and female affected equally.
Distribution: Bimodal

7. Crohn’s disease:
Risk factors:
• Family history: First degree relatives with Crohn's disease
• Smoking(twice than non smokers)
• Drugs:(oral contraceptives, Aspirin, NSAIDs)
• Diet: Decrease dietary fibres , increase fat intake
• Ethnicity: Ashkenazi Jews has 2-4 fold higher incidence.

8. Crohn’s disease:
Aetiology:
• Idiopathic
• Infectious agents: Mycobacterium paratuberculosis,
Enteroadherent E.Coli.
• Aberrant mucosal immune responses
• Genetic Factors: Genes associated are NOD2,MHC,MST1 3p21.
• Environmental factors: Smoking ,Countries adopting western
lifestyle
• Intestinal epithelial dysfunction
• Defects of host interactions with intestinal microbes

9. Pathophysiology:
Mutations of the NOD2 gene → defects in the lamina propria and
epithelial barrier of the gastrointestinal (GI) tract → more pathogens
penetrate the GI tract → recruitment and activation of cytotoxic cells.
Activation of Th1-mediated cells in the GI wall → release of pro-
inflammatory cytokines(like IL-2 and TNF) → intestinal inflammation.
Lack of the down-regulation of immune responsiveness after an
infection or initial flare → chronic inflammation → granulomas

10. Pathophysiology:
Intestinal tissue damage including edema, ulcerations, erosions and
necrosis
Since the inflammation is transmural, it may lead to intestinal
perforation and fistulas.
Chronic and repetitive episodes → scarring
Fibrosis and obstruction of the intestinal wall.

11. Crohn’s disease:
Pathology:
• May include any portion of the GI tract.
• The most common site is terminal ileum and proximal colon.
• Associated with skip lesions
• The rectum is often spared.

12. Crohn’s disease:
Macroscopic findings:
• Fibrotic thickening of intestinal
wall with narrowing of lumen.
• Fat wrapping
• Deep mucosal ulceration with
linear or serpiginous pattern
• Cobblestone appearance of mucosa
• Inflammatory masses,mesenteric
abscess and fiistulas.

13. Crohn’s disease:
Microscopic findings:
• Transmural inflammation
• Noncaseating granulomas
(60% of patients)
• Lymphoid aggregates of the
lamina propria

14. Clinical features:
Symptoms:
• GI manifestations:
Chronic, intermittent diarrhea that is usually non-bloody.
Intermittent and colicky abdominal pain (may be diffuse or localized
to the right lower quadrant)
Odynophagia or dysphagia
Flatulence and bloating
Fissures and fistulas
Signs of malabsorption with vitamin B12 and D deficiencies and
iron deficiency anemia

16. Symptoms:
General manifestations:
• Low-grade fever
• Signs of anemia -
• fatigue
• pallor, dyspnea
• palpitations
• Loss of appetite
• Weight loss
• Failure to thrive or growth delay in children

17. Extraintestinal manifestations:

18. Montreal classification:

19. Diagnosis:
A multimodal approach of clinical features, laboratory investigations ,
endoscopy , Radiology and Pathological findings are required.
Laboratory Studies
• Routine
• Special
Imaging Studies
Tissue diagnosis
• Cytology
• FNAC
• Histology
• Germ line Testing and Molecular Analysis
Diagnostic Laparotomy.

20. Endoscopy:
Ileocolonoscopy with biopsies of terminal ileum:-Gold standard.
Sigmoidoscopy or colonoscopy may reveals characteristic aphthous
ulcer with granularity and normal appearing surrounding mucosa.
Presence of discrete ulcers ,cobblestone appearance ,discontinuous
segments of involved bowel favors diagnosis.
Capsule endoscopy also helpful in diagnosis of superficial mucosal
abnormalities.

21. Differential diagnosis:
Ulcerative colitis
Infectious colitis
Celiac disease
Irritable bowel syndrome (IBS)
Celiac disease
Lactose intolerance
Intestinal TB

22. Management:
Medical Therapy: Directed towards inducing and maintaining steroid
free remission as well as prevent acute exacerbations and
complications.
It includes:
• Corticosteroids :To treat acute flare of Crohn’s disease.
• Antibiotics: Metronidazole or ciprofloxacin
• Amino salicylates: Colonic symptoms can be treated.
• Immunomodulatory agents:
• Azathioprine: Additive and steroid sparing effects
• Ciclosporin: inhibits cell mediated immunity

23. Management:
Monoclonal Antibody(Biological) Therapy:
• Induce remission in moderately severe and severe CD
• Infliximab: Murine chimeric anti TNF alpha
• Adalimumab: Entirely human anti TNF alpha Monoclonal Ab.
• Prevent leukocyte migration:
Vedolizumab ,Etrolizumab
• Targets IL 12/23 and dampen immune system
Ustekinumab

24. Management:
Nutritional therapy:
• Chemically defined elemental diet
• Liquid polymeric diet
• Total parenteral nutrition
Smoking Cessation
Balloon dilatation of fibro-stenotic disease may result in substantial
symptomatic improvement and obviate the need for surgery in
selected cases.

