temesgen dechasssaseminaron ibd IBD SEM.pptx

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1. IBD,Intestinal TB and Typhoid fever By : Dr.Temesgen ( GSR 3) Moderator : Dr. Bonge (consultant general surgeon) 5/28/2024 temesgen d 1

2. outlines Objective Introduction Epidemiology of IBD, Intestinal TB and Typhoid fever Clinical Manifestation and diagnosis of IBD, Intestinal TB and Typhoid fever Treatment of IBD, Intestinal TB and Typhoid fever References 5/28/2024 temesgen d 2

3. Objective To illustrate epidimology IBD To List Clinical Manifestation and diagnostic work up of IBD, Intestinal TB and Typhoid fever To outline treatment of IBD, Intestinal TB and Typhoid fever 5/28/2024 temesgen d 3

4. Introduction Idiopathic, chronic, inflammatory diseases of GIT It includes ulcerative colitis, Crohn’s disease , and indeterminate colitis(15%). Anti-TNF agents the most effective available therapy Abdominal TB usually involves intestines, peritoneum, and mesenteric lymph nodes, commonest site being ileocecal region Typhoid fever is a major health problem 5/28/2024 temesgen d 4

5. Epidemiology of IBD Epidemoilogy ; Ulcerative colitis occurs in 8 to 15 people per 100,000 and peak age 3 rd and 7 th decade of life, Crohn’s disease occurr in 1 to 5 people per 100,000 between ages 15 to 30 years and ages 60 to 70 years. In 15% of patients with IBD are classified as having indeterminate colitis 5/28/2024 temesgen d 5

6. Etiology Enviromental factor;diet,microorganism,alcohol,oral contraceptive,smoking,location Genetics;account about 10-30%, There is a stronger genetic influence in CD compared with UC Thus, non-genetic factors may have a more important role in UC than in CD Immunity Antibiotics;due to shift of bacterial community structure NSAIDS . Appendectomy 5/28/2024 temesgen d 6

7. Clinical Manifestation UC Diarrhoea Rectal bleeding Rectal urgency Nocturnal defecation Tenesmu s Passage of mucopurulent exudates Crampy abdominal pain Systemic symptoms CD Diarrhoea Abdominal pain Weight loss Systemic symptoms Blood and/or mucus in the stool Obstruction Perianal fistula/abscess malnutrition 5/28/2024 temesgen d 7

8. Features distinguishing Crohn’s disease from ulcerative colitis 5/28/2024 temesgen d 8

9. E xtraintestinal manifestations of IBD 5/28/2024 temesgen d 9

10. Extraintestinal manifestation of CD 5/28/2024 temesgen d 10

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12. Diagnosis CBC OFT CRP ESR Faecal calprotectin Serological Markers pANCA ASCA Mycobacterial investigation 5/28/2024 temesgen d 12

13. Imaging Barium enema-lead pipe colon Abdominal x ray-in acute severe colitis see toxic megacolon or perforation CT scan-to see moderate to severe small bowel or colonic inflammation,intraabdominal or perianal abscess,and bowel obstruction chxs by transitional point and evaluation of enteric fistula U/S-to see stricture and fibrosis MRI-for perianal crohns diseasea 5/28/2024 temesgen d 13

14. Endoscopy Colonoscopy with terminal ileal intubation Findings abnormal erythematous mucosa ulcerations The most commonly used criterion for an abnormal finding is the presence of three or more ulcers in the absence of NSAID 5/28/2024 temesgen d 14

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16. Classification and Grading of IBD The Montreal classification and the Paris classification (for pediatric patients) remain the most well-accepted classification. 5/28/2024 temesgen d 16

17. Treatment of IBD Objective of treatment Induce remission Prevent relapse Treat complication Can be Surgical or Medical : 5/28/2024 temesgen d 17

18. Medical treatment of CD Antibiotics - role in the treatment of infectious complications,associated with Crohn’s disease,they are also used to treat,patients with perianal disease, enterocutaneous fistulas, and active colonic disease Aminosalicylates Corticosteroids Immunomodulators B iologic therapies 5/28/2024 temesgen d 18

19. Indications for surgical intervention in Crohn’s disease 5/28/2024 temesgen d 19

20. Emergency surgery Uncontrolled Hemorrhage Perforation Toxic megacolon Abscesses 5/28/2024 temesgen d 20

21. Preoperative considerations Preoperative high-dose glucocorticoids increase the risk of postoperative infectious complications and attempts should typically be made to wean glucocorticoids before surgical intervention. Immunomodulators are not associated with increased risk of postoperative infectious complications and do not typically need to be held before surgery Preoperative nutritional support for patients with malnutrition may decrease postoperative morbidity Smoking cessation may reduce postoperative morbidity in patients with Crohn’s disease 5/28/2024 temesgen d 21

