Inflammatory bowel disease

（IBD）
Zhenjiang First People's Hospital
Caiyu Qiu
2020-02-24
 purposes and requirements
1.Grasp the clinical manifestations of IBD
2.Grasp the identification of Crohn's disease (CD)and ulcerative
colitis (UC)

3.Familiar with the differential diagnosis and treatment of IBD

4.To understand the etiology, pathogenesis and complications of

IBD

5.Understand the pathological features of IBD

 Definition
IBDs：are chronic inflammatory diseases of
the gastrointestinal tract, including ulcerative
colitis(UC) and Crohn's desease（CD）.

They are diagnosed by a set of

clinical,endoscopic,and histologic characteristcs,
but no single finding is absolutely diagnostic for
one disease or the other.
 Etiology and pathogenesis
The etiology of this disease is unknown, the
pathogenesis is not very clear.

It can be caused by multi-factor interactions,

including environmental, infectious, genetic,
immune and other factors.
 Environmental factor

• The incidence of developed countries

continued to increase
• Smoking can promote thrombosis, increase
the risk of Crohn's disease, but can prevent
the role of UC
• Fast food increases the incidence of CD, UC.
Another cause of allergic food may aggravate
intestinal reaction
 Infectious factors
 Some infectious bowel disease have the similar
clinical symptoms (symptoms,pathology)
No positive results are found during long-term
exploration of suspicious pathogen by a variety of
channels.
Tuberculosis infection：Mycobacterium
tuberculosis DNA is detected by PCR in Crohn's
disease. There is chronic granulomatous
inflammation in CD, similar to mycobacterium
granuloma.
 Others
• Virus, chlamydia infection: failed to
make experimental animal model (poor
repeatability)

• Most scholars believe that bacterial

infection may be its trigger factor
 Abnormal immune response (self-normal
intestinal flora）
Animal models and experiments have confirmed:
• No pathogenic or minor damage in aseptic state.

• Inflammatory lesions often occur in densely

populated parts of the bacteria where the positive
rate of the bacteria migrate is 60%. Other parts of
the intestine normal flora translocation also
increased. So bacterial retention can promote the
occurrence of CD.
• Therefore, IBD patients may have defects in immune
tolerance to normal flora
 Immune factors
The relationship between the IBD and the abnormal immune response
is important.
Various autoantibodies→Pathological damage→Disease occurs
p-ANCA（Antineutrophil cytoplasmic antibody,抗中性粒细胞胞浆
抗体） UC↑
CCA-IgG（Colitis conjunction antibody,结肠炎结合抗体）
UC↑
T cells Th1 lymphocytes CD ↑ ↑
Th2 lymphocytes UC ↑ ↑
Immune factors, inflammatory mediators: Regulatory cytokines IL-2
Immunosuppressive cytokines IL-10
Pro-inflammatory cytokines IL-6
Repair substances participated in inflammatory damage：
Reactive oxidation products
Nitric oxide（NO)
 Genetic factors

• A large number of research data show that:

The rate in the monozygotic twins is higher
than in dizygotic twins.

The first-degree relatives of patients have high

incidence, but the incidence of spouses is not
high.
 Spiritual factors
Mental depression and anxiety may have
some impact on the occurrence and recurrence of
this disease. Mental factors can be the cause of
the disease attacks, it can aslo be the secondary
manifestations of recurrent seizures ot this
disease.
 Main content
Overview
pathology
Clinical manifestations
CD Laboratory and other examinations Diagnostic UC
criteria
Differential diagnosis
Treatment
 Ulcerative colitis
The etiology of rectal and colitis lesions is unknown.
Lesions are limited to the large intestine mucosa and
submucosa.

Clinical manifestations: repeated diarrhea, Mucus purulent

blood feces, abdominal pain

The disease can occur at any age, more common in 20 to

40 years old, the incidence of men and women has no
significant difference.
 Pathology
•Lesion site：Located in the large intestine, is non-
segmental distribution of continuity, mostly in the rectum,
sigmoid colon. Can also be extended to the whole colon, if
involved the terminal ileum, known as IPD

•Early lesions：Mucosal diffuse inflammation, showing

congestion, edema, focal hemorrhage, mucosal surface
diffuse fine granular, tissue brittle, easy to bleed of touch
ing. A shallow ulcer, crypt abscess, goblet cell reduction,
lesions mainly in the mucosa and submucosa
 Pathology

• Advanced course of disease : a large

number of granuloma tissue hyperplasia,
false polyps, shorten the deformation of
the colon, intestinal narrowing, a few can
turn into cancer
 Clinical manifestations
• Most of the slow onset, a small number of acute
onset, occasionally outbreak onset

