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Inflammatory Bowel Diseases
- 1. INFLAMMATORY BOWEL DISEASES DR. DURGESHMAHAJAN MD MEDICINE ASSISTANT PROFESSOR SVNGMC, YAVATMAL
- 2. Inflammatory bowel disease Itincludes a group of chronic disorders that cause inflammation or ulceration in large and small intestines.
- 3. TYPES Ulcerative colitis • causesulceration and inflammation of the inner lining of the colon and rectum. • It is usually in the form of characteristic ulcers or open sores. Crohn’s disease • Extends into the deeper layers of the intestinal wall, and may affect the mouth, esophagus, stomach, and small intestine. • Transmural inflammation and skip lesions. • In 50% cases -ileocolic,30% ileal and 20% -colic region. • Regional enteritis
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- 5. OTHER FORMS OFIBD • Collagenous colitis • Lymphocytic colitis • Ischemic colitis • Behcet’s syndrome • Infective colitis • Intermediate colitis
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- 7. Etiopathogenesis • Exact causeis unknown. • Genetic factors • Immunological factors • Microbial factors • Psychosocial factors
- 8. Genetic factors • Ulcerativecolitis is more common in DR2-related genes • Crohn’s disease is more common in DR5 DQ1 alleles • 3-20 times higher incidence in first degree relatives
- 9. Immunologic factors • Defectiveregulation of immunesuppresion • Activated CD+4 cells activate other inflammatory cells like macrophages & B-cells or recruit more inflammatory cells by stimulation of homing receptor on leucocytes & vascular epithelium.
- 11. Pathogenesis of IBD AmericanGastroenterological Association Institute, Bethesda, MD. Sartor RB. Nat Clin Pract Gastroenterol Hepatol. 2006;3:390-407. Normal Gut Tolerance- controlled inflammation Tolerance Acute Injury Environmental trigger (Infection, NSAID, other) Complete Healing Chronic Inflammation Genetically Susceptible Host Acute Inflammation ↓ Immunoregulation, failure of repair or bacterial clearance
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- 13. Pathology Macrocopic features Usually involvesrectum & extends proximally to involve all or part of colon. Spread is in continuity. May be limited colitis( proctitis & proctosigmoiditis) in total colitis there is back wash ileitis (lumpy- bumpy appearance)
- 15. • Mild disease-erythema & sand paper appearance(fine granularity) • Moderate-marked erythema,coarse granularity,contact bleeding & no ulceration • Severe- spontaneous bleeding, edematous & ulcerated(collar button ulcer). • Long standing-epithelial regeneration so pseudopolyps , mucosal atrophy & disorientation leads to a precancerous condition. • Eventually can lead to shortening and narrowing of colon. • Fulminant disease-Toxic colitis/megacolon
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- 17. Microscopic features Cryptsatrophy & irregularity Superficial erosion Diffuse mixed inflammation Basal lymphoplasmacytosis
- 18. Clinical features Ulcerative colitis Diarrhea Rectalbleeding Tenesmus Passage of mucus Crampy abdominal pain
- 19. • Diarrhea &bleeding blood-intermittent &mild. do not seek medical attention. • Patient with proctatis-pass fresh or blood stained mucus with formed or semi formed stool. They also have tenesmus , urgency with feeling of incomplete evacuation. • With proctosigmoiditis-constipation • Severe disease-liquid stools with blood , pus & fecal matter.
