Inflammatory Bowel Inflammatory Bowel DiseaseDisease

ByBy

Dr. Nousheen SaleemDr. Nousheen Saleem

House OfficerHouse Officer

MU1MU1

Inflammatory bowel diseaseInflammatory bowel disease

Refers to two chronic diseases that cause Refers to two chronic diseases that cause inflammation of the intestines: inflammation of the intestines: ulcerative ulcerative colitiscolitis and and Crohn's diseaseCrohn's disease. .

Although the diseases have some features in Although the diseases have some features in common, there are some important differences.common, there are some important differences.

EtiologyEtiology FamilialFamilial

Common amongst 1Common amongst 1stst degree relative. degree relative. EnvironmentEnvironment

UC: Common in non smoker and in ex smoker.UC: Common in non smoker and in ex smoker. CD: Common in smokers.CD: Common in smokers. Appendicetomy protects against UC. Appendicetomy protects against UC.

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Diet :associated with low residue and high Diet :associated with low residue and high refined sugar dietrefined sugar diet

GeneticsGenetics Mutations in CARD 15/ NOD-2 Gene on CH16.Mutations in CARD 15/ NOD-2 Gene on CH16.

Cont…Cont…

Current evidence suggests that there's likely Current evidence suggests that there's likely a genetic defect that affects how our immune a genetic defect that affects how our immune system works and how the inflammation is system works and how the inflammation is turned on and off in those people with turned on and off in those people with inflammatory bowel disease, in response to an inflammatory bowel disease, in response to an offending agent, likeoffending agent, like::

Bacteria: Bacteria: Mycobacterium, listeria, H.hepaticus Mycobacterium, listeria, H.hepaticus and endogenous bac.and endogenous bac.

Virus: Virus: Measeles…Measeles… or a protein in foodor a protein in food

Ulcerative colitisUlcerative colitis

Is an inflammatory disease of the large Is an inflammatory disease of the large intestine. In which the intestine. In which the mucosamucosa - of the - of the intestine becomes inflamed and develops intestine becomes inflamed and develops ulcers with diffuse friability and erosions with ulcers with diffuse friability and erosions with bleedingbleeding

Ulcerative colitis –Ulcerative colitis –gut involvementgut involvement

40-50% of patients have disease limited to the rectum 40-50% of patients have disease limited to the rectum and rectosigmoidand rectosigmoid (proctosigmoiditis) (proctosigmoiditis)

30-40% of patients have disease extending beyond 30-40% of patients have disease extending beyond the sigmoidthe sigmoid (left sided colitis) (left sided colitis)

20% of patients have a total20% of patients have a total/extensive/extensive colitis colitis

Ulcerative colitis – macroscopic featuresUlcerative colitis – macroscopic features

Mucosa isMucosa is : :

- erythematous, has a granular surface that looks like a sand - erythematous, has a granular surface that looks like a sand paperpaper

In more severe diseasesIn more severe diseases::

- hemorrhagic, edematous and ulcerated- hemorrhagic, edematous and ulcerated

In fulminant diseaseIn fulminant disease a toxic colitis or a toxic megacolon may a toxic colitis or a toxic megacolon may develop ( wall become very thin and mucosa is severly develop ( wall become very thin and mucosa is severly ulcerated)ulcerated)

Colonic pseudopolyps

ulcerative colitis:the left side of the colon is affected The image shows confluent superficial ulceration and loss of mucosal architecture.

Ulcerative colitis – microscopic featuresUlcerative colitis – microscopic features

Process is limited to Process is limited to the mucosa and submucosathe mucosa and submucosa with with deeper layer unaffecteddeeper layer unaffected

Two major histologic features:Two major histologic features:

- the crypt architecture of the colon is distorted- the crypt architecture of the colon is distorted

- some patients have basal plasma cells and multiple - some patients have basal plasma cells and multiple basal lymphoid aggregatesbasal lymphoid aggregates

UCUC

Ulcerative colitis – clinical presentationUlcerative colitis – clinical presentation

The major symptoms of UC are:The major symptoms of UC are: BloodyBloody diarrhea diarrhea(hallmark)(hallmark)

TenesmusTenesmus PPassage of mucusassage of mucus CCrampy abdominal painrampy abdominal pain

Ulcerative colitis – clinical presentationUlcerative colitis – clinical presentation