• The course of disease was chronic, alternation

between seizure and remission, a small number
can be continued and gradually increased
• Causes: eating disorders, fatigue, mental
stimulation, infection and so on
• Clinical manifestations are related to the
extent of the disease, clinical type and
duration of the disease
 Digestive system symptoms
diarrhea Mainly due to inflammation caused by
colonic mucosa on sodium and water absorption
disorders and colonic motility disorders
Features: mucus purulent blood feces
Abdominal pain：Different levels of pain
Location: left lower quadrant
Features：dull pain，Paroxysmal pain
persistent severe abdominal pain in toxic megacolon，
Other: Often abdominal swelling, loss of appetite,
nausea, vomiting and so on
 Signs

 Light, moderate type: left lower quadrant

tenderness, strip mass

Severe and fulminant type: obvious tenderness

and irritable bowel

 Peritonitis can occur when complications such

as toxic colon dilation and intestinal perforation
occur
Performance
Active period：Low or moderate fever,
severe or complications with high fever,
fast heart rate.
Progress and deterioration of
patients:Organ failure, weight loss,
anemia, water and electrolyte imbalance,
hypoproteinemia, nutritional disorders
 Extraintestinal manifestations
• Peripheral arthritis, erythema nodosum,
pyoderma gangrenosum, outer sclera, anterior
uveitis, oral recurrent ulcer;
Sacroiliitis, Forced Spondylitis, Primary
Sclerosing Cholangitis, Amyloidosis, etc.
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 Clinical classification
Comprehensive classification according to
the course, extent, scope and duration
According to the course of the type：
Initial, chronic relapse, chronic persistent,
acute type
• Severity classification
 mild: 4 times / day diarrhea, no systemic symptoms, ESR
normal

 moderate: between light and severe, usually refers to

diarrhea 4 times / d or more, with only mild systemic
manifestations

 severe: diarrhea 6 times/d or more, obvious mucus bloody

stool, T> 37.5 ℃, P> 90 beats / min, Hb≤100g / L, ESR>
30mm / h, serum albumin <30g / Obviously relieved
 Complication
Toxic megacolon:Occurs more in fulminant
or severe patients.
Rectal and colon cancer
Other complications:
The incidence of colon bleeding about 3%,
intestinal perforation, intestinal obstruction rare.
 According to the lesion range type:
 Rectitis
 Left-sided colitis (colon spleen far)
 Total colitis
 According to stage of the disease :
 Active period
 Remission
 Laboratory and other tests
1.Blood test：
• Hb: moderate and severe patients decrease↓
• WBC：Active period increase↑
• ESR(erythrocyte sedimentation rate)↑and CRP↑：
the marker of active period
• Serum albumin ↓
• Water and electrolyte imbalance
• PT(prothrombine time) be extended
 Laboratory and other tests
2.Stool examination：
• Routine examination: Often mucus, pus and
blood stool, microscopic examination with
RBC, WBC and macrophages
• Etiological examination： to exclude
infectious colitis
 Laboratory and other tests
3. Autoantibodies detection

Specific antibodies

Specificity UC p－ANCA 14％～98％

CD ASCA 56％～92％

(antisacchromyces cerevisia antibody)

 Laboratory and other tests
4. Colonoscopy:
Characteristic lesions are:
Mucosal rough fine particles, mucous membrane
blood vessels, crisp easy to bleed
Multiple mucosal superficial ulcers, its shape,
size,diffuse distributed, with purulent discharge,
mucosal diffuse congestion, edema
Pseudo-polyps (inflammatory polyps) form, colon
bags often blunt or disappear
 Laboratory and other tests

• Biopsy: see the performance of

inflammation, may have erosion, ulcers,
crypt abscess, abnormal glandular structure,
goblet cells and epithelial changes
Early stage
of UC in
rectum
早
期
（
轻
度
）
溃
结

直
肠
中
度
溃
结

直
肠
溃
结

乙
状
结
肠
，
中
度
溃
结

降
结
肠
，
中
重
度
溃
结

脾
曲
溃
结

横
结
肠
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 Laboratory and other tests

5.X barium enema examination：

purpose：
① determine the lesion site and scope
② understand disease activity and severity
③ confirm complications and differential
diagnosis
 performance：

• Mucosa rough or fine particles change

• Multiple shallow ulcers, manifested as burr-like edges or jagged edges

of the tube wall, and see the niche shadow or bar-shaped barium
storage areas, but also seen a small number of small prototype filling
defect

