Inflammatory Bowel Disease

7th year
Dr Felix Michelo.
OUTLINE
• Definitions • Crohn’s Disease
• Epidemiology • Pathology
• Clinical feature
• Pathogenesis • Diagnosis
• Ulcerative colitis • Complications
• Pathology • TREATMENT
• Clinical features
• Diagnosis
• Complications
DEFINITION
• Inflammatory bowel disease (IBD) is an idiopathic disease caused by a
dysregulated immune response to host intestinal microflora.
• Two common types occur: Ulcerative colitis and Crohn’s disease
• Not the same as irritable bowel disease
Crohn’s disease
• Extends into the deeper layers of
the intestinal wall, and may
occur anywhere from mouth to
anus
• Transmural inflammation and
skip lesions.
• In 50% cases -ileocolic,30% ileal
and 20% -colic region.
Ulcerative colitis
• Causes ulceration and
inflammation of the inner lining
of the colon and rectum.
• Mucosal inflammation and
continuous
• It is usually in the form of
characteristic ulcers or open
sores.
EPIDIMIOLOGY
Ulcerative colitis Crohns
Incidence / 1 lac. 2.2-14.3 3.1-14.6

Age of onset 15-30, 60-80 15-30, 60-80

Ethnicity Jewish Jewish

Male: Female 1:1 1.1-1.8 : 1
Smoking May prevent Causative

Oral contraceptives No risk 1.4 odds ratio

Appedicectomy Protective Not

Monozygotic 6% 58%

Dizygotic 0% 4%
Pathogenesis
• Exact cause is unknown.
• Associations made with:
• Genetic factors
• Immunological factors
• Microbial factors
• Psychosocial factors
Genetic factors

• Ulcerative colitis 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

Immunologic factors

• Defective regulation 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.
Microbial factors Psychosocial factors
• Altered response to gut • Stress
microorganisms • Luck of exercise
ULCERATIVE COLITIS
Pathology
Macroscopic feature
• Usually involves rectum & 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)
On endoscopy
• 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
Microscopic features
• Crypts atrophy & irregularity
• Superficial erosion
• Diffuse mixed inflammation
• Basal lymphoplasmacytosis
Clinical features

• Diarrhea
• Rectal bleeding
• Tenesmus
• Passage of mucus
• Crampy abdominal pain
• Diarrhea & bleeding blood-intermittent &mild pt may 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.
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
EXTRA INTESTINAL MANIFESTATIONS
COMPLICATIONS
Diagnosis

• Laboratory tests
• Endoscopy
• Radiography
• Biopsy
Laboratory tests

Hemogram
• C-reactive protein is increased
• ESR is increased
• Platelet count-increased
• Hemoglobin-decreased
• Fecal Calponectin levels correlate with histological
inflammation,predict relapses & detect pouchitis
ENDOSCOPY
• Always abnormal
• Loss of vascular patterns
• Granularity
• Friability
• ulceration
BARRIUM ENEMA
• Fine mucosal granularity
• Superficial ulcers seen
• Collar button ulcers
• lead pipe appearance with loss
of haustrations
• Narrow & short colon ribbon
contour colon
CROHN’S DISEASE
Macroscopic features
• Can affect any part of GIT
• Transmural
• Segmental with skip lesions
• Cobblestone appearance
• Creeping fat- adhesions & fistula
Microscopic features
• Aphthous ulcerations
• Focal crypt abscesses
• Granuloma-pathognomic
• Submucosal or subserosal lymphoid aggregates
• Transmural with fissure formation
Clinical features

• Ileal
• 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
Diagnosis

• Laboratory tests
• Endoscopy
• Radiography
• Biopsy
• CT enterography
Laboratory tests

• CRP-elevated
• ESR-elevated
• Anemia
• Leukocytosis
• hypoalbuminemia
CT enterography
• Mural hyperenhancement
• Stratification
• Engorged vasa recta
• Perienteric inflammatory
changes
TREATMENT
TREATMENT MODALITIES
• Diet change
• Lifestyle change
• Medical management
• surgery
Diet change Lifestyle change
• High fiber diet • No smoking
• Fruits • Exercising
• vegetables • Taking a rest
• Stress reduction
Drugs
• 5-ASA agents
• Glucocorticoids
• Antibiotics
• Immunosuppresants
• Biological therapy
5-ASA Agents

• Sulfasalazine (5-aminosalicylic acid and sulfapyridine as carrier

substance)
• Mesalazine (5-ASA), e.g. Asacol, Pentasa
• Balsalazide (prodrug of 5-ASA)
• Olsalazine (5-ASA dimer cleaves in colon)
Can be oral, enema or suppository
Action of 5-ASA: Extent of Disease
Impacts Formulation Choice
 Use
• In mild 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
Glucocorticoids

• Anti inflammatory agents 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
Antibiotics

• No role in active/quienscent UC
• Metronidazole is effective in active inflammatory,fistulous & perianal
CD.
• Dose-15-20mg/kg/day in 3 divided doses.
• Ciprofloxacin
• Rifaximin
Immunosuppressant

• Thiopurines
• Azathioprine
• 6-mercaptopurin
• Methotrexate
• Cyclosporine
Biological therapy

Infliximab
• Anti TNF 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
Other medications

• Anti- diarrheals - Loperamide (Imodium)

• Laxatives - senna, bisacodyl
• Pain relievers. acetaminophen (Tylenol).
• Iron supplements
• Nutrition
Surgery

Indications :
• Fulminating disease
• Chronic disease with anemia, frequent stools, urgency & tenesmus
• Steriod dependant disease
• Risk of neoplastic change
• Extraintestinal manifestations
• Severe hemorrhage or stenosis
Surgery types
Ulcerative colitis
• Reconstructive proctocolectomy
with ileanal anastomosis
• Proctocolectomy & ileostomy
• Rectal &anal dissection
• Colectomy with ileorectal
anastomosis
• Ileostomy with intraabdominal
pouch
Crohns
• Ileocaecal resection
• Segmental resection
• Colectomy & ileorectal
anastamosis
• Temporary loop ileostomy
• Proctocolectomy
• Stricturoplasty
THE END