Pathology and Management of Inflammatory Bowel Disease

Brian Wells, MS-3, MSM, MPH

St. George’s University School of Medicine

I have finally come to the conclusion that a good set of bowels is worth more to a man than any quantity of brains.

- Josh Billings (4/20/1818 – 10/14/1885)

© 2010 Brian Wells

IBD

Informative

Beneficial

Deployable

Inflammatory Bowel Disease

© 2010 Brian Wells

Today’s Goals

Mathematical Description of Transmural Involvement

(+) Informative

(-) Beneficial

(-) Deployable

© 2010 Brian Wells

Infammatory Bowel Disease

Ulcerative Colitis

Crohn’s Disease

(Leśniowski-Crohn’s Diease in Poland)

© 2010 Brian Wells

Infammatory Bowel Disease

© 2010 Brian Wells

Crohn’s Disease - How did we get here?

Giovanni Battista Morgagni2/25/1682 – 12/6/1771

First description: 1769

Burrill B. Crohn, MD6/13/1884 – 7/29/1983

1932 - “Regional ilitius” thought due to Mycobacterium paratuberculosis

Similar to Johne’s Disease

Thomas Kennedy Dalziel 1861–1924

Chronic interstial enteritis. Br Med J 1913; 2: 1068–1070

Antoni Leśniowski1/28/1867–4/4/1940Annals of the Warsaw Medical Association 1903-1905 – “a chronic inflammatory process in the wall of the gut.”

© 2010 Brian Wells

Epidemiology

Ulcerative Colitis Crohn’s Disease

Incidence (per 100,000) 10 (0.5–24.5) 5.8 (0.1-16)

Prevalence (per 100,000) 229 (=) 133 (↑)

At-risk population High in Jewish, low in African-American, +FHx in 20%

High in Jewish, low in African-American, ~equal in Caucasian and AA

Sex Male > Female (slightly) Female > Male (slightly)

Distribution Bimodal: 20-35, 50-65 Bimodal: 25-40, 50-65

Factors More common with ex-smokers and nonsmokers

More common with smokers

*Centers for Disease Control and Prevention

U.S. Population estimate (July 2009): 307,006,550

Overall prevalence (2006): 396/100,000 persons

Total estimated cases (July 2009): ~1.2-1.4 M cases

*Lakatos PL. Recent trends in the epidemiology of inflammatory bowel diseases: up or down?World J Gastroenterol 2006;12(38):6102–08.

© 2010 Brian Wells

Comparative Summary

Ulcerative Colitis Crohn’s Disease

Type of Involvement Diffuse, No skip areas Skip areas

Depth of Involvement Mucosa & submucosa Transmural

Rectal Involvement 95% 50%

Perianal disease - +

Fistulas - +

© 2010 Brian Wells

Comparative Summary

Ulcerative Colitis Crohn’s Disease

Ileal involvement - +

Aphthous ulcers & linear ulcers

- +

Cobblestone appearance - +

Ulceration Fine, superficial Deep with submucosal extension

P-ANCA 70% Occasional

© 2010 Brian Wells

Comparative Summary

Ulcerative Colitis Crohn’s Disease

Anti-saccharomyces Occasional >50%

Risk of colon CA ++ +

Granulomas - Non-caseating

Extraintestinal manifestations

Arthritis, iritis, erythema nodosum, pyoderma gangrenosum

© 2010 Brian Wells

Comparative Summary

Ulcerative Colitis Crohn’s Disease

Medical Treatment Ulcerative proctitis5-ASA suppositoriesConsider adding: rectal steroid enema, steroid foam, 5-ASA enemas

Ulcerative colitisOral 5-ASA and/or rectal 5-ASA enemas or steroid foamFor severe disease consider adding enema or IV steroids, or TNF-α inhibitors

Mild to moderate diseaseOral 5-ASA or sulfasalazine. Consider adding: antibiotics flagyl +/- cipro

SevereIV steroids, immunosuppressive drugs, TNF-α inhibitors

FistulasTNF-α inhibitors

© 2010 Brian Wells

© 2010 Brian Wells

Horton K M et al. Radiographics 2000;20:399-418

©2000 by Radiological Society of North America

Contrast-enhanced CT scan shows minimal diffuse thickening of the sigmoid colon with minimal inflammatory stranding.

Ulcerative colitis in a 27-year-old man

© 2010 Brian Wells

Horton K M et al. Radiographics 2000;20:399-418

©2000 by Radiological Society of North America

CT scan obtained with oral contrast material shows moderate thickening of the terminal ileum (curved arrow) and cecum (straight arrow) with adjacent inflammatory changes in the pericolic fat.

Crohn’s Disease

Medical Management

• Drug selection– 5-ASA– Sulfasalazine, mesalamine– Steroids– TNF-α inhibitors

• Dosing• Role of technology

© 2010 Brian Wells

Surgical Management

• Indications for surgery in ulcerative colitis

Urgent Surgery Elective Surgery

Ongoing hemorrhage Failure of medical therapy

Toxic megacolon Intolerable side effect of medical therapy

Colonic perforation Development of dysplasia

Fulminant ulcerative colitis Carcinoma

Colonic stricture

Growth retardation in children

© 2010 Brian Wells

*Current Surgical Therapy 9th Edition

Surgical Management

• Surgical alternatives for ulcerative colitis

Emergency Operation Elective Operation±Subtotal colectomy with end ileostomy

Panproctocolectomy withpermanent end ileostomy (simple and curative)

Panproctocolectomy with permanent end ileostomy

Subtotal colectomy with ileorectalAnastomosis (rarely performed)

Proctocolectomy with continentileostomy (Kock pouch) - Rarely performedPanproctocolectomy with IPAAwith or without diverting ileostomy (CI in Crohn’s disease)

± Standard procedure*Construction of a pouch is avoided in the emergency setting

© 2010 Brian Wells

Surgical Management

• Indications for surgery in Crohn’s DiseaseUrgent Surgery Elective Surgery

Perforation Stricture

Abscess Fistula

Uncontrollable hemorrhage Malignancy

Toxic megacolon Malnutrition

Bowel obstruction Poorly controlled despite management

Extra-intestinal manifestations

*Medical Management of the Surgical Patient: A Textbook of Perioperative Medicine*ASCRS – American Society of Colon and Rectal Surgeons

Most patients with Crohn's disease ultimately require one or more operations in their lifetime. Operative indications are the same no matter where the disease manifests itself.

© 2010 Brian Wells

Thank you!

Any questions?

© 2010 Brian Wells