Inflammatory bowel disease clinical revised.pptx

IBD SEVERITY, SYMPTOMS, MEDICAL AND SURGICAL MANAGEMENT

1. Inflammatory bowel disease (IBD ) PRESENTOR:- Dr. Rohan Kumar (DrNB Resident Fortis Hospital Jaipur)

2. Inflammatory bowel disease (IBD ) Crohn disease Ulcerative colitis Inflammatory bowel disease (IBD) of undetermined type.

3. Introduction & History. Ulcerative Colitis Ulcerative colitis (UC) is idiopatic inflammatory disease potentially affecting the entire large bowel (colon and rectum). The inflammation is confined to mucosa. UC can go into remission and recur. extraintestinal manifestations. Crohn's Disease Is an idiopathic, chronic regional enteritis that most commonly affects the terminal ileum but has the potential to affect any part of the gastrointestinal tract from mouth to anus. Periods of symptomatic relapse and remission.

4. Aetiology Idiopathic Congenital/ Genetic Nutritional Deficiency/excess Traumatic Infections /Infestation Autoimmune Neoplastic (Benign/Malignant) Degenerative Iatrogenic Psychosomatic

5. Aetiology Ulcerative Colitis Idiopathic genetic factors, immune system reactions, environmental factors, NSAID) use, low levels of antioxidants, psychological stress factors, consumption of milk products Crohn's Disease Idiopathic Risk factors- family history Smoking oral contraceptives Diet ethnicity. aberrant mucosal immune responses intestinal epithelial dysfunction defects of host interactions with intestinal microb es  

6. Aetiology Ulcerative Colitis Certain types of food composition oral contraceptives protective effect of tobacco seen in ulcerative colitis Disturbed intestinal flora. Crohn's Disease polygenic basis- clear genetic predisposition- First-degree relatives have a 13-18% increase in incidence. concordance rates of 50% in monozygotic twins hygiene hypothesis

7. Pathology Ulcerative Colitis ulcerative colitis characteristically involves the large bowel. Starts in rectum and proceeds proximally upto terminal ileum ( backwa sh ileitis). No skip lesions. Ulcerative colitis is a lifelong illness. Mucosal disease.  Crohn's Disease Can affect any part of GI tract. skip lesions +nt.  transmural (full-thickness) inflammation, involvement of discontinuous segments of the intestine (skip areas), and, in a proportion of cases, by non-necrotizing granulomas composed of epithelioid histiocytes. 

8. Pathology Ulcerative Colitis Rectum 95% Terminal ileum 10% extraintestinal manifestations. Crohn's Disease limited to the small intestine in approximately 40-50% of cases, whereas another 30-40% of cases involve both the small intestine and the colon. The remaining cases involve only the colon.   Aphthoid ulcers in the mouth and anal fissures, skin tags, and abscesses are frequently seen, cobblestoned" appearance of the mucosa,. 

9. Pathology Crohn's Disease Mucosal pseudopolyps (inflammatory pseudopolyps) of the terminal ileum in a patient with Crohn disease. These polyps can reach giant proportions, up to 5 cm in maximum dimension, and are often seen on the proximal side of an ulcerated stricture (a "sentinel" inflammatory polyp). Deep ulcers, vertical fissures, and fistula tracts are commonly seen. In particular, vertical fissuring can be especially helpful in the distinction between Crohn disease and ulcerative colitis.   In addition, small, pinpoint hemorrhages and shallow ulcers with white bases (aphthoid ulcers) are frequent along the periphery of the involved segments of mucosa.

10. Gross Psedopolyps UC Creeping fat in Crohn disease

11. Microscopic Pathology Ulcerative Colitis acute and chronic inflammatory infiltrate of the lamina propria, crypt branching, and villous atrophy are present in ulcerative colitis. inflammation of the crypts of Lieberkühn and abscesses. granulomas are also seen in tuberculosis, yersiniosis, and can even be seen in ulcerative colitis Crohn's Disease Areas of chronic inflammation Skip lesions comprising focal, patchy erosions or ulcers, vertical fissures, and fistulas Transmural inflammation  Granulomas Submucosal fibrosis and neuromuscular hyperplasia of submucosa

