This document summarizes recent advances in the diagnosis and treatment of inflammatory bowel disease (IBD). Key points include: 1) New imaging techniques like CT enterography and MRI enterography allow better visualization of the bowel. Narrow band imaging and confocal laser endoscopy provide enhanced detection of dysplasia. 2) Treatment advances include biologics targeting TNF and IL-12/23, as well as endoscopic balloon dilation and stenting. 3) Surgery options depend on disease severity but include laparoscopic approaches, which provide better outcomes than open surgery. Surgical treatments include resection, stricturoplomy, and restorative proctocolectomy with ileal pouch-anal

1. By
Mohammed Ezzat Algazar
Assistant lecturer of surgery , Faculty of Medicine ,
Zagazig University .
Email: drmohammedezzat4@gmail.com
Inflammatory bowel
diseaes ( IBD ),
what`s new ?
ALLPPT.com _ Free PowerPoint Templates, Diagrams and Charts

2. Inflammatory bowel disease
(IBD)
Ulcerative colitisChron`s diseaes

3. Historical perspectives
Alfred the great
(849–899 CE ) Burrill Crohn
(1884-1983)
Samuel Wilks
(1824 – 1911)
Stephan Targan

5. Mechanism of IBD

6. Damage to epithelial cells and barrier function is a key underlying
mechanism, leading to excessive stimulation from luminal bacteria, leading
to the activation and recruitment of immune cells, resulting in a feed-forwar
d loop, in which all of the above processes are further promoted, eventually
also leading to tissue fibrosis

7. Diagnosis
Clinical presentation

8. New imaging
studies of IBD

9. Traditional imaging

10. CT scan

11. Comb sign
- Comb sign on contrast CT or MRI : Increased number of visible
vessels on the mesenteric side of the affected segments of small
bowel, which give the appearance of the teeth of a comb
- Found in Crohn's disease or lupus enteritis.

12. - CT Enterography Allows visualization of
lumen, mucosa, bowel wall and extraluminal
pathology
- It uses :
1- High volume of (1200 ml ) negative oral
contrast ( VoLumen ) over one hour
2- Multidetector CT scanner
3- +/- methylcellulose, lactulose, PEG or
sorbitol (improves distension)
4- Traditional IV contrast
CT enterography

14. Ileosigmoid fistula

15. MRI and MRI enterography
Coronal gadolinium-based contrast material–enhanced
MR image shows luminal narrowing, mural thickening, and mildly
increased vascularity of the terminal ileum (arrow)

16. Complex perianal fistula
PSC
Choangiocarcinoma
on top of PSC

17. ADVANCES IN ENDOSCOPIC
DIAGNOSTIC MODALITIES

18. 1- Capsule Endoscopy
- In 2001, wireless capsule endoscopy (WCE) was
approved by (FDA).
- [European Crohn's and Colitis Organization ]
criteria for diagnosing CD by WCE study is the
presence of more than three ulcers in the absence
of NSAIDs' use.
- When this definition was used, WCE had a
sensitivity of 77%, specificity of 89%, PPV of 50%,
and an NPV of 96% for the diagnosis of suspected
CD.

19. - FICE images ((FICE: Fujinon Intelligent Color Enhancement) captured by
video capsule endoscopy seen with (a) conventional imaging, (b) FICE
setting 1 (c) FICE setting 2 , and (d) FICE setting 3

21. - Conventional endoscopy can explore the entire small bowel
- In 2002, deep endoscopy is introduced to overcome this
problem
- The typical endoscope used for this procedure has a total
working length ranging between 200 and 250 cm.
- With various maneuvers, this length allows the endoscopist
to examine approximately 430 cm of small bowel via an
oral antegrade approach or a retrograde approach through
the rectum.
2-Small bowel deep endoscopy

22. Small bowel enteroscopy

23. In chromoendoscopy, dye solutions ( methylene blue
or indigocarmine stain ) are applied to the mucosa
of the colon, enhancing the recognition of details to
uncover the mucosal changes not seen by the optical
methods before targeted biopsy and histology
A recent meta-analysis showed that pan-colonic
chromoendoscopy was significantly better than white
light endoscopy in detecting intraepithelial neoplasia
in patients with UC
3- Chromoendoscopy

25. - A new optical technology, facilitates enhanced visualization
of the microvasculature structure of the mucosal layer with
the use of special optical filters.
- NBI allows for the accentuation of surface mucosal and
vascular structures, thus permitting early detection of
dysplastic changes
. - A pilot study by Machida and colleagues showed that
NBI was equivalent to chromoendoscopy in differentiating
neoplastic from nonneoplastic lesions.
4- Narrow band imaging

26. - Both techniques had a sensitivity of 100% and specificity of
75% in distinguishing between these lesions, compared with
a sensitivity of 83% and specificity of 44% with conventional
colonoscopy.
Irregular mucosa with high-grade neoplasia in a patient with long-standing
ulcerative colitis, viewed by WLE (a) and by NBI, revealing a Kudo type IV pit
pattern

27. - This technique facilitates the simultaneous performance
of white-light endoscopy and confocal microscopy, with
the ability to perform targeted biopsies.
- This technology incorporates a confocal microscope at
the distal end of a conventional colonoscopy.
- A fluorescent contrast agent is applied topically
(acriflavine 0.2%) or systemically (fluorescein 10%) to
achieve high-contrast images.
- This new technique allows for the detection of
neoplastic changes with an accuracy of 99.2% (97.4%
sensitivity and 99.4% specificity)
5- Conofocal Laser Microendoscopy

