Inflammatory Inflammatory Bowel DiseaseBowel Disease By Dr. Osman Bukhari By Dr. Osman Bukhari

-Includes ulcerative colitis (UC) & Crohns -Includes ulcerative colitis (UC) & Crohns disease( CD).disease( CD).

-There is overlap between or they are spectrum of the -There is overlap between or they are spectrum of the same disease.same disease.

-In 10% of colitis it is difficult to differentiate -In 10% of colitis it is difficult to differentiate between them.between them.

-Common in the west. Peak age is20-40 y. M=F.-Common in the west. Peak age is20-40 y. M=F.

-Remission & relapses.-Remission & relapses.

AetiologyAetiology -Genetic & enviromental factors.-Genetic & enviromental factors.

-Familial:10% with high concordance in id. twins-Familial:10% with high concordance in id. twins

-Genetics: HLAB27. Association with autoimmune -Genetics: HLAB27. Association with autoimmune diseases.diseases.

-High sugar & low residue diet and smoking -High sugar & low residue diet and smoking are associated with CD.are associated with CD.

-Transmissible agent in CD( measles & T.b.)-Transmissible agent in CD( measles & T.b.) -Multiangiitis leading to infarction.-Multiangiitis leading to infarction. -Bact. Endotoxins release NO causing damage.-Bact. Endotoxins release NO causing damage. -Immune response to luminal Ag.( bacterial -Immune response to luminal Ag.( bacterial

product or diet) leading to inflammation product or diet) leading to inflammation through cytokins & free O2 radicals with through cytokins & free O2 radicals with activation & attraction of polymorphs, plasma activation & attraction of polymorphs, plasma cells & lymphocytes causing inflmm.& cells & lymphocytes causing inflmm.& ulcers .ulcers .

PathologyPathology --In CD whole GIT is involved. Terminal ileum In CD whole GIT is involved. Terminal ileum

& ascending colon being commonly affected. & ascending colon being commonly affected. Rectal disease is rare. In UC proctitis is Rectal disease is rare. In UC proctitis is

invariable & back wash ileitis is rareinvariable & back wash ileitis is rare.. -Macroscopically : In CD small bowel is -Macroscopically : In CD small bowel is

thickened & narrowed. The lesions are skipped thickened & narrowed. The lesions are skipped deep ulcers with enlarged L.nodes, abscesses, deep ulcers with enlarged L.nodes, abscesses, fissures & fistulae. Toxic colonic dilatation fissures & fistulae. Toxic colonic dilatation can follow fulminant colitis.can follow fulminant colitis.

-In UC colitis is continuous with ulceration & -In UC colitis is continuous with ulceration & is more distally. Pseudopolyps are common.is more distally. Pseudopolyps are common.

toxic dilatation can follow fulminant colitis.toxic dilatation can follow fulminant colitis. -Microscopically: In CD there is transmural -Microscopically: In CD there is transmural

non casiating granuloma with normal goblet non casiating granuloma with normal goblet cells & infrequent crypt abscesses. In UC cells & infrequent crypt abscesses. In UC inflamm. is superficial with chronic inflamm. inflamm. is superficial with chronic inflamm. infiltrates, loss of goblet cells, frequent crypt infiltrates, loss of goblet cells, frequent crypt abscesses. Displasia & Ca are more common.abscesses. Displasia & Ca are more common.

Clinical features of CDClinical features of CD -- presentation is variable depending on the presentation is variable depending on the

severity & extent of the disease. Mild cases severity & extent of the disease. Mild cases lead normal life with repeated admission in lead normal life with repeated admission in severe cases. severe cases.

-Major symptoms of abd. Pain, diarrhoea -Major symptoms of abd. Pain, diarrhoea (80%) & weight loss. Abd. Pain is due to (80%) & weight loss. Abd. Pain is due to peritoneal involvement or obstruction. 10% peritoneal involvement or obstruction. 10% present wuth acute pain in RIF. Diarrhoea is present wuth acute pain in RIF. Diarrhoea is bloody in colitis & steatorrhoeic in small bloody in colitis & steatorrhoeic in small bowel diseasebowel disease

-Constitutional symptoms of anorexia, N, V, -Constitutional symptoms of anorexia, N, V, general illhealth & fatigue ( Anemia due to general illhealth & fatigue ( Anemia due to malabsorption of Fe, FA,& B12).malabsorption of Fe, FA,& B12).