12. Microscopic Pathology Ulcerative Colitis The ulcerated areas are soon covered by granulation tissue inflammatory polyps or pseudopolyps. Excessive fibrosis is not a feature of the disease Crohn's Disease Microscopically, the inflammation in ulcerative colitis and Crohn disease can appear similar, but noncaseating granulomas are present only in Crohn disease 

13. Grading Ulcerative Colitis Mild : Bleeding per rectum, fewer than four bowel motions per day Moderate : Bleeding per rectum, more than four bowel motions per day Severe : Bleeding per rectum, more than four bowel motions per day, and a systemic illness with hypoalbuminemia (< 30 g/L)

14. Clinical Features Demography Symptoms Signs Prognosis Complications

15. Demography Ulcerative Colitis The annual incidence is 10.4 -12 cases per 100,000 people, and the prevalence rate is 35-100 cases per 100,000 people. Three times more common than Crohn disease white individuals living in Western industrialized nations  2-4 times higher in Ashkenazi Jews. Crohn's Disease Incidence in Europe is about 5.6 per 100,000 inhabitants white individuals living in Western industrialized nations European (Ashkenazi) Jewish heritage have a 2-4 times higher prevalence than members of the general population.

16. Demography Ulcerative Colitis Bimodal pattern, with a peak at 15-25 years and a smaller one at 55-65 years, although the disease can occur in people of any age. slightly more common in women than in men.  Crohn's Disease The incidence and prevalence of the disease (especially colonic CD) are steadily increasing  peaks of incidence, one in early adulthood (range, teens–20s) and another in the 60-70 year age group.  slight female predilection for the disease.

17. Geographical d istribution Ulcerative Colitis Ulcerative colitis is more common in the Western and Northern hemispheres; the incidence is low in Asia and the Far East.   Crohn's Disease Highest in North America Incidence in Asia0.5 to 4.2 cases per 100,000 persons The lowest rates in South Africa (0.3-2.6 cases per 100,000 persons) and Latin America (0-0.03 cases per 100,000 persons).   .

18. Demography As new regions assume Western cultural practices, an increased prevalence of ulcerative colitis is usually found approximately 1 decade before the observed increase in Crohn disease.

19. Symptoms Ulcerative Colitis Rectal bleeding Frequent stools Mucous discharge from the rectum Tenesmus (occasionally) Lower abdominal pain and severe dehydration from purulent rectal discharge (in severe cases, especially in the elderly). Crohn's Disease crampy abdominal pain Prolonged nonbloody diarrhea , which may be complicated by intestinal fistulas, particularly after surgical intervention, intramural abscesses bowel obstruction. diarrhea may contain blood, mucus, and pus

20. Symptoms Ulcerative Colitis In some cases, UC has a fulminant course marked by the following: Severe diarrhea and cramps Fever Leukocytosis Abdominal distention Crohn's Disease weight loss and possible malabsorption syndromes Low-grade fever and feeling of general fatigue and malaise Nausea, vomiting In pediatric patients, unexplained growth failure in addition

21. Types of UC and symptoms:- Proctitis: Rectal bleeding & mucous discharge some times with tenesmus ,no constitutional symptoms. Proctosigmoiditis: bloody diarrhea with mucous Small no. of patients with v. active limited disease develop fever, lethargy & abdominal discomfort. Extensive colitis: bloody diarrhea with passage of mucous, in sever cases anorexia , nausea ,weight loss & abdominal pain ,patient is toxic with fever & tachycardia & signs of peritoneal inflammation.

22. Symptoms colonic Crohn disease may be clinically indistinguishable from ulcerative colitis, with symptoms of bloody mucopurulent diarrhea, cramping abdominal pain, and urgency to defecate .

23. Symptoms: extraGI manifestations Unrelated to IBD activity:- Autoimmune hepatitis Primary Sclerosing Cholangitis & Cholangiocarcinoma Gallstones. Amyloidosis & oxalate calculi. Sacroiliitis/ankylosing spondylitis. Metabolic bone disease.

