IBDIBD Inflammatory Bowel DiseaseInflammatory Bowel Disease

Dr. László OroszDr. László Orosz

Surgical DepartmentSurgical Department

University Of DebrecenUniversity Of Debrecen

IBDIBD

Crohn’s DiseaseCrohn’s Disease

Ulcerative colitisUlcerative colitis

Suspicion of IBDSuspicion of IBD

Diarrhoea for more than 4 weeksDiarrhoea for more than 4 weeks Opening the bowels more than twice Opening the bowels more than twice

a day a day wet/fluidwet/fluid-like-like stool stool Abdominal painAbdominal pain Stool containing blood,Stool containing blood, mucus or mucus or

pus pus

Ulcerative colitisUlcerative colitis Chronic inflammatory bowel disease that Chronic inflammatory bowel disease that

is only localised in the mucus membrane is only localised in the mucus membrane of the colonof the colon/rectum. /rectum.

There are ulcers and signs of There are ulcers and signs of inflammation in the rectum and the colon. inflammation in the rectum and the colon. It is a recurrent disease.It is a recurrent disease.

Diarrhoea, bloody stool, crampDiarrhoea, bloody stool, crampyy abdominal pain, weight loss, loss of abdominal pain, weight loss, loss of appetiteappetite

Diffuse ulceration in colon mucus Diffuse ulceration in colon mucus membrane,membrane, crypt crypt abscess, abscess, infiltration.infiltration.

Crohn’s diseaseCrohn’s disease Chronic, segmental or multy-segmentalChronic, segmental or multy-segmental. .

AAll the layers of the intestine is affectedll the layers of the intestine is affected Both small intestines and the colon Both small intestines and the colon

might be affectedmight be affected Cramp-like abdominal pain, weight loss, Cramp-like abdominal pain, weight loss,

diarrhoea, feverdiarrhoea, fever Local inflammation, micro-erosions, Local inflammation, micro-erosions,

fissuresfissures, granuloma, , granuloma, fistulas , fistulas , infiltrations, lymphatic vessel infiltrations, lymphatic vessel enlargementenlargement

LocalisationLocalisation

UlcerativeUlcerative Colitis Colitis Sigmoid-rectum 54%Sigmoid-rectum 54%Left colon 27%Left colon 27%Pancolitis 19%Pancolitis 19%

Crohn’s diseaseCrohn’s disease Small intestine Small intestine and and colon 50%colon 50%Ileitis 29%Ileitis 29%Colitis 19%Colitis 19%Anorectal 2%Anorectal 2%

Distribution of Distribution of gastrointestinal Crohn's gastrointestinal Crohn's

disease. disease.

EpidemiologyEpidemiology Young ageYoung age Incidence has not changed in the recent yearsIncidence has not changed in the recent years Crohn’s disease: 6/100000Crohn’s disease: 6/100000 Ulcerative Colitis: Ulcerative Colitis: 2-3/100000 in the 2-3/100000 in the

developped countriesdevelopped countries 10-20 x frequent in afected families10-20 x frequent in afected families genetical predisposition: In1996-ban Hugot et genetical predisposition: In1996-ban Hugot et

al found IBD1 locus on the 16 chromosome, al found IBD1 locus on the 16 chromosome, which predispose for CD, IBD2 that which predispose for CD, IBD2 that predispose for CUpredispose for CU

EthiologyEthiology

UnkUnknnownown!!!! Infective: herpes, Infective: herpes, measeles, measeles, E. coli, E. coli,

M. paratuberculosisM. paratuberculosis Genetic background: familiar Genetic background: familiar

dispositiondisposition Diet?Diet? ImmunImmunee system: autoimmun system: autoimmunee?? Emmotional statusEmmotional status

SymptomsSymptoms

Ulcerative Coilits Crohn’ Ulcerative Coilits Crohn’ diseasedisease

Bleeding 80% 22%Bleeding 80% 22% Diarrhoea 52% 73%Diarrhoea 52% 73% Abdominal pain 47% 77%Abdominal pain 47% 77% Fistulas 0% 16%Fistulas 0% 16% Weight-loss 5% 54% Weight-loss 5% 54% Fever 1% 35%Fever 1% 35% Anaemia 15% 27%Anaemia 15% 27% Joint pain 13% 16%Joint pain 13% 16% Eye symptoms 11% 10%Eye symptoms 11% 10%

Extraintestinal symptomsExtraintestinal symptoms

Arthritis, polyarthritis 26%Arthritis, polyarthritis 26% Erythema nod., Pyoderma gangr. 19%Erythema nod., Pyoderma gangr. 19% Fatty liver, Chr. Active hepatitis, PSC 7%Fatty liver, Chr. Active hepatitis, PSC 7% Iridocyclitis, Uveitis 4%Iridocyclitis, Uveitis 4% Oral, stomatitis aphtosa 4%Oral, stomatitis aphtosa 4% Alveolitis, lung fibrosis <1%Alveolitis, lung fibrosis <1%

