33 IBD Arsalan diagnosis and treatment.pptx

IBD

1. Prepared by Dr.Arsalan Radman Instructor: Dr.Nosherwan IBD

2. Defination Etiology Type Sign and symptom Extraintestinal manifestation Lab and other diagnostic tool Treatment

3. IBD is chronic idiopathic inflammatory disorder of GI tract It has two type UC and CD

4. ULCERATIVE COLITIS CROHNS DISEASE AGE OF ONSET SECOND TO FORTH DECADE SECOND TO FORTH DECADE SMOKING MAY PREVENT DISEASE MAY CAUSE DISEASE CONTRACEPTIVE NO INCREASE RISK HAZARD APPENDECTOMY PROTECTIVE NOT PROTECTIVE

5. Previous appendectomy with confirmed appendicitis particularly at young age has a protective effect on development of UC Breast feeding has protective role against IBD Diet high in animal protein shellfish omega 3 sweet and sugar increase risk of IBD

6. Pathology of ulcerative colitis UC is a mucosal disease that usually involve the rectum and extend proximally to involve all or part of colon With mild inflammation the mucosa is erythematous and has a fine granular that resemble sandpaper in more severe disease the mucosa is hemorrhagic edematous and ulcerated In long standing disease inflammatory polyp may present as a result of epithelial regeneration

7. UC microscopic feature The process is limited to mucosa and superficial sub mucosa with deeper layer unaffected except in fulminant disease Two major histologic feature suggest chronicity and help to distinguishit from infectious and acute self limited colitis 1-the crypt architecture of the colon is distorted crypt may be bifid or decrease in number and gap in between 2-some patient have basal plasma cell and multiple basal lymphoid aggregated

8. Cohn's disease macroscopic appearance Crohn can affect any part of GI TRACT from mouth to anus . Unlike UC which almost always affect rectum the rectum spared in in CD Unlike UC crohn is trans mural process cobble stone appearance is characteristic of CD both endoscopically and barium radiography as UC pseudopolyp can form in CD

9. Crohn disease microscopic appearance Sub mucosal and subserosal lymphoid aggregation particularly away from area of ulceration gross microscopic area of skip lesion

10. The major sign of uc is diarrhea rectal bleeding tenesmus passage of mucus and crampy abdominal pain the severity of symptom correlate with severity of disease Patient with proctitis usually pass fresh blood or blood stain mucus either with stool or streaked or grossly bloody diarrhea may be noted SIGN AND SYMPTOM OF UC

11. When disease extend beyond rectum blood is usually mixed with stool or grossly bloody diarrhea may be noted Diarrhea is often noctural and postprandial Other symptom in moderate to severe disease is anorexia nausea vomiting fever weight loss Physical sign of proctitis is tender anal canal and blood on rectal examination . With more extensive disease patient have tendernce to palpation directly over the colon

12. LAB ENDOSCOPIC FINDING Active disease can be associated with increase inflammation marker decrease hemoglobin Fecal lactoferin is a glycoprotein that found in neutrophil highly sensitive and specific Fecal calprotectin is present in neutrophil and monocyte level is correlated with histologic inflammation predict relaps and detect pouchitis

13. In severly ill patient the serum albumin level will fall rather quickly luekocytosis present but not indicator of active disease Complication : massive hemorrhage , toxic mega colon which define as a transverse or right colon with diameter of >6cm with loss hausteration in patient with severe attack of UC

14. Perforation and sign of peritonitis may not obvious in patient receiving glucocorticoid Stricture: a stricture that prevent passage of colonoscope is an indication for surgery

15. CROHN DISEASE Ileocolitis because the most common site of inflammation is terminal ileum the usual presentation of ileocolitis is a chronic history of recurrent episode of RLQ pain a palpable mass fever and luekocytosis the initial presentation mimic appendicitis

16. An inflammatory mass composed of inflammed bowel induration of mesentery and enlarged abdominal lymph node The string appearance result of narrow loop of bowel COLITIS AND PERIANAL DISEASE Patient with colitis present with low grade fever malaise diarrhea crampy abdominal pain and sometimes hematochesia

17. Perianal disease affect one third of crohn disease patient is manifested by incontenance large hemorrhoidal tag anal stricture anorectal fistula and perirectal abscess Gastroduedenal disease most of patient complain nausea vomiting epigastric area pain Patient usually are h pylori negative the second portion of duodenum commonly involve

