Inflammatory Bowel Disease: Imaging Modalities of Crohn's Disease ...
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Transcript of Inflammatory bowel disease. refers to two chronic diseases that cause inflammation of the...
Inflammatory bowel Inflammatory bowel diseasedisease
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 common, there are some important differences.differences.
Inflammatory bowel diseaseInflammatory bowel disease
Medical research hasn't determined yet what Medical research hasn't determined yet what causes inflammatory bowel disease. But causes inflammatory bowel disease. But researchers believe that a number of factors researchers believe that a number of factors may be involved, such as may be involved, such as
environment diet possibly possibly genetics
Inflammatory bowel diseaseInflammatory bowel disease
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 a virus a virus or a protein in foodor a protein in food
Epidemiology of IBDEpidemiology of IBD
Ulcerative colitisUlcerative colitis Crohn’s diseaseCrohn’s diseaseIncidence (US)Incidence (US) 11/100 00011/100 000 7/100 0007/100 000Age of onsetAge of onset 15-30 & 60-8015-30 & 60-80 15-30 & 60-8015-30 & 60-80Male:female ratioMale:female ratio 1:11:1 1,1-1,8:11,1-1,8:1SmokingSmoking May prevent May prevent
diseasediseaseMay cause diseaseMay cause disease
Oral contraceptiveOral contraceptive No increased riskNo increased risk Relative risk 1,9Relative risk 1,9AppendectomyAppendectomy Not protectiveNot protective ProtectiveProtectiveMonozygotic twinsMonozygotic twins 8% concordance8% concordance 67% concordance67% concordance
Genetics
Studies suggested that 1st degree relatives of an affected patient have a risk of IBD that is 4-20 times higher than that of general population.
The best replicated linkage region, IBD1, on chromosome 16q contains the CD susceptibility gene, NOD2/CARD15.
Having one copy of the risk alleles confers a 2–4-fold risk for developing CD, whereas double-dose carriage increases the risk 20–40-fold.
EtiologyEtiology
Mutations within the NOD2/ CARD15 gene contribute to CD susceptibility.
Functional studies suggest that inappropriate responses to bacterial components may alter signaling pathways of the innate immune system, leading to the development and persistence of intestinal
inflammation. Initiating pathogen?Initiating pathogen?
Infectious?Infectious? ? Possibly non-pathogenic commensal enteric flora? Possibly non-pathogenic commensal enteric flora
Pathogenesis
The mucosa of CD patients is dominated by Th1 (T helper), which produce interferon-γ and IL-2.
In contrast, UC dominated by Th2 phenotype, which produce transforming growth factor (TGF-) and IL-5.
Activation of Th1 cells produce the down-regulatory cytokines IL-10 and TGF-.
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
Ulcerative colitisUlcerative colitis
is an inflammatory disease of the large is an inflammatory disease of the large intestine, also called the colon. In ulcerative intestine, also called the colon. In ulcerative colitis, the inner lining - or colitis, the inner lining - or mucosamucosa - of the - of the intestine becomes inflamed and develops intestine becomes inflamed and develops ulcers ulcers
is often the most severe in the rectal area, is often the most severe in the rectal area, which can cause frequent which can cause frequent diarrhea. .
Ulcerative colitis – macroscopic featuresUlcerative colitis – macroscopic features
40-50% of patients have disease limited to the rectum 40-50% of patients have disease limited to the rectum and rectosigmoidand rectosigmoid
30-40% of patients have disease extending beyond 30-40% of patients have disease extending beyond the sigmoidthe sigmoid
20% of patients have a total colitis20% of patients have a total colitis Proximal spread occurs in continuity without areas of Proximal spread occurs in continuity without areas of
uninvolved mucosauninvolved mucosa
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)
Ulcerative colitis – clinical presentationUlcerative colitis – clinical presentation
The major symptoms of UC are:The major symptoms of UC are:
- diarrhea- diarrhea
- rectal bleeding- rectal bleeding
- tenesmus- tenesmus
- passage of mucus- passage of mucus
- crampy abdominal pain- crampy 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
Ulcerative colitis - complicationUlcerative colitis - complication
HemorrhageHemorrhage PerforationPerforation StrictureStricture Toxic megacolon (transverse colon with a Toxic megacolon (transverse colon with a
diameter of more than 5,0 cm to 6,0 cm with diameter of more than 5,0 cm to 6,0 cm with loss of haustration)loss of haustration)
UC – disease presentationUC – disease presentation
MILDMILD MODERATEMODERATE SEVERESEVERE
BOWEL BOWEL MOVEMENTSMOVEMENTS
< 4 per day< 4 per day 4-6 per day4-6 per day >6 per day>6 per day
BLOOD IN BLOOD IN STOOLSTOOL
smallsmall moderatemoderate SevereSevere
FEVERFEVER nonenone <37,5<37,5°°C C > 37,5> 37,5°°C C
TACHYCARDIATACHYCARDIA nonenone <90 mean <90 mean pulsepulse
>90 mean >90 mean pulsepulse
UC – disease presentationUC – disease presentation
MILDMILD MODERATEMODERATE SEVERESEVERE
ANEMIAANEMIA mildmild >75%>75% <75%<75%
SEDIMENTATION SEDIMENTATION RATERATE
<30mm<30mm >30mm>30mm >30mm>30mm
ENDOSCOPIC ENDOSCOPIC APPEARANCEAPPEARANCE
Erythema, Erythema, decreased vascular decreased vascular pattern, fine pattern, fine granularitygranularity
Marked erythema, Marked erythema, coarse granularity, coarse granularity, contact bleeding, no contact bleeding, no ulcerationulceration
Spontaneous Spontaneous bleeding, ulcerationbleeding, ulceration
Crohn’s diseaseCrohn’s disease
Crohn's disease differs from ulcerative colitis in the Crohn's disease differs from ulcerative colitis in the areas of the bowel it involves - it most commonly areas of the bowel it involves - it most commonly affects the last part of the small intestine and parts of affects the last part of the small intestine and parts of the large intestine. the large intestine.
