Inflammatory bowel Inflammatory bowel disease and lungdisease and lung

Prof Dr Berrin CeyhanProf Dr Berrin CeyhanMarmara Univ School of Medicine, Marmara Univ School of Medicine,

ISTANBUL, TURKEYISTANBUL, TURKEY

İnflammatory bowel diseaseİnflammatory bowel disease

IBD is a chronic IBD is a chronic inflammatory disease inflammatory disease commonly involving the commonly involving the gastrointestinal system gastrointestinal system characterised by mucosal characterised by mucosal inflammation and ulcersinflammation and ulcers

EtiologyEtiology İnfectionİnfection Food allergyFood allergy Environmental factorsEnvironmental factors GeneticsGenetics Immunologic factorsImmunologic factors

NormalUC

CD

İnflammatory bowel diseaseİnflammatory bowel disease

The incidence of ulcerative colitis The incidence of ulcerative colitis is 1.5-20.3/100.000 person-yearsis 1.5-20.3/100.000 person-yearsThe incidence of Crohn’s disease The incidence of Crohn’s disease is 0.7-9.8/100.000 person-yearsis 0.7-9.8/100.000 person-years

Frequency of extraintestinal Frequency of extraintestinal manifestations occur in %21-41 of manifestations occur in %21-41 of patients with IBD patients with IBD

Lung and gastrointestinal system Lung and gastrointestinal system are originated from primitiv gut are originated from primitiv gut and they have same pathogenetic and they have same pathogenetic changeschanges

Ulcerative colitisUlcerative colitis Crohn’s diseaseCrohn’s disease

DistributionDistribution Diffuse inflammation extending Diffuse inflammation extending from rectumfrom rectum

Rectal sparing, frequent skip Rectal sparing, frequent skip lesionslesions

InflammationInflammation Diffuse, with mucosal granularity Diffuse, with mucosal granularity or friabilityor friability

Focal and asymmmetric; Focal and asymmmetric; cobblestoning, granularity and cobblestoning, granularity and friability less commonfriability less common

UlcerationUlceration Small ulcers in a diffusely Small ulcers in a diffusely inflamed mucosa; deep ulcers in inflamed mucosa; deep ulcers in severe diseasesevere disease

Afphtoid ulcers; Afphtoid ulcers; linear/serpiginous ulceration; linear/serpiginous ulceration; intervening mucosa often normalintervening mucosa often normal

Colonic lumenColonic lumen Often narrowed in long-standing Often narrowed in long-standing chronic disease; strictures very chronic disease; strictures very rarerare

Strictures commonStrictures common

Extraintestinal manifestations of Extraintestinal manifestations of inflammatory bowel diseaseinflammatory bowel disease

MusculoskletalMusculoskletal Peripheral arthropathyPeripheral arthropathy Ankylosing spondylitisAnkylosing spondylitis SacroileitisSacroileitis Hipertrophic osteoarthropathyHipertrophic osteoarthropathy OsteopeniaOsteopenia OsteoporosisOsteoporosis OsteomalaciaOsteomalacia OsteonecrosisOsteonecrosis Relapsing polychondritisRelapsing polychondritis

DermatologicDermatologic Er. NodosumEr. Nodosum Pyoderma gangrenosumPyoderma gangrenosum StomatitisStomatitis PsoriasisPsoriasis Ert. MultiformeErt. Multiforme Metastatic Crohn’s diseaseMetastatic Crohn’s disease Sweet’s syndromeSweet’s syndrome EpidermolysisEpidermolysis

Hematolojgic

•Anemia

•Leucocytosis

•Leucopenia

•Thrombocytosis

•Thrombocytopenia

•Coagulation abnormalities and hypercoaguable state

Neurologic

•Neuropathy

•Myopathy

•Vasculopathy

•Meningitis

•Seizures

Extraintestinal manifestations of Extraintestinal manifestations of inflammatory bowel diseaseinflammatory bowel disease

OpthalmologicOpthalmologic UveitisUveitis ScleritisScleritis EpiscleritisEpiscleritis Retinal vascular diseaseRetinal vascular disease ConjunctivitisConjunctivitis