30. NEW Serological markers of
IBD

31. Treatment

32. - The aim of the medical TTT of IBD is to induce long term
remission and prevent relapse or recurrence after surgery
.
- Conventional IBD treatment paradigms have followed
a stepwise treatment approach, with intensified therapies
used only when symptoms are not resolved.
Medical advances

33. 1- TNF antagonists:
The introduction of anti-TNF therapy for treating IBD was
considered a breakthrough in medical management.
To date, four TNF antagonists are used for the treatment of CD
and UC .
I- IFX (Remicade®) II- Adalmumab (Humira®) III- Certolizumab
(Simzia®) IV- Golimumab (GOL) (Symponi®) .
2- Leukocyte trafficking inhibitors e.g. Natalizumab
(NTZ) (Tesabri®)
3- Probiotics
4- Interleukin (IL)-12/23 inhibitor: Ustekinumab (UKB)
(Stelara®)

34. 1- Endoscopic balloon dilatation:
The literature regarding the role of EBD is mainly limited to
short-term non-controlled observational studies involving
small numbers of patients.
Therefore, the long-term efficacy and safety of EBD is not yet
well defined
Endoscopic treatment

35. 2- Endoscopic stenting:
ES is used to treat cases of CD with refractory fibrostenotic
stricture involves the placement of a temporary self-expandable
metal stent (SEMS) through the endoscope.
Although it sounds feasible, but serious complications may occur
such as perforation, fistula formation, stent migration, and
difficult stent extraction.
However, the use of stents with an anti-migratory design and
biodegradable stents showed encouraging results, but their
long-term efficacy and safety requires further studies.

37. Surgery for IBD

38. Indications of surgery
UC
1- intractability
2- Dysplasia
3- carcinoma
4- Massive bleeding
5- toxic megacolon
CD
1- IO
2-intractability
3-intra-abd. Abcess
4- fistula
5- Massive bleeding
6- toxic megacolon
7- fulminant colitis
8- cancer
9- growth retardation

39. Surgical options of CD
ResectionStricturoplasty
1- Heineke-Mikulicz like
2- Finney like
( for long segment )

40. 1- stricturoplasty

41. 2- Resection :

42. - A recent meta-analysis by Tan et al looked at almost
900 patients undergoing laparoscopic and open surgery
for Crohn’s disease.
- Ileocolic resection was the most common operation
performed.
- This study confirmed an improvement in recovery of
bowel function and decreased length of stay at the cost
of slightly longer operative times.
- In addition, overall morbidity was significantly lower in
the laparoscopic group (12.8% versus 20%).
Role of Laparoscopy in CD

43. Surgical options for UC

44. - Introduced by parks in 1979 , now it`s the standard
approach for elective .surgery for UC it includes :
1- A near-total proctocolectomy
2- Preservation of the anal sphincter complex
3-A single chambered pouch is fashioned from the
distal 30 cm of the ileum
4- Tension Free Anastomosis between the pouch and
the anus either
A- Double stapled technique
B- Hand sewn after mucosectomy
5- proximal ileostomy
Total proctocolectomy with ileal pouch–anal
Anastomosis (IPAA).

48. - liquid diets are offered to patients in the early recovery period
- Diet is advanced with return of bowel function, as evidenced by
ileostomy function
- If a pelvic drain is used, it is typically removed after 48 to 72 hs
- Bladder catheters are left in place for 3 to 4 days, depending on
the difficulty of pelvic dissection
- A contrast enema is performed approximately 10 weeks postop
eratively to ensure an intact IPAA :
I- Contrast leak = repeated in 6 weeks; almost 95% of anastomotic
leaks heal in the absence of pelvic sepsis
II- No leak= the diverting ileostomy is closed
Postoperative care of IPAA

49. 1- Small bowel obstruction (27%).
2- leakage = pelvic abcess which may affect pouch function or
leads to fistula (10%).
3- Pouchitis : inflammation of pouch mucosa (7-33%) :
- a/e: unknown, may be related to bacterial overgrowth, mucosal
ischemia, or other local factors
- C/P: increased stool frequency, fever, bleeding, cramps, and
dehydration
- TTT: rehydration and oral antibiotics, usually metronidazole or
ciprofloxacin. Probiotics in resistant cases
Complications of IPAA

50. A large retrospective review of the American National
Surgical Quality Improvement Program database from 2005
to 2008 for all patients undergoing surgery for UC showed :
- a laparoscopic approach was used in more than
29% of patients with rates increasing each year, starting at
18.5% in 2005 and reaching 41% in 2008
- A laparoscopic approach was associated with a lower comp-
lication rate in total abdominal colectomy (18.8% versus 41.7
%) and IPAA (18.2% versus 29.9%)
Laparoscopic Approaches for UC

51. - Decrease in an overall lower mortality rate (0.2% versus 1.7%)
- Laparoscopic abdominal colectomy for severe ulcerative coliti
s in a hemodynamically stable patient is safe and associate
d with decreased ileus and shorter length of stay
- In addition, patients are able to undergo subsequent
restorative proctectomy sooner than patients who have open
abdominal colectomy.
-