18. Lab finding Elevated level of ESR CRP in more severe disease finding include hypoalbuminemia anemia and luekocytosis

19. Complication of CD Because it is a transmural process serosal adhesion develop that provide direct pathway for fistula formation and reduce incidence of perforation Intra abdominal and pelvic abcess

20. SEROLOGIC MARKER For success in differentiating between CD and UC we use antisaccharmyces (ASCA) level increase in CD while level of perinuclear antinutrophil cytoplasmic antibody increase more commonly in patient with UC

21. Once a diagnosis of IBD is made distinguishing Between UC and CD is impossible in up to 15 %of cases these are termed indeterminate colitis but later on the nature of disease will become evident Differential diagnosis of uc and cd

22. Salmonella can cause watery or bloody diarrhea nausea vomiting Shigellosis causes watery diarrhea abdominal pain and fever followed by rectal tenesmus Other bacterial infection that may mimic IBD include C .difficle which present with watery diarrhea tenesmus nausea and vomiting INFECTIOUS DISEASE

23. Other parasitic infection that mimic IBD include hookworm ,whip worm and stronglyloides stercalis Ischemic colitis confused with IBD and should be consider in adult patient after aortic aneurysm repair or when the patient have hypercoagulable state or severe cardiac or peripheral disease

24. ERYTHEMA NODUSUM COMMENLY OCCURE in CD but occur in UC also attack is usually correlate with bowel activity skin lesion develop after the onset of bowel symptom and patient frequently have concomitant peripheral arthritis OCULAR conjunctivitis anterior uveitis iritis Symptom include ocular pain photophobia blurry vision and headache EXTRAINTESTINAL MANIFESTATION

25. 5-ASA agent These agents are effective at inducing and maintaining remission In UC Salfasalazine is effective against mild to moderate UC but high level of side effect limit its use Although at higher dose 6-8 gr \ day its effective but some patient experience nausea vomiting headache TREATMENT

26. Delzicol and asacol are enteric coated form of meselamine with the 5-asa being released at PH>7 LIALDA is a once a day formulation of meselamine design to release in the colon Apriso is a formulation containning encapsulated meselamine granule that deliver to terminal ileum and colon the outer coated of tablet dissolve at PH>6

27. Pentasa is another formulation of meselamine that use an ethyl cellulose coating to allow water absorption in to small bead containing the meselamine More common side effect of 5-ASA medication include headache nausea vomiting hair loss abdominal pain. Renal test and urine analysis should check yearly

28. Prednisolone started at dose of 40-60 mg Per day for active UC and unresponsive to 5-ASA Parenteral steroid hydrocortisone 300mg / day Methylprednisolone 40-60 mg / day Newer steroid budesonide at dose of 9mg /day for 8 week and no tapering is required GLUCORTICOID

29. Antibiotic has no role in the treatment of active or quiescent UC some time need prolong treatment with antibiotic in pouchitis Antibiotic

30. Are purine analogues use concomitantly with biologic treatment Azatioparine MP toseioinosic acid Efficacy seen in 3-4 week but can take up to 4-6 week Dose is range from 2-3mg\kg per day AZATIOPARINE AND MERCAPTOPURINE

31. Inhibit dihydrofolate reeducates result in impaired DNA synthesis Also by inhibition of IL-1 have anti inflammatory Dose intramuscular or subcutaneous range from 15-25mg/week METHOTREXATE

32. Is a macrolide antibiotic with immune medulatory property similar to cyclosporine but 100 times more potent and not dependent on bile and mucosal integrity for absorption thus it has good absorption despite proximal small bowel crohn involvement Tacrolimus is effective in children with refractory IBD and in adult with glucocorticoid dependent or refractory UC and CD TACROLIMUS

33. Infliximab 5mg/kg at 0 ,2 ,6 and 8 week Adalimumab 160 mg/kg subcutaneously initially then 80 mg after two week maintenance is 40 mg fortnightly to weekly Golimumab 50 mg SC every four week Certolizumab ANTI-ANF

34. Natalizomab and vedolizumab are integrin blockers and are indicate for difficult to treatment Diarrhea in the presence of bile salt is the side effect can be treated with cholysteramine and antidiarrheal drug

35. Persistent bowel obstruction Symptomatic fistula with other viscera and perianal fistula Intraabdominal abscess Perforation Severe bleeding Surgery

36. HARRISON CURRENT REFERENCE