25. Surgical Management:
Goals: To preserve bowel length ,Minimize post operative
complications and disease recurrence.
Aim:
• Achieve inflammation free margin with minimal surgery
• Intended to remove just grossly inflamed tissue.
• Even if adjacent bowel are clearly diseased ,they should be
ignored.
• Frozen section to be considered only if malignant disease is
suspected.

27. Laparoscopic surgery:
• Localized abscess
• Simple intrabdominal fistula
• Perianastomotic recurrent disease
• Disease limited to distal ileum.

28. Ulcerative Colitis:
Continuous inflammation in colorectal
mucosa confined to mucosa and
sub-mucosa & almost always starts from
& involve the rectum
(Rectal sparing in ~ 5% cases)
Distribution
• Proctitis / Procto-sigmoiditis – 50%
• Left sided colitis – 30%
• Pan-colitis – 20%

29. Epidemiology:
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.
The incidence is low in Asia and the Far East.

30. Clinical features:

31. Symptoms:
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).

32. Clinical features:
In some cases, UC has a fulminant course marked by the following:
• Severe diarrhea and cramps
• Fever
• Leukocytosis
• Abdominal distention

33. Signs:
Normal in mild disease
Mild tenderness in the lower left abdominal quadrant
Severe cases-
• Fever
• Tachycardia
• Significant abdominal tenderness
• Weight loss

34. Extra GI Manifestations:
Uveitis
Pyoderma gangrenosum
Pleuritis
Erythema nodosum
Ankylosing spondylitis
Spondyloarthropathies
Primary sclerosing cholangitis (PSC)
Recurrent subcutaneous abscesses unrelated to pyoderma gangrenosum
Multiple sclerosis
Immunobullous disease of the skin

35. Classification of severity:
Determined by frequency of bowel action and presence of systemic
signs of illness, Proposed by Trulove and Witt’s:
• Mild: Fewer than four bowel motions per day with or without
bleeding.
• Moderate: More than four bowel motions per day, few signs of
systemic illness, pain abdomen may occur, CRP and ESR raised.
• Severe: More than six bloody stool per day, and a systemic illness
with hypoalbuminemia (< 30 g/L)
• Fulminant : More than ten bowel motions per day with continuous
bleeding ,fever ,tachycardia, anemia,
Hypoalbuminemia ,abdominal distension and tenderness.

36. Cancer risk in colitis:
The risk of cancer in ulcerative colitis increases with duration of
disease.
 At 10 years from diagnosis, it is approximately 1%, increasing to 10–
15% at 20 years and 20% at 30 years.
 Patients with pancolitis (defined as the presence of inflammation
proximal to the splenic flexure) of more than 10 years duration should
be entered into endoscopic screening programs in order to detect
clinically silent dysplasia, which is predictive of increased cancer risk.

37. Investigations:
Endoscopy and biopsy:
• Endoscopy and biopsy-Abnormal erythematous mucosa, with or
without ulceration, extending from the rectum to a part or all of the
colon
• Contact bleeding may also be observed, with mucus identified in the
lumen of the bowel

38. Investigations:
Colonoscopy: Mucosa hyperemic loss of the normal vascular pattern.

39. Investigations:
• 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: To exclude infective colitides, notabely Camphylobacter

40. Scoring system for assessment of UC activity:

41. Define severity of disease:
true love and witt’s criteria

42. Treatment:
Principles of management:
• Most patients are maintained on optimized medical therapy.
• Acute severe colitis (ASC) requires multidisciplinary management.
• Toxic dilatation or impending complication should be suspected if
the patient develops abdominal tenderness or distension, or
deteriorates clinically
• Patients with colitis are at increased risk of developing cancer;
those with pancolitis of long duration are most at risk

43. Medical treatment:
Cyclo-oxygenase Inhibitor : 5-Aminosalicylic acid derivatives
topically(per rectal)or systemically.
Corticosteroid either topically or systemically acts as anti
inflammatory.
Immunosuppressive drugs: Azathioprine and ciclosporin
Monoclonal Antibodies: Infliximab , Adalimumab, Ustekinumab
Nutritional support.

44. Medical treatment of acute, severe UC :
Hospitalization
Intravenous high-dose corticosteroids
Alternative induction medications: Cyclosporine, Tofacitinib,
tacrolimus, infliximab, adalimumab, golimumab

45. Indications for urgent surgery :
Toxic megacolon refractory to medical management
Fulminant attack refractory to medical management
Refractory acute severe colitis
Uncontrolled colonic bleeding by endoscopic or interventional
radiologist team.

46. Indications for surgery:

Severe or fulminating disease failing to respond to medical therapy

Chronic disease with anemia, frequent stools, urgency and tenesmus

Steroid-dependent disease where remission cannot be maintained
without substantial doses of steroids with harmful side effects

Intolerance or side effects of medical therapy required to control the
disease, e.g. steroid psychosis, azathioprine induced pancreatitis
 ●

47. Indications for surgery:
Growth retardation in children or adolescents
Neoplastic change: patients who have severe dysplasia or carcinoma
Associated sclerosing cholangitis
Extraintestinal manifestations
Rarely, severe hemorrhage or stenosis causing obstruction.