GenitourinaryGenitourinary NephrolithiasisNephrolithiasis Obstructive uropathyObstructive uropathy FistulasFistulas AmiloidosisAmiloidosis GlomerulitisGlomerulitis MembranoglomerulonephritisMembranoglomerulonephritis

CardiovascularCardiovascular•PleuropericarditisPleuropericarditis•CardiomyopathyCardiomyopathy•EndocarditisEndocarditis•MyocarditisMyocarditis

PancreaticPancreatic•Granulomatous pancreatitisGranulomatous pancreatitis

Hepatobiliary•Primary sclerosing cholangitis•Pericholangitis•Cirrhosis•Cholangiocarcinoma•Steatosis•Granulomatous hepatitis•Cholelithiasis•Autoimmune hepatitis•Hepatic abscess•Portal vein trombosis

Ulcerative colitis and lung

involvement

Upper airway obstruction

Tracheobronchitis

Bronchiectasis

Constrictive bronchiolitis

Panbronchiolitis

Necrobiotic nodule

Lung bullaeINterstitial lung diseaseBOOPSarcoidosisPulmonary vasculitisPulmonary eosinophiliaWegener granulomatosis?(lack of kidney involvement)Apical fibrosis

Crohn’s disease and lung involvementCrohn’s disease and lung involvement

BOOPBOOP

ILDILD

Subclinical lymhocyctic alveolitisSubclinical lymhocyctic alveolitis

Chronic bronchitisChronic bronchitis

Chronic bronchial suppurationChronic bronchial suppuration

BronchiectasisBronchiectasis

Granulomatous infiltration and peripheral eosinophiliaGranulomatous infiltration and peripheral eosinophilia

Necrobiotic noduleNecrobiotic nodule

33 IBD cases(21 F, 12 M, 17-80 years old) , (27 ulcerative colitis 33 IBD cases(21 F, 12 M, 17-80 years old) , (27 ulcerative colitis and 8 Crohn’s disease) with lung involvement were reported and 8 Crohn’s disease) with lung involvement were reported and 57 IBD cases in literature were reviewedand 57 IBD cases in literature were reviewed

Camus et al Medicine 1993;151Camus et al Medicine 1993;151..

400 IBD cases from literature and a review was published in 400 IBD cases from literature and a review was published in 20032003

Storch I et al Inf Bowel Dis 2003; 9:104-115Storch I et al Inf Bowel Dis 2003; 9:104-115

Milestones in the literature of lung involvement in IBDMilestones in the literature of lung involvement in IBD

Firstly, Kraft et al reported 6 IBD cases (5 ulcerative Firstly, Kraft et al reported 6 IBD cases (5 ulcerative colitis) with lung involvement in 1976 (1400 cases were colitis) with lung involvement in 1976 (1400 cases were screened in 40 years)screened in 40 years)

Kraft et al Arch Intern Med 1976;454.Kraft et al Arch Intern Med 1976;454.

28/33 IBD diagnosis preceded lung involvement, 5/33 lung disease preceded IBD diagnosis

Inactive bowel diease 17(%60.7) active 3(%10.7) postcolectomy 8(%28.6)

Camus et al 1993

Diagnosis of lung involvement mean age: 42.7±2.9 yaş

IBD diagnosis mean age: 35.3±2.9 yearsIBD diagnosis mean age: 35.3±2.9 years

IBD diagnosis preceded 9.3±5.3 years the lung involvement (range: 1 week-36 years)

Symptoms:Symptoms: Stridor, severe dyspnea during 2-3 weeks Stridor, severe dyspnea during 2-3 weeks

Differential diagnosis of subglottik stenosisDifferential diagnosis of subglottik stenosis: Intubation, tuberculosis, : Intubation, tuberculosis, sarkoidosis, amiloidosissarkoidosis, amiloidosis

Bronchoscopy:Bronchoscopy: F Fragile, bleeding tissue and %50-80 obstruction in ragile, bleeding tissue and %50-80 obstruction in the lumenthe lumen

Airway DiseaseAirway Disease

Upper airway obstructionUpper airway obstructionSubglottic inflammation and Subglottic inflammation and stenosis in tracheal obstruction stenosis in tracheal obstruction (3/33 cases in Camus’s cases)(3/33 cases in Camus’s cases)