Patients with proctitis usually pass Patients with proctitis usually pass fresh blood or blood-fresh blood or blood-stained mucusstained mucus either mixed with stool or streaked onto the either mixed with stool or streaked onto the surfacesurface of normal or hard stool of normal or hard stool

When the disease extends beyond the rectum, blood is usually When the disease extends beyond the rectum, blood is usually mixed with stool or grossly bloody diarrhea may be notedmixed with stool or grossly bloody diarrhea may be noted

When the disease is severe, patients pass a liquid stool When the disease is severe, patients pass a liquid stool containing blood, pus, fecal mattercontaining blood, pus, fecal matter

Other symptoms in moderate to severe disease include: Other symptoms in moderate to severe disease include: anorexia, nausea, vomitting, fever, weight lossanorexia, nausea, vomitting, fever, weight loss

EXAMINATIONEXAMINATION

PHYSICALPHYSICAL:: Hydration & volume status determined by B.PHydration & volume status determined by B.P Pulse ratePulse rate Nutritional statusNutritional status

ABDOMINALABDOMINAL:: Tenderness & evidence of peritoneal inflammation Tenderness & evidence of peritoneal inflammation Presence of red blood on DREPresence of red blood on DRE

UC assessment of disease activityUC assessment of disease activity

Ulcerative Colitis assessment of disease activity

Mild Moderate Severe

Stool frequency per day >4 -4 6 >6 )mostly bloody(Pulse (beats/min( >90 -90 100 <100

Hematocrits ) (% Normal -30 40 >30Weight Loss ) (% None -1 10 <10

Temperature (*F( Normal -99 100 <100ESR (mm/h( >20 -20 30 <30Albumin (g/dl( Normal - .3 3 5 >3

MILD DISEASE (UC)MILD DISEASE (UC)

Gradual onsetGradual onset

Infrequent diarrhoea (<5movements/day)Infrequent diarrhoea (<5movements/day)

Intermittent rectal bleedingIntermittent rectal bleeding

Stool may be formed or too loose in consistencyStool may be formed or too loose in consistency

Fecal urgency ,tenesmus,left lower quadrant Fecal urgency ,tenesmus,left lower quadrant pain relieved by defecation pain relieved by defecation

NO significant abdominal tendernessNO significant abdominal tenderness

MODERATE DISEASE (UC)MODERATE DISEASE (UC)

More severe diarrhoea with frequent bleedingMore severe diarrhoea with frequent bleeding Abdominal pain & tenderness but not severeAbdominal pain & tenderness but not severe Mild fever , anemia & hypoalbuminemiaMild fever , anemia & hypoalbuminemia

SEVERE DISEASE (UC)SEVERE DISEASE (UC)

Severe diarrhoea with >6-10 bloody bowel Severe diarrhoea with >6-10 bloody bowel movements /daymovements /day

Severe anemia , hypovolemia ,imparied Severe anemia , hypovolemia ,imparied nutrition & hypoalbuminemianutrition & hypoalbuminemia

Abdominal pain & tenderness Abdominal pain & tenderness FULMINANT COLITIS:FULMINANT COLITIS:

Subset of severe disease with rapidly worsening Subset of severe disease with rapidly worsening symptoms & signs of toxicitysymptoms & signs of toxicity

CHRON’S DISEASECHRON’S DISEASE

It is the chronic recurrent disease It is the chronic recurrent disease characterised by patchy transmural characterised by patchy transmural inflammation involving any segment of GIT inflammation involving any segment of GIT from mouth to anus from mouth to anus

Cigarette smoking is strongly associated with Cigarette smoking is strongly associated with the development of chrons disease,resistance the development of chrons disease,resistance to medical therapy and early disease relapseto medical therapy and early disease relapse

Crohn’s disease – Crohn’s disease – gut involvementgut involvement

30-40% of patients have small bowel disease alone30-40% of patients have small bowel disease alone

40-55% of patients have both small and large intestines 40-55% of patients have both small and large intestines diseasedisease

15-25% of patients have colitis alone15-25% of patients have colitis alone

In 75% of patients with small intestinal disease the terminal In 75% of patients with small intestinal disease the terminal ileum in involved in 90%ileum in involved in 90%

Distribution of gastrointestinal Crohn's disease. Based on data from American Gastroenterological Association.

