Inflammatory Bowel Diseases

Inflammatory
bowel diseases
Objectives
• Define the IBD
• Classify inflammatory bowel disease
• describe common presenting
symptoms
• Outline the important investigations
• outline management of ulcerative
colitis and Crohn's disease.
• List the most important complications
of both diseases
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Inflammatory bowel
diseases
• Ulcerative colitis and Crohn's disease
an immune-mediated chronic
inflammatory bowel diseases with
relapsing and remitting course
• ulcerative colitis only involves the colon

• Crohn's disease can involve any part of the
gastrointestinal tract from mouth to anus.
Inflammatory bowel
diseases
Etiology
• abnormal host response to an
environmental trigger in genetically
susceptible individuals
• This causes inflammation of the intestine

and release of inflammatory mediators,
such as TNF, IL-12 and IL-23, which
cause tissue damage.
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Inflammatory bowel
diseases
Pathology
Ulcerative Colitis
Macroscopic Features
• Inflammation from proximally to involve
all or part of the colon.
• 40–50% of patients involve the rectum ,
rectosigmoid
• 30–40% beyond the sigmoid
• 20% have a total colitis
Inflammatory bowel
diseases
• Inflammation is diffused
Mild :
• the mucosa is erythematous and fine
granular surface
more severe
• the mucosa is hemorrhagic, edematous,
and ulcerated (superficial diffused)
fulminant disease can develop a toxic
megacolon where the bowel wall thins and
the mucosa is severely ulcerated
In long-standing disease
• inflammatory polyps (pseudopolyps) may
be present as a result of epithelial
regeneration.
Inflammatory bowel
diseases
Ulcerative Colitis
Microscopic Features
• Mucosal vascular congestion, edema and
focal hemorrhage
• inflammatory cell infiltrate of neutrophils,

lymphocytes, plasma cells, and
macrophages may be present.
• The neutrophils invade the epithelium,

usually in the crypts, giving rise to
cryptitis and, to crypt abscesses ,
• the crypt architecture of the colon is
distorted
Inflammatory bowel
diseases
Crohn's Disease:
Macroscopic Features
• 30–40% of patients have small-bowel
alone
• 40–55% have disease involving the ileum
and the Rt colon
• 15–25% have colitis alone.
• 30 % have anal involvement
• the rectum is often spared in CD.
Inflammatory bowel
diseases
• segmental inflammation (skip areas of

inflammation)
• Aphthous ulcerations
• stellate ulcerations fuse longitudinally and

transversely to demarcate islands of
mucosa that frequently are histologically
normal. "cobblestone" appearance
Inflammatory bowel
diseases
• Ulcers may penetrate bowel wall to initiate
abscesses or fistulas
• the bowel
• bladder
• uterus
• vagina
• skin of the perineum
• Bowel narrowed and fibrotic, with

chronic, recurrent bowel obstructions
Inflammatory bowel
diseases
Microscopic
• transmural inflammation
• fissures penetrate deeply into the bowel
wall
• bowel wall thickened
• chronic inflammatory infiltrate all layers.
• focal crypt abscesses
• noncaseating granulomas
Inflammatory bowel
diseases
Clinical features
• young adults (between 15 and 30 years) ,
second smaller incidence peak in the
seventh decade (between 60 and 80 years)
• The male to female ratio for UC is 1:1 and

for CD is 1.1–1.8.
• UC and CD have two- to fourfold

increased frequency in Jewish.
Inflammatory bowel
diseases
Clinical features
Ulcerative colitis
bloody diarrhoea relapses and remissions
Proctitis
• Rectal bleeding
• mucus discharge
• tenesmus.
• frequent, small-volume fluid stools
Proctosigmoiditis
• bloody diarrhoea with mucus.
Inflammatory bowel
diseases
Extensive colitis
• bloody diarrhea
• passage of mucus.
• Severe cramping
• abdominal pain can occur with severe
attacks of the disease.
• Constitutional symptoms do not occur
only in moderate to severe disease
Inflammatory bowel
diseases
severe colitis
• Bleeding
• Severe diarrhea
• severe pain
• fever
• Tachycardia
• Abdominal tenderness
• Edema
Inflammatory bowel
diseases
Crohn's Disease
• The major symptoms are
• pain is often associated with diarrhoea
• diarrhoea usually watery not contain