24. Occur during the active phase of IBD: Conjunctivitis. Episcleritis. Mouth ulcers. Fatty liver. Liver abscess / Portal pyaemia. Mesenteric or portal vein thrombosis. Venous thrombosis. Arthralgia of large joints. Erythema nodosum. Pyoderma gangrenosum

25. Signs Ulcerative Colitis normal in mild disease mild tenderness in the lower left abdominal quadrant  Severe cases- Fever Tachycardia Significant abdominal tenderness Weight loss Crohn's Disease Chronic intermittent fever is a common presenting sign. Abdominal findings may vary from normal to those of an acute abdomen Fullness or a discrete mass may be appreciated, typically in the right lower quadrant of the abdomen perianal region can reveal skin tags, fistulae, ulcers, abscesses, and scarring

26. Prognosis Both are lifelong diseases. For both conditions, the overall mortality has decreased steadily, and currently is less than 5%.  Both follow a more severe course in children and adolescents Both are at increased risk for the later development of cancer. most patients with these diseases are able to maintain normal occupations and enjoy reasonably stable social and economic situations. 

27. Prognosis Ulcerative Colitis Ulcerative colitis is curable with proctocolectomy and ileostomy. The excess risk is limited to colorectal cancer Crohn's Disease The recurrence rate after proctocolectomy and ileostomy for Crohn's disease of the colon also is considerable, increased cancer rates for both the small and large bowel. 

28. Complications Ulcerative Colitis Colonic perforation. Carcinoma. Benign strictures. Crohn's Disease Intestinal fistulas, particularly after surgical intervention, Strictures intramural abscesses bowel obstruction. colonic adenocarcinoma.

29. Investigations Laboratory Studies Routine Special Imaging Studies Tissue diagnosis Cytology FNAC Histology

30. Diagnostic Studies Imaging Studies X-Ray USG CT Angiography MRI Endoscopy Nuclear scan

31. Investigations Ulcerative Colitis Serologic markers (eg, antineutrophil cytoplasmic antibodies [ANCA], anti–  Saccharomyces cerevisiae  antibodies [ASCA]) Complete blood cell (CBC) count Comprehensive metabolic panel Inflammation markers (eg, erythrocyte sedimentation rate [ESR], C-reactive protein [CRP]) Stool assays Crohn's Disease C-reactive protein (CRP) and erythrocyte sedimentation rate (ESR

32. Imaging Studies Ulcerative Colitis endoscopy and biopsy- Abnormal erythematous mucosa, with or without ulceration, extending from the rectum to a part or all of the colon Uniform inflammation, without intervening areas of normal mucosa (skip lesions tend to characterize Crohn disease) Contact bleeding may also be observed, with mucus identified in the lumen of the bowel Crohn's Disease Upper gastrointestinal (GI) endoscopy and histologic examination Colonoscopy Capsule endoscopy CT enterography or magnetic resonance (MR) enterography 

33. Colonscopy M ucosa hyperemic loss of the normal vascular pattern Normal colon Ulcerative Colitis

34. Colonscopy Ulcer in Crohn diseasee

35. Imaging Studies Ulcerative Colitis Plain abdominal radiography Double-contrast barium enema examination Cross-sectional imaging studies (eg, ultrasonography, magnetic resonance imaging, computed tomography scanning) Radionuclide studies Angiography Crohn's Disease

36. UC: Barium enema strictures in the transverse and descending colon  Mucosal ulcers

37. Crohn Disease Cobblestone appearance string sign, with narrowing and stricturing .

38. Plain abdominal radiography Ulcerative Colitis pseudopolyposis  deep ulcers The colon may appear shortened loss of colonic haustra Toxic megacolon -massive colonic dilatation associated with an abnormal mucosal contour. Colonic perforation Thumbprinting  long stricture/spasm of the ascending colon/cecum Increased postrectal space Crohn's Disease

39. Barium enema findings Ulcerative Colitis Colon may appear narrow , short and loose. granular mucosa. Pseudopolyposis mucosal ulcers collar-button ulcers double-tracking ulcers burnt-out ulcerative colitis Similar radiographic signs may be seen in cases of infective diarrhea, Crohn disease, ischemic colitis, drug-induced colitis, and amebic colitis Crohn's Disease

40. Computed Tomography Ulcerative Colitis Difuse , circumferential, symmetrical wall thickening with fold enlargement. Submucosal fat deposition  target sign The halo sign typically occurs in ulcerative colitis . Crohn's Disease CT has become the procedure of choice not only for helping diagnose Crohn disease but also for managing abscesses.  

