INFLAMMATORY BOWEL

DISEASE (IBD)
 Lecture Learning Outcomes
By the end of this lesson, students should be able to:
1. Define the terms Crohn’s disease and ulcerative colitis &
describe its pathological features.
2. Describe the intestinal and extra intestinal manifestations of IBD.
3. Define commonest complications due to malabsorption in
Crohn’s disease.
4. List the complications of IBD.
5. Select & interpret the laboratory and radiological investigations
for diagnosis of IBD.
6. Construct a management plan for patients with IBD, in different
grades of disease severity.
7. Recognize the indications of surgical intervention in IBD
 INFLAMMATORY BOWEL DISEASE
(IBD)

 Two major forms of inflammatory bowel

disease are recognized: Crohn's disease (CD),
which can affect any part of the GI tract, and
ulcerative colitis (UC), which affects only the
large bowel.
Epidemiology

 Both conditions have a world-wide distribution

but are more common in the West.
 Crohn's disease is slightly commoner in
females (M : F = 1 : 1.2) and occurs at a
younger age (mean 26 years) than ulcerative
colitis (M : F = 1.2 : 1; mean 34 years).
AETIOPATHOGENESIS
Although the aetiology of IBD
is unknown, it is the outcome
of three essential interactive
co-factors: genetic
susceptibility, environment
and host immune response
Environmental factors
 Smoking: increases the risk and exacerbations
of CD, but UC is more in non- or ex-smokers
 NSAIDs: related to onset and exacerbations
 Hygiene: good domestic hygeine is a risk
factor for UC
 Nutritional factors: breast feeding is protective
 Psychological stress: increases relapses
 Appendicectomy: protective from UC but
increases the risk of CD
The intestinal microbiota
 Play a crucial role in IBD
 Intestinal dysbiosis: alteration of bacterial flora
 Specific pathogenic organisms as increased
E.coli
 Bacterial antigens: bacteria exert their effects
by interactions with the immune system
 Defective chemical barrier or intestinal
defensins
 Impaired mucosal barrier function
Pathology
 Crohn's disease may affect any part of the GIT from the
mouth to the anus but usually the terminal ileum and
ascending colon (ileocolonic disease).
 The disease can involve one small area of the gut such as
the terminal ileum, or multiple areas with relatively normal
bowel in between (skip lesions).

 Ulcerative colitis can affect the rectum alone (proctitis),

can extend proximally to involve the sigmoid and
descending colon (left-sided colitis), or may involve the
whole colon (total colitis).
Macroscopic changes

 In Crohn's disease the involved small bowel is usually

thickened and narrowed.
 There are deep ulcers and fissures in the mucosa,
producing a cobblestone appearance.
 Fistulae and abscesses may be seen in the colon.
 In ulcerative colitis the mucosa looks reddened, inflamed
and bleeds easily.
 In severe disease there is extensive ulceration with the
adjacent mucosa appearing as inflammatory polyps.
 In fulminant colonic disease of either type toxic dilatation
occurs.
Microscopic changes
 In Crohn's disease the inflammation extends through all layers
(transmural) of the bowel, whereas in ulcerative colitis a
superficial inflammation is seen.
 In Crohn's disease there is an increase in chronic inflammatory
cells and lymphoid hyperplasia, and granulomas are present.
 In ulcerative colitis the mucosa shows a chronic inflammatory
cell infiltrate in the lamina propria. Crypt abscesses and goblet
cell depletion are also seen.
Extragastrointestinal manifestations

 Eyes: uveitis, episcleritis, conjunctivitis

 Joints: type I [pauciarticular] arthropathy, type II
[polyarticular] arthropathy, arthralgia, ankylosing
spondylitis
 Skin: erythema nodosum, pyoderma gangrinosum
 Liver and biliary tree: sclerosing cholangitis, fatty liver,
chronic hepatitis, cirrhosis, gall stones
 Nephrolithiasis
 Venous thrombosis
Crohn's disease
Clinical features
 Diarrhoea, abdominal pain and weight loss.
 Malaise, lethargy, anorexia, nausea, vomiting and low-grade
fever
 Variable severity and recurrence rate
 The disease may present insidiously or acutely
 The abdominal pain can be colicky, suggesting obstruction or
minimal discomfort
 Can present as an emergency with acute right iliac fossa pain
mimicking appendicitis.
 Crohn's disease can be complicated by anal and perianal
disease and this is the presenting feature in 25% of cases, often
preceding colonic and small intestinal symptoms by many
years .
 Enteric fistulae, e.g. to bladder or vagina, occur in 20-40% of
cases.
Examination
 Physical signs are few, apart from loss of weight and
general ill-health.
 Aphthous ulceration of the mouth is often seen.
 Abdominal examination is often normal although
tenderness and a right iliac fossa mass are
occasionally found.
 The anus should always be examined to look for
oedematous anal tags, fissures or perianal abscesses.
 Extragastrointestinal features of inflammatory bowel
disease should be looked for.
Investigations

