IBD and ulcerative colitis for the science

Ibd and ulcerative colitis

1. IRRITABLE BOWEL SYNDROME & ULCERATIVE COLITIS GUIDED BY: DR. NIBEDITA MAHAPATRA maam (HOD DEPT OF KAYA CHIKITSA) DR. KABI CHANDRA SAHU SIR (LECTURER OF KAYA CHIKITSA) PRESENTED BY: ANKITA DASH (4 TH PROFESSIONAL BAMS)

2. IBD & ULCERATIVE COLITIS

3. DEFINITION Inflammatory bowel disease (IBD) represents a group of intestinal disorders that cause prolonged inflammation of the digestive tract. It is a spectrum of chronic idiopathic inflammatory condition. It is a condition that can affect any part of the digestive tract and causes inflammation swelling Redness & ulceration .

4. Classification Ulcerative colitis Crohn’s disease

5. ETIOLOGY Infectious agents Viruses (Measles)
Bacteria (Mycobacteria) Genetics Environmental factors Diet
Smoking Psychological factors Stress Emotional or physical trauma

6. Mucosal immune response • Inflammatory cells
• In IBD, activated CD4+Tcells are present in the lamina propria and in the peripheral blood
• These cells either activate other inflammatory cells like macrophages, and B cells or recruit more inflammatory cells by stimulation of homing receptors on leukocytes and vascular endothelial cells

7. PATHOPHYSIOLOGY 1 . Inflammatory process usually confined to rectum and sigmoid colon
2. Inflammation leads to mucosal hemorrhages and abscess formation, which leads to necrosis and sloughing of bowel mucosa. 3. Mucosa becomes red, friable, and ulcerated; bleeding is common 4. Chronic inflammation leads to atrophy, narrowing, and shortening of colon.

8. PATHOPHYSIOLOGY Dietary and bacterial antigens penetrate into the intestinal wall and activates the immune system.
This causes increased production of pro-inflammatory mediators which will lead to inflammation of the mucosal layer. ALTERED MUCOSAL IMMUNE RESPONSE

9. Ulcerative colitis Ulcerative colitis is an inflammatory bowel disease (IBD).
Ulcerative colitis occurs when the lining of your large intestine (also called the colon), rectum, or both becomes inflamed.
This inflammation produces tiny sores called ulcers on the lining of your colon. It usually begins in the rectum and spreads upward. It can involve your entire colon. Ulcerative colitis can be debilitating and can sometimes lead to life-threatening complications. While it has no known cure, treatment can greatly reduce signs and symptoms of the disease and bring about long-term remission.

10. There is no difference between men and women.
The worldwide incidence is 0.5~24 new cases per 100 000
individuals, and prevalence is 100~200 cases per 100 000.

11. ETIOLOGY The cause of UC remains unclear, although interplay of genetic, microbial, and immunologic factors clearly exists.
A limited number of environmental factors have clearly been proven to either modify the disease or regulate the lifetime risk of developing it. These include:
Tobacco use. Appendectomy. Oral contraceptive pills. Antibiotic use.

12. SYMPTOMS Rectal bleeding and tenesmus are universally present.
Diarrhea and abdominal pain are more frequent with proximal colon involvement.
Nausea and weight loss in severe cases.
Severe abdominal pain or fever suggests fulminant colitis or toxic megacolon .

13. CLINICAL FEATURES Age: Ulcerative colitis presents at a young age, often in adolescence. The median age of diagnosis is the fourth decade of life.
Onset: acute or subacute .
Course: - Most patients experience intermittent exacerbations with nearly complete remissions between attacks.
About 5-10% of patients have one attack without subsequent tsymptoms for decades

14. Sign Pallor may be evident.
Mild abdominal tenderness most localized in the hypogastrium or left lower quadrant.
PR examination may disclose visible red blood.
Signs of malnutrition.
Severe tenderness, fever, or tachycardia suggests fulminant disease.

15. TYPES Of UC Ulcerative proctitis :limited nited to the rectum, diarrhea, bloody stool, pain in the rectal area, and a sense of urgency to empty the bowel. Proctosigmoiditis : rectum and the sigmoid colon.diarrhea , bloody stool, cramps and pain in the rectal area, and moderate pain on the left side of the abdomen Left-sided colitis : Left-sided colitis affects the entire left side of the colon, from the rectum to splenic flexure. Diarrhea, bleeding, weight loss, loss of appetite, and sometimes severe pain on the left side of abdomen. Pancolitis : If the entire colon is affected, the term pancolitis is used (“pan” meaning total).

16. Complications Severe bleeding
A hole in the colon (perforated colon)
Severe dehydration
Bone loss (osteoporosis)
Inflammation of the skin, joints and eyes
An increased risk of colon cancer
A rapidly swelling colon (toxic megacolon )
Increased risk of blood clots in veins and arteries

17. When do we suspect Inflammatory Bowel Disease Chronic diarrhoea Rectal bleeding

Unexplained weight loss, joint problems & skin problems

Family history

Children with family history who exhibit any of the above symptoms

18. DIFFERENTIAL DIAGNOSIS

19. DIAGNOSIS Physical Examination
Endoscopy
Biopsy
Radiology
Blood Test

20. PHYSICAL EXAMINATION The main features to look for are: oral aphtosis , abdominal tenderness and masses, anal tags, fissure and fistulae, nutritional deficiency.
An important feature in children retardation. Is growth ENDOSCOPY/ COLONOSCOPY/SIGMOIDOSCOPY Colonoscopy helps to determine the pattern and severity of colonic and terminal ileum inflammation and allows biopsies to be obtained.
Endoscopic features are aphtous ulcers, deeper ulceration, postinflammatory polyps (which indicate previous severe inflammation), but always accompanied by intervening normal mucosa, which is an important differential feature between CD and UC.