22. General principles … Extent of resection 2cm margin = is similar to 12cm margin resection Feel normal bowel from mesenteric border Internal bypass Not advisable-risk of malignancy in bypassed segment Gastro-duodenal stricture- bypass can be used Anastomosis-comparable outcome Stapled or Hand sewn Side to side or End to End anastomosis Approach to mesentery- standard-clamp-tie technique -Gently tissue handling-risk of hematoma 5/28/2024 temesgen d 22

23. Cont.. Segmental intestinal resection of grossly evident disease followed by primary anastomosis is the usual procedure of choice An alternative to segmental resection for obstructing lesions is stricturoplasty 5/28/2024 temesgen d 23

24. Anastomostic types 5/28/2024 temesgen d 24

25. Stricturoplasty Indicated in pt who had Hx of resection and maintenance of intestinal length is of great importance .Short strictures,< 12cm -make longitudinal incision and close defect transversely - Heinicke - Mikulicz Strictroplasty . Intermediate up to 25cm -Finney Strictroplasty . Long segment>25cm -side to -Side isoperistaltic Strictroplasty 5/28/2024 temesgen d 25

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28. Stoma indication H emodynamically unstable S eptic Malnourished R eceiving high-dose immunosuppressive therapy A mong patients with extensive intra-abdominal contamination . 5/28/2024 temesgen d 28

29. Outcome-CD Post-op complication rate is 15-30% Wound site infection Anastomotic leak Abscess & etc . Clinical Recurrence rate after surgery:- 60% by 5yrs 94% by 15yrs Endoscopic recurrence 70% with in 1year and 85% with in 3years 5/28/2024 temesgen d 29

30. Anal and perianal Crohn's disease Occur in 35% of patient with CD Isolated anal CD occur in 3 to 4 % patients Th e most common perianal lesions in Crohn’s disease are skin tags Fissure located laterally Perianal abscess and fistula Treatment: A lleviation of symptoms 5/28/2024 temesgen d 30

31. Medical Management UC 5/28/2024 temesgen d 31

32. Surgical management of UC 1. E mergency surgery Life threatening hemorrhage , T oxic megacolon F ulminant colitis who fail to respond rapidly to medical therapy. 2. E lective surgery Medically refractory Colitis R isk of developing colorectal carcinoma patient with dysplasia 5/28/2024 temesgen d 32

33. cont … Emergent Operation Total abdominal colectomy with end ileostomy Loop ileostomy and decompressing colostomy Blow hole colostomy Elective Operation Total proctocolectomy with end ileostomy (Gold standard for chronic UC) Total proctocolectomy with continent ileostomy (Kock’s pouch) Restorative proctocolectomy with ileal pouch–anal anastomosi s Abdominal colectomy with ileorectal anastomosis 5/28/2024 temesgen d 33

34. Surveillance Endoscopy in IBD F or all UC patients and CD patients with colonic involvement colonoscopic surveillance at 8yrs A t diagnosis if PSC is present annual surveillance colonoscopy for Patients at high risk (PSC, family history of CRC, stricture, or dysplasia while those with intermediate risk (including those with active mucosal inflammation) should undergo surveillance colonoscopy in 1–3 years those at low risk should undergo surveillance colonoscopy every 3–5 years Surveillance is recommended annually after 8 years in patients with pancolitis , and annually after 15 years in patients with left-s ided colitis. 5/28/2024 temesgen d 34

35. Abdominal TB Abdominal tuberculosis is prevalent in developing countries It can be commonly intestinal and peritoneal TB It commonly involves ileocecal region that presents with constitutional symptoms and features of subacute intestinal obstruction Abdominal tuberculosis accounted for 6 to 11% of extra-pulmonary tuberculosis 5/28/2024 temesgen d 35

36. Epidemiology Abdominal TB has been considered the sixth most common form of EPTB Intestinal TB is the commonest, accounting for 30–50% cases of abdominal TB and about 1/3 coexist with PTB Up to 25% cases of ITB may have concomitant pulmonary disease 5/28/2024 temesgen d 36

