IBD

INFLAMMATORY BOWEL DISEASE

المحاضر:الدكتور خلدون ذنون كلية طب نينوى- المرحلة الرابعة

Objectives

To know the features that alerts you to the diagnosis of IBD.
How to establish the diagnosis.
To know the complications of IBD.
Basics of management and the use of drugs.
Prognosis of such chronic disease and its burden on the life of the patient.

Introduction

Ulcerative colitis(UC) & Crohns disease(CD) are chronic inflammatory bowel diseases with relapse & remission occurring over years .
Many similarities between both diseases & sometimes impossible to differentiate between them .
UC: involves the colon only . CD: involves the whole GIT from the mouth to the anus .Both may be associated with systemic features .
In IRAQ UC is fairly common while CD is rare .
IBD starts in young adults , 2nd peak : 7th decade .

Pathogenesis

Genetic factors : commoner in Ashkenazi Jews , 1st degree relatives &identical twins , HLA-association , associated with autoimmune thyroiditis & SLE .
Environmental factors : UC commoner in non-smokers & ex-smokers , CD : most patients are smokers .
Low-residue , high refined sugar diet blamed as a risk factor.
Appendicectomy protect against UC .
Inflammation is due to activation of macrophages , lymphocytes , PMN cells with release of inflammatory mediators e.g interleukins .


Pathology of ulcerative colitis
Proctitis is invariable .
Proctosigmoiditis or in minority pancolitis .
In longstanding pancolitis the colon shortens & pseudopolyps develop due to hypertrophied residual mucosa .
Inflammation is limited to the mucosa with sparing of the deeper layers.
Multiple small mucosal ulcerations occur with bleeding .
Acute and chronic inflammatory cells infiltrate the lamina propria and the crypts forming crypyt abscess with goblet cell loss .
Mucosal cell dysplasia may occur in longstanding cases: heaping of cells within crypts,nuclear atypia,(mitotic rates,may herald the development of colon cancer .

Pathology of Crohns disease

Terminal ileum and right side of the colon are most commonly involved .
Entire wall of the bowel is involved by chronic inflammation i.e transmural involvement .
Deep mucosal ulcers and the mucosa in between is described as cobble stone .
Abscess formation and fistulae between bowel loops and between bowel and bladder,uterus and vagina & may appear in the perineum .
Changes are patchy : inflamed mucosa is interrupted by normal mucosa i.e skip lesions .
Mesenteric lymph nodes are enlarged.
Focal aggregates of epitheloid histiocytes , surrounded by lymphocytes and giant cells , non-caseating microgranuloma is also seen.

Clinical features of ulcerative colitis

Attacks of bloody diarrhea with relapses and remissions .
Attack is provoked by emotional stress , infection , gastroenteritis , antibiotics and NSAIDS .
Proctitis( rectal bleeding and mucus discharge , tenesmus , some are constipated , no systemic symptoms .
proctosigmoiditis( bloody diarrhea and mucus , generally well , a minority develop fever, lethargy and abdominal discomfort .
Extensive colitis( anorexia , malaise , weight loss , abdominal pain , fever and toxicity , tachycardia , signs of peritoneal inflammation , decreased albumin , E.S.R >30 , HB < 10 , dilated bowel in abdominal radiography .


Clinical features of Crohns diseas
( ILeal disease ( abdominal pain , inflammatory mass , abscess or
acute
intestinal obstruction , often watery diarrhea without blood or
mucus , all patients lose weight because of food provoking pain
and malabsorption of fat, protein and vitamins .
( Crohns colitis : similar to UC , bloody diarrhea , passage of
mucus with lethargy , malaise , anorexia and weight loss , perianal
disease , rectum may be spared .
( Many patients present with colonic and small bowel disease .
( Few have isolated perianal disease .
( Vomiting due to jejunal stricture , oral ulceration may occur .
( Weight loss , anaemia , glossitis , angular stomatitis , abdominal
tenderness , abdominal mass , intra-abdominal abscess , perianal
skin tags , fissures, fistulae are found in at least 50% of patients .

