Inflammatory Bowel Diseases pdf - D. Faiz

THI QAR U. MEDICAL COLLEGE GIT LECTURES 2020

DEPARTMENT OF INTERNAL MEDICINE

Dr. Faez Khalaf,

SUBSPACIALITY GIT

Inflammatory bowel diseases

Ulcerative colitis and Crohn's disease

An immune-mediated chronic inflammatory bowel diseases with relapsing and remitting course

• ulcerative colitis only involves the colon
• Crohn's disease can involve any part of the gastrointestinal tract from mouth to anus.

Epidemiology

• In developing world

• Crohn's disease appears to be rare

• Ulcerative colitis, more common.

•

• In the West

• ulcerative colitis prevalence of 100-200 per 100 000

• Crohn's disease prevalence of 50-100 per 100 000.

•

young adults (between

15 and 30 years

) , second smaller incidence peak in the seventh decade

(between

60 and 80 years

)

•

The male to female ratio for UC is

1:1

and for CD is

1.1–1.8

•

UC and CD have

two- to fourfold

increased frequency in Jewish.

Etiology

• abnormal host response to an environmental trigger in genetically susceptible individuals

• This causes inflammation of the intestine and release of inflammatory mediators, such as TNF,

IL-12

and

IL-23

, which cause tissue damage.

Factors associated with the development of IBD Genetic

1. More common in Ashkenazi Jews

10%

have a first-degree relative or at least one close relative with IBD

3. High concordance between identical twins

4. Some abnormal genes detected

5. Associated with autoimmune thyroiditis and SLE

Environmental

a. Ulcerative colitis is more common in non-smokers and

ex-

smokers.

2.  Most Crohn's patients are smokers
3.  CD associated with low-residue, high-refined-sugar diet
4.   Commensal gut microbiota altered (dysbiosis) in CD and UC
5.  Appendicectomy protects against ulcerative colitis

Pathology

Ulcerative Colitis

Macroscopic Features

• Extends proximally to involve all or part of the colon.
•

40–50%

of patients involve the rectum , recto sigmoid

•

30–40%

beyond the sigmoid

•

20%

have a total colitis

• Inflammation is

diffused

Mild:

• the mucosa is erythematous and fine granular surface

More severe

• the mucosa is hemorrhagic, edematous, and ulcerated (superficial diffused)

•

Fulminant

disease can develop a toxic megacolon where the bowel wall thins and the mucosa is

severely ulcerated; this may lead to perforation.

In long-standing disease

• Inflammatory polyps (pseudo polyps) may be present as a result of epithelial regeneration.

• many years of disease it appears atrophic and featureless and the entire colon becomes narrowed and

shortened

Ulcerative Colitis

Microscopic Features

• Mucosal vascular congestion, edema and focal hemorrhage

• Inflammatory cell infiltrate of neutrophils, lymphocytes, plasma cells, and macrophages may be

present.

• The neutrophils invade the epithelium, usually in the crypts, giving rise to cryptitis and, to crypt

abscesses

Histological features of chronicity

• First, the crypt architecture of the colon is distorted
• Second, some patients have basal plasma cells and multiple basal lymphoid aggregates

Crohn's Disease:

Macroscopic Features

•

30–40%

of patients have small-bowel alone

•

40–55%

have disease involving the ileum and the Rt colon

•

15–25%

have colitis alone.

•

30 %

have anal involvement

• the rectum is often spared in CD.

• segmental inflammation (skip areas of inflammation)

• Aphthous ulcerations

• Stellate ulcerations fuse longitudinally and transversely to demarcate islands of mucosa that

frequently are histologically normal. "cobblestone" appearance

• Ulcers may penetrate bowel wall to initiate abscesses or fistulas

the bowel

bladder

uterus

vagina

skin of the perineum

• Bowel narrowed and fibrotic, with chronic, recurrent bowel obstructions

• Mesenteric lymph nodes are enlarged and the mesentery is thickened.

Microscopic

• trans mural inflammation

• fissures penetrate deeply into the bowel wall

• bowel wall thickened

• Chronic inflammatory infiltrate all layers.

• focal crypt abscesses

• noncaseating granulomas

• microscopic skip areas

• Other histologic features sub mucosal or subserosal lymphoid aggregates.

Clinical features

Ulcerative colitis

Bloody diarrhoea relapses and remissions

1. Emotional stress

2. intercurrent infection

3. gastroenteritis

4. antibiotics

5. NSAID therapy may all provoke a relapse

Proctitis

• Rectal bleeding

• mucus discharge

• Tenesmus.

