LEARNING OUTCOMES

Describe the disease process of Crohn’s versus Ulcerative Describe the disease process of Crohn’s versus Ulcerative Colitis.Colitis.

Identify the clinical presentation of a patient with Crohn’s Identify the clinical presentation of a patient with Crohn’s Disease and Ulcerative Colitis.Disease and Ulcerative Colitis.

Discuss the various diagnostic workups and how they may Discuss the various diagnostic workups and how they may differentiate Crohn’s & U.C. from other GI ailments.differentiate Crohn’s & U.C. from other GI ailments.

Select appropriate treatments for a patient with Crohn’s Select appropriate treatments for a patient with Crohn’s Disease and Ulcerative Colitis.Disease and Ulcerative Colitis.

DEFINITION

It includes a group of It includes a group of chronic disorders that chronic disorders that cause inflammation or cause inflammation or ulceration in large and ulceration in large and small intestines. small intestines.

TYPES OF IBD

Collagenous colitisCollagenous colitis Lymphocytic colitisLymphocytic colitis Ischemic colitisIschemic colitis Behcet’s syndromeBehcet’s syndrome Infective colitisInfective colitis Intermediate colitisIntermediate colitis

Global Prevalence of IBD

AETIOLOGY

Exact cause is Exact cause is

unknownunknown

Genetic factorsGenetic factors

Immunological factorsImmunological factors

Microbial factorsMicrobial factors

Psychosocial factorsPsychosocial factors

PATHOGENESIS OF IBD

NormalGut

Tolerance-controlled

inflammation

Environmental trigger

(Infection, NSAID, other)

Acute Injury

Complete Healing

Chronic Inflammation

GeneticallySusceptible

HostAcute Inflammation

↓ Immunoregulation, failure of repair or

bacterial clearance

Tolerance

ULCERATIVE COLITIS

UC is an non granulomatous UC is an non granulomatous inflammatory disorder that affects the inflammatory disorder that affects the rectum and extends proximally to affect rectum and extends proximally to affect variable extent of the colon.variable extent of the colon.

It strictly affects the colon and has It strictly affects the colon and has mucosal involvementmucosal involvement

15-40 years (Young adults)15-40 years (Young adults) No variation between sexes No variation between sexes High incidence areas: USA and northern-High incidence areas: USA and northern-

western Europewestern Europe More common in non-smokersMore common in non-smokers

CD is a condition of chronic CD is a condition of chronic granulomatous inflammation potentially granulomatous inflammation potentially involving any location of the GIT from involving any location of the GIT from mouth to anus.mouth to anus.

Crohn’s Disease - affects mouth to anus Crohn’s Disease - affects mouth to anus and has transmural involvementand has transmural involvement

1st peak 15-30 years of age, 2nd peak 1st peak 15-30 years of age, 2nd peak around 60 yaround 60 y

Marginally more common in femalesMarginally more common in females High incidence areas: North America, UK, High incidence areas: North America, UK,

northern Europenorthern Europe More common in smokersMore common in smokers

CROHN’S DISEASE

I B D

PATHOLOGY

CROHN’S DISEASE ULCERATIVE COLITIS

Ileum – most common site Ileum – most common site Transmural Transmural Skip lesionSkip lesion Hose - pipe patternHose - pipe pattern Linear ulcerLinear ulcer Cobble stone app. - of Cobble stone app. - of

mucosamucosa Fat wrapping around Fat wrapping around

bowel bowel

Rectum – most commonRectum – most common

site site Mucosa & sub-mucosaMucosa & sub-mucosa Continuous lesion Continuous lesion Pipe stem colonPipe stem colon Pin point ulcersPin point ulcers Crypt abscess Crypt abscess Pseudopolyps Pseudopolyps

ULCERATIVE COLITIS CROHN’S DISEASE

Abdominal painAbdominal pain Diarrhea Diarrhea Weight lossWeight loss Low grade feverLow grade fever MalabsorptionMalabsorption SteatorrheaSteatorrhea Anorectal lesions, Anorexia, Anorectal lesions, Anorexia,

AnemiaAnemia Malnutrition (weight loss)Malnutrition (weight loss)

DiarrheaDiarrhea Rectal bleedingRectal bleeding TenesmusTenesmus Passage of mucusPassage of mucus Crampy abdominal painCrampy abdominal pain Pain of colonic origin, often left Pain of colonic origin, often left

sided and related to sided and related to defecationdefecation

Relapses and remissions at Relapses and remissions at regular intervals.regular intervals.

