INFLAMMATORY BOWEL DESEASE.pptx OF GI TRUCT

INFLAMMATORY BOWEL DESEASE

1. . INFLAMMATORY BOWEL DESEASE INFLAMATORY BOWEL DESEASE 08-Sep-24 PRESENTED BY MUTEGEKI ADOLF

2. 08-Sep-24 2 OBJECTIVES AND GOALS Define IBD Differentiate between Crohn’s & Ulcerative Colitis Discuss epidemiology of disease Discuss current management strategies for acute and chronic disease states Discuss its Clinical presentation Discuss future directions for research

3. DEFINITION Inflammatory Bowel Diseases (IBD) refer to a group of chronic, relapsing inflammatory conditions of the gastrointestinal tract, primarily including Crohn’s disease and ulcerative colitis . Both conditions involve an abnormal immune response leading to inflammation of the digestive tract, though they affect different areas and layers of the gut.

4. TYPES OF IBD Crohn’s Disease: Can affect any part of the gastrointestinal tract from mouth to anus but most commonly affects the terminal ileum and the beginning of the colon. It is characterized by patchy, transmural inflammation, meaning it can affect the full thickness of the bowel wall and cause complications like strictures and fistulas. Ulcerative Colitis: Primarily affects the colon and rectum, causing continuous inflammation and ulcers in the innermost lining of the colon. Inflammation typically begins in the rectum and can extend proximally in a continuous manner.

5. Feature Crohn’s Disease Ulcerative Colitis Area Affected Any part of the GI tract (mouth to anus), most commonly the terminal ileum and colon Only the colon and rectum Pattern of Inflammation Patchy (skip lesions) Continuous inflammation starting from the rectum Depth of Inflammation Transmural (full thickness of the bowel wall) Limited to the mucosa and submucosa COMPARISON OF CROHN'S DISEASE AND ULCERATIVE COLITIS

6. Common Symptoms Abdominal pain (often right lower quadrant), diarrhea (may be bloody), weight loss, fever Bloody diarrhea, urgency, tenesmus, abdominal pain (often left-sided) Complications Fistulas, strictures, abscesses, perianal disease, malnutrition Toxic megacolon, perforation, colorectal cancer Endoscopic Findings Cobblestone appearance, skip lesions, deep ulcers Continuous inflammation, superficial ulcers, pseudopolyps Surgical Intervention Not curative; surgery for complications like strictures and fistulas Colectomy can be curative

7. Risk of Colorectal Cancer Increased, especially if colon is involved High, especially with long-standing and extensive disease Association with Smoking Smoking increases risk and severity Smoking is protective (decreases risk) Response to Surgery Surgery manages complications, not curative Surgery (colectomy) can be curative Perianal Disease Common (fissures, abscesses, fistulas) Rare Granulomas Often present on histology Absent

8. Treatment Approach Aminosalicylates , corticosteroids, immunomodulators , biologics, surgery for complications Aminosalicylates, corticosteroids, immunomodulators, biologics, curative surgery (colectomy) Onset Age Bimodal distribution: peaks in late teens/early 20s and 50s Typically peaks in 15-30 years of age Bowel Obstruction Common due to strictures Uncommon Extraintestinal Manifestations Common (e.g., arthritis, uveitis, erythema nodosum ) Common (e.g., primary sclerosing cholangitis, arthritis, uveitis)

9. ETIOLOGY The exact cause of IBD is unknown, but it is believed to result from a combination of genetic, environmental, immune, and microbial factors: Genetic predisposition: A family history of IBD increases the risk, with certain genetic mutations linked to both Crohn’s disease and ulcerative colitis. Immune system dysfunction: Abnormal immune responses may attack the gastrointestinal tract, leading to inflammation. Environmental factors: Smoking increases the risk of Crohn’s disease but is protective against ulcerative colitis. Other factors include diet, stress, and use of NSAIDs. Microbiome alterations: Imbalances in the gut flora may trigger or exacerbate the inflammation.

10. PATHOPHYSIOLOGY Crohn’s Disease: Involves a T-helper 1 (Th1)-mediated immune response with granulomatous inflammation, often affecting all layers of the bowel wall. It is characterized by skip lesions, fistula formation, and bowel wall thickening. Ulcerative Colitis: Primarily involves a Th2-mediated immune response leading to inflammation restricted to the mucosal layer of the colon. It starts in the rectum and can extend proximally in a continuous pattern, leading to ulceration and bleeding.

11. CLINICAL PRESENTATIONS

12. Ulcerative colitis Crohn’s disease Clinical feature -Watery or bloody diarrhea -Rectal discharge of mucus - Proctitis -Lt sided & total colitis -Chronic diarrhea - Abdominal pain - Food fear wt loss -pyrexia -RIF pain (?? Appendicitis) -as abdominal mass -acute intestinal obstruction - multiple perianal fissures, fistula & abscess

13. Ulcerative colitis Crohn’s disease Clinical feature Toxic megacolon Fulminating colitis Perforation Severe hemorrhage Intra-abdominal fistula Entero-enteric Entero-cutaneous Severity Mild Moderate Severe Complex anal fistula

14. Ulcerative colitis Crohn’s disease (regional ileitis) Extra-colonic manifestation 1-Arthritis. 2-skin disorder- erythema nodosum , pyoderma -gangrenosum. 1-Peripheral Arthritis, Ankylosing spondylitis, Sacro-ilitis 2-skin condition-erythemanodosum , pyoderma gangrenosum.