37. Classification of Abdominal TB Intestinal Ulcerative Stenotic Hyperplastic Ulcero-hyperplastic Peritoneal Acute Chronic Ascitic Encysted ( loculated ) Plastic (Fibrous/adhesive) Purulent Tubercular abdominal cocoon 5/28/2024 temesgen d 37

38. Modes of Spread of Abdominal Tuberculosis By ingestion Hematogenous spread from tuberculosis of lungs From tuberculous cervical lymphadenitis through lymphatics From fallopian tubes by retrograde spread to involve peritoneum 5/28/2024 temesgen d 38

39. Clinical Manifestations Abdominal pain Anaemia, loss of weight and appetite Mass in right iliac fossa Diarrhea/ constipation Bleeding per-rectum Fever and other constitutional symptoms 5/28/2024 temesgen d 39

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41. Diagnosis History and P/E CBC ESR OFT Microbiology Gene- Xpert AFB TB-PCR Culture for MTB Biopsy-peritoneal or intestinal biopsy TB marker-ADA 5/28/2024 temesgen d 41

42. Imaging X ray-to see if there is chest involvement ,dilated small bowel with air fluid level Abdominal US-detect lyphadenopathy,ascites,peritoneal thickening,omental thichening and bowel thickening CT In setting of intestinal TB- concetric mural thickening in ICV region,asymetric thickening of medial cecal wall,lyphadenopathy with hypodense center In setting of peritoneal TB-seen ascites,lymph nodes,thickeng of mesentery and omentum,thichening of peritonium Barium enema- demostrate mucosal ulceration and stricture,deformed cecum and incompetent ICV 5/28/2024 temesgen d 42

43. Case Definition of Tuberculosis Paustian’s criteria Caseating granuloma on histology Acid-fast bacilli (AFB) positivity in tissue Suggestive operative findings Consistent histology from mesenteric lymph nodes Logan’s criteria Paustian’s criteria plus Response to treatment 5/28/2024 temesgen d 43

44. Feature that help to differentiate between crohn disease and intestinal TB 5/28/2024 temesgen d 44

45. Complications of abdominal tuberculosis Obstruction Malabsorption, blind loop syndrome Dissemination of tuberculosis to other areas of abdomen as well as extra-abdominal sites Faecal fistula Cold abscess formation Haemorrhage Perforation 5/28/2024 temesgen d 45

46. Treatment of Intestinal TB Medical treatment : Anti TB drugs for atleast 6months Surgical treatment: Emergent indications—obstruction, perforation, and bleeding Persistent symptoms—ileocecal mass, stricture, cocoon abdomen Fistulizing intestinal tuberculosis 5/28/2024 temesgen d 46

47. Intestinal Obstruction Most commonly caused by intestinal stricture Presents usually present with recurrent subacute intestinal obstruction one-fifth of patient with stricture requires surgery Treatment Stricturoplasty Resection 5/28/2024 temesgen d 47

48. Perforation Incidence of ranges from 1–11% of intestinal tuberculosis Clinical presentation Free perforation with peritonitis, Contained perforation, Chronic perforation in cocoon abdomen chronic fistula Have poor outcome with mortality as high as 30% 5/28/2024 temesgen d 48

49. Treatment of Perforation Intestinal resection and anastomosis Ileostomy -for poor general condition patient Resection of diseased segment and ileostomy 5/28/2024 temesgen d 49

50. A bdominal cocoon - the entire intestine is plastered with very dense omental and bowel adhesions . Treatment- extensive adhesiolysis and ileostomy if there is ileal perforation 5/28/2024 temesgen d 50

51. Outcome Mortality rate in tubercular gut perforation is very high ranging from 25% to 100% The factors associated with high mortality include Old age Cachexia Delayed operation (36 h) Multiple perforations Multiple strictures Primary closure of the perforation Anastomotic leakage Steroid therapy 5/28/2024 temesgen d 51