41. Computed Tomography Ulcerative Colitis Crohn's Disease wall thickening is eccentric and segmental thickening with homogeneous attenuation, fistula and abscess formation, pseudodiverticula and mesenteric abnormalities.  target sign string sign of Kantor on computed tomography 

42. Differential Diagnosis Ulcerative Colitis Crohn's Disease cathartic colon. collagenous colitis lymphocytic colitis infectious colitis ischemic colitis Crohn's Disease Ulcerative colitis Acute appenicitis Fistula in ano Infectious disease yersiniosis and tuberculosis Drugs-induced colitis NSAID, methyldopa, gold, and penicillins Conditions with small bowel fissuring ulcers-Behçet disease, malignant lymphoma, and "ulcerative jejunitis Diverticular disease Ischemic changes

43. Differential Diagnosis Ulcerative Colitis Crohn's Disease About 7% of large bowel strictures in patients with long-standing Crohn disease are malignant; these should be surveyed with multiple biopsies and cytologic brushing for neoplastic transformation.

44. Management Ulcerative Colitis Crohn's Disease General goals of treatment: To achieve the best possible clinical, laboratory, and histologic control of the inflammatory disease with the least adverse effects from medication To permit the patient to function as normally as possible In children, to promote growth with adequate nutrition

45. Drugs used in treatment of IBDs Aminosalysilates: (( Mesalasine, Olsalazine , Balsalazide)) Modulate cytokine release from mucosa Delivered to the colon by: 1-PH-dependent ( Asacol ) 2-Time-dependent ( Pentasa ) 3-Bacterial breakdown by colonic bacteria from carrier molecule ( Sulfasalazine, Olsalazine,Balsalized ).

46. Corticosteroids Topical corticosteroids can be used as an alternative to 5-ASA in ulcerative proctitis or distal UC. Oral prednisone or prednisolone is used for moderately severe UC or CD, in doses ranging up to 60 mg per day. IV is warranted for patients who are sufficiently ill to require hospitalization; the majority will have a response within 7 to 10 days.

47. No proven maintenance benefit in the treatment of either UC or CD. Many and serious side effects. Budesonide: less side effects, its use is limited to patients with distal ileal and right-sided colonic disease

48. Methotrexate:- Anti-inflammatory Side Effect: Intolerance in 10-18%. nausea stomatitis hepatotoxicity pneumonitis.

49. Anti-TNF antibodies (Infliximab & adalimumab) Given as I.V infusion 4-8 weekly. Induce apoptosis of inflammatory cells Uses: Moderately-severely active CD especially fistulating & in sever active UC. Anaphylactic reaction after multiple infusions. Contraindicated in presence of infection , reactivation of TB. Increased risk of infection & malignancy.

50. Ciclosporin Suppression of T cell expansion. As rescue therapy to prevent surgery in UC responding poorly to corticosteroid. No value in CD. Side Effects:- Nephrotoxicity. Neurotoxicity. Hirsutism.

51. Antibacterial. Useful in perianal CD.Side Effects: Peripheral neuropathy in long term metronidazole. Antidiarrheal agents: ( Codeine phosphate , Loperamide , lomotil) Avoided in moderately or severe active UC may precipitate colonic dilatation.

52. Non Operative Therapy Ulcerative Colitis Mild disease confined to the rectum: Topical mesala m ine via suppository (preferred) or budesonide rectal foam Left-side colonic disease: Mesalazine suppository and oral aminosalicylate (oral mesala m ine is preferred to oral sulfasalazine) Systemic steroids, when disease does not quickly respond to aminosalicylates Oral budesonide After remission, long-term maintenance therapy (eg, once- daily mesalazine) Crohn's Disease Sulfasalazine is useful mainly in colonic disease mesalamine,in small bowel Crohn disease Corticosteroids Budesonide immunosuppressants azathioprine  Methotrexate 