• frequent, small-volume fluid stools

Proctosigmoiditis

• Bloody diarrhoea with mucus.

Extensive colitis

• bloody diarrhea

• Passage of mucus.

• Severe cramping

• Abdominal pain can occur with severe attacks of the disease.

• Constitutional symptoms do not occur only in moderate to severe disease

Severe colitis

•  Bleeding
•  Severe diarrhea
•  severe pain
•  fever
•  Tachycardia
•  Abdominal tenderness
•  Edema

Crohn's Disease

• The major symptoms are

•

pain

is often associated with diarrhea

•

Diarrhea

usually watery not contain blood or mucus.

• weight loss

• malabsorption

•

intestinal obstruction

sub-acute or even acute

Crohn's colitis

•  as ulcerative colitis
•  rectal sparing
•  Structuring can occur in the colon

Perianal disease

•  affects about one-third of
•  large hemorrhoid tags
•  anal strictures
•  anorectal fistulae
•  Perirectal abscesses.
•   incontinence

Ileocolitis

• Recurrent right lower quadrant pain

• Diarrhea.

• palpable mass

• Fever, leukocytosis.

• Weight loss is common

• fistula formation

• abscess cavity in the mesentery

Small intestinal Crohn's

• Malabsorption and steatorrhea.
• Nutritional deficiencies.

Vomiting from jejunal strictures or severe oral ulceration

Complications

Toxic megacolon



Acute colonic dilatation due severe flare of the colitis



More with extensive colitis



incidence



Precipitating factors as hypokalemia , antimotility, colonoscopy

Clinical features



Features of severe colitis with



Diffused abdominal distension



Diffused tenderness



Decease bowel sound



Lab sings of systemic inflammation

Treatment



Conservative

Indication for surgery



No response within

72 hr.



Sings of peritonitis or perforation

Hemorrhage

• Acute Haemorrhage (major artery) is rare

Fistulas

Enteroenteric

diarrhoea

malabsorption.

Enterovesical

recurrent UTI

pneumaturia.

Enterovaginal

a feculent

vaginal discharge.

Note: Toxic megacolon. Transverse colon diameter> 6 cm

Bowel fistulation

perianal

ischiorectal

Abscesses

Fissures

Cancer

• Active colitis of more than 8 years'.

• The cumulative risk 10%

• Lower for Crohn's colitis.

• Tumors develop in areas of dysplasia

• Surveillance programmes beginning 8 years after diagnosis by colonoscopy 1-2-yearly.

• Moderate-high-grade dysplasia panproctocolectomy

Strictures

In Crohn's disease

Extra intestinal complications

•  common in IBD
•  May dominate the clinical picture.
•  Some of these occur during relapse of intestinal disease
•  others unrelated to intestinal disease activity
•  Include skin, joints, mouth, hematological, coagulopathy, eye and hepatobiliary

Investigations

• confirm the diagnosis

• define disease distribution

• define activity

• Identify complications.

•

Full blood count

may show anemia

• Serum albumin.

• The ESR and CRP

• elevated in exacerbations and in response to abscess formation

Bacteriology



Stool microscopy



Culture and examination

Ova

Cysts

Clostridium difficile toxin



Blood cultures

Endoscopy with Biopsies

• Confirm the DX

• define disease extent

• Detect dysplasia in long-standing colitis.

Capsule endoscopy

• The identification of small bowel inflammation.

Radiology

• Barium enema

• less sensitive investigation than colonoscopy

• Crohn's disease; affected areas are narrowed and ulcerated, and multiple strictures are common

• Abdominal CT and MRI scans

• provide bowel thickening

Pelvic or perineal involvement.

• A plain abdominal X-ray

Dilatation of the colon

In small bowel Crohn's disease there may be evidence of intestinal obstruction

•

Ultrasound

• thickened small bowel loops

Abscess development in Crohn's

Management

•  Treat acute attacks
•  Prevent relapses
•  Select patients for surgery
•  Detect carcinoma at an early stage

Treat acute attacks

Aminosalicylates

Mode of action: modulate cytokine release

Oral or topical (enema/suppository)

Mesalamine

• Pentasa (time dependent release)

• Ascol ( PH dependent release)

With carrier

• Sulfasalazine, balsalazide, olsalazine

Side-effects

10-45%

  headache
  nausea
  diarrhoea
  blood dyscrasia

Corticosteroids

   Anti-inflammatory
   Topical and oral and I.V
  prednisolone
  hydrocortisone

Budesonide

Cyclosporine

 Suppresses T-cell expansion

 Rescue' therapy to prevent surgery in severe ulcerative colitis responding poorly to corticosteroids.