Crohn’s disease – macroscopic featuresCrohn’s disease – macroscopic features

CD is a transmural processCD is a transmural process

CD is segmental with skip CD is segmental with skip leisions in the leisions in the diseased diseased intestineintestine..

In one –third of patients with CD perirectal fistulas, In one –third of patients with CD perirectal fistulas, fissures, abscesses, anal stenosis are presentfissures, abscesses, anal stenosis are present

Crohn’s disease – macroscopic featuresCrohn’s disease – macroscopic features

mild diseasemild disease is characterized by: is characterized by: aphtaphthhous or small superficial ulcerationsous or small superficial ulcerations

In more In more active diseaseactive disease:: stellate ulcerations fuse longitudinally and stellate ulcerations fuse longitudinally and

transversely to demarcate island of mucosa that are transversely to demarcate island of mucosa that are histologically normalhistologically normal

Cobblestone appearanceCobblestone appearance is characteristic of CD (both is characteristic of CD (both endoscopically and by barium radiography)endoscopically and by barium radiography)

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Active CD is characterized by focal Active CD is characterized by focal inflammation and formation of fistula tractsinflammation and formation of fistula tracts

The bowel wall thickens and becomes The bowel wall thickens and becomes narrowed and fibrotic, leading to chronic, narrowed and fibrotic, leading to chronic, recurrent bowel obstructionrecurrent bowel obstruction

serpiginous ulcer, a classic finding in Crohn's disease

Chrons disease: MicroscopicChrons disease: Microscopic

Crohn’s disease – sign and Crohn’s disease – sign and symptomssymptoms

IleocolitisIleocolitis - right lower quadrant pain and- right lower quadrant pain and non bloody non bloody diar diarrrhhooeaea - palpable mass, fever and leucocytosis- palpable mass, fever and leucocytosis - pain is colickly and relieved by defecation- pain is colickly and relieved by defecationRight lower quadrant tenderness & a palpable massRight lower quadrant tenderness & a palpable mass JejunoileitisJejunoileitis - inflammatory disease is associated with loss of - inflammatory disease is associated with loss of

digestive and absorptive surfacedigestive and absorptive surface

Crohn’s disease – sign and symptomsCrohn’s disease – sign and symptoms

Colitis and perianal diseaseColitis and perianal disease - low grade fever, malaise, diarrhea, crampy abdominal pain, - low grade fever, malaise, diarrhea, crampy abdominal pain,

sometimes hematocheziasometimes hematochezia - pain is caused by passage of fecal material through narrowed - pain is caused by passage of fecal material through narrowed

and inflamed segments of large boweland inflamed segments of large bowel

Gastroduodenal diseaseGastroduodenal disease - - nusea, vomiting, epigastric painnusea, vomiting, epigastric pain - second portion of duodenum is more commonly involved than - second portion of duodenum is more commonly involved than

the bulbthe bulb

Cont...Cont...

INTESTINAL OBSTRUCTION IN CD:INTESTINAL OBSTRUCTION IN CD: PostprandialPostprandial bloating,cramping pains & loud bloating,cramping pains & loud

borborygmiborborygmi (narrowing can occur due to inflammation spasm (narrowing can occur due to inflammation spasm

or fibrosis)or fibrosis)

FISTULATING DISEASE:FISTULATING DISEASE:

Can result in intra abdominal or retroperitoneal Can result in intra abdominal or retroperitoneal abscess menifested by fever chills, a tender abscess menifested by fever chills, a tender abdominal mass & leucocytosis.abdominal mass & leucocytosis.

Cont…Cont…

Enterocolic fistulas :Enterocolic fistulas :

presents with diarrhoea , weight loss & presents with diarrhoea , weight loss & malnutrition.malnutrition.

Enterovesical fistulas/enterovaginal fistulas:Enterovesical fistulas/enterovaginal fistulas:

presents with recurrent infections.presents with recurrent infections. Enterocutaneous fistulas: Enterocutaneous fistulas:

usually develop at site of surgical scars.usually develop at site of surgical scars.

Endoscopic image of Crohn's colitis showing deep ulceration.

Extraintestianal Menifestation

25% of the pts develop a number of 25% of the pts develop a number of extraintestinal menifestationsextraintestinal menifestations

Almost one-third of the patients have at least Almost one-third of the patients have at least one.one.