53. Non Operative Therapy Ulcerative Colitis Medical treatment of acute, severe UC Hospitalization Intravenous high-dose corticosteroids Alternative induction medications: Cyclosporine, tacrolimus, infliximab, adalimumab, golimumab Crohn's Disease Anti–tumor necrosis factor (anti- TNF) agents (eg, infliximab, adalimumab, certolizumab pegol, and natalizumab) Antibiotics  Nutritional Therapy Partial small bowel obstruction or intra-abdominal abscess may sometimes be treated conservatively granulocyte monocyte apheresis*

54. DEFINITIONS - The following definitions of ulcerative colitis have been proposed: Steroid-responsive disease - Clinical response to high-dose glucocorticoids (prednisone 40 to 60 mg/day or equivalent) within 30 days for oral therapy or 7 to 10 days for intravenous therapy. Steroid-dependent disease - Ulcerative colitis is defined as steroid- dependent if glucocorticoids cannot be tapered to less than 10 mg/day within three months of starting steroids, without recurrent disease, or if relapse occurs within three months of stopping glucocorticoids. Steroid-refractory disease - Lack of a meaningful clinical response to glucocorticoids up to doses of prednisone 40 to 60 mg/day (or equivalent) within 30 days for oral therapy or 7 to 10 days for intravenous therapy.

55. Operative Therapy Ulcerative Colitis Indications for urgent surgery include the following: Toxic megacolon refractory to medical management Fulminant attack refractory to medical management Uncontrolled colonic bleeding Crohn's Disease If medical therapy for active Crohn disease fails, surgical resection of the inflamed bowel, with restoration of continuity, Urgent surgery may be required in rare cases of sustained or recurrent hemorrhage, perforation, abscess, and toxic megacolon. Stem cell transplantation  

56. Operative Therapy Ulcerative Colitis Indications for elective surgery - Long-term steroid dependence Dysplasia or adenocarcinoma found on screening biopsy Disease being present for 7 -10 years Crohn's Disease

57. Operative Therapy Ulcerative Colitis Surgical options - Total colectomy (panproctocolectomy) and ileostomy Total colectomy Ileoanal pouch reconstruction or ileorectal anastomosis In an emergency, subtotal colectomy with end- ileostomy Crohn's Disease Resection is generally performed when strictures cannot be appropriately surveyed, if neoplastic changes are observed, or obstruction is persistent.  

58. Summary Ulcerative Colitis UC is generally limited to the colon, apart from minimal distal "back-wash" ileitis; ulcerative colitis usually involves only the mucosal layer of the bowel, and, in some cases, superficial submucosa, unless there is fulminant colitis  may also manifest cecal or appendiceal patches of involvement that can simulate the "skip" lesions of CD Crohn's Disease presence of skip lesions Granulomas transmural inflammation Fissures, involvement of any part of the gastrointestinal tract aphthous ulceration is considered unique to Crohn disease.

59. Summary Ulcerative Colitis risk of neoplastic transformation, the risk is higher continuous process, worse distally, with increased span of involvement distal to proximal, as the disease progresses Surgical intervention is better tolerated in UC Crohn's Disease risk of neoplastic transformation,is lower. Higher risk of recurrence and ulceration, fissure, and fistula formation at sites of reanastomosis or stoma formation. creeping fat aphthous ulceration is considered unique to Crohn disease.

60. Summary Ulcerative Colitis Crohn Disease Only colon involved Panintestinal Continuous inflammation extending proximally from rectum Skip-lesions with intervening normal mucosa Inflammation in mucosa and submucosa only Transmural inflammation   Perianal lesions No granulomas Noncaseating granulomas Perinuclear ANCA (pANCA) positive ASCA positive Bleeding (common) Bleeding (uncommon) Fistulae (rare) Fistulae (common)

61. Grey Areas CD can occasionally affect only the distal colon. granulomas may be present in UC (although typically adjacent to ruptured crypts, whereas CD granulomas have no necessary spatial relationship to injured crypts). regional involvement/skip lesions of CD may not be apparent endoscopically or in small mucosal biopsies. approximately 15 % may remain indeterminate- ”indeterminate colitis”

62. Thank you.