Blood tests
 Anaemia is common and is usually the normocytic,

normochromic anaemia of chronic disease. Deficiency of

iron and/or folate also occurs.
 Raised ESR and CRP and a raised white cell count

Stool tests :
 Stool culture should always be performed on presentation

if diarrhoea is present
 microscopic examination for parasites
 Fecal calprotectin and lactoferrin are raised in active

colonic disease
Endoscopy and radiological imaging

 Colonoscopy
 Upper GI endoscopy
 Small bowel imaging: barium follow through,
CT scan with oral contrast, small bowel
ultrasound or MRI enteroclysis
 Perianal MRI or endoanal ultrasound
 Capsule endoscopy
 Radionuclide scans
Options for medical treatment of
Crohn's disease
Induction of remission
 Oral or i.v. glucocorticosteroids
 Enteral nutrition
 Anti-TNF antibodies

Maintenance of remission
 Azathioprine, 6MP, methotrexate, mycophenolate mofetil
 Anti-TNF antibodies

Perianal disease
 Ciprofloxacin and metronidazole
 Azathioprine
 Anti-TNF antibodies
Surgical management
 Approximately 80% of patients will require an operation at
some time during the course of their disease.
 Surgery should be avoided if possible and only minimal

resections undertaken, as recurrence (15% per year) is almost

inevitable.
The indications for surgery are:
 failure of medical therapy, with acute or chronic symptoms

producing ill-health
 complications (e.g. toxic dilatation, obstruction, perforation,

abscesses, enterocutaneous fistula)

 failure to grow in children.
 Presence of perianal sepsis
Ulcerative colitis
Clinical features

 The major symptom in ulcerative colitis is diarrhoea with blood and

mucus, sometimes accompanied by lower abdominal discomfort.
 General features include malaise, lethargy and anorexia.
 Aphthous ulceration in the mouth
 The disease can be mild, moderate or severe, and in most patients
runs a course of remissions and exacerbations.
 When the disease is confined to the rectum (proctitis), blood mixed
with the stool, urgency and tenesmus are common. There are
normally few constitutional symptoms. In an acute attack of UC,
patients have bloody diarrhoea, passing up to 10-20 liquid stools per
day. Diarrhoea also occurs at night, with urgency and incontinence
that is severely disabling for the patient.
Toxic megacolon
 Toxic megacolon is a serious complication.
 The plain abdominal X-ray shows a dilated thin-
walled colon with a diameter of > 6 cm; it is gas
filled and contains mucosal islands.
 It is a dangerous stage of advanced disease with
impending perforation and a high mortality (15–
25%).
 Urgent surgery is required in all patients in whom
toxic dilatation has not resolved within 48 hours
with intensive therapy.
Plain abdominal X-ray showing toxic
dilatation
Examination

 There are no specific signs in ulcerative colitis.

 The abdomen may be slightly distended or
tender to palpation.
 The anus is usually normal.
 Rectal examination will show the presence of
blood.
 Rigid sigmoidoscopy is usually abnormal,
showing an inflamed, bleeding, friable mucosa.
Investigations
Blood tests

 In moderate to severe attacks an iron deficiency anaemia is

commonly present and the white cell and platelet counts are
raised.
 The ESR and CRP are often raised; liver biochemistry may be

abnormal, with hypoalbuminaemia occurring in severe disease.

 pANCA may be positive. This is contrary to Crohn's disease,

where pANCA is usually negative .

Stool culture
 To exclude infective colitis
Colonoscopy
 Colonoscopy with mucosal biopsy is the gold
standard investigation of UC
 In severe attacks a limited unprepared sigmoidoscopy
should be used for fear of perforation

Imaging
 A plain X-ray in severe attacks to exclude colonic

dilatation
 Ultrasound can show inflammation of colonic wall

and presence of free fluid in abdominal cavity

Medical management of ulcerative colitis (UC)
 All patients with ulcerative colitis should be
treated with an aminosalicylate. The active
moiety of these drugs is 5-aminosalicylic acid
(5-ASA) as (sulfasalazine), (Asacol) or (Pentasa)
 Proctitis: rectal 5-ASA suppositories
 Left sided colitis: topical 5-ASA enemas. Oral 5-
ASA increases remission
 Extensive colitis: oral 5-ASA with enemas. If
not responding add oral steroids
Indications for surgery in ulcerative colitis

Fulminant acute attack

 Failure of medical treatment
 Toxic dilatation
 Haemorrhage
 Perforation

Chronic disease
 Incomplete response to medical treatment / steroid

dependent
 Dysplasia on surveillance colonoscopy
Cancer in inflammatory bowel disease

 Patients with UC and Crohn’s colitis have an

increased incidence of developing colon cancer
and patients with CD of the small intestine, a
small increase in incidence of small bowel
carcinoma.
 The risk is increased with the extent and
duration of disease, family history of colorectal
cancer and presence of sclerosing cholangitis