• colon bag disappeared, intestinal wall hardening, intestinal shortened,

thinner, can be plumbous

• polyps formation
 Diagnostic criteria
 Clinical manifestations: persistent or recurrent diarrhea
and mucus abscess, abdominal pain, tenesmus, with or
without systemic symptoms of varying degrees, in the
exclusion of infectious enteritis, Crohn's disease, ischemic
enteropathy, radiation enteritis, etc. On the basis of having
at least one of the above important changes in colonoscopy
and mucosal biopsy histology can diagnose the disease.
• The initial cases of disease, clinical
manifestations, colonoscopy atypical cases do
not make a diagnosis temporarily, followed up
for 3-6 months to observe the onset of the
situation.
 Diagnostic steps
Clinical chronic diarrhea, mucus or mucus bloody
stool, suspected of the disease should be checked as
follows:
 Multiple stool culture to find dysentery bacilli, smear
amoeba and according to the characteristics of
endemic areas except for schistosomiasis check
 Colonoscopy, also known as mucosal biopsy, fulminant
and critically ill patients can suspend examination
 Barium enema examination to determine the nature of
disease, extent and scope, except for other intestinal
diseases
 Differential diagnosis

• Chronic bacterial dysentery

• Amoeba enteritis
• Chronic schistosomiasis
• Colorectal cancer
• Irritable bowel syndrome
• CD
 Identification of UC and CD in Colon
project Crohn's Disease Ulcerative Colitis

symptom Have diarrhea, but sepsis Pus and blood will be more
less common

Lesions distribution segmental Continuous disease

Rectal involvement Rare Mostly involved

The distal ileum More common Rare,

involvement

Intestinal stenosis More common, eccentric Rare, central

Fistula formation commom rare

 Identification of UC and CD in Colon

Endoscopic Longitudinal or Superficial ulcers,

performance creeping ulcers with mucosal diffuse
peripheral mucosal congestion, edema,
normal or pebble- granular, increased
like changes brittleness

Pathological changes Segmental whole Lesions mainly in the

wall inflammation, mucosal layer, a
fissure Superficial ulcer,
crypt abscess, goblet
cells decreased
 Treatment
Control of acute attack, mucosal healing, maintain
remission, reduce recurrence, prevention and treatment of
complications
General treatment:
• rest, diet and nutrition
• Correct water, electrolyte imbalance
• Blood transfusion to improve anemia, lose albumin and so
on
•Serious cases of fasting, intravenous nutrition
•Psychological treatment
•Abdominal pain, diarrhea symptomatic treatment, control
of secondary infection
 Treatment
• medical treatement:
Amino salicylic acid formulations
Sulfasalazine（SASP)
5-Aminosalicylic acid（5-ASA）：
Lesions confined to the sigmoid colon can be
considered enema treatment
Glucocorticoids：
Immunosuppressant
 Treatment
•Surgical treatment：

Emergency surgery indications：Large

bleeding, intestinal perforation, heavy patients,
especially with toxic colon dilatation after active
medical treatment ineffective with severe sepsis
 Crohn's disease
• Crohn's disease, known as localized
enteritis, Crohn's disease or
granulomatous enteritis, is an
unexplained gastrointestinal chronic
inflammatory granulomatous disease
Presents with one of three major patterns:
• Disease in the ileum and cecum(40% of
patients)
• Disease confined to the small intestine(30%)
• Disease confined to the colon(25%)
• Much less commonly, Crohn’s disease
involves more proximal parts of the
gastrointistinal tract----the
mouth,tongue,esophagus,stomach,and the
duodenum.
 Pathology
Invasion sites: the distal ileum and the right colon
most commonly
Lesions are segmental distribution
Pathological features: Histology of the entire wall
enteritis, lymphatic vessel occlusion, lymph leakage,
submucosal edema, intestinal non-cheese
granulomatous inflammation
Crohn's disease lesion (shaded part of the lesion)
•Clinical manifestations

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 The digestive system performance
• Abdominal pain: the most common symptom
• Location: right lower quadrant or umbilical
• Characteristic：Intermittent seizures, spasmodic pain
accompanied by bowel, postprandial exacerbation,
temporary relief after defecation
Such as persistent abdominal pain, tenderness
significantly, suggesting that inflammation affects the
formation of peritoneal or intraabdominal abscess
• Acute abdomen: may be caused by acute perforation of
intestinal lesions
 the digestive system performance
• Diarrhea: a common symptom
• Caused by the inflammatory bowel disease
exudation, increased peristalsis and secondary
malabsorption
• Features: Intermittent diarrhea, Moxibustion,
usually without purulent blood or mucus, lesions
involving the lower colon or rectum, may have
mucus and tenesmus
• Abdominal mass:10% to 20% patients, in the
right lower quadrant and umbilical
 the digestive system performance
• Fistula formation：Due to transmural inflammatory
lesions penetrate the full thickness of the intestinal wall
to the parenchyma tissue or organ. Fistula formation is
one of the clinical features of Crohn's disease, and
divided into internal and external fistula