-Abdominal ex.=normal or tender or masses in -Abdominal ex.=normal or tender or masses in the RIF ( Inflm. Loops of bowel or the RIF ( Inflm. Loops of bowel or abscesses). abscesses).

-PR =perianal abscess, skin tags, fissures & -PR =perianal abscess, skin tags, fissures & fistulae sp. with colitis.fistulae sp. with colitis.

-Sigmoidoscopy= rectum may be spared or -Sigmoidoscopy= rectum may be spared or may be indistinguishable from UC. Take may be indistinguishable from UC. Take biopsies.biopsies.

Clinical feature of UCClinical feature of UC -Presentation is variable depending on the -Presentation is variable depending on the

extent & severity of the disease.extent & severity of the disease. -Bloody diarrhea with mucus & occasionally -Bloody diarrhea with mucus & occasionally

only blood &mucus. Lower abdominal pain.only blood &mucus. Lower abdominal pain. -Urgency & tensmus in proctitis without -Urgency & tensmus in proctitis without

constitutional symptom. constitutional symptom.

-Anorexia ;nausea & lethargy in total colitis.-Anorexia ;nausea & lethargy in total colitis. -Slight abdominal distension & tenderness.-Slight abdominal distension & tenderness. -PR= normal or tender with blood in the -PR= normal or tender with blood in the

examining finger.examining finger. -Mild colitis=up to 4 motions per day.-Mild colitis=up to 4 motions per day. -Mod. Colitis=4-6 motions per day.-Mod. Colitis=4-6 motions per day. -Severe Colitis = more than 6 motions per day, -Severe Colitis = more than 6 motions per day,

patient very ill temp. >37.5, pulse >90, Hb <10 patient very ill temp. >37.5, pulse >90, Hb <10 g./dl., ser. Albumin <30 g./l. & under g./dl., ser. Albumin <30 g./l. & under nutrition.nutrition.

Anorexia, nauseaAnorexia, nausea

* Fulminent colitis may cause toxic mega- * Fulminent colitis may cause toxic mega- colon with perforation or septicemia.colon with perforation or septicemia.

Extra-intestinal manifestations of IBSExtra-intestinal manifestations of IBS (Related to disease activity & more in UC.)(Related to disease activity & more in UC.) -Clubbing of fingers, E. nodosum, pyoderma -Clubbing of fingers, E. nodosum, pyoderma

gangrenosum & oral aphthus ulcers.gangrenosum & oral aphthus ulcers. -Episcleritis, conjunctivitis, iritis & uveitis.-Episcleritis, conjunctivitis, iritis & uveitis. -Monoarthritis, sacro-ilitis & ankylosing -Monoarthritis, sacro-ilitis & ankylosing

spondylitis.spondylitis. -Fatty liver, chronic hep., cirrhosis, -Fatty liver, chronic hep., cirrhosis,

autoimmune hep. scl.cholanhitis, cholanioCa.autoimmune hep. scl.cholanhitis, cholanioCa.

-Portal pyaemia &liver abscess.-Portal pyaemia &liver abscess. -Auto-immune hemolytic anemia, vasculitis & -Auto-immune hemolytic anemia, vasculitis &

thrombosis of portal & mesenteric veins.thrombosis of portal & mesenteric veins. -Amyloidosis.-Amyloidosis.

* **** ***RelapsesRelapses in UC are precipitated by:- in UC are precipitated by:-Stress, intercurrent infection, G.E, antibiotics & Stress, intercurrent infection, G.E, antibiotics & NSAIDs.NSAIDs.