Extraintestinal manifestationExtraintestinal manifestation

•Eyes: Uveitis, Episcleritis, Conjuctivitis

•Joints: Peripheral arthropathy, arthralgia, ankylosing spondylits, inflammatory Back pain

•Skin: Erythema nodosum, pyoderma gangrenosum

•Liver and Biliary tree: Sclerosing cholangitis [UC]

•Nephrolithiasis [Oxalate Stone in pt with small bowel disease or after resection] (CD)

•Oral apthous leisions (CD)

•Gall stone(CD)

•Venous thrombosis

Patients with IBD have an increased prevelance of osteoporosis secondary to vitamin D deficiency, calcium malabsorbtion, malnutrition, corticosteroid use

More common cardiopulmonary manifestations include endocarditis, myocarditis, pleuropericarditis and interstitial lung disease.

Examination findings_in CDExamination findings_in CD

Loss of weightLoss of weight General ill healthGeneral ill health Aphthous ulceration of mouth, glossitis Aphthous ulceration of mouth, glossitis

angular stomatitisangular stomatitis Abdominal tenderness and RIF massAbdominal tenderness and RIF mass Perianal skin tags, fissures, fistulaePerianal skin tags, fissures, fistulae

??

Extraintestinal menifestations common to Extraintestinal menifestations common to chrons disease & UC include all except chrons disease & UC include all except

A) amyloidosisA) amyloidosis B) gall stonesB) gall stones C) pyoderma gangreonosumC) pyoderma gangreonosum D) uveitisD) uveitis E) ankylosing spondylitisE) ankylosing spondylitis

Answer is BAnswer is B

InvestigationsInvestigationsCD UC

Blood Test

•CP with morphology: Normocytic normocromic anemia of chronic disease•Serum B12 level may be low.•Raised ESR, CRP and raised WBC count.•Hypo albuminaemia.•Blood culture in septicaemia.

•Fe deficiency anemia•Raised white cell and platelet count•Raised ESR, CRP•Hypo albuminaemia

Serological Test

•Saccharamyces cerevisiae antibody is usually present•P-ANCA negative

•P-ANCA may be positive

Stool culture

•Should always be performed in both to rule out infective cause

Cont…..Cont…..

CD UC

Radiology

Plain ABD. X-ray:•Intestinal obstruction or displacement of bowel loops by a mass.

•Extent of the disease can be judge by air distribution in the colon and the presence of colonic dialatation

Ultrasound:•Thickened small bowel loops and mesentery or abscess

•Thickening of colonic wall and presence of free fluid in abdominal cavity

Barium follow through:•Asymmetrical alteration mucosal pattern with narrowing or stricturing.•Skip lesions

•Fine mucosal granularity•Mucosa become thickenned and superficial ulcers are seen (collar-button ulcers)•Loss of haustration

Cont…..Cont…..

CD UC

Instant Barium enema•Patchy sup. Ulceration to wide spread deep (rose thorn ulcer)•Cobble stone appearance and narrowing

•Superficial ulcers •Shortened and narrowed colon in long standing disease

Colonoscopy•Fissures and fistulae •Pseudopolyps

•Mucosal granularity and hyperemia

High resolution USG. And spiral CT•Radionuclide scan with gallium labeled polymorphs or indium or technetium labeled leucocytes •Capsule imaging of the gut.

•Radionuclide scan used to assess colonic inflammation

RADIOGRAPHSRADIOGRAPHS

CComplicationomplication

IN UC:IN UC:

HaemorrageHaemorrage PerforationPerforation Toxic megacolon (transverse colon with a Toxic megacolon (transverse colon with a

diameter of more than 5 cm to 6cm with loss diameter of more than 5 cm to 6cm with loss of haustrationof haustration

Cancer: in patient with active colitis of more Cancer: in patient with active colitis of more than eight year than eight year

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IN CD:IN CD: Strictures with intestinal obstruction Strictures with intestinal obstruction Abscesses Abscesses FistulasFistulas

TreatmentTreatment

Medical treatmentMedical treatment Amino salicylatesAmino salicylates Cortico steroidCortico steroid ThiopurinesThiopurines MethotrexateMethotrexate CiclosporinCiclosporin InfliximabInfliximab AntibioticAntibiotic Antidiarrhoeal agentsAntidiarrhoeal agents

T/M OF UCT/M OF UC

ACTIVE PROCTITISACTIVE PROCTITIS: : 11stst line line Mesalazine enemas/suppositries+ oral mesalazineMesalazine enemas/suppositries+ oral mesalazine

Pt NOT RESPONDINGPt NOT RESPONDING:: Oral prednisolone 40mg dailyOral prednisolone 40mg daily

ACTIVE LEFT SIDED OR EXTENSIVE UC:ACTIVE LEFT SIDED OR EXTENSIVE UC: High dose aminosalicylates High dose aminosalicylates

Cont....Cont....