blood or mucus.
• weight loss
• intestinal obstruction sub acute or even
acute
• malabsorption
Inflammatory bowel
diseases
Crohn's colitis
• as ulcerative colitis
• rectal sparing
• Stricturing can occur in the colon
Inflammatory bowel
diseases
Perianal disease
• affects about one-third of
• large hemorrhoidal tags
• anal strictures
• anorectal fistulae
• perirectal abscesses.
• incontinence
Inflammatory bowel
diseases
Ileocolitis
• Recurrent right lower quadrant pain
• Diarrhea.
• palpable mass
• Fever , leukocytosis.
• Weight loss is common
• fistula formation
• abscess cavity
Inflammatory bowel
diseases
Small intestinal crohns

• malabsorption and steatorrhea.
• Nutritional deficiencies.
• vomiting from jejunal strictures or severe
oral ulceration.
Inflammatory bowel
diseases
Differential diagnosis
• Colitis
• Infective
• Non-infective
• Vascular
• Ischaemic colitis
• Radiation proctitis
• Idiopathic
• Collagenous colitis
• Behçet's disease
• Drugs
• NSAIDs
• Neoplastic
• Colonic carcinoma
• Other
• Diverticulitis
Inflammatory bowel
diseases
small bowel Crohn's disease
• Right iliac fossa mass
caecal carcinoma
appendix abscess
• Infection
intestinal tuberculosis
Yersinia
actinomycosis
• Intestinal Lymphoma
• Mesenteric adenitis
Inflammatory bowel
diseases
Complications
toxic megacolon
▪ Acute colonic dilatation due severe flare of
the colitis
▪ More with extensive colitis
▪ 5% incidence
▪ Precipitating factors as hypokalemia ,
antimotility, colonoscopy
Inflammatory bowel
diseases
Clinical features
▪ Features of severe colitis with
▪ Diffused abdominal distension
▪ Diffused tenderness
▪ Decrease bowel sound
▪ Lab sings of systemic inflammation
Treatment
▪ Conservative
Indication for surgery
▪ No response within 72 hr
▪ Sings of peritonitis or perforation
Toxic megacolon. Transverse colon diameter> 6 cm