Complications A-Intestinal 1.Severe life- threatening colitis
Occur in both UC & CD .
Colonic dilatation which lead to toxic megacolon .
Most commonly occur during the first attack of colitis .
features : >6 bowel motion / day , bloody stool +++ , pulse> 90/ min ,temp.> 37.8 , sigmoidoscopy shows blood in the lumen , abdominal X-ray shows dilated bowel , HB < 10 , ESR > 30 , albumin < 30gm/ L .
Needs daily abd.radiograph , when transverse colon dilates >6cm there is a high risk of perforation .
2. Perforation of the small intestine or colon , with or without toxic dilatation of the colon .
3. Acute haemorrhage which may be life threatening due to erosion of major artery .
4. Fistula and perianal disease : between loops of bowel or between bowel and bladder , vagina , are specific for Crohns . Abscess & fissures .
5. Cancer :
Occur in patients with extensive colitis > 8y duration, in UC risk is 20% after 30 y and less for Crohns colitis .
Tumor occurs in areas of dysplasia and may be multiple .
Small bowel adenocarcinoma is rare and occurs in CD .
Surveillance colonoscopy is done every 8-10y after diagnosis , multiple biopsies are taken every 10cm , low-grade or high- grade dysplasias may be found , low-grade is screened every 1-2 y while high-grade is considered for panproctocolectomy .
B. Extra intestinal
Occur during active disease : conjunctivitis , iritis , episcleritis , mouth ulcers , fatty liver , liver abscess and portal pyaemia , venous thrombosis e.g mesenteric or portal vein thrombosis , big joint arthralgia , erythema nodosum , pyoderma gangrenosum .
2. Unrelated to disease activity : autoimmune hepatitis ,( sclerosing cholangitis , cholangiocarcinoma occur in UC ) , gall stones , amyloidosis , renal oxalate stones ,( sacroiliitis and ankylosing spondylitis occur in CD with HLA-B27) , metabolic bone disease .


Differential diagnosis
A- Ulcerative & Crohns colitis : infective diarrheas e.g bacterial :salmonella , shigella , pseudomembranous colitis .
Viral e.g herpes simplex proctitis , chlamydia proctitis , CMV . Protozoal e.g amoebiasis . non-infective : ischaemic colitis , collagenous colitis , NSAID , colon cancer , diverticulitis , radiation , Behjets disease .

B. Small bowel Crohns disease Right iliac fossa mass: ( CA caecum, appendicular mass,TB, yersinia, actinomycosis mesenteric adenitis , pelvic inflammatory disease , lymphoma .) .

Investigations

Blood tests : anaemia due to blood loss & malabsorption of iron , folic acid & vitamin B12 . Decreased albumin : due to protein losing enteropathy & poor nutrition . ( ESR , ( CRP: monitor activity of CD.
Bacteriology : stool culture to exclude superimposed enteric infection . Blood culture: in severe colitis & fever .
Endoscopy : sigmoidoscopy & biopsy is essential . Rectal sparing , perianal disease & discrete ulcers suggest CD . Colonoscopy may show active inflammation , pseudopolyps , dysplasia & carcinoma . Capsule endoscopy is useful but avoided in stricture.
In UC : inflammation is most severe in the distal colon & rectum ,
if stricture is present it is due to carcinoma .
In CD : patchy inflammation , aphthoid-deep ulcers with normal
mucosa in between , stricture due to fibrosis .
Barium studies :
Less sensitive than endoscopy .
In long-standing UC : colon shortens & loses haustra , pseudopolyps occur .
In CD : skip lesions , stricture , deep ulcers may involve colon & small bowel .
Plain radiograph : in severe active colitis may show dilated colon & mucosal edema (thumb printing) or perforation . In small bowel CD : intestinal obstruction , mass displacing bowel loops .
Radionuclide scan : radio-labelled WBC scan shows areas of active inflammation , less sensitive than others but useful in severely ill patient in whom invasive tests are difficult
MRI is very accurate in defining pelvic or perianal disease in CD .
Management
Ideal treatment : team approach : physician , surgeon , radiologist & dietitian .
Aims : treat acute attack , prevent relapse , detect cancer early & selection for surgery .


Drugs for IBD:
Aminosalicylates: e.g (mesalazine,olsalazine, balsalazide, sulfasalazine). Modulate cytokine release, delivered to the colon. Available as oral, suppository and enema. Side-effects mainly due to sulfasalazine (headache,nausea, diarrhea,blood dyscrasias). Safe in pregnancy.
Corticosteroids: prednisolone, hydrocortisone, budesonide. Topical enema, oral or i.v. anti-inflammatory. Budesonide has less side effects because of hepatic clearance.
Thiopurines: azathiopurine, 6-MP. Immunomodulator by inducing T-cell apoptosis. Effective after 12 weeks. Myalgia,leucopenia. Safe in pregnancy.
Methotrexate: anti-inflammatory. Intolerance,nausea, stomatitis, diarrhea, hepatotoxic, pneumonitis.
Ciclosporin: suppress T-cell. Rescue therapy in UC, no value in CD, nephrotoxic.
Anti-TNF antibodies: infliximab,adalimumab. For severe CD,fistula, severe UC. Anaphylaxis, infections, TB, malignancy.
Antibiotics: for perianal CD. Metronidazole causes peripheral neuropathy.
Antidiarrheal agents: codeine, lopermide, lomotil. Avoided in acute flare-ups may precipitate colonic dilatation.