21. Biopsy Rectal and colonic biopsies should be examined to find the nature of the inflammation (ulcerative colitis versus CD), collagenous colitis or microscopic inflammation if macroscopic appearance is normal, and infection.

22. Barium enema
Barium inserted into rectum
Fluoroscopy used to image bowel
Rarely used due to colonoscopy
Useful for identifying colonic strictures or colonic fistulae Radiology

23. Blood test Anemia may be present due to blood loss (iron deficiency), chronic inflammation or B12 malabsorption (macrocytic) . Hypoalbuminemia suggests severe disease with denutrition.The best markers of inflammation severity are elevation of the C-reactive protein and platelet count. Anti-saccharomyces cerevisiae antibodies (ASCA) are positive in 50-60% of CD patients while anti-neutrophil polynuclear antibodies (ANCA) are positive in 50-60% of UC patients.

24. NON PHARMACOLOGICAL TREATMENT To avoid smoking cessation
To reduce alcohol consumption
To avoid the use of NSAIDs
To avoid spicy and fried/oily food
To take fiber rich diet as tolerated that include tender cooked vegetables, canned or cooked fruits, and starches like cooked cereals and whole wheat noodles and tortillas.
To incorporate more omega-3 fatty acids in the diet. These fats may have an anti-inflammatory effect. They are found most probably in fish.

25. Surgery for ulcerative colitis Proctocolectomy (removing the colon and rectum) with ileostomy : If UC is severe, surgery may be required to remove the entire colon and rectum, plus bring the ileum (end of the small intestine) through a stoma (opening) in the abdominal wall to allow drainage of intestinal waste out of the body. The second part of the procedure is called ileostomy. After the procedure, an external bag must be worn over the opening to collect waste. Restorative proctocolectomy , also known as ileoanal pouch anal anastomosis (IPAA): It involves removing the colon and rectum, but the patient can continue to pass stool through the anus in place of an ileostomy, the ileum is fashioned into a pouch and pulled down and connected to the anus.

26. PHARMACOLOGICAL TREATMENT The major types of drug therapy used in IBD include
Aminosalicylates
Corticosteroids
Immunosuppressive agents
TNF-Tumor Necrosis Factor Inhibitor
Antimicrobials

27. Aminosalicylates/5-ASA These agents have anti-inflammatory effects. They are used to maintain remission and to induce remission of mild flares of disease. Egs ., Sulfasalazine, Mesalamine Sulfasalazine and mesalamine are used to treat mild to moderate disease and to maintain remission induced by corticosteroids.

Sulfasalazine is useful for ileocolonic and colonic disease.

28. CORTICOSTEROIDS Corticosteroids (1 mg/kg/day) are effective in decreasing disease activity and inducing remission in most patients.
Oral or parenteral corticosteroids are indicated for the treatment of ambulatory patients with moderate to severe colitis whose symptoms cannot be controlled by aminosalicylates .
The adverse effects include cosmetic effects, suppression of linear growth in children and osteopenia. Egs ., Prednisolone, Budenoside

29. Ambulatory patients are usually treated with prednisolone. Budesonide, a potent steroid that undergoes extensive first- pass hepatic metabolism, is useful, but approximately one- third of patients experience adverse effects related to budesonide use.

30. IMMUNE SUPRESSIVE AGENTS If it is impossible to taper corticosteroids or frequent relapses occur, immunomodulating therapy should be considered. However, the use of immunomodulators is not approved by the national health insurance scheme.

Azathioprine and 6-mercaptopurine are used due to their steroid – sparing or steroid reducing effects, since approximately 50% of patients experience adverse effects from corticosteroids.

Due to delayed onset of action, these agents are not used to treat acute colitis.
Cyclosporine and tacrolimus have been used to treat acute steroid-refractory UC when surgery seemed inevitable.

31. TNF INHIBITORS Increased production of inflammatory cytokines, especially tumor necrosis factor alpha (TNF-α), has been described in both normal and inflamed mucosa. These agents prevent the endogenous cytokine from binding to the cell surface receptor and exerting biological activity. These agents adversely affect normal immune responses. The inhibitors are: Thalidomide Infliximab Golimumab Adalimumab

32. ANTI MICROBIAL AGENTS Metronidazole and ciprofloxacin are useful in the treatment of mild to moderate disease, particularly in patients with perianal disease and infectious complications.
Sensory neuropathy, which may be seen with long-term metronidazole use, usually resolves completely or improves after discontinuation of the drug.

33. AYURVEDIC MANAGEMENT Deepaniya drugs : Pippali , Pippali-moola , Chavya , Chitrak , Shringavera , Amlavetas , Marich , Ajmoda , Bhallatak asthi , and Hingu niryas . Ama pachaka drugs: Paneeya – Shunti ,, Panchakola , Jeeraka + Dhanyaka Kashaya – Amrutottara kashaya , Drakshadi kashaya Churna-Taleesadi churna , Hingvashtaka churna , Ajamodadi churna , Vati – Agnitundi vati , Chitrakaadi vati , Sanjeevini vati , Laghumalini vasanta Arishta – Amrutaarishta – the best Sthambaka drugs: Tulasi beeja,Mishri,kutaja,synoka,lodhradi gana etc.

34. IBD CONCLUSION It is a chronic disorders.
Need to exclude other possibilities
Need to differentiate between the two
Need long term management with primary goal to induce then maintain remission and prevent complications of both the disease and drugs.