Treatment: Good response to inhaled and oral steroids, one case stayed in remission state during 8 years

Rupture following biju dilatation was noted in one case who was unresponsive to previous steroid treatment and he died with pneumomediastinum

Biopsy: Granulation tissue and inflammation (plasma cells, lymphocytes, neutrophils, and erythrocytes) in airway, epithelial ulceration and thin fibrin layer

Clinical progress:IBD was diagnosed 10 and 20 years before in two cases , IBD was diagnosed 1 month after pulmonary disease in the other case

Large airway involvementLarge airway involvementChronic bronchitis and bronchiectasis Chronic bronchitis and bronchiectasis

Symptoms; cough, sputum and Symptoms; cough, sputum and dyspnea( mucopurulent sputum up to 800 dyspnea( mucopurulent sputum up to 800 ml/day)ml/day)

15/33 cases in Camus’ cases (13UC, 2 15/33 cases in Camus’ cases (13UC, 2 Crohn)Crohn) Camus et al Medicine 1993;151Camus et al Medicine 1993;151..

9 cases with colectomy and 1 case with 9 cases with colectomy and 1 case with asthmaasthma

Airway disease was diagnosed in 9/22Airway disease was diagnosed in 9/22

pulmonary involvement cases with Crohn’s pulmonary involvement cases with Crohn’s diseasedisease

Omori H et al Inf Bowel Dis 2004Omori H et al Inf Bowel Dis 2004

Radiology:Radiology: Tubuler bronchial opacities, bronchiectasis in Tubuler bronchial opacities, bronchiectasis in CTCT

Lung function test:Lung function test: FEV1/FVC FEV1/FVC

BronchoscopyBronchoscopy: Eritematous and edematous mucosa and : Eritematous and edematous mucosa and inflammation in the wallinflammation in the wall

Bronchial biopsy revealed Bronchial biopsy revealed submucosal lymphocytes, plasma submucosal lymphocytes, plasma cells, neutrophilic infiltration, cells, neutrophilic infiltration, mucosal ulceration, chronic mucosal ulceration, chronic inflammation with abundant plasma inflammation with abundant plasma cells=Bronchial biopsy is mimicking cells=Bronchial biopsy is mimicking colon biopsycolon biopsy

BAL BAL commonly reveals leucocytes, but lymhocytes in one commonly reveals leucocytes, but lymhocytes in one case case 9 cases were in postcolectomy state, airway disease occured 9 cases were in postcolectomy state, airway disease occured in days and weeks after colectomyin days and weeks after colectomy

The mean interval after IBD diagnosis was 7.4±1.9 yearsThe mean interval after IBD diagnosis was 7.4±1.9 yearsExtraintestinal manifestations were detected in 10/15 casesExtraintestinal manifestations were detected in 10/15 cases

Camus et al Medicine 1993;151.Camus et al Medicine 1993;151.

In the other study of 7 cases with large airway disease, In the other study of 7 cases with large airway disease, interval was 12 years (4 months-35 years)interval was 12 years (4 months-35 years)

Spira et al Chest 1998Spira et al Chest 1998

Airway involvement was not associated with intake Airway involvement was not associated with intake of sulphasalazin and 5-ASA of sulphasalazin and 5-ASA

Symptoms of bronchiectasisSymptoms of bronchiectasis and bowel were activated and bowel were activated at the same time at the same time

Bronchiectasis was activated after colectomy (3/7 Bronchiectasis was activated after colectomy (3/7

cases 1-4 months after colectomycases 1-4 months after colectomy))

Bronchial steroid lavage is helpful, (40-80 mg metil prednisolon in serum physiologic in 2-3 days)

There was no response in 2 cases of Camus’ cases, they were in waiting list of transplantation

Immuran and cyclophosphamide were not effective treatment choices

TREATMENTSteroids are more effective in chronic bronchitis than bronchiectasis, therefore inhaled steroids should be started in the early stage and progression to bronchiectasis should be slowed.Lung function test and bronchoscopy show response with inhaled +/- oral steroid