With topical aminosalicylates + corticosteroidsWith topical aminosalicylates + corticosteroids SEVERE/FULMINANT UC:SEVERE/FULMINANT UC:

SUPPORTIVE T/M:SUPPORTIVE T/M: I/V fluids,nutritional support,blood transfusion if I/V fluids,nutritional support,blood transfusion if

HB <100g/lHB <100g/l

MEDICAL T/M:MEDICAL T/M:

I/V steroids,prophylaxis for venous thrombosis,I/V steroids,prophylaxis for venous thrombosis,

I/V cyclosporin or infliximab for non responders to I/V cyclosporin or infliximab for non responders to steroidssteroids

Cont….Cont….

MAINTAINANCE OF REMISSIONMAINTAINANCE OF REMISSION:: Oral salicylatesOral salicylates Thiopurines should be considered for frequent Thiopurines should be considered for frequent

relapsersrelapsers

Ulcerative ColitisUlcerative Colitis

Nursing careNursing care Report S/S of problemsReport S/S of problems Provide emotional Provide emotional

supportsupport Skin careSkin care Record # of stools and Record # of stools and

typetype Monitor bowel soundsMonitor bowel sounds Vitals and I/OVitals and I/O

Watch for dehydrationWatch for dehydration Monitor ElectrolytesMonitor Electrolytes Weigh dailyWeigh daily Dietary consultDietary consult Watch for Watch for

complicationscomplications

T/M OF CDT/M OF CD

INDUCTION OF REMISSIONINDUCTION OF REMISSION Enteral nutritionEnteral nutrition Oral or I/V steroidsOral or I/V steroids AminosalicylatesAminosalicylates

MAINTAINANCE OF REMISSIONMAINTAINANCE OF REMISSION Cessation of smokingCessation of smoking AminosalicylatesAminosalicylates ThiopurinesThiopurines MTX with folic acid(resistant to thiopurines)MTX with folic acid(resistant to thiopurines) infliximabinfliximab

Cont….Cont….

FISTULATING AND PERIANAL DISEASEFISTULATING AND PERIANAL DISEASE Metronidazole and ciprofloxacinMetronidazole and ciprofloxacin Thiopurines in chronic diseaseThiopurines in chronic disease infliximabinfliximab

Crohn’s DiseaseCrohn’s Disease

Nursing careNursing care Identical to colitisIdentical to colitis Watch for internal bleedingWatch for internal bleeding Dietary changesDietary changes

Restricted fiber diet with no raw fruit or vegetables and no nuts or Restricted fiber diet with no raw fruit or vegetables and no nuts or whole grainswhole grains

Low fat diet to reduce fatty stoolsLow fat diet to reduce fatty stools

Surgical TreatmentSurgical Treatment

UCUC IND:IND:

PerforationPerforation

Toxic megacolonToxic megacolon Uncontrolled hemorrhageUncontrolled hemorrhage Possibility of malignancy (surgery is indicated if dysplastic change Possibility of malignancy (surgery is indicated if dysplastic change

is present)is present) Intractability (Acute; fulminant colitis or chronic illness)Intractability (Acute; fulminant colitis or chronic illness) Extraintestinal manifestationsExtraintestinal manifestations

Panproctocolectomy with ileostmy or Panproctocolectomy with ileostmy or proctocolectmy with ilealanal pouch proctocolectmy with ilealanal pouch anastomosis anastomosis

Cont…Cont…

CDCD INDIND: fistulae, abscesses, perianal disease, small or : fistulae, abscesses, perianal disease, small or

large bowel obstructionlarge bowel obstruction For localized segment: segmental resection or For localized segment: segmental resection or

multiple stricturoplastiesmultiple stricturoplasties For extensive colitis: total colectomy (ileoanal For extensive colitis: total colectomy (ileoanal

pouch should be avoided)pouch should be avoided)

