Review

Ashraf M. AbdelKader
General surgery Lecturer
Faculty of medicine
Banha University
2014 1
IBD
 Definition ,Epidemiology ,Etiology and Pathology .

 Diagnosis and Activity Assessment :

1. Clinical .
2. Radiological .
3. Endoscopic .
4. Histological .

 Treatment of active IBD

 (IBD)
It is an idiopathic inflammatory intestinal disease resulting from
an inappropriate immune activation to host intestinal
microflora.

Types of IBD are

 Ulcerative colitis
 Crohn’s disease
 Indeterminate colitis
GEOGRAPHICAL
PREVALENCE OF IBD
Europe NA
 Age-Specific Incidence of IBD *
Ulcerative Colitis Crohn’s Disease
10 10

8 8

6 6

4 4

2 2

0 0
0 20 40 60 80 0 20 40 60 80
Age (yrs) Age (yrs)
Incidence in both CD and UC have 2 peaks
( in 3 rd and 6 th decades ).
Current Etiologic Hypothesis for IBD
One model of IBD pathogenesis. Aspects of both CD and UC.
Comparison of the distribution patterns, ulcers and wall
thickenings of CD and UC.
 Pathological Features That Differ between CD and UC

Artwork is reproduced, with permission, from the Johns Hopkins Gastroenterology and Hepatology Resource Center,
www.hopkins-gi.org,copyright 2006, Johns Hopkins University, all rights reserved.
CD: Gross Appearance
UC: Gross Appearance
 Diagnosis and Assessment

of Activity in IBD
THERE IS NO ONE SINGLE TEST
TO D X I B D
 Clinical
diagnosis
and
Assessment of IBD Activity
Clinical presentation of IBD
A- symptoms:
- diarrhea
- rectal bleeding
- tenesmus
- passage of mucus
- abdominal pain
- other symptoms: anorexia,
nausea, vomiting, fever,
and weight loss
 B- Signs

Examination findings in CD
 Loss of weight
 General ill health
 Aphthous ulceration of mouth, glossitis angular stomatitis
 Abdominal tenderness and RIF mass
 Perianal skin tags, fissures, fistulae
Examination findings in UC
 Hydration & volume status determined by B.P
 Pulse rate
 High temperature
 Abdominal: Tenderness & evidence
of peritoneal inflammation
 Presence of blood on DRE
 Clinical findings That Differ between CD and UC
CD UC

Defecation Often porridge like Often mucus-like and

,sometimes steatorrhea with blood

Tenesmus Less common More common

Fever Common Indicates severe
disease
Fistulae Common Seldom

Weight loss Often More seldom

Malignant With colonic Yes
potential involvement

Toxic megacolon No Yes

after surgery Recurrence is common No recurrence
Artwork is reproduced, with permission, from the Johns Hopkins Gastroenterology and Hepatology Resource Center,
www.hopkins-gi.org,copyright 2006, Johns Hopkins University, all rights reserved.
Complication of UC
 Haemorrhage
 Perforation
 Toxic megacolon (transverse colon with a diameter of
more than 5 cm to 6cm with loss of haustration
 Cancer: with active colitis of more than eight year
 Complication of CD
 Strictures with intestinal obstruction
 Abscesses
 Fistulas
 Cancer: Risk related to the severity and duration of the disease.

watering-can perineum secondary to severe

perianal Crohn disease.
Clinical Assessment of Activity in IBD

 A-Ulcerative colitis Clinical Activity Index(UCCAI)

 B-Crohn's Disease clinical Activity Indices:

I - Harvey-Bradshaw index
II - Crohn's Disease Activity Index
 A-Ulcerative colitis Clinical Activity Index.
Criteria for Evaluating Severity of Ulcerative Colitis
Criteria Mild Severe Disease Fulminant Disease
Disease
Stools < 4/day > 6/day > 10/day
Blood in stool Intermittent Frequent Continuous
Temperature Normal > 37.5°C > 37.5°C
Pulse Normal > 90 beats/min > 90 beats/min
Hemoglobin Normal < 75% of normal Transfusion required
ESR ≤30 mm/hr > 30 mm/hr > 30 mm/hr
Colonic _ Air, edematous wall, Dilatation
features on thumbprinting
radiography
Clinical signs _ Abdominal Abdominal distention
tenderness and tenderness
 B-Crohn's Disease clinical Activity Indices
I - Harvey-Bradshaw index
 A-general well-being (0 = very well, 1 = slightly below
average, 2 = poor, 3 = very poor, 4 = terrible)
 B- abdominal pain (0 = none, 1 = mild, 2 = moderate, 3 =
severe) .
 C- number of liquid stools per day.
 D- abdominal mass (0 = none, 1 = dubious, 2 = definite, 3 =
tender) .
 E- Complications, with one point for each.
-----------------------------------------------------------------------------
A score of less than 5 represent clinical remission.
II - Crohn's Disease Activity Index(CDAI)
Crohn's Disease Activity Index.
Clinical or laboratory variable Weighting factor