Small airway disease (Chronic bronchiolitisSmall airway disease (Chronic bronchiolitis))

Less common presentationLess common presentationThis disease was diagnosed in 2 UC patients in This disease was diagnosed in 2 UC patients in Camus’ casesCamus’ cases

Both of them had inactive disease and open lung Both of them had inactive disease and open lung biopsy revealed chronic and stenotic chronic biopsy revealed chronic and stenotic chronic bronchiolitis=diffuse panbronchiolitis bronchiolitis=diffuse panbronchiolitis

Chronic bronchiolitis

Diffuse panbronchiolitis (DPB) is diagnosed in non Diffuse panbronchiolitis (DPB) is diagnosed in non Asian peopleAsian people

1 patient with DPB has been reported 5 years before 1 patient with DPB has been reported 5 years before UC diagnosisUC diagnosis

Limited treatment, mild-moderate response to oral steroids Limited treatment, mild-moderate response to oral steroids

1 patient of Camus’ cases responded to steroid, the other one 1 patient of Camus’ cases responded to steroid, the other one was transplantedwas transplanted

Macrolid effect??Macrolid effect??

Bronchiolitis obliterans organised pneumonia Bronchiolitis obliterans organised pneumonia (BOOP)(BOOP)

6 patients in Camus’ cases (5UC, 1 6 patients in Camus’ cases (5UC, 1 Crohn’s disease)Crohn’s disease)

Interval 2 months- 36 yearsInterval 2 months- 36 yearsBOOP was diagnosed 6 months BOOP was diagnosed 6 months before the onset of IBD in one case before the onset of IBD in one case

LFTLFT: Restriction in all subjects: Restriction in all subjects

BAL: BAL: One case with neutrophilia, One case with neutrophilia, one with lymphocytosisone with lymphocytosis

TREATMENTTREATMENT: Steroids were used in 4 patients and led to : Steroids were used in 4 patients and led to complete remission, two patients with mild symptoms complete remission, two patients with mild symptoms improved without any tretment in 2 and 6 monthsimproved without any tretment in 2 and 6 months

There was no relation to sulphasalazine and 5-ASA intake, There was no relation to sulphasalazine and 5-ASA intake, remission occured in one case while taking the drugremission occured in one case while taking the drug

There was no association with colectomyThere was no association with colectomy

Pyoderma gangrenosum in skin (lung and skin biopsies Pyoderma gangrenosum in skin (lung and skin biopsies are similar) have been reportedare similar) have been reported

4 cases with necrobiotic nodules are reported in the 4 cases with necrobiotic nodules are reported in the literatureliterature

2 new cases were included in Camus’ serie, in one of them 2 new cases were included in Camus’ serie, in one of them had p. gangrenosum and pANCA(+). had p. gangrenosum and pANCA(+).

IBD has been diagnosed 11 ve 25 years earlier, both of IBD has been diagnosed 11 ve 25 years earlier, both of them were inactive and one was taking low dose steroid them were inactive and one was taking low dose steroid and sulfasalazine and sulfasalazine

Nekrobiotic parenchymal nodulesNekrobiotic parenchymal nodules

Rounded and cavitated nodules Rounded and cavitated nodules Biopsy: Biopsy: Neutrophilic infiltration in necrotic areaNeutrophilic infiltration in necrotic area

Early nodules show neutrophils and fibrinous exudateThese nodules undergo central necrosis and cavitated to form large necrotic nodules resembling necrotic granulomas

There are no giant cells, no severe vasculitis (there were secondary inflammatory cells in vascular walls), and no non-necrotizing granuloma

IBD complicated by pulmonary vasculitis (Wegener granulomatosis?)

There are vasculitis( inflammatory cells in vascular walls, giant cells, granuloma, cANCA, pANCA and intestinal manifestations (25 cases)

Parencymal necrobiotic nodules

Relationship with skin neutrophilic dermatosis?