 No value in Crohn's disease

 Major side-effects in

Nephrotoxicity, infections, neurotoxicity

 Minor complications:

Tremor, paresthesia, abnormal liver function tests, hirsutism

Anti-TNF antibodies

(Infliximab and adalimumab)

• Suppress inflammation and induce apoptosis of inflammatory cells

• Fistulating Crohn's disease

• Severe active ulcerative colitis with no response to steroids or cyclosporine

Side effects:

• Anaphylactic reactions

• Contraindicated in the presence of infections; reactivation of tuberculosis

Antibiotics

• Useful in perianal Crohn's disease

Antidiarrheal agents

(codeine phosphate, lope amide, lomotil)



Reduce gut motility and small bowel secretion



Avoided in acute flare-ups of disease



May precipitate colonic dilatation

Prevent relapses

Thiopurines

(Azathioprine, 6-mercaptopurine)



Immunomodulation by inducing T-cell cytotoxic effect



Effective after

12 weeks

of starting therapy

Complications :



Flu-like syndrome with myalgia
Leucopenia in

Methotrexate

•  Anti-inflammatory (folic acid antagonist)
•   Nausea, stomatitis, diarrhoea, hepatotoxicity and pneumonitis
•  Used in Crohn's disease

Anti-TNF antibodies (infliximab)

Ulcerative colitis
Active proctitis and Proctosigmoiditis

• Mesalamine enemas or suppositories combined with oral mesalamine are effective first-line therapy.

• Topical corticosteroids for intolerant of topical mesalamine.

Active left-sided or extensive colitis

• high-dose aminosalicylates
• Oral prednisolone 40 mg daily is indicated for more active disease or when initial aminosalicylate

therapy is ineffective

Severe ulcerative colitis



Hospital admission



monitored clinically: for the presence of abdominal pain, temperature, pulse rate, stool blood and frequency



Radiologically: for colonic dilatation on plain abdominal X-rays.



intravenous fluids



Transfusion blood if

Hb < 10 g/L



nutritional support



IV corticosteroids



Oral aminosalicylates.



Patients who do not promptly respond to corticosteroids are considered for intravenous ciclosporin or
infliximab



Those who do not respond after ' maximal medical treatment usually require urgent colectomy.

Maintenance of remission



Life-long therapy

recommended



Extensive disease



Distal disease who relapse more than once a year.



Drugs:



Oral aminosalicylates first line



Patients who frequently relapse despite aminosalicylate drugs are treated with Thiopurines.

Crohn's disease

Active colitis or ileocolitis

• Aminosalicylates

• corticosteroids

• In severe disease intravenous steroids

Isolated ileal disease

•  Corticosteroids.
•  Amino salicylates have little added value
•  Biological treatment

Fistulas and perianal disease.

• Surgical intervention required for abscess

• For simple perianal disease metronidazole and/or ciprofloxacin are first-line therapies.

• Treatment of underlying active disease with corticosteroids.

• Infliximab heal enter cutaneous fistulas and perianal disease in many patients.

Maintenance of remission



Aminosalicylates have minimal efficacy.



Thiopurines for relapse more than once a year or severe disease.



Patients who are intolerant of or resistant to Thiopurines should be treated with once-weekly methotrexate
combined with folic acid.



Patients with aggressive disease are managed using a combination of immunosuppressive and anti-TNF
therapy.

Indications for surgery in ulcerative colitis
Failure of medical therapy

• Failure of remission induction (severe colitis)

• Toxic megacolon no response to Rx

• Failure of remission

• Complications of drug therapy

Disease complications unresponsive to medical therapy

• Arthritis , Pyoderma gangrenosum

Colon cancer or severe dysplasia
Impaired quality of life

• Loss of occupation or education

• Disruption of family life

Indications for surgery in Crohn's disease

•  The indications for surgery are similar to those for ulcerative colitis.
•  Unresponsive  fulminant disease
•  Operations are often necessary to deal with abscesses
•  Relieve small or large bowel stricture.
•  Chronic Fistulating small bowel disease may require resection if no response