Number of liquid or soft stools each day for seven days x2

Abdominal pain (graded from 0-3 on severity) each day for seven x5
days
General well-being, subjectively assessed from 0 (well) to 4 x7
(terrible) each day for seven days

Presence of complications* x 20

Taking Lomotil or opiates for diarrhea x 30

Presence of an abdominal mass (0 as none, 2 as questionable, 5 as x 10

definite)
Hematocrit of <0.47 in men and <0.42 in women x6

Percentage deviation from standard weight x1

Remission of CD below 150.

Severe CD greater than 450
Laboratory tests
for
diagnosis
and
Assessment of IBD Activity
A-Routine blood work
 CBC: HB, WBCS and platelets.

 Nutritional evaluation:
Vitamin B12 , iron studies, folate & other nutritional
markers
 B - Serological Markers
ESR
In UC, the correlation between ESR and disease activity is good.
In CD, the ESR appears to be a less accurate measure of disease
activity.
CRP
CRP is a valuable marker to detect the activity of IBD Can be
used as a marker to treatment response
Orosomucoid :
The levels of circulating orosomucoid correlate with
disease activity of IBD.
C-Serologic Markers Antibodies
 1-Anti-neutrophil cytoplasmic antibodies (ANCAs)
 2-Antibodies to outer membrane porin (Anti-OmpC).
 3-Anticarbohydrate antibodies: antilaminaribioside
carbohydrate IgG (ALCA).
D-Fecal Biomarkers
Fecal calprotectin
Measured in stool by ELISA
sensitive marker of inflammation
Fecal lactoferrin
Measured in stool by ELISA
Sensitive marker of inflammation
Fecal S100A12:
Detectable in serum and stool
But the fecal assay is more sensitive and specific for
IBD
 Radiological
Diagnosis
and
Assessment of IBD activity
Barium enema
 Abdominal Ultrasonography

Endoscopic Ultrasound Abdominal Ultrasonography

 Computed tomography

Mural enhancement Comb sign Intestinal stricture with

prestenotic dilatation.
Magnetic resonance enterography with gadolinium contrast in
CD. shows mural hyperenhancement, mural thickening, and the comb
sign (engorged perienteric vasculature) involving the terminal ileum.
(signs of active disease ).
VI - Wireless capsule endoscopy
(WCE)
VII-Double balloon enteroscopy
 VIII-Nuclear Medicine
Tc-99m (WBC) imaging is superior to contrast
radiology for assessing the extent and activity of
inflammatory bowel disease. can be used to accurately
distinguish CD from UC .

More recently PET/CT and PET-MRI has been

combined with CT enterography or enteroclysis
techniques to further improve localization and reduce
false positives
PET-MRI of patient with cecal active inflammation
 Endoscopy
for Diagnosis
and Assessment of IBD activity
Endoscopic Features of IBD
Ulcerative colitis

 Edema

 Erythema/Loss of vascularity

 Friability

 Erosions

 Mucopurulent exudate

 Spontaneous bleeding

 Ulceration

45
Endoscopic Features of IBD
Crohn’s Disease
 Patchyedema, erythema
(Discontinuous)

 Apthous ulcerations

 Coalescing ulcerations

 Cobblestoning

 Longitudinal “bear claw” ulcers

46
2- Endoscopic Indices of IBD Activity
A-Endoscopic assessment of disease activity in the UC

I - The Mayo Score.

II- The Baron Score

III - The Ulcerative Colitis Endoscopic Index of Severity (UCEIS).

B - Endoscopic assessment of disease activity in the CD

I - Crohn’s Disease Endoscopic Index of Severity (CDEIS).