Pyoderma gangrenosum was reported in a patient with cavitated lung nodules,who had no IBD history 1 of the 8 patients with neutrophilic dermatosis originally described by Sweet had ulcerative colitis, however pulmonary lesions could not be found

Churg Strauss syndrome was considered in a case with face Churg Strauss syndrome was considered in a case with face swelling, arthralgia, wheezing, nasal congestion, and skin swelling, arthralgia, wheezing, nasal congestion, and skin vasculitisvasculitis

Oral steroids are effectiveOral steroids are effective

Pulmonary infiltrates and eosinophiliaPulmonary infiltrates and eosinophilia

3/33 ( 2UC, 1 Chron) cases were reported in Camus’ paper 3/33 ( 2UC, 1 Chron) cases were reported in Camus’ paper involvement was concomitant, preceding, or following the onset involvement was concomitant, preceding, or following the onset of IBDof IBD

There was no history of sulfasalazine and 5-ASA intakeThere was no history of sulfasalazine and 5-ASA intake

There were peripheral eosinophilia in all subjects and 18% There were peripheral eosinophilia in all subjects and 18% eosinophilia in BAL in one patienteosinophilia in BAL in one patient

Serositis developed in 41 literature cases (32 UC, 9 Crohn)Serositis developed in 41 literature cases (32 UC, 9 Crohn)and one case in Camus’ paperand one case in Camus’ paper

Pleural fluid was rich in neutrophils and lymphocytesPleural fluid was rich in neutrophils and lymphocytes

Tamponade was reported in 3 casesTamponade was reported in 3 cases

Response to steroids was excellentResponse to steroids was excellent

Recurrent episodes of serositis are reportedRecurrent episodes of serositis are reported

SerositisSerositis

DRUG EFFECT

Sulfasalazin induced pneumonitis; fever, infiltration in upper lobes, skin rash, and peripheral eosinophilia (38 cases, 2weeks-8 years)

Drug induced BOOP, granulomatous reaction, interstitial fibrosis, and lupus (15 cases) were reported

Mesalamin(5-ASA); it induces hepatitis and nephritis in addition to the same adverse reactions (7 cases, 5 days-44 months)

Other drugs; methodrexate, azathioprin, anti-TNF

Treatment: Withdrawal of the agent, steroids

1 case in1 case in Camus’ paper; ANA (+) and UC onset was 7 years Camus’ paper; ANA (+) and UC onset was 7 years beforebefore

12 cases were reported in literature (2 DIP, 6 sarcoidosis )12 cases were reported in literature (2 DIP, 6 sarcoidosis )

3 cases were preceding the IBD diagnosis 3 cases were preceding the IBD diagnosis

Drug effect?: 4 case with sulfasalazin, 3 cases with 5-ASA, and 5 Drug effect?: 4 case with sulfasalazin, 3 cases with 5-ASA, and 5

cases with no medicationcases with no medication

Treatment: Treatment: Steroids are effectiveSteroids are effective

İnterstitial lung disease İnterstitial lung disease

Enterokütanöz fistül

Anal fistül

Fistulae (1/3in CD cases)

Ileobronchial fistula (1 case)

Colobronchial fistula (5 cases)

Osephagobronchial fistula (4 cases)

Pulmonary embolism

Thromboembolism risk is high (%1-8)

Homocystein, genetics, drugs, cardiolipin ?

Overlap syndrome

Granulomatous lung disease (46 cases, negative ACE and gallium scanning)

Alpha 1 antitrypsin deficiency (12 cases, 8 had lung involvement)

LABORATORY

Eosinophil (BOOP, drug effect, and eosinophilia+lung

infiltration)

ANA

pANCA

RF

A latent pulmonary involvement was reported with abnormal Tc-A latent pulmonary involvement was reported with abnormal Tc-99mDTPA aerosol scintigraphy in patients with UC but without 99mDTPA aerosol scintigraphy in patients with UC but without respiratory symptoms, and was not related to the disease activityrespiratory symptoms, and was not related to the disease activity

Gursoy S ve ark Inf Bow Dis 2005Gursoy S ve ark Inf Bow Dis 2005

P-A chest X-Ray occasionally shows bronchiectasis and HRCT is not P-A chest X-Ray occasionally shows bronchiectasis and HRCT is not routinely performed in each patientroutinely performed in each patient

SUBCLINIC, LATENT PULMONARY INVOLVEMENTSUBCLINIC, LATENT PULMONARY INVOLVEMENT

Hastalarda akciğer sorunu gözden kaçıyor.Hastalarda akciğer sorunu gözden kaçıyor.