Inflammatory bowel
diseases
Hemorrhage
• Acute Haemorrhage (major artery) is rare
Fistulas
Enteroenteric diarrhoea
malabsorption.
Enterovesical recurrent UTI
pneumaturia.
Enterovaginal a feculent
vaginal discharge.
Bowel fistulation perianal
ischiorectal
abscesses
fissures
.
Inflammatory bowel
diseases
Cancer
• active colitis of more than 10 years'.
• The cumulative risk 10%
• lower for Crohn's colitis.
• Tumours develop in areas of dysplasia
• surveillance programmes beginning 10
years after diagnosis by colonoscopy 1-2-
yearly.
• Moderate-high-grade dysplasia
panproctocolectomy
Inflammatory bowel
diseases
Strictures
in Crohn's disease
Extra intestinal complications
• common in IBD
• may dominate the clinical picture.
• Some of these occur during relapse of
intestinal disease
• others unrelated to intestinal disease
activity
• Include skin, joints, mouth, hematological,
caogulopathy, eye and hepatobiliary
Inflammatory bowel
diseases
Investigations
• confirm the diagnosis
• define disease distribution
• define activity
• identify complications.
• Full blood count may show anaemia
• Serum albumin.
• The ESR and CRP
• elevated in exacerbations and in response
to abscess formation
• Stool microscopy Culture
Inflammatory bowel
diseases
Endoscopy with Biopsies
• Confirm the DX
• define disease extent
• Detect dysplasia in long-standing colitis.
• Barium enema
• less sensitive investigation than
colonoscopy
• Useful in ileal Crohn's disease; affected
areas are narrowed and ulcerated, and
multiple strictures are common
• Abdominal CT and MRI scans
• provide bowel thickening
• pelvic or perineal involvement.
.
Inflammatory bowel
diseases
Management
• Treat acute attacks
• Prevent relapses
• Select patients for surgery
• Detect carcinoma at an early stage
Inflammatory bowel
diseases
Treat acute attacks
Aminosalicylates
Mode of action: modulate cytokine
release
oral or topical (enema/suppository)
mesalamine
• Pentasa (time dependent release)
• Ascol ( PH dependent release)
with carrier
• Sulfasalazine, balsalazide, olsalazine
Inflammatory bowel
diseases
Corticosteroids
▪ Anti-inflammatory
▪ Topical and oral and I.V
Cyclosporine
▪ Suppresses T-cell expansion
▪ Rescue' therapy to prevent surgery in
severe ulcerative colitis responding poorly
to corticosteroids.
▪ No value in Crohn's disease
▪ Major side-effects in
nephrotoxicity, infections, neurotoxicity
Inflammatory bowel
diseases
BIOLOGICS
Anti-TNF antibodies
(infliximab and adalimumab)
• Suppress inflammation and induce
apoptosis of inflammatory cells used:
• Fistulating Crohn's disease
• Severe active ulcerative colitis with no
response to steroids or cyclosporine
side effects:
• Anaphylactic reactions
• Contraindicated in the presence of
infections; reactivation of tuberculosis
• Anti IL23 ustekinumab
• ANTI integrin vedolizumab
Inflammatory bowel
diseases
Antibiotics
• Useful in perianal Crohn's disease
• Ciprol.and metronidazol
Antidiarrhoeal agents (codeine

phosphate,
loperamide, lomotil)
▪ Reduce gut motility and small bowel
secretion
▪ Avoided in acute flare-ups of disease
▪ May precipitate colonic dilatation
Inflammatory bowel
diseases
Prevent relapses
Thiopurines
(azathioprine, 6-mercaptopurine)
• Immunomodulation by inducing T-cell
cytotoxic effect
• Effective after 12 weeks of starting
therapy
Methotrexate
• Anti-inflammatory (folic acid antagonist)
• Used in crohns disease
biologics
Inflammatory bowel
diseases
Indications for surgery in ulcerative colitis
Failure of medical therapy
• Failure of remission induction(severe
colitis)
• Toxic megacolon no response to Rx
• Failure of remission
• Complications of drug therapy
Disease complications unresponsive to
medical therapy
• Arthritis , Pyoderma gangrenosum
Colon cancer or severe dysplasia
Impaired quality of life
• Loss of occupation or education
• Disruption of family life
Inflammatory bowel
diseases
Indications for surgery in Crohn's
disease
• The indications for surgery are similar to
those for ulcerative colitis.
• Unresponsive fulminant disease
• Operations are often necessary to deal with
abscesses
• relieve small or large bowel stricture.
• Chronic fistulating small bowel disease
may require resection if no reponse

Inflammatory Bowel Diseases

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Inflammatory Bowel Diseases

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Inflammatory

• ulcerative colitis only involves the colon

• This causes inflammation of the intestine

• inflammatory cell infiltrate of neutrophils,

• The neutrophils invade the epithelium,

• 15–25% have colitis alone.

• 30 % have anal involvement

• the rectum is often spared in CD.

• segmental inflammation (skip areas of

• stellate ulcerations fuse longitudinally and

• Bowel narrowed and fibrotic, with

• The male to female ratio for UC is 1:1 and

• UC and CD have two- to fourfold

• diarrhoea usually watery not contain

Small intestinal crohns

Downloaded from: StudentConsult (on 1 May 2012 09:12 AM)

Antidiarrhoeal agents (codeine

▪ Avoided in acute flare-ups of disease

▪ May precipitate colonic dilatation

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