II - Endoscopic Crohn’s Disease Index (SES-CD).

III - Rutgeerts’ score .

A - Endoscopic assessment of disease activity in
the ulcerative colitis.
I - The Mayo Score
score Endoscopic Findings Disease
severity
0 Normal mucosa , Mucosal healing or Inactive
inactive UC
1 Mild friability, reduced vascular pattern, and Mild disease
mucosal erythema
2 Friability, erosions, complete loss of Moderate
vascular pattern, and significant erythema disease

3 Ulceration and spontaneous bleeding Sever disease

 II-The Baron Score
score Endoscopic findings

0 Normal mucosa with no bleeding and normal

vascular pattern present throughout the colon
1 Abnormal mucosa that is not expressly hemorrhagic

2 Bleeding with light intervention with an instrument

of the mucosa but no spontaneous bleeding
3 Spontaneous bleeding before the instrument is
introduced.

Endoscopic activity is defined as a Baron Score of >1

 III-The Ulcerative Colitis Endoscopic Index of Severity
(UCEIS) (It is a newer scoring system)
Score Endoscopic findings (vascular pattern)

1 normal vascular pattern

2 partial loss of pattern
3 complete obliteration of vascular pattern
Score Endoscopic findings (Bleeding)
1 none
2 mucosal bleeding
3 mild colonic luminal bleeding
4 moderate or severe luminal bleeding
Score Endoscopic findings (Erosions and ulcers )
1 none
2 erosions
3 superficial ulcerations
4 deep ulcers
B - Endoscopic assessment of disease activity in the CD

I - Crohn’s Disease Endoscopic Index of Severity (CDEIS)

Rectum Sigmoid and left colon Transverse colon Right colon Ileum
Total
Deep ulcerations (12 if present) Total 1
Superficial ulcerations (12 if present) Total 2
Surface involved by disease (cm) Total 3
Surface involved by ulcerations (cm) Total 4
Total 1 + Total 2 + Total 3 + Total 4 = Total A
Number of segments totally or partially explored n
Total A ⁄ n = Total B
If an ulcerated stenosis is present anywhere add 3 = C
If a non-ulcerated stenosis is present anywhere add 3= D
Total B + C + D = CDEIS
II - Rutgeerts’ score
Grade Endoscopic findings
i0 No lesions in the distal ileum
i1 ≤ 5 apthous lesions
i2 >5 apthous lesions with normal mucosa between the
lesions, or skip areas of larger lesions or lesions
confined to ileocolonic anastomosis
i3 Diffuse apthous ileitis with diffusely inflamed mucosa
i4 Diffuse inflammation with already larger ulcers,
nodules, and ⁄ or narrowing

Rutgeerts’ score is the gold standard for

Endoscopical post-surgical recurrence evaluation
Histological Examination
for
Assessment of IBD activity
A - Histological Assessment of activity in UC
Histologic scoring system for the assessment of severity in UC.
Grade 0 Structural (architectural change) Subgrades : 0.0 No
abnormality 0.1 Mild abnormality 0.2 Mild or
moderate diffuse ormultifocal abnormalities 0.3 Severe
diffuse or multifocal abnormalities

Grade 1 Chronic inflammatory infiltrate Subgrades 1.0 No increase

1.1 Mild but unequivocal increase 1.2 Moderate increase
1.3 Marked increase
Grade 2 Lamina propria neutrophils and eosinophils
2A Eosinophils 2B Neutrophils
Grade 3 Neutrophils in epithelium
Grade 4 Crypt destruction
Grade 5 Erosion or ulceration.
B - Histological Assessment of activity in CD
Pointes of histologic assessment of disease activity in CD
Histologic findings Score
Epithelial damage 0-2
Architectural changes 0-2
Mononuclear infiltrate in LP 0-2
PMN infiltrate in epithelium 0-3
Erosion / ulcers 0-1
Granulomas 0-1
Proportion of biopsies affected 0-3
Fig. 14:UC. Mucosal atrophy with loss Fig.15: CD Stomach. Gastric mucosal
of crypts. Neutrophils are still present biopsy containing two characteristic
in the lumen and wall of one of the granulomas. (H&E x10).
crypts indicating persistent activity.
(H&E x10).
 Ischemic colitis
 Intestinal tuberculosis
 Radiation-induced colitis
 Arteriovenous malformations
 NSAID enteropathy
 Behcet disease
 Colorectal malignancy
 AIDS
 Celiac disease
 Microscopic colitis
 Irritable bowel syndrome
 Lactose intolerance
 Functional diarrhea
 Gastrointestinal infections
 Behcet disease
 Colorectal malignancy
Principles For Treatment
of active IBD
 One size does not fit all.