• Lesions around anus and rectum. : fistula, abscess

formation and anal fissure and other lesions, is part of
the patient's first symptom
Systematic performance

• fever

• Nutritional disorders

• Acute exacerbation of water, electrolyte

disorders
 Parenteral manifestations
Similar to parenteral manifestations of UC
oral mucosal ulcers, erythema nodosum,
arthritis and eye disease common.
 Complication
•intestinal obstruction: The most common
•Abdominal abscess
•Malabsorption syndrome
• Acute perforation, a lot of blood in the stool：
Occasionally
• Toxic colon dilatation：rare
• Cancerous：1%
• Paraintestinal complications：Cholelithiasis,
urinary tract stones, fatty liver
 Laboratory and other examinations
anemia，Hb↓，Active period:WBC↑，ESR↑，
Serum albumin↓，Stool Occult blood(OB) test (+)
X-ray examination：
Performance: mucosal folds Rourui, longitudinal
ulcer or cleft, cobblestoning sign, false polyps,
multiple stenosis, fistula formation and other signs,
the lesions were segmental distribution. Visible
jump sign, line-like sign
 Laboratory and other examinations
Endoscopy：
1、Segment distribution
2、See longitudinal or creeping ulcers,
cobblestoning sign
3、Intestinal stenosis, inflammatory polyps，
Mucosal appearance is normal between the bowel
lesions
Biopsy: Non-caseous necrotizing granuloma
Transverse
colon
Ileocecal
Department
Descending
colon
rectum
Sigmoid
colon
 Diagnostic criteria

A comprehensive analysis of clinical

diagnosis of Crohn's disease is mainly
based on history, X-ray and colonoscopy.
However, the need to rule out intestinal
or non-infectious diseases and intestinal
cancer.
WHO standards：
①Discontinuous bowel leisions
②Intestinal mucosa is paved a cobblestone appearance
or longitudinal ulcers
③A full-thickness intestinal inflammatory disease with
lumps or stenosis
④Nodular non-cheese necrotizing granuloma
⑤Fissure or fistula
⑥Anal lesions, refractory ulcers, anal fistula or anal
fissure
①②③Suspected；Plus④⑤⑥One can be diagnosed；
④plus the two of ①②③, also can be confirmed
Terminal small
intestine mucosal
change was
cobblestone.
Crohn's disease with
intussusception
Intestinal
mucosal edema,
thickening
 Differential diagnosis

• Identification with a variety of intestinal

infectious or non-infectious diseases and
intestinal tumor
 C D and intestinal tuberculosis identification
Clinical identification CD Intestinal tuberculosis
Parenteral tuberculosis (-) may have
Abdominal wall or organ may have (-)
abscess
Anorectal lesions may have (-)
Activity of the blood in the may have rare
stool
Intestinal fistula may have rare
Bowel perforation may have rare
PPD skin test (-) (+)
Blood ADA activity (-) have
increased
acid bacilli in urine or (-) (+)
stool
Postoperative recurrence high low
rate
Anti-TB treatment invalid Good effect
 C D and intestinal tuberculosis identification
Pathological Crohn's disease Intestinal tuberculosis
identification
Cracked ulcer More common rare
Lymphocyte common visible
accumulation
Submucosa widened common have

Lymphatic vessels, common have

vasodilation
Submucosa atresia rare have
Muscle damage rare have
Lymph node or no common
intestinal wall
Caseous necrotizing
granuloma
 Treatment
Objective:
To control the disease activity,
mucosal healing,
maintain remission and prevent
complications
• General treatment:
 Dietary conditioning and nutritional
supplements, add a variety of vitamins and trace
elements
 Severe malnutrition, intestinal fistula and short
bowel syndrome, total parenteral nutrition
 Severe illness fasting, transfusion, albumin,
broad-spectrum antibiotics
 Abdominal pain, diarrhea symptomatic
treatment
• Glucocorticoids:
For the active period, especially in small
bowel disease, there are extraintestinal
manifestations. Can not prevent recurrence,
prednisone 30 ~ 60mg / day, reduce the
severity of the disease to maintain
• Immunosuppressant:Applicable to the poor
efficacy of or hormone-dependent chronic
active cases, can reduce the amount of
hormones
• Azathioprine
Methotrexate
Cyclosporine
• Amino salicylic acid formulations：
SASP
5-ASA
• Others：
antibiotics
Surgical treatment: high recurrence rate
after surgery
Surgery indications: limited to complete
intestinal obstruction, fistula and abscess
formation, acute perforation or
uncontrollable bleeding
Proinflammatory cytokines or immune
modulators
Thinking questions

• 1. UC diagnostic criteria？
• 2. CD diagnostic criteria？
• 3.UC and CD identification？
THANKS
FOR WATCHING