- 20. Physical signs Proctitis –Tender anal canal & blood on rectal examination Extensive disease-tenderness on palpation of colon Toxic colitis-severe pain &bleeding If perforation-signs of peritonitis
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- 23. Diagnosis • Laboratory tests •Endoscopy • Radiography • Biopsy
- 24. Laboratory tests • Hemogram C-reactiveprotein is increased ESR is increased Platelet count-increased Hemoglobin-decreased Fecal Calponectin levels correlate with histological inflammation,predict relapses &detect pouchitis
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- 26. BARIUM ENEMA • Finemucosal granularity • Superficial ulcers seen • Collar button ulcers • Pipe stem appearance- loss of haustrations • Narrow & short colon- ribbon contour colon
- 27. SIGMOIDOSCOPY • Always abnormal •Loss of vascular patterns • Granularity • Friability • ulceration
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- 34. Macroscopic features Can affectany part of GIT Transmural Segmental with skip lesions Cobblestone appearance Creeping fat- adhesions & fistula
- 37. Microscopic features • Aphthousulcerations • Focal crypt abscesses • Granuloma-pathognomic • Submucosal or subserosal lymphoid aggregates • Transmural with fissure formation
- 38. Clinical features Ileal Crohn’sDisease Abdominal pain Diarrhea Weight loss Low grade fever Jejunoileitis disease Malabsorption Steatorrhea Colitis and perianal disease Bloody diarrohea Passage of mucus Lethargy Malaise Anorexia Weight loss
- 39. Diagnosis • Laboratory tests •Endoscopy • Radiography • Biopsy • CT enterography
- 40. Laboratory tests • CRP-elevated •ESR-elevated • Anemia • Leukocytosis • hypoalbuminemia
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- 43. CT enterography • Muralhyperenhancement • Stratification • Engorged vasa recta • Perienteric inflammatory changes
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- 50. Drugs • 5-ASA agents •Glucocorticoids • Antibiotics • Immunosuppresants • Biological therapy
- 52. 5-ASA Agents •Sulfasalazine (5-aminosalicylic acidand sulfapyridine as carrier substance) •Mesalazine (5-ASA), e.g. Asacol, Pentasa •Balsalazide (prodrug of 5-ASA) • Olsalazine (5-ASA dimer cleaves in colon)
- 53. Distribution of 5-ASAPreparations Oral • Varies by agent: may be released in the distal/terminal ileum, or colon1 Suppositories • Reach the upper rectum2,5 (15-20 cm beyond the anal verge) Liquid Enemas • May reach the splenic flexure2-4 • Do not frequently concentrate in the rectum3 Topical Action of 5-ASA: Extent of Disease Impacts Formulation Choice 1. Sandborn WJ, et al. Aliment Pharmacol Ther. 2003;17:29-42; 2. Regueiro M, et al. Inflamm Bowel Dis. 2006;12:972–978; 3. Van Bodegraven AA, et al. Aliment Pharmacol Ther. 1996; 10:327-332; 4. Chapman NJ, et al. Mayo Clin Proc. 1992;62:245-248; 5. Williams CN, et al. Dig Dis Sci. 1987;32:71S-75S.
- 54. • Use Inmild to moderate UC & crohn’s colitis Maintaining remission May reduce risk of colorectal cancer • Adverse effects Nausea, headache, epigastric pain, diarrhoea, hypersensitivity, pancreatitis Caution in renal impairment, pregnancy, breast feeding
- 55. Glucocorticoids • Anti inflammatoryagents for moderate to severe relapses. • Inhibition of inflammatory pathways • Budesonide- 9mg/dl used for 2-3 months & then tapered. • Prednisone-40-60mg/day • No role in maintainence therapy
- 56. Antibiotics • No rolein active/quienscent UC • Metronidazole is effective in active inflammatory,fistulous & perianal CD. • Dose-15-20mg/kg/day in 3 divided doses. • Ciprofloxacin • Rifaximin
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- 58. Cyclosporine • Preventing clonalexpansion of T cell subsets • Used in Steroid sparing Active and chronic disease • Side effects Tremor, paraesthesiae, malaise, headache, gingival hyperplasia, hirsutism Major: renal impairment, infections, neurotoxicity
- 59. Biological therapy • Infliximab AntiTNF monoclonal antibody Infliximab binds to TNF trimers with high affinity, preventing cytokine from binding to its receptors It also binds to membrane-bound TNF- a and neutralizes its activity & also reduces serum TNF levels. • Use Fistulizing CD Severe active CD Refractory/intolerant of steroids or immunosuppression • Side effects Infusion reactions, Sepsis, Reactivation of Tb, Increased risk of Tb
- 60. Other medications Anti- diarrheals- Loperamide (Imodium) Laxatives - senna, bisacodyl Pain relievers. acetaminophen (Tylenol). Iron supplements Nutrition
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- 62. • Reconstructive proctocolectomywith illeoanal pouch • Proctocolectomy & ileostomy • Rectal &anal dissection • Colectomy with ileorectal anastomosis • Ileostomy with intraabdominal pouch SURGERIES IN ULCERATIVE COLITIS
- 64. SURGERIES IN Crohn’sdisease Ileocaecal resection Segmental resection Colectomy & ileorectal anastamosis Temporary loop ileostomy Proctocolectomy Stricturoplasty
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