Investigations in IBD.Investigations in IBD. -anemia( multifactorial), raised WBC, ESR & CRP.-anemia( multifactorial), raised WBC, ESR & CRP. -stools ex. To exclude bacterial ,protozal & helmithic -stools ex. To exclude bacterial ,protozal & helmithic

infections.infections.

-Low serum albumin & abnormal LFT.-Low serum albumin & abnormal LFT.

-Blood culture in suspected septicemia.-Blood culture in suspected septicemia.

-Stool culture if diarrhea persist despite Tr.-Stool culture if diarrhea persist despite Tr.

-Plain abd. X-ray in toxic megacolon.-Plain abd. X-ray in toxic megacolon.

-Ba.enema : shortening, narrowing & loss of -Ba.enema : shortening, narrowing & loss of haustrations of colon, granular appearance of colon, haustrations of colon, granular appearance of colon, pseudopolyps & filling defects. Avoided in acute pseudopolyps & filling defects. Avoided in acute cases.cases.

-Sigmoidoscopy: engorged hyperemic mucosa which -Sigmoidoscopy: engorged hyperemic mucosa which bleed spontaneously in severe cases.bleed spontaneously in severe cases.

-Colonoscopy: assesses extent & severity of disease-Colonoscopy: assesses extent & severity of disease

and take multiple biopsies to distinguish and take multiple biopsies to distinguish between UC & CD.between UC & CD.

-Small bowel Ba. follow- through ( abn. -Small bowel Ba. follow- through ( abn. Mucosal pattern, skipped lesions, deep ulcers Mucosal pattern, skipped lesions, deep ulcers & narrowing_string sign.)& narrowing_string sign.)

- US fore masses & CT for abscesses & bowel - US fore masses & CT for abscesses & bowel thickening.thickening.

Diff. diagDiff. diag::

--Small bowel disease: chronic diarrhea, Small bowel disease: chronic diarrhea, malabsorption & malnutrition, ileocecal Tb., malabsorption & malnutrition, ileocecal Tb.,

actinomycosis, yersinia, appendicitis & append. actinomycosis, yersinia, appendicitis & append. Abscess, lymphoma &Ca caecum.Abscess, lymphoma &Ca caecum.

-Infective diarrhea :salmonella, shigella, -Infective diarrhea :salmonella, shigella, campylobacter., E.coli hagic colitis, GN & campylobacter., E.coli hagic colitis, GN & Chlamydia proctitis, pseudomembraneous, Chlamydia proctitis, pseudomembraneous, herpes simplex & amebiasis.herpes simplex & amebiasis.

-Noninfecive colitis: ischemic, radiation, -Noninfecive colitis: ischemic, radiation, diffuse lymphoma, behcet, NSAID, diffuse lymphoma, behcet, NSAID, diverticulitis & colonic Ca.diverticulitis & colonic Ca.

Management of IBS.Management of IBS. Medical :well balanced diet with proteinMedical :well balanced diet with protein and and

energy. Maintain fluid & elect. balance.energy. Maintain fluid & elect. balance.

-Low fat & milk if malabsorption. High fibre avoided -Low fat & milk if malabsorption. High fibre avoided in mall bowel disease, it is beneficial in proctitis & in mall bowel disease, it is beneficial in proctitis & constipation. Iron, folic acid, B12,Vit. D & Ca constipation. Iron, folic acid, B12,Vit. D & Ca supplements.supplements.

-Drugs: Mild CD treated symptomatically with -Drugs: Mild CD treated symptomatically with antidiarrheal.In acute CD admit for induction of antidiarrheal.In acute CD admit for induction of remission with Prednsolone 40-60 mg/ day for 2W remission with Prednsolone 40-60 mg/ day for 2W & reduce to 10-20mg for 6-8 w. Azathioprin for & reduce to 10-20mg for 6-8 w. Azathioprin for maintenance of steroid induced remission or if maintenance of steroid induced remission or if Prednsolone fails. Sulphasalasine ( 5ASA) & Prednsolone fails. Sulphasalasine ( 5ASA) & mesalasine for maintenance of remiss. In colonic mesalasine for maintenance of remiss. In colonic CD . Methotrexate, ciclosp & TNF Abs.for those CD . Methotrexate, ciclosp & TNF Abs.for those who do not respond to a.m. drugs.who do not respond to a.m. drugs.