FEATURES MILD MODERATE SEVERE FULMINANTStool frequency

< 4 4 - 6 > 6 > 10

Blood in stools

Intermittent

Intermediate

Frequent Continuous

Pulse < 90 90 - 100 > 100 > 110Haematocrit

Normal 3 - 40 < 30 Req. Transfusion

Weight loss - %

None 1-10% > 10% Req. TPN

Temperature

Normal 99 - 100 > 100 > 100

ESR < 20 20 - 30 > 30 > 30 Albumin Normal 3 – 3.5 < 3.5 Severe

CLINICAL GRADING – U C

COMPLICATIONS

CROHN’S DISEASE ULCERATIVE COLITIS

Obstruction Obstruction Peritonitis Peritonitis Perianal Perianal

abscessabscess

Toxic megacolon Toxic megacolon Massive HgeMassive Hge Fistula-in-ano Fistula-in-ano

EXTRA – INTESTINAL COMPLICATIONS - BOTH

MalnutritionMalnutrition Pancreatitis Pancreatitis Amyloidosis Amyloidosis Anaemia Anaemia Intracranial Intracranial

Thromboembolic events Thromboembolic events DVT DVT

INVESTIGATIONS

CCRP - RP - increasedincreased ESRESR - - increasedincreased Platelet ct - Platelet ct -

increasedincreased HHb b - decreased- decreased LeukocytosisLeukocytosis HypoalbuminemiaHypoalbuminemia

Endoscopy Endoscopy Colonoscopy Colonoscopy HistopathologyHistopathology RadiologyRadiology Serology Serology tests tests Microbiological Microbiological

stool test stool test

ULCERATIVE COLITIS CROHN’S DISEASE

Hose – pipe colon Hose – pipe colon Toxic megacolon Toxic megacolon Loss of haustrations Loss of haustrations

Rose-thorn Rose-thorn appearance appearance

String sign of String sign of KantorKantor

Straightening of Straightening of bowel bowel

ULCERATIVE COLITIS CROHN’S DISEASE

“Creeping Fat”

DIFFERENTIAL DIAGNOSIS

Chronic infectious colitisChronic infectious colitis Ischemic colitisIschemic colitis DiverticulitisDiverticulitis Irritable Bowel SyndromeIrritable Bowel Syndrome Amoebic colitis Amoebic colitis Intestinal tuberculosis Intestinal tuberculosis D / D – R I F – Mass D / D – R I F – Mass Colon CancerColon Cancer

GENERAL MEASURES

Correction of anemia.Correction of anemia. Fluid & electrolyte Fluid & electrolyte

supplementation.supplementation. Nutrition ( high protein, Nutrition ( high protein,

carbohydrate ,vitamin, but low carbohydrate ,vitamin, but low fat diet ) ,TPNfat diet ) ,TPN

Sedatives and tranquilizers.Sedatives and tranquilizers. Psychological counselingPsychological counseling

DEFINITIVE TREATMENT

AcuteAcute - Induce remission - Induce remission

Chronic - Maintenance of Chronic - Maintenance of

remissionremission

SurgicalSurgical - Correct complications - Correct complications

ACUTE THERAPY

IV +/- PO Hydrocortisone or IV +/- PO Hydrocortisone or MethylprednisoloneMethylprednisolone

Rectal +/- Oral 5-ASA; Rectal +/- Oral 5-ASA; SulfasalazinesSulfasalazines

BSA +/- Metronidazole BSA +/- Metronidazole IV Cyclosporine 2-4 mg/kgIV Cyclosporine 2-4 mg/kg Bowel RestBowel Rest

CHRONIC THERAPY

Goals:Goals:

Remission of bowel Remission of bowel

inflammationinflammation

1-4 BM/day with mucosal 1-4 BM/day with mucosal

healinghealing

Prevention of strictures, Prevention of strictures,

fistulas, fistulas,

other complicationsother complications

Prevention of need for surgeryPrevention of need for surgery

CROHN’S DISEASE

Failure of medical therapyFailure of medical therapy Recurrent obstructionRecurrent obstruction PerforationPerforation Fistula / Abscess / StrictureFistula / Abscess / Stricture HemorrhageHemorrhage Steroid dependency diseaseSteroid dependency disease Growth retardation (children)Growth retardation (children) Malignant changeMalignant change

INDICATIONS - SURGERY

SURGERY

REFERENCES

“DIAGNOSIS OF DISEASES OS OFTEN EASY; OFTEN DIFFICULT & OFTEN

IMPOSSIBLE”