Probiotic use in IBDProbiotic use in IBD

(lactobacilli, bifidobacterium, nonpathogenic (lactobacilli, bifidobacterium, nonpathogenic E.coli,)E.coli,)

They maintain remission in inflammation of They maintain remission in inflammation of pouch which is created by surgrey;possibly by pouch which is created by surgrey;possibly by increasing tissue levels of IL-10increasing tissue levels of IL-10

May also be useful in maintaining remission in May also be useful in maintaining remission in UC UC

ESSENTIALS OF DIAGNOSIS ESSENTIALS OF DIAGNOSIS in UCin UC

Bloody diarrhoeaBloody diarrhoea Lower abdominal cramps & fecal urgencyLower abdominal cramps & fecal urgency Anemia and low serum albuminAnemia and low serum albumin Negative stool cultures Negative stool cultures Sigmoidoscopy is the key to diagnosis Sigmoidoscopy is the key to diagnosis

ESSENTIALS OF DIAGNOSIS ESSENTIALS OF DIAGNOSIS in CDin CD

Insidious onsetInsidious onset Intermittent bouts of low grade fever diarrhoea Intermittent bouts of low grade fever diarrhoea

& right lower quadrant pain& right lower quadrant pain Right lower quadrant mass & tendernessRight lower quadrant mass & tenderness Perianal disease with fistulas Perianal disease with fistulas Radiographic evidence of ulceration stricturing Radiographic evidence of ulceration stricturing

or fistulas of the small intestine & colonor fistulas of the small intestine & colon

MCQsMCQs

ScenerioScenerio

A 23yr old women has chronic diarrhoea with A 23yr old women has chronic diarrhoea with blood & mucus accompanied by lower blood & mucus accompanied by lower abdominal discomfort.she has about 8 abdominal discomfort.she has about 8 stools/day,albumin is 29g/l,hb 9g/l,& ESR is stools/day,albumin is 29g/l,hb 9g/l,& ESR is 60mm/l.colonoscopy reveals left sided 60mm/l.colonoscopy reveals left sided proctocolitis.biopsy shows a chronic proctocolitis.biopsy shows a chronic inflammatory cell infiltrate in lamina propria inflammatory cell infiltrate in lamina propria crypt abscess & goblet cell depeletion are crypt abscess & goblet cell depeletion are seen.seen.

Select the best medication for this Select the best medication for this patient.patient.

A) Oral aminosalicylates only A) Oral aminosalicylates only

B) Parentral aminosalicylates B) Parentral aminosalicylates

C) Oral aminosalicylates with predisolone 20mg C) Oral aminosalicylates with predisolone 20mg enemaenema

D) Oral aminosalicylates with oral prednisoloneD) Oral aminosalicylates with oral prednisolone

E) Oral sulphapyridineE) Oral sulphapyridine

Answer is DAnswer is D

What is not true regarding What is not true regarding azathioprine use in IBDazathioprine use in IBD

A) May be useful in pt of chronic IBD A) May be useful in pt of chronic IBD

B) Helps to lower the dose of corticosteroids B) Helps to lower the dose of corticosteroids

C) Used more frequently in UC than CDC) Used more frequently in UC than CD

D) Bone marrow suppression with fetal D) Bone marrow suppression with fetal neutropenia may occurneutropenia may occur

E) Usual dose is 2.5mg/kg/dayE) Usual dose is 2.5mg/kg/day

Answer is CAnswer is C

Initial investigation of choice to Initial investigation of choice to diagnose ulcerative colitis isdiagnose ulcerative colitis is

A) SigmoidoscopyA) Sigmoidoscopy

B) ColonoscopyB) Colonoscopy

C) Barium enemaC) Barium enema

D) Barium follow throughD) Barium follow through

Answer is AAnswer is A

Lab investigations in IBD shows Lab investigations in IBD shows all except all except

A) Anemia A) Anemia

B) Raised ESR B) Raised ESR

C) LeucocytosisC) Leucocytosis

D) Raised amylaseD) Raised amylase

E) Abnormal LFTsE) Abnormal LFTs

Answer is DAnswer is D

Thank youThank you