-Antibiotics & Metronidazole bacterial -Antibiotics & Metronidazole bacterial colonization & perianal disease.colonization & perianal disease.

-Surgery is required in 80% CD but should be -Surgery is required in 80% CD but should be avoided & conservative with minim. resection avoided & conservative with minim. resection ( stricture & fistulae, abscess, perforation , ( stricture & fistulae, abscess, perforation , toxic megacolon & severe extensive colonic toxic megacolon & severe extensive colonic disease if no response to med . TR..). Unlike disease if no response to med . TR..). Unlike UC surgery is not curative.UC surgery is not curative.

-Medical management in UC: In severe active -Medical management in UC: In severe active colitis--- fluid & elect. correction, blood & colitis--- fluid & elect. correction, blood & plasma transfusion , nutrition, S/C heparin to plasma transfusion , nutrition, S/C heparin to prevent DVT, blood culture & antibiotics if prevent DVT, blood culture & antibiotics if septicemia is suspected.septicemia is suspected.

-Parentral methylprednsolone or oral -Parentral methylprednsolone or oral Prednsolone ( 40-60) for 2W to induce Prednsolone ( 40-60) for 2W to induce remission & maintain on (5ASA) to prevent remission & maintain on (5ASA) to prevent relapse. If no response use azathioprin. If no relapse. If no response use azathioprin. If no response then surgery. Azathioprin is also used response then surgery. Azathioprin is also used for patients who require high dose steroids for for patients who require high dose steroids for Maintaince.Maintaince.

-Steroid suppositories for proctitis & steroid -Steroid suppositories for proctitis & steroid enema for mild proctocolitis. If no response or enema for mild proctocolitis. If no response or if the patient can not retain enema; use if the patient can not retain enema; use systemic steroids. 5ASA can induce remission systemic steroids. 5ASA can induce remission in mild & mod. colitis but less effective.in mild & mod. colitis but less effective.

--Surgery for UCSurgery for UC: Emergency proctocolectomy : Emergency proctocolectomy or colectomy Ist.& later proctosigmoidectomy or colectomy Ist.& later proctosigmoidectomy for toxic dilatation, perforation & hage ,. Acue for toxic dilatation, perforation & hage ,. Acue severe UC failing to med. TR , colonic abscess severe UC failing to med. TR , colonic abscess stricture & long standing total colitis & severe stricture & long standing total colitis & severe extra-intestinal not responding to med. TR are extra-intestinal not responding to med. TR are another indications.another indications.

Complications of IBS:Complications of IBS: -Fistulae, fissures, abscess & local perforation -Fistulae, fissures, abscess & local perforation

in CD.in CD. -Toxic colonic dilatation.-Toxic colonic dilatation. - Perforation in toxic dilt.- Perforation in toxic dilt.

-Massive hage is rare.-Massive hage is rare.

-Ca colon (3-5%) specially in extensive colitis of > -Ca colon (3-5%) specially in extensive colitis of > 10 years.10 years.

-Amyloidosis.-Amyloidosis.

Course in IBS:Course in IBS:

--RRelapses & remiss. Mortality is twice as common as elapses & remiss. Mortality is twice as common as in normals in CD & is associated with surgery.in normals in CD & is associated with surgery.

-Prognosis is good in proctitis & worse with severe -Prognosis is good in proctitis & worse with severe colitis. Mortality 15-25 % in fulmin. colitis colitis. Mortality 15-25 % in fulmin. colitis

-Low serum albumin & abnormal LFTs.-Low serum albumin & abnormal LFTs. -Blood culture in suspected septicemia.-Blood culture in suspected septicemia. -Stool culture if diarrhea is persistent.-Stool culture if diarrhea is persistent. =In colitis plain in toxic dilatation of colon,=In colitis plain in toxic dilatation of colon,Ba enema : avoided in acute cases.There is Ba enema : avoided in acute cases.There is

narrowing, shoryening, loss of haustration , narrowing, shoryening, loss of haustration , ulceration, pseudo polyps &granular ulceration, pseudo polyps &granular appearance.appearance.