 Risks vs benefits.
TREATMENT
Treatment for IBD may include:

DIETARY CHANGES LIFESTYLE CHANGES

DRUG THERAPY SURGERY

 Dietary Changes
 Eating :

 Low-fat foods.
 Smaller, more
frequent meals.

 Avoiding :

 foods high in
undigestible fiber.
 Refined sugars .
LIFESTYLE CHANGES
.

Taking rest No smoking

Doing exercise Stress reduction

Acute Management of Active IBD
Treatment
 General Care
Proper resuscitation.
Hospitalization.
Bowel rest to reduces the volume of diarrhea.
Blood products should be administered to treat
significant anemia or coagulopathy.
Pain relievers. Acetaminophen.
Iron supplements.
Nutrition(TPN).
Avoid (Narcotics, antidiarrheal agents and
anticholinergic ) can precipitate toxic dilation of the
colon.
Drug Therapies
1- 5-Aminosalicylates (5-ASA)
2- Glucocorticoids (steroids)
3- Antibiotics
4- Immunosuppressants
Thiopurines
Azathioprine
6-mercaptopurin
Methotrexate
Cyclosporine
5- Biological Therapy
Infliximab
 1- 5-ASA; Sulfasalazine (Supp. , enemas or Oral)
Distribution of 5-ASA Preparations
Oral
•Varies by agent: may be released in the
distal/terminal ileum, or colon1

Liquid Enemas
• May reach the splenic flexure2-4
• Do not frequently concentrate in the rectum3

Suppositories
• Reach the upper rectum2,5
(15-20 cm beyond the anal verge)

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.
2 - Hydrocortisone or Methylprednisolone (IV , Oral or
enema)
 Fast symptom relief
 40 to 60 mg/day in a continuous I.V. infusion
 5 to 10 days
 Not advised for prolonged use (120 day max)
 Does not improve long term surgery rates

3 - Ciprofloxacin +/- Metronidazole

 Effectiveness arguable but often seen used anyway
4 - IV Cyclosporine 2-4 mg/kg

 Effective for induction of remission but not long-term

maintenance
 Patients who did not respond to I.V. steroid
 If no improvement within 4 to 5 days or if complete
remission is not achieved by 10 to 14 days, surgical
treatment is advised. (32)

5 - Infliximab is currently approved for use in IBD

Induction- 3 separate infusions of 5 mg/kg for
moderate to severe IBD at weeks 0, 2, and 6
Maintenance- infusions every 8 weeks
Surgical
Management of
IBD

74
Indications for surgery in ulcerative colitis
Urgent Surgery Elective Surgery
Ongoing hemorrhage Failure of medical therapy
Toxic megacolon Intolerable side effect of
medical therapy
Colonic perforation Development of dysplasia
Fulminant ulcerative colitis Carcinoma
Colonic stricture
Growth retardation in
children
*Current Surgical Therapy 9th Edition
Artwork is reproduced, with permission, from the Johns Hopkins Gastroenterology and Hepatology Resource Center,
www.hopkins-gi.org,copyright 2006, Johns Hopkins University, all rights reserved.
Artwork is reproduced, with permission, from the Johns Hopkins Gastroenterology and Hepatology Resource
Center,
Indications for surgery in Crohn’s Disease
Urgent Surgery Elective Surgery
Perforation Stricture
Abscess Fistula
Uncontrollable Malignancy
hemorrhage
Toxic megacolon Malnutrition
Bowel obstruction Poorly controlled despite
management
Extra-intestinal manifestations

*Medical Management of the Surgical Patient: A Textbook of Perioperative Medicine

*ASCRS – American Society of Colon and Rectal Surgeons
Surgical treatment
Artwork is reproduced, with permission, from the Johns Hopkins Gastroenterology and Hepatology Resource Center,
www.hopkins-gi.org,copyright 2006, Johns Hopkins University, all rights reserved.
Thank You