52. Methods A prospective descriptive study of patients who presented with abdominal tuberculosis was conducted at Bugando Medical Centre (BMC) in northwestern Tanzania from January 2006 to February 2012. Ethical approval to conduct the study was obtained from relevant authorities. Statistical data analysis was performed using SPSS version 17.0. Results Out of 256 patients enrolled in the study, males outnumbered females. The median age was 28 years (range = 16–68 years). The majority of patients (77.3%) had primary abdominal tuberculosis . A total of 127 (49.6%) patients presented with intestinal obstruction, 106 (41.4%) with peritonitis, 17 (6.6%) with abdominal masses and 6 (2.3%) patients with multiple fistulae in ano. Forty-eight (18.8%) patients were HIV positive. A total of 212 (82.8%) patients underwent surgical treatment for abdominal tuberculosis. Bands /adhesions (58.5%) were the most common operative findings. Ileo-caecal region was the most common bowel involved in 122 (57.5%) patients . Release of adhesions and bands was the most frequent surgical procedure performed in 58.5% of cases . Complication and mortality rates were 29.7% and 18.8 % respectively. The overall median length of hospital stay was 32 days and was significantly longer in patients with complications ( p < 0.001). Advanced age (age ≥ 65 years), co-morbid illness, late presentation, HIV positivity and CD4+ count < 200 cells/ μl were statistically significantly associated with mortality (p < 0.0001). The follow up of patients were generally poor as only 37.5% of patients were available for follow up at twelve months after discharge. 5/28/2024 temesgen d 52

53. Typhoid Ileal Perforations Typhoid fever is a major health problem in third world countries Incidence varies from region to region Seen in young males in the age group of 20–30 years. Rarely seen in <5 years or >50 years of age Perforation occur during late second or early third week of illness 5/28/2024 temesgen d 53

54. Etiology Salmonella typhi Salmonella paratyphi Non-typhoidal infection S. Typhimurium. S. Enteritidis 5/28/2024 temesgen d 54 Enteric fever

55. Clinical Features History High-grade fever for the past 2–3 weeks Headache Sudden onset central abdominal pain 5/28/2024 temesgen d 55

56. Diagnosis CBC Widal test Blood culture stool cultures Bone marrow culture Erect chest X-ray Abdominal ultrasound 5/28/2024 temesgen d 56

57. Complication of Typhoid fever Meningitis. Lobar pneumonia. Osteomyelitis. Intestinal hemorrhage Intestinal perforation Myocarditis 5/28/2024 temesgen d 57

58. morphology of ileal typhoid perforation Multiple/single Punched out Located with in 30cm of distal ileum on antimesenteric border Oval in shape 5/28/2024 temesgen d 58

59. Treatment intestinal perforation Aggressive preoperative resuscitation IV Antibiotics Exploration laparotomy Primary closure Wedge resection and closure Resection-anastomosis : Ileostomy Drainage of peritoneal cavity 5/28/2024 temesgen d 59

60. Outcome Have high morbidity and mortality. Morbidity includes Wound infection( 40–60% ) Fecal fistula( 3.8–16.5% ) abdomeninal wound dehiscence Intra-abdominal abscess Psychosis Bleeding diathesis E mpyema 5/28/2024 temesgen d 60

61. 5/28/2024 temesgen d 61 Patients and Methods: The study retrospectively reviewed all patients diagnosed with typhoid perforation and managed in Damaturu and Potiskum district Hospitals North-Eastern Nigeria between January 2012 and December 2016. Results: A total of 279 patients were seen, 268 analyzed and 11 were excluded due to incomplete records. Age ranged from 3 to 50 years with male to female ration of 1.1:1 and a mean of 14.75 years. The peak age group was 11-20 years accounting for 39.93%. The clinical features were abdominal pain in 99.25 % and abdominal tenderness Perforations were single in 183 (68.28%) while 85 (31.72%) were multiple with 13 perforations in an individual being the highest in all patients. Procedures done were simple closure of perforation in 87.31% patients, resection and anastomosis in 70.84%. Post-operative complications were surgical site infection in 21.64%, and renal failure in 1.12%. The mortality was 14.18%.

62. SUMMARY IBD is comprised of two major disorders: ulcerative colitis and Crohn's disease Ulcerative colitis - relapsing and remitting episodes of inflammation limited to the  mucosal layer of the colon  Crohn's disease - transmural   inflammation and by  skip lesions  Tuberculous enteritis consists of relatively vague, nonspecific symptoms and signs Intestinal perforation and bleeding are surgical complication of typhoid fever 5/28/2024 temesgen d 62

63. References The ASCRS Textbook of Colon and Rectal Surgery,Fourth Edition Schwartz's Principles of Surgery, 11 th edition Hot Topics in Acute Care Surgery and Trauma , Abdominal Sepsis a Multidisciplinary Approach Primary surgery, volume one sabiston textbook of surgery, 21 th edition Shackelford’s Surgery of The Alimentary Tract , 8 th edition Gordon surgery of Colon,Rectum and Anus , 4 rd edition Up todate 2024 5/28/2024 temesgen d 63

64. 5/28/2024 temesgen d 64 THANK YOU