-Sigmoidoscopy :engorged hyperemic mucosa -Sigmoidoscopy :engorged hyperemic mucosa which bleeds spontaneously or or touchwhich bleeds spontaneously or or touch

-Colonoscopy: To assess extenty & severity of -Colonoscopy: To assess extenty & severity of the disease, to distinguish between UC &CD the disease, to distinguish between UC &CD & take multiple biopsies.& take multiple biopsies.

-Small bowel follow through in CD( skipped -Small bowel follow through in CD( skipped lesions, abnormal mucosa, deep ulcerations & lesions, abnormal mucosa, deep ulcerations & narrowing ( string sign)narrowing ( string sign)

-CT for abscesses & bowel thickening & US -CT for abscesses & bowel thickening & US for masses.for masses.

Diff. Diagnosis:Diff. Diagnosis: -CD of small bowel: chronic diarrhea, -CD of small bowel: chronic diarrhea,

malabsorption, malnutrition, ileocecal Tb.,malabsorption, malnutrition, ileocecal Tb.,

actinomycosis, appendicitis &abscess, Yesinia actinomycosis, appendicitis &abscess, Yesinia ielitis, lymphoma & Ca cecum.ielitis, lymphoma & Ca cecum.

-Colitis: infective colitis ( salmonella, shigella, -Colitis: infective colitis ( salmonella, shigella, campylobacter, E. coli hemorrhagic colitis, campylobacter, E. coli hemorrhagic colitis, G.N.& Chlamydia proctitis, G.N.& Chlamydia proctitis, pseudomembr.colitis & amebiasis.) AND pseudomembr.colitis & amebiasis.) AND noninfective colitis ( ischemic, radiation, noninfective colitis ( ischemic, radiation, Behcets, NSAIDs, Ca colon & diverticulitis )Behcets, NSAIDs, Ca colon & diverticulitis )

IBD includes UC & CD:IBD includes UC & CD: -There is overlap between them & could be -There is overlap between them & could be

spectrum of the same disease & in 10% of spectrum of the same disease & in 10% of colitis it is difficult to say which is which.colitis it is difficult to say which is which.

-Common in the west .F=M. 20-40 ys.-Common in the west .F=M. 20-40 ys. -Relapses & remissions.-Relapses & remissions.

AetiologyAetiologyGenetic & enviromental factors are implicatedGenetic & enviromental factors are implicated-Familial-Familial-Genetic associated with HLAB27.-Genetic associated with HLAB27.- Dietary: low residue & high sugar diet. - Dietary: low residue & high sugar diet.

--Smoking in CD. UC more common in non Smoking in CD. UC more common in non smokers.smokers.

-Transmissible agent e.g. measels-mycob.Tb.-Transmissible agent e.g. measels-mycob.Tb. -Multifocal angiitis—infarction.-Multifocal angiitis—infarction. -Bacterial endotoxins liberating NO3 causing -Bacterial endotoxins liberating NO3 causing

damage.damage. -Luminal Ag. Evocing immune response causing -Luminal Ag. Evocing immune response causing

inflammatory response through cytokins & free inflammatory response through cytokins & free O2 radicals.O2 radicals.

PathogenesisPathogenesis Involves activation of macrophages in response to Involves activation of macrophages in response to

dietary element or bacterial product with release of dietary element or bacterial product with release of inflammatory cytokins with activation & attraction inflammatory cytokins with activation & attraction of polymorphs, plasma cells & lymphocytes leading of polymorphs, plasma cells & lymphocytes leading to inflammation & ulceration.to inflammation & ulceration.