48. Pre-operative preparation:
Correction of
• Anemia
• Fluid and electrolyte
• Acid-base disorder
• Nutritional deficiencies
Most drugs can be discontinued without sequelae except
corticosteroids
Ostomy site selection
Mechanical Bowel prep – not necessary
Anti-microbial treatment

49. Surgical Management:
Emergency
• Aim:
• Treatment of fulminant state
• Emergency Surgery:
• Total abdominal colectomy + end ileostomy + rectal stump
closure/fistula
• Able to discontinue all the medication
• Preserve ileal branch of Ileocolic vessel
• Avoid rectum mobilization

50. Surgical Management:
Elective:
• Subtotal colectomy and Ileostomy
• Pan-proctocolectomy and permanent end-ileostomy
• Restorative proctocolectomy with Ileal pouch-anal
anastomosis(IPAA)
• Sub-total colectomy and ileorectal anastomosis(IRA)
• Segmental Colectomy(Crohn’s Colitis only)

51. Pan-proctocolectomy and permanent end-
ileostomy
• This operation removes the entire colon and rectum and,
• By doing so, removes any risk of colorectal neoplasia or colitic symptoms
• It results in a permanent ileostomy.
• It has a lower complication rate than an ileal pouch procedure, although
the perineal wound can be problematic (10% fail to heal) and stoma
problems are common.
• It is indicated for patients who are not candidates for restorative surgery
owing to impaired anal sphincter function, comorbidities or patient
preference

52. Total procto-colectomy + Brooke ileostomy
Indications
• Old age / anal incontinence
• Distal rectal Ca
• Patient preference
Disadvantage
• Loss of fecal continence
• SAIO

53. Total procto-colectomy + Continent ileostomy
Indication
• As Brooke ileostomy
Operative principles
• Exclude CD
• Aperistaltic reservoir
• Terminal 45-60 cm of the ileum – S pouch
• Early post-op - wide plastic tube drain in the pouch
• Drainage -- by intubating the pouch 3 times/D

54. Restorative Procto-colectomy + IPAA

55. IPAA:
• Near total proctocolectomy + ileal reservoir
• Anal sphincter preserved
• Stapled anastomosis
• Mobilization of rectum
• Ileal reservoir
• J- pouch; 15-20 cm length of both limb
• Lengthening maneuvers
• Defunctioning loop ileostomy

57. IPAA Contd….
Complication
• Small bowel obstruction – 20%
• Pelvic sepsis – 5%
• I-A anastomotic stricture – 5-38%
• Pouch vaginal fistula
• Pouchitis
• Antibiotic, probiotic, steroid enema, ileostomy+/- pouch
excision
• Incontinence
• Bulking agent/ anti-diarrheal medication – 50% pts

58. Abdominal Colectomy + IRA
Indication
• Indeterminate colitis (IC)
• Upper rectal disease- rectal compliance remains adequate
Advantage
• Avoid perineal complication of proctocolectomy
• Minimal sexual dysfunction/ fertility
• Control of feces and flatus

59. Abdominal Colectomy + IRA:
Disadvantage
• Rectal mucosa remaining
• Increased frequency of defecation – 2-5 times/d, semi-liquid
• Conversion to IPAA
• Poor rectal compliance
• Persistent proctitis
• Upper rectal Ca

60. Abdominal Colectomy + IRA:
Complication
• Nocturnal defecation
• Ca risk ( In remaining rectum)
• Overall risk – 6%
• Most Ca. appear 15-20 yrs. after operation
• Recurrent or persistent inflammation
• Incidence – 20%-45%
• Severe diarrhea, tenesmus, bleeding, urgency
• Topical or systemic therapy – if no response – rectal excision

61. Controversial issue in Surgical Management:
Indeterminate colitis- In 10% colitis patients
• Overlapping features of UC & CD
• If CD cant be excluded – subtotal colectomy + ileostomy
• IPAA for IC
• Definitive pathologic diagnosis of UC
• IC without development of signs or symptoms of CD
• Long term functional outcome nearly identical to chronic UC
• Pouch loss
• Higher perineal complications
• IPAA for UC/IC
• 7% have revised diagnosis of CD
• High rate of perianal fistula / stricture

62. Take home message:
• Crohn's disease is a chronic, recurrent condition that causes patchy
transmural inflammation that can involve any part of the
gastrointestinal tract.
• Diagnosis is established via endoscopy with biopsy that shows
transmural inflammation, characteristic “cobblestone” mucosa, and
noncaseating granulomas.
• Management is with corticosteroids, azathioprine, antibiotics, and
anti-TNF agents (infliximab and adalimumab).
• Complications include malabsorption, malnutrition, intestinal
obstruction or fistula, and an increased risk of colon cancer.

63. Take home message:
• 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 caecal or appendiceal patches of involvement that
can simulate the "skip" lesions of CD

64. References:
• Bailey and love’s short practice of surgery-28th
edition
• Sabiston textbook of surgery-21st
edition
• Schwartz’s principles of surgery 11th
edition
• British Society of Gastroenterology consensus guidelines on the
management of inflammatory bowel disease in adults; 2019