Inflammatory Bowel Disease

Prof. Shorena Chumburidze MD,

PhD
 Vignette
• A 35 years old man presents to the emergency
department complaining to bloody diarrhea. He says that
he has been having diarrhea for the past two weeks, but
he was prompted to come because this afternoon he
noticed a maroon color in his stool.
• He says that he has abdominal pain, but is unable to point
to an exact spot.
• He rates it +6/10, and he has been trying to control it with
Pepto- Bismol to no avail.
• He has lost 10 pounds since his previous visit to the ER
for a broken thumb 6 months ago
• His vitals are stable, but he is slightly feverish: BP 125/83,
HR 80, temperature 100.5 gradus F
Inflammatory Bowel Disease
• Idiopathic, inflammatory, autoimmune disease
processes that involve the GI tract
• Higher incidence in Caucasians and
Ashkenazic Jews
• Higher incidence in developing countries
• Increased risk of colon cancer, as well reduced
quality of life from symptoms
• Two types: Crohn’s disease and Ulcerative
colitis
 Epidemiology of IBD
Ulcerative colitis Crohn’s disease
Incidence (US) 11/100 000 7/100 000
Age of onset 15-30 & 60-80 15-30 & 60-80
Male:female ratio 1:1 1.1-1.8:1
Smoking May prevent May cause disease
disease
Oral contraceptive No increased risk Relative risk 1.9
Appendectomy Not protective Protective
Monozygotic twins 8% concordance 67% concordance
 Inflammatory Bowel Disease
Symptoms :

• Chronic abdominal pain

• Hematochezia
• Mucus in stool
• Diarrhea
• Systemic sx (fever, weight loss, sweats, malaise,
arthralgia, nausea, vomiting),
• Extra intestinal manifestations
 Extraintestinal
Manifestations of IBD
 Skin
Erythema nodosum
Pyoderma gangrenosum
 Joints
Peripheral arthritis
Sacroileitis
Ankylosing spondylitis
 Eye
Uveitis
Episcleritis
Iritis
 Hepatobiliary complications
Gallstones
Primary sclerosing cholangitis
 Renal complications
Nephrolithiasis
Recurrent UTIs
Inflammatory Bowel Disease

• Hx: FHx is common, but not necessary at all

• Dx: Colonoscopy with biopsy is the diagnostic test of

choice !!!
Erythema nodosum
Pyoderma gangrenosum
Scleritis /Episcleritis
 CD vs UC Manifestations
• Crohn’s disease affects the entire thickness of the GI
tissue (transmural) and affects the entire GI tract (from
mouth to anus)

• Fistulae: Communication between one lumen to another.

Only occurs in Crohn’s disease. Examples: enteroenteric,
enterocystic, enterovaginal, perianal, etc

• Aphthous ulcers: “ Canker sores”, increased incidence in

CD, may occur in esophagus and stomach as well

• Crohn’s ileitis:Inflammation/ulceration of the terminal ileum

 CD vs UC Manifestations

• Ulcerative colitis is limited to the large bowel,

primarily the rectum

• Tenesmus + musus passage: More common in

UC, but not exclusive
 CD vs UC Manifestations
• Gold standart is colonoscopy with biopsy

Crohn’s disease
• ASCA+(Anti- Saccharomyces cervisae antibody)
• On colonoscopy: “Skip lesions”- altering regions of
inflammation and healthy tissue frequently encompassing the
entire large intestine to the ileum (Crohn’s ileitis)

Ulcerative colitis
• ANCA+ (Anti- neutrophil cytoplasmic antibody)
• On colonoscopy: Confluent inflammation primarily limited to
rectal area, but possible encompassing other areas of the
large intestine
 UC – Disease severity
MILD MODERATE SEVERE

BOWEL
MOVEMENTS
< 4 per day 4-6 per day >6 per day

BLOOD IN
STOOL
small moderate Severe

FEVER
none <37.5°C >37.5°C

TACHYCARDIA
none < 90 >90
 UC – Disease severity
MILD MODERATE SEVERE

ANEMIA
mild <75% >75%

ESR
< 30mm >30mm

ENDOSCOPIC Erythema, Marked erythema, Spontaneous

APPEARANCE decreased coarse granularity, bleeding, ulceration
vascular pattern, contact bleeding,
fine granularity no ulceration
 Crohn’s disease – macroscopic
features
• Can affect any part of GI tract from the mouth to the anus

• 30-40% of patients have small bowel disease alone

• 40-55% of patients have both small and large intestines

disease

• 15-25% of patients have colitis alone

• In 75% of patients with small intestinal disease the terminal

ileum is involved in 90%
Crohn’s disease
Monitoring of Crohn’s disease with
ileocolonoscopy
 Crohn’s Disease Activity Index
(CDAI)
• Incorporates 8 variables:

1. liquid or very soft stools /day

2. Abdominal pain & cramping
3. Extraintestinal manifestations
4. Complications
5. Abdominal mass
6. Use of anti diarrheal medications
7. Hematocrit
8. Body weight
 Crohn’s Disease Red Flags

• Onset after stopping smoking

• Bleeding only
• Diverticulosis
• Atherosclerosis
• Prolapse
 Symptoms of IBD
UC vs CD
Feature UC CD
Fever Uncommon Common
Rectal bleeding Common < ½ of patients
Abdominal May be present Common
tenderness
Abdominal mass Uncommon Common
Abdominal pain Uncommon Very common
Weight loss Uncommon Common
Tenesmus Very common Uncommon
 UC vs CD
Complications/Response to Treatment
UC CD
Fistulas No Yes

Small intestine No Frequently

obstruction
Colonic Rarely Frequently
obstruction
Response to No Yes
antibiotic
Recurrence No Yes
after surgery
 UC vs CD
Different endoscopic features
UC CD

Rectal sparing Rarely Frequently

Continuous Yes Occasionally

disease
„Cobblestoning” No Yes

Granuloma on No Occasionally
biopsy
 Inflammatory Bowel Disease
• Tx:
• Mesalamine derivates (ASAs): first line of therapy for long-
term treatment. ASAs ameliorate symptoms

• Pentasa (5-ASA): Works on the entire GI tract (Crohn’s)

• Rowasa: Works primarily on the anorectal area (Ulcerative

colitis)

• Steroid-sparings: Conjunctive therapy when ASA alone is

not sufficient. Inhibit Inflammation by cytotoxicity
 Inflammatory Bowel Disease
• 6- MP
• Azathioprine

• Biologics: Monoclonal antibodies that selectively block

TNF-a. Conjunctive. Particularly used for fistulizing
Crohn’s
Infliximab (Remicade)

• Steroids: Used for flares only. Not for use long term.
• Budesonide
• Methylprednisolone
 Inflammatory Bowel Disease

• Adverse effects:

• 6-MP and azathioprine: Drug- induced

pancreatitis, myelotoxicity
Get a TPMT phenotype test before stating on 6- MP or
azathioprine.

• Infliximab: Re- activation of latent TB

Always get a PPD before starting Infliximab on a pt
 Inflammatory Bowel Disease
• Adverse effects:

• Steroids: Weight gain, buffalo hump, hypernatremia,

hypokalemia

• If a pt has an active perianal mass or fistula, add

metronidazole and ciprofloxacin

• Surgical treatment is curative for ulcerative colitis, but not

for Crohn’s
 Inflammatory Bowel Disease

• Long-term complications:

• Colon cancer: Increased risk when colon disease has

been present >10 yrs.

• Sx: include bloody stools, change in stool caliber,

constitutional sx, pallor.

• All pts w/IBD should get a surveillance colonoscopy

every 1-2 years and more often if polyps are present
 Inflammatory Bowel Disease
Long-term complications:

• Toxic megacolon: Surgical emergency .

• Primarily a complication of UC.

• Pt will present w/ fever, severe abdominal pain,

distention, and eventually shock.

• Dx on abdominal plain film: colonic dilatation.

• Tx is surgical resection, antibiotics

 Inflammatory Bowel Disease
• Long-term complications:

• Strictures: Segmental narrowing of the large bowel.

• Sx: intestinal obstruction.
• Dx: barium studies.
• Can be treated w/endoscopic dilatation, may require
surgery

• Fistulae/Abscesses: Communication from the bowel to

another cavity.
• Vigorous medical tx (biologics), drainage of abscesses,
often surgery
 Inflammatory Bowel Disease
• Long-term therapy

• Initial drug of choice is an ASA (5- ASA)

• If inadequate response to ASA, start on oral corticosteroid
(budesonide, prednisone)
• Taper steroid once symptoms remit
• If symptoms persist after 4 months of corticosteroid use,
taper it and start a steroid- sparing agent (6- MP,
azathioprine)
• For refractory disease, consider use of a biologic
(Infliximab)
 Flares:
• ED management: Start IV fluids, get routine labs

• Be vigilant for acute complications (obstruction, perforation,

toxic megacolon) and investigate accordingly

• Admit: Start IV corticosteroids (methylprednisolone)

• Diet is tolerated.

• Assess progress. If symptoms are remitting, gradually switch to

PO corticosteroids (budesonide, prednisone)

• If symptoms are persisting, consider surgical options.