PathologyPathology General:General:

-In CD whole GIT is involved sp. Terminal ileum &-In CD whole GIT is involved sp. Terminal ileum &

ascending colon are commonly affected while ascending colon are commonly affected while proctitis is rare. In UC proctitis is invariable & proctitis is rare. In UC proctitis is invariable & backwash ileitis is rare.backwash ileitis is rare.

Macroscopic:Macroscopic: -In CD small bowel is thickened with skipped -In CD small bowel is thickened with skipped

lesions & deep ulcers. Aphthus ulcers, lesions & deep ulcers. Aphthus ulcers, abscesses & fistulae are common. Fulminant abscesses & fistulae are common. Fulminant colitis & toxic diltation can occur. In UC there colitis & toxic diltation can occur. In UC there is confluent colitis with extensive ulceration is confluent colitis with extensive ulceration and pseudopolyps. and pseudopolyps.

MicroscopyMicroscopy In CD there is transmural non casiating In CD there is transmural non casiating

granuloma of the bowl &L. nodes with granuloma of the bowl &L. nodes with infrequent crypts abscesses & normal goblet infrequent crypts abscesses & normal goblet cells. In UC there is superficial chronic cells. In UC there is superficial chronic inflammatory infiltrate, no granuloma with inflammatory infiltrate, no granuloma with loss of goblet cells & crypt abscesses.loss of goblet cells & crypt abscesses.

Clinical picture Clinical picture In UC clinical picture is variable depending on In UC clinical picture is variable depending on

the site, extent & severity of the disease. the site, extent & severity of the disease.

-bloody diarrhoea with mucus. Occasionally only -bloody diarrhoea with mucus. Occasionally only mucus & blood. There is lower abdominal pain, mucus & blood. There is lower abdominal pain, distension & tenderness.distension & tenderness.

-Urgency & tensmus without constitutional -Urgency & tensmus without constitutional symptoms in proctitis.symptoms in proctitis.

-Anorexia, malaise & lethergy in total colitis with -Anorexia, malaise & lethergy in total colitis with aphthoid ulcers.aphthoid ulcers.

*Mild colitis =Up to 4 motions/day.*Mild colitis =Up to 4 motions/day. *Mod. Colitis = 4-6 motions/day.*Mod. Colitis = 4-6 motions/day.

*Severe colitis=More than 6 motions/day. Pat. Is *Severe colitis=More than 6 motions/day. Pat. Is very ill , febrile, Hb < 10gm, pulse >90, albumin very ill , febrile, Hb < 10gm, pulse >90, albumin <30 gm & undernutrition. Fulminant colitis with <30 gm & undernutrition. Fulminant colitis with diltation, perforation & septicaemia can occur.diltation, perforation & septicaemia can occur. PR= PR= tender with blood.tender with blood.

In CD clinical picture is variable depending on the In CD clinical picture is variable depending on the extent & severity of disease ranging from mild extent & severity of disease ranging from mild disease to severe disease with repeated admission.disease to severe disease with repeated admission.

-Acute or chronic onset with abd. Pain & -Acute or chronic onset with abd. Pain & diarrhoea(80%) with constitutional symptoms of diarrhoea(80%) with constitutional symptoms of fever, fever,A, N,V, weight loss & fatigue. Colicky fever, fever,A, N,V, weight loss & fatigue. Colicky pain suggests obstruction. Pain RIF like acute pain suggests obstruction. Pain RIF like acute appendicitis.appendicitis.

-Features of malabsorption with anaemia, weihgt loss -Features of malabsorption with anaemia, weihgt loss & vitamin deficiency. Aphth. Ulcer& vitamin deficiency. Aphth. Ulcer

-Abd. Ex. Normal or tender with masses-Abd. Ex. Normal or tender with masses -Colitis in CD is similar to UC.-Colitis in CD is similar to UC. -PR: skin tags, perianal abscesses, fissures & -PR: skin tags, perianal abscesses, fissures &

fistulae sp. In CD with colitis.fistulae sp. In CD with colitis.

Extraintestinal manifestations of Extraintestinal manifestations of IBD.IBD.