Diagnostics: Crohn’s Diagnostics: Crohn’s diseasedisease

Colonscopy, (biopsy) capsule-Colonscopy, (biopsy) capsule-endoscopyendoscopy

X-ray, Barium anema and mealX-ray, Barium anema and meal UH, CTUH, CT Laboratory (blood) tests Laboratory (blood) tests

( Sedimentation, WBC, CRP, liver ( Sedimentation, WBC, CRP, liver enzymes, stool culture )enzymes, stool culture )

Endoscopy image of colon showing serpiginous ulcer, a classic finding in Crohn's disease

Crohn's disease can mimic ulcerative colitis on endoscopy. This endoscopic image is of Crohn's colitis showing diffuse loss of mucosal architecture, friability of mucosa in sigmoid colon and exudate on wall, all of which can be found with ulcerative colitis.

Endoscopic image of colon cancer identified in the sigmoid colon (anatomy) on screening colonoscopy for Crohn's disease.

Diagnostics: Ulcerative Diagnostics: Ulcerative colitiscolitis

Colonscopy, (biopsy) capsule-Colonscopy, (biopsy) capsule-endoscopyendoscopy

X-ray, Barium anema and mealX-ray, Barium anema and meal UH, CTUH, CT Laboratory (blood) tests Laboratory (blood) tests

( Sedimentation, WBC, CRP, liver ( Sedimentation, WBC, CRP, liver enzymes, stool culture )enzymes, stool culture )

Endoscopic image of a sigmoid colon afflicted with ulcerative colitis. Note the vascular pattern of the colon granularity and focal friability of the mucosa.

Colonic pseudopolyps of a patient with intractable ulcerative colitis. Colectomy specimen.

Patients with ulcerative colitis can occasionally have aphthous ulcers involving the tongue, lips, palate and pharynx

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 may be similar in appearance, a fact that can make diagnosing UC a challenge.

Biopsy sample (H&E stain) that demonstrates marked lymphocytic infiltration (blue/purple) of the intestinal mucosa and architectural distortion of the crypts.

H&E stain of a colonic biopsy showing a crypt abscess, a classic finding in ulcerative colitis

Medical therapyMedical therapy

PentasaPentasa Steroids, imuran, (budesonid)Steroids, imuran, (budesonid) Anti-TNF-Anti-TNF-alfa (Remicade)alfa (Remicade) Ciprofloxacin, metronidazolCiprofloxacin, metronidazol Nutritional advicesNutritional advices

Crohn’s disease: Therapy Crohn’s disease: Therapy

Acute fulminate: exclusion of Acute fulminate: exclusion of abscess than Steroid 40-60 mg, abscess than Steroid 40-60 mg, wide spectrum antibioticswide spectrum antibiotics

SuSubbacute disease: Steroid in acute disease: Steroid in decreasing dosagedecreasing dosage Budenofalk, Budenofalk, sulfasalazin, Pentasa, Salofalk, sulfasalazin, Pentasa, Salofalk, metronidasolmetronidasol

Chronic: constant low dose steroid, Chronic: constant low dose steroid, Imuran, 5-aminosalicImuran, 5-aminosalicyyll

Ulcerative Ulcerative colitis :Therapycolitis :Therapy

Acute inflammation: Steroid, Acute inflammation: Steroid, antibioticum, 5-ASAantibioticum, 5-ASA

Chronic : 5-ASA, ImuranChronic : 5-ASA, Imuran

Crohn’s disease: Crohn’s disease: complicationscomplications

Stenosis, ileus (bowel obstruction)Stenosis, ileus (bowel obstruction) Fistula formationFistula formation Abscess formationAbscess formation BleedingBleeding Toxic megacolonToxic megacolon Malignant transformationMalignant transformation

Ulcerative colitis: Ulcerative colitis: complicationscomplications

Stenosis, ileus (bowel obstruction)Stenosis, ileus (bowel obstruction) bleedingbleeding Perforation, abscess formation, Perforation, abscess formation,

peritonitisperitonitis Toxic megacolonToxic megacolon Malignant transformationMalignant transformation

Crohn’disease: Surgical Crohn’disease: Surgical therapytherapy

Maximally conservative !!!Maximally conservative !!! Resection (preserving as much small Resection (preserving as much small

intestine as possible!)intestine as possible!) Srticturopalsty (small intestine)Srticturopalsty (small intestine)

Toxic megacolonToxic megacolon

Ulcerative colitis: Surgical Ulcerative colitis: Surgical treatmenttreatment

In acute case: In acute case: Hartmann procedureHartmann procedure ProctocolectomyProctocolectomy Elective operation:Elective operation: Proctocolectomy with ileostomyProctocolectomy with ileostomy Total colectomy with ileo-rectal Total colectomy with ileo-rectal

anastomosisanastomosis Proctocolectomia , ileo-analis anastomisis Proctocolectomia , ileo-analis anastomisis

with ileum pauchwith ileum pauch Proctocolectomia, Koch-reservoirProctocolectomia, Koch-reservoir

Colon J-pouchColon J-pouch

J-pouchJ-pouch

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