Subclinic alveolitis was describedSubclinic alveolitis was described In Crohn’s disease casesIn Crohn’s disease cases without without respiratory symptoms and with normal X-Ray.respiratory symptoms and with normal X-Ray. Ratio of CD4/CD8 in induced sputum samples was high in 65% of casesRatio of CD4/CD8 in induced sputum samples was high in 65% of cases

Wallaert B et al Chest 1985Wallaert B et al Chest 1985

Fireman Z Am J Gastroenterol 2000Fireman Z Am J Gastroenterol 2000

HRCT showedHRCT showedBonchiectasis 13 /17 (11UC, 2CD)Bonchiectasis 13 /17 (11UC, 2CD)Tree in bud 5/17Tree in bud 5/17Air trapping 11/17Air trapping 11/17ILD 1/17ILD 1/17Groung glass 1/17Groung glass 1/17 Mahadeva et al Eur Respir J 2002;15:41-48Mahadeva et al Eur Respir J 2002;15:41-48

RADIOLOGYRADIOLOGY17 cases with respiratory symptoms (14 UC and 3 CD)17 cases with respiratory symptoms (14 UC and 3 CD)

IBD diagnosis preceded lung involvement in 16/17 (1-25 years)IBD diagnosis preceded lung involvement in 16/17 (1-25 years) 7 patients with colectomy and 3 with extraintestinal manifestations7 patients with colectomy and 3 with extraintestinal manifestations

Smoking: 7 ex-smoker bırakmış, 3 current, and 7 nonsmokerSmoking: 7 ex-smoker bırakmış, 3 current, and 7 nonsmoker

Smoking negatively correlated with severe colitis and colectomySmoking negatively correlated with severe colitis and colectomy

LUNG FUNCTION TESTLUNG FUNCTION TEST

Abnormal lung function tests have been found in patients Abnormal lung function tests have been found in patients without any respiratory symptoms without any respiratory symptoms

Low DLCO has been found in 17/ 32 (53%) nonsmoker Low DLCO has been found in 17/ 32 (53%) nonsmoker UC patients with no symptoms and normal HRCT,UC patients with no symptoms and normal HRCT,

DLCO associated with disease activity DLCO associated with disease activity

Marvisi et al Eur Respir J 2000Marvisi et al Eur Respir J 2000

30/55 (%55) random UC patients had abnormal LFT 30/55 (%55) random UC patients had abnormal LFT 15/55 obstructive15/55 obstructive19/55 abnormal diffusion19/55 abnormal diffusion1/55 restrictive1/55 restrictive5/55 obstructive+abnormal diffusion5/55 obstructive+abnormal diffusion

No relation with smoking, family history, occupation, drugsNo relation with smoking, family history, occupation, drugs

Godet et al Am J Gastroenterol 1997Godet et al Am J Gastroenterol 1997

LFT in 17 IBD patients with respiratory symptoms revealedLFT in 17 IBD patients with respiratory symptoms revealed4 restrictive4 restrictive5 obstructive5 obstructive2 obs+rest2 obs+rest4 Low DLCO4 Low DLCO

6 normal LFT (bronchiectasis, air trapping, tree in bud) 6 normal LFT (bronchiectasis, air trapping, tree in bud)

Mahadeva et al Eur Respir J 2000Mahadeva et al Eur Respir J 2000

BHR and asthma in IBD

3 month-follow-up of 44 random (22 UC, 22Crohn) IBD patients

21/44 (%48) respiratory symptoms11/44 bronchitis4/44 allergic rhinitis1/44 pleuritis4/44(%10) asthma

14/44 (%32) abnormal LFT, 7/44 (%16) abnormal DLCO, and relation to disease activity have been found with FRC and RV

Douglas et al Respir Med 1989

BHR has been shown in 10/14 (%71) children with CD using metacholine challenge test ( no history of clinic, radiologic, and functional airway disease )