-Clubbing ,E. nodosum, Py. Gangrenosum, -Clubbing ,E. nodosum, Py. Gangrenosum, Aphthus ulcers & amyloidosis. Aphthus ulcers & amyloidosis.

-A spondylitis, S/ Ilitis & monoarthritis.-A spondylitis, S/ Ilitis & monoarthritis. -Conjunctivitis, episcleritis, iritis & uveitis.-Conjunctivitis, episcleritis, iritis & uveitis. -Fatty liver ,chronic hepatitis, cirrhosis, Scler -Fatty liver ,chronic hepatitis, cirrhosis, Scler

cholangitis, cholangioCa, autoimmune cholangitis, cholangioCa, autoimmune hepatitis, portal pyemia &liver abscess.hepatitis, portal pyemia &liver abscess.

-Autoimmune hemolytic anemia, vasculitis, -Autoimmune hemolytic anemia, vasculitis, thrombosis including portal mesen. thrombosis including portal mesen. Thrombosis.Thrombosis.

Investigations Aimed at confirming diagnosis, defining

disease extent & activity and identifying complications.

-Anemia: multifactorial, high ESR & CRP. -Low serum albumin & abn. Liver biochemst. -Stool culture to exclude infections & biood

cultures in patients with IBD who develop fever.

-Plain abdominal XR if toxic dilatation & perforation are suspected.

-BA. E-BA. Enema: narrow & short colon, loss of nema: narrow & short colon, loss of haustrations, granular appearance, haustrations, granular appearance, pseudopolyps & filling defects. Ba. Avoided pseudopolyps & filling defects. Ba. Avoided in active disease.in active disease.

-Sigmoidoscopy: ranges from abnormal -Sigmoidoscopy: ranges from abnormal vascular pattern in mild colitis to engorged vascular pattern in mild colitis to engorged mucosa which may bleeds spontaneously or on mucosa which may bleeds spontaneously or on touch. Take biopsies. Rectal sparing in CD.touch. Take biopsies. Rectal sparing in CD.

-Colonoscopy: In UC the pathology is -Colonoscopy: In UC the pathology is continuous, while in CD it I patchy, ulcers are continuous, while in CD it I patchy, ulcers are deep & strictures are common. Take multiple deep & strictures are common. Take multiple biopsies biopsies

-Small bowel follow-through in CD shows skipped lesions, deep ulcers & narrow segments ( string sign).

-CT for bowel thickening & abscesses.

-US to detect masses.

Differential diagnosis -CD should be differentiated from other causes

of chronic diarrhoea, malabsosption & malnutrition, ileocaecal Tb., actinomycosis, yersinia, appendicitis & append. Abscess, lymphomas & Ca caecum.

-Colitis in UC & CD should be differentiated -Colitis in UC & CD should be differentiated from infective colitis ( bacterial or amoebic, & from infective colitis ( bacterial or amoebic, & pseudomembraneous colitis ) Or non infective pseudomembraneous colitis ) Or non infective colitis ( ischemic, radiation, lymphoma, colitis ( ischemic, radiation, lymphoma, behcet, Ca & diverticulitis,).behcet, Ca & diverticulitis,).

ManagementManagement

A-Medical of CD:A-Medical of CD:

-Fluid & electrolyte balance. Maintenance of -Fluid & electrolyte balance. Maintenance of nutrition with low fat & milk diet if there is nutrition with low fat & milk diet if there is malabsorption. Iron, folic acid, B12, vit. D & malabsorption. Iron, folic acid, B12, vit. D & calcium supplements. calcium supplements.

-Symptomatic treatment with antidiarrhoeals in -Symptomatic treatment with antidiarrhoeals in mild cases.mild cases.

-For severe acute attacks, Prednsolone 40-60 -For severe acute attacks, Prednsolone 40-60 mg. for 1-2 weeks reduced to 10-20 mg. for 6-mg. for 1-2 weeks reduced to 10-20 mg. for 6-8 weeks ( Budesonide has less S.E.).8 weeks ( Budesonide has less S.E.).