Crohn's disease isn't limited to these areas and can Crohn's disease isn't limited to these areas and can attack any part of the digestive tractattack any part of the digestive tract
Crohn's disease generally tends to involve the entire Crohn's disease generally tends to involve the entire bowel wallbowel wall
Crohn’s disease – macroscopic featuresCrohn’s disease – macroscopic features
Can affect any part of GI tract from the mouth to the anusCan affect any part of GI tract from the mouth to the anus
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 disease40-55% of patients have both small and large intestines disease
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 areas in the midst of CD is segmental with skip areas in the midst of diseased intestinediseased intestine
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: aphtous or small superficial ulcerationsaphtous 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)
Crohn’s disease – macroscopic featuresCrohn’s disease – macroscopic features
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
Crohn’s disease – macroscopic featuresCrohn’s disease – macroscopic features
Aphtoid ulceration and focal crypt abscesses with Aphtoid ulceration and focal crypt abscesses with loose aggregation of macrophages which form loose aggregation of macrophages which form granulomasgranulomas
Transmural inflammation that is accompanied by Transmural inflammation that is accompanied by fissures that penetrate deeply into the bowel wallfissures that penetrate deeply into the bowel wall
Crohn’s disease – sign and symptomsCrohn’s disease – sign and symptoms
IleocolitisIleocolitis - right lower quadrant pain and diarhhea- right lower quadrant pain and diarhhea - palpable mass, fever and leucocytosis- palpable mass, fever and leucocytosis - pain is colickly and relieved by defecation- pain is colickly and relieved by defecation
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
IBD is associated with variety of extraintestinal menifestation.
Almost one-third of the patients have at least one.
Extraintestinal manifestationExtraintestinal manifestation
Dermatologic
1. Erythema nodosum occurs in up to 15% of CD patients and 10% of UC patients
The lesions of EN are hot, red, tender nodules measuring to 5cm in diameter and are found on the anterior surface of the legs, ankles, calves, thighs and arms
2. Pyoderma gangrenosum (PG) is seen in 1 to 12% of UC patients and is less common in CD colitis. PG may occur years before the onset of bowel symptoms.
Lesions are common on the dorsal surface of the feet and legs but may occur on the arms, chest and even face.
Extraintestinal manifestationExtraintestinal manifestation
RheumatologicRheumatologic Peripherial arthritisPeripherial arthritis developes in 15 to 20% of IBD patients, is more developes in 15 to 20% of IBD patients, is more
common in CD.common in CD.
It is asymmetric, polyarticular and migratory.It is asymmetric, polyarticular and migratory.
Most often affects large joints of the upper and lower extremitiesMost often affects large joints of the upper and lower extremities
Ankylosing spondylosisAnkylosing spondylosis (AS) occurs in 10% of IBD. (AS) occurs in 10% of IBD.
SacroilitisSacroilitis is symetrical, occurs equally in UC and CD, often asymptomatic is symetrical, occurs equally in UC and CD, often asymptomatic
Extraintestinal manifestationExtraintestinal manifestation
OcularOcular
The incidence of ocular complications in IBM patients is 1 to The incidence of ocular complications in IBM patients is 1 to 10%10%
The most common is The most common is conjunctivitis, anterior uveitis, conjunctivitis, anterior uveitis, episcleritisepiscleritis
Symptoms includeSymptoms include: ocular pain, photophobia, blurred vision, : ocular pain, photophobia, blurred vision, headacheheadache
Extraintestinal manifestationExtraintestinal manifestation
UrologicUrologic
The most frequent genitourinary complications are: The most frequent genitourinary complications are: calculi, ureteral obstruction, fistulascalculi, ureteral obstruction, fistulas
The highest frequency of nephrolithiasis (10-20%) The highest frequency of nephrolithiasis (10-20%) occurs in patients with CD.occurs in patients with CD.
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.
Different clinical featuresDifferent clinical features
UCUC Crohn’s diseaseCrohn’s disease
Blood in stoolBlood in stool YesYes OccasionallyOccasionally
MucusMucus YesYes OccasionallyOccasionally
Systemic Systemic symptomssymptoms
OccasionallyOccasionally FrequentlyFrequently
PainPain OccasionallyOccasionally FrequentlyFrequently
Abdominal massAbdominal mass RarelyRarely YesYes
Perineal diseasePerineal disease NoNo FrequentlyFrequently
Different clinical featuresDifferent clinical features
UCUC Crohn’s diseaseCrohn’s disease
FistulasFistulas NoNo YesYes
Small intestine Small intestine obstructionobstruction
NoNo FrequentlyFrequently
Colonic Colonic obstructionobstruction
RarelyRarely FrequentlyFrequently
Response to Response to antibioticantibiotic
NoNo YesYes
Recurrence after Recurrence after surgerysurgery
NoNo YesYes
Different endoscopic featuresDifferent endoscopic features
UCUC Crohn’s diseaseCrohn’s disease
Rectal sparingRectal sparing RarelyRarely FrequentlyFrequently
Continuous Continuous diseasedisease
YesYes OccasionallyOccasionally
„„cobblestoning”cobblestoning” NoNo YesYes
Granuloma on Granuloma on biopsybiopsy
NoNo OccasionallyOccasionally