2/14 (%17) asthma was diagnosed3/14 (%21) skin prick test was positive

No relation to disease activity, drug, and disease duration

Mansi et al Am J Respir Crit Care Med 2000

BHR has been found in 20% of asymptomatic 25 Crohn patients and 8% of asymptomatic 35 UC patients using metacholine. Female sex and extraintestinal manifestations are risk factors

No relation with smoking, disease activity and disease duration

Kullmann et al Am Respir Crit Care Med 1998

BHR has been found in 45% of IBD patients with normal LFT and without respiratory symptoms. Skin prick tests were positive in 42% of patients

Louis E et al Allergy 1995

IBD patients without allergic symptoms revaled high serum IgE levels

Levo et al Ann Allergy 1986

ResultsResults: : 15/30 respiratory symptoms15/30 respiratory symptoms

14/30 allergic symptoms (more common in UC )14/30 allergic symptoms (more common in UC )

3/30 asthma (1 case concurrent, 1 case diagnosed 6 years before 3/30 asthma (1 case concurrent, 1 case diagnosed 6 years before

IBD onset, 1 case10 years after IBD onset)IBD onset, 1 case10 years after IBD onset)

Ceyhan B ve al Respiration 2003Ceyhan B ve al Respiration 2003

Atopism and BHRAtopism and BHR

Study population Study population 30 patients with IBD (19 UC, 11CD) followed in 30 patients with IBD (19 UC, 11CD) followed in

Gastroenterology Dept of Marmara University Hospital 5.3+/- 4.8 Gastroenterology Dept of Marmara University Hospital 5.3+/- 4.8

years disease duration,years disease duration,

15 non-smoker, 8 current smoker, 7 ex-smoker15 non-smoker, 8 current smoker, 7 ex-smoker

Skin prick testSkin prick test 15/30(50%) 15/30(50%)

11/30(37%) High IgE level 11/30(37%) High IgE level

7/30(24%) positive skin prick test+high IgE level7/30(24%) positive skin prick test+high IgE level

Ceyhan B et al Respiration 2003Ceyhan B et al Respiration 2003

LFTLFT abnormal 8/30 (27%)abnormal 8/30 (27%)

BHR 5/30 (17%) (2 CD, 3 UC)BHR 5/30 (17%) (2 CD, 3 UC)

6/30(20%) rhinitis/sinusitis history6/30(20%) rhinitis/sinusitis history

8/30 (27%) urticaria history8/30 (27%) urticaria history

IBD and lung involvement- SummaryIBD and lung involvement- Summary

In 83% of patients, IBD onset precedes respiratory symptomsIn 83% of patients, IBD onset precedes respiratory symptomsIn 10% of patients lung involvement precedes gastrointestinal symptoms In 10% of patients lung involvement precedes gastrointestinal symptoms

In 7% of patients, diagnosis of lung disease and IBD is concurrentIn 7% of patients, diagnosis of lung disease and IBD is concurrent

Colectomy history is positive in half of IBD patients with airway Colectomy history is positive in half of IBD patients with airway disease.disease.

Colonic surgey may aggravate prior airway diseaseColonic surgey may aggravate prior airway disease

Untreated airway inflammation puts the patient at risk of developing Untreated airway inflammation puts the patient at risk of developing irreversible airway diseaseirreversible airway disease

Local and systemic steroids are effective against airway diseasesLocal and systemic steroids are effective against airway diseases

Small airway disease is usually refractory to inhaled steroids, oral Small airway disease is usually refractory to inhaled steroids, oral steroid effect is slight to modeststeroid effect is slight to modest

The drugs sulfasalzine and 5-ASA may play a role in some casesThe drugs sulfasalzine and 5-ASA may play a role in some cases

Interstitial lung disease is more common in inactive patients taking Interstitial lung disease is more common in inactive patients taking drugsdrugs

Most cases of ILD, necrotic nodules and serositis are very responsive Most cases of ILD, necrotic nodules and serositis are very responsive to steroidsto steroids

The true incidence of pulmonary involvement in IBD patients is unknown because of subclinical pulmonary involvement

Although the incidence of colorectal cancer is known to be increased among patients with UC, the incidence of lung cancer is not increased