15. Ulcerative colitis Crohn’s disease Extra-colonic manifestation 3- Eye disease-Iritis 4-Bile duct cancer 5-Sclerosing cholangitis 6-Hepatic disease 7-Urology- Nephrolithiasis 3- Eye disease-Iritis 4-Bile duct cancer 5-Sclerosing cholangitis 6-Hepatic disease

16. INVESTIGATIONS: Blood tests: CBC: To detect anemia or inflammation. C-reactive protein (CRP) and ESR: Markers of inflammation. Liver function tests: To rule out primary sclerosing cholangitis in UC.

17. Stool tests: To rule out infections and check for fecal calprotectin , which is elevated in IBD. Endoscopic evaluations: Colonoscopy with biopsy: Essential for diagnosing and distinguishing between Crohn’s disease and ulcerative colitis. It provides visual evidence of inflammation, ulcerations, and biopsies to assess histological changes. Capsule endoscopy: Used in Crohn’s disease to visualize the small intestine.

18. Imaging: CT or MRI enterography : To assess the extent of inflammation, complications like abscesses, fistulas, and bowel wall thickening in Crohn’s disease. Abdominal ultrasound: Less commonly used but can assess bowel thickening and complications.

19. Ulcerative colitis Crohn’s disease (regional ileitis) Investigation -CBC -stool culture -plain film of abdomen - Barium enema - sigmoidoscopy - colonoscopy -biopsy -small bowel enema - Ba Enema -sigmoidoscopy -colonoscopy -biopsy

20. 08-Sep-24 22 Procedures: Barium Enema

21. Ulcerative colitis. Double-contrast barium enema study shows pseudopolyposis of the descending colon Crohn’s disease (regional ileitis)

22. 08-Sep-24 24 Procedures:Colonoscopy

23. Endoscopic image of ulcerative colitis affecting the left side of the colon . The image shows confluent superficial ulceration and loss of mucosal architecture Crohn's disease (regional ileitis)

24. COMPLICATIONS: Crohn’s Disease: Fistulas (e.g., enterocutaneous , enteroenteric , enterovesical ). Strictures leading to bowel obstruction. Perianal disease (e.g., abscesses, fissures ). Increased risk of small bowel cancer. Ulcerative Colitis: Toxic megacolon : Acute dilation of the colon, which can be life-threatening. Perforation: Due to severe ulceration. Colorectal cancer: Increased risk, especially with extensive colitis and long disease duration

25. 08-Sep-24 27 MANAGEMENT Acute Management During Crisis Diarrhea and Constipation Pain Infections Extensive Intestinal Damage Fistulas

26. Medications: Aminosalicylates (e.g., mesalamine ): Primarily for mild to moderate ulcerative colitis. Corticosteroids (e.g., prednisone): For inducing remission in moderate to severe IBD but not for long-term use due to side effects. Immunomodulators (e.g., azathioprine, methotrexate): For maintenance therapy in moderate to severe cases. Biologic therapies (e.g., anti-TNF agents like infliximab, adalimumab ; anti- integrins like vedolizumab ): Used for moderate to severe IBD unresponsive to conventional therapies. Janus kinase inhibitors (e.g., tofacitinib ): Used for moderate to severe ulcerative colitis.

27. Surgery Crohn’s Disease: Indicated for complications like strictures, fistulas, or disease unresponsive to medical therapy; surgery is not curative. Ulcerative Colitis: Colectomy can be curative and is indicated for refractory disease, severe complications, or cancer prevention. Nutritional Support: Addressing malnutrition, vitamin deficiencies, and dietary modifications to manage symptoms and complications.

28. Lifestyle Modifications: Smoking cessation (especially important in Crohn’s disease). Stress management and regular follow-up to monitor disease activity

29. Cancer risk in UC 3.5% 20y=12%

30. Prevention There is no known way to prevent IBD, but the following can help manage the disease and reduce flares: Regular follow-ups and adherence to prescribed medications. Avoiding known dietary triggers and maintaining a healthy diet. Smoking cessation. Early intervention at the first signs of a flare to prevent severe complications.

31. 08-Sep-24 33 References Braat H, et . al. Immunology of Crohn's Disease. Inflammatory Bowel Disease Genetics, Barrier Function, Immunologic Mechanisms, and Microbial Pathways . August 2006 1072 : 135–154 (2006). Lakatos PL. Recent trends in the epidemiology of inflammatory bowel disease: Up or Down? World Journal of Gastroenterology. October 14, 2006. 12 (38): 6102-6108 Cardon LR. Delivering New Disease Genes . Science . December 2006. 314 (5804): 1403-1405 Ruemmele FM et. al. Characteristics of Inflammatory Bowel Disease With Onset During First Year of Life . Journal of Pediatric Gastroenterology and Nutrition . Nov. 2006. Vol 43: 603-609 Scholmerich J. Inflammatory Bowel Disease: Pandora’s Box, Present and Future. Annals of NY Academy of Science . 2006. Vol. 1072:365-378

32. Thank you