Active proctitis

Mesalazine enema or suppositories combined with oral mesalazine
Patients intolerant or poorly responsive to mesalazine are treated with topical steroid or 40 mg daily prednisolone.

More extensive UC

Higher doses of oral and topical aminosalicylates combined with topical steroids or oral 40 mg prednisolone.

Severe or fulminant UC

Hospital admission, team support.
Monitor abdominal pain, temp., pulse, frequency of diarrhea.
Check HB,WBC, albumin,electrolytes, ESR, CRP.
Imaging and plain abdominal X-ray for colonic dilatation.
i.v fluids
blood trassfusion if HB <100gm/L
i.v 60 mg methyl prednisolone or 400mg daily hydrocortisone
antibiotics
nutritional support
prophylactic SC heparin
avoid opiates and antidiarrheal agents
consider i.v ciclosporin or infliximab for those unresponsive to 5days of steroids.
Urgent colectomy for colonic dilatation >6cm, deterioration despite optimal therapy after 7-10 days.


Maintenance of remission in UC
Life-long oral aminosalicylates for extensive disease and those with distal disease who relapse more than once/year.
Thiopurines for frequent relapses despite aminosalicylates.

Crohns disease

Active disease
Active colitis or ileocolitis: aminosalicylates and steroids induce remission.
Polymeric or elemental diets induce remission also. Except in children, now rarely used as primary therapy.
Ileal disease: steroids only.
Surgery for poorly responsive.
Biological agents: Infliximab or adalimumab can induce remission in CD at any site of the GIT. Also effective in fistula, pyoderma gangrenosum and arthritis.
Relapse after 12 weeks, so it is usually combined with thiopurines or methotrexate.

Fistulas and perianal disease

Image and define fistula.
Steroid and nutritional support
Metronidazole and ciprofloxacin are first- line therapy.
Thiopurines in chronic disease.
Biological agents induce healing.
Surgery is needed frequently.


Maintenance of remission in CD
Smoking cessation is the most effective step.
Thiopurines for those who relapse more than once/year.
Methotrexate for those intolerant or resistant to thiopurines.
Steroids should be avoided as it does not prevent relapse.

Surgical treatment of UC

60% may need surgery.
Removal of colon and rectum results in cure.
Impaired quality of life.
Failure of medical therapy.
Fulminant colitis
Arthritis and pyoderma gangrenosum unresponsive to therapy.
Colon cancer and severe dysplasia.

Surgery in CD

Indications like in UC. 80% may need surgery.
Unlike UC surgery is not curative. Limited resection is adopted as relapse is frequent.
It is frequently needed in perianal disease, fistula, abscess, small and large bowel obstruction.
Ileal-anal pouch formation should be avoided because of recurrence.


IBD during childhood
Growth failure, metabolic bone disease, and delayed puberty.
Affect psychology, loss of schooling and social contact.
Same treatment as adults.
Monitor weight, height, and sexual development.

IBD and pregnancy

Activity of disease is usually not affected.
Relapse more common after labour,
Aminosalicylates, steroids, and thiopurines can be safely continued.
Daily folic acid.
In severe disease rate of premature delivery and low birth weight are increased.
Sigmoidoscopy is safe after the 1st trimester.
Avoid X-ray and colonoscopy.
Normal labour is possible.
Caesarean section may be needed in perianal disease and ileo-anal pouch.
Breastfeeding is safe.
Most drugs excreted in milk are probably safe for babies.

Metabolic bone disease

Osteoporosis is more frequent due to disease activity, malnutrition, malabsorption, and steroids.
Osteomalacia is less frequent.
Treated by proper nutrition, vitamin D and calcium supplement.
Prognosis ( life expectancy now is similar to that of the general population . ( 90% of UC have relapse & remission , 10% continous symptoms , 1/3 need
colectomy .
(In CD 80% undergo surgery with 50% recurrence after surgery .









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