Engidaw Ambelu

1. Inflammatory Bowel
Disease (IBD)
Andualem F. (MD)
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2. Outline
• Introduction
• Etiologies and risk factors
• Clinical manifestation of chron’s
disease and ulcerative colitis
• Diagnosis
• Treatment of IBD
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3. Introduction
• Inflammatory bowel disease (IBD) is
an immune-mediated chronic
intestinal condition. Ulcerative colitis
and Chron’s disease are the two major
subtypes.
• Under physiologic conditions,
homeostasis normally exists between
the commensal microbiota, intestinal
epithelial cells and immune cells.
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4. Cont’d…
• These host compartments function together as an
integrated “supraorganism”. This relation can be
affected by specific environmental (e.g. smoking,
antibiotics, enteropathogens), and genetic factors
that in a susceptible host, cumulatively and
interactively disrupt homeostasis, which in so doing
culminates in a chronic state of dysregulated
inflammation; that is IBD.
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5. Cont’d…
• IBD is considered as an inappropriate immune
response to the endogenous commensal
microbiota within the intestines, with or without
some component of autoimmunity.
• Some common genetic disorders associated with
IBD include Turner’s syndrome, wiskott-Aldrich
syndrome (WAS) and Glycogen storage diseases.
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6. Epidemiology and risk factors
• Peak incidence of IBD is in the second to fourth
deacdes. The second peak is between the seventh to
ninth decade (Bimodal).
• Greatest disease incidence among whites and Jewish
people.
• Concomitant Oral contraceptive pill use and smoking
increase risk of CDs in females.
• Positive family history
• Antibiotic use in early life increases risk of IBD.
• Breast feeding, early appendectomy and smoking are
protective from UC.
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7. Ulcerative colitis
• Ulcerative colitis is characterized by recurring
episodes of inflammation limited to the mucosal
layer of the colon.
• It commonly involves the rectum and may extend in
a proximal and continuous fashion to involve other
parts of the colon
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8. Cont’d…
• Different terms have been used to describe the
degree of involvement.
Proctitis
Proctosigmoiditis
Left sided or Distal ulcerative colitis
Extensive colitis
Pancolitis
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9. Clinical manifestations
History
• Patients usually present diarrhea (may be bloody).
• Bowel movements are frequent and small in volume
• Colicky abdominal pain, urgency, tenesmus, and
incontinence.
• Distal disease may manifest with constipation with
frequent discharge of blood and mucus.
• Onset of symptoms is usually gradual and progressive
over weeks.
• Systemic symptoms including fever, fatigue, and weight
loss
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10. Cont’d…
Physical examination - is often normal.
• -abdominal tenderness to palpation,
• -fever, hypotension, tachycardia
• -pallor
• -Rectal examination –blood
• -muscle wasting & loss of subcutaneous fat
• -peripheral edema due to weight loss and
malnutrition.
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11. Cont’d…
Disease severity
• The severity of disease in patients with ulcerative
colitis is important in guiding clinical management
and can predict long-term outcomes.
• Montreal classification of severity of ulcerative
colitis stratifies ulcerative colitis severity into mild,
moderate, and severe based on the frequency and
severity of Diarrhea, and the presence of systemic
symptoms/signs and laboratory abnormalities.
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12. Cont’d…
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mild moderate sever
Endoscopic
appearance
Erythema,
decreased vascular
pattern, fine
granularity
Marked erythema,
coarse granularity,
absent vascular
markings, contact
bleeding, no
ulcerations
Spontaneous
bleeding,
ulcerations
Tachycardia none <90 >90
Anemia mild > 75% < 75%
ESR <30 --- >30
Blood in stool small moderate sever
Bowel
movements
<4 per day 4–6 per day >6 per day
fever none <37.5 >37.5

13. Acute complications
• bleeding
• Fulminant colitis
• Toxic mega colon: colonic diameter ≥6 cm or cecal
diameter >9 cm with systemic toxicity
• Perforation - commonly consequence of toxic mega
colon or first attack of UC
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14. Chronic complications
• Colorectal cancer
• Stictures (benign or malignant)
• Anal fissures
• Perianal abscesses,
• Hemorrhoids
• Obstruction????? But not as cmn as crhons disease
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15. Cont’d…
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16. Investigations
Imaging modalities
• Flexible sigmoidoscopy or colonoscopy
• Plain abdominal x-ray
• Barium enema
• Trans abdominal bowel sonography (TABS)
• Abdominal CT scan
Laboratory
• CBC, ESR, fecal lactoferrin and calprotectin
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17. Crohn’s disease
• CD is a disorder of uncertain etiology that is
characterized by transmural inflammation of the
gastrointestinal tract with skip lesions
• The transmural inflammatory nature of Crohn's disease
often leads to fibrosis and to obstructive clinical
presentations that are not typically seen in ulcerative
colitis
• CD may involve the entire gastrointestinal tract from
mouth to the perianal area, sparing the rectum, In
contrast to UC.
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18. Clinical manifestation
More variable than those of ulcerative colitis.
Abdominal pain
colonic obstruction
Diarrhea
Bleeding
Fatigue
Prolonged diarrhea with or without gross
bleeding
Abdominal pain, weight loss, and fever are the
hallmarks of CD .
N.B, Patients may Present with complication
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19. Extra-intestinal manifestations
• Arthritis – the most common extra intestinal manifestation.
• Eye involvement – uveitis, iritis, and episcleritis
• Skin disorders – erythema nodosum and pyo derma
gangrenosum
• Primary sclerosing cholangitis
• Secondary amyloidosis is very rare but may lead to renal failure
and other organ system involvement
• Venous and arterial thrombo embolism resulting from hyper
coagulability
• Renal stones
• Bone loss and osteoporos
• Vitamin B12 deficiency
• Pulmonary involvement:- bronchiectasis, chronic bronchitis, ILD
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20. Complications
Perforation: Penetrating trans-mural disease may lead to
abscess or fistula formation.
 Stricures: fibro-stenotic strictures of the ileum secondary
to acute inflammation and edema, compression due to the
mass effect of an abscess or formation of adhesions.
 Peri-rectal disease: ano-rectal fistulas and abscesses.
 Nutritional deficiencies
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21. Cont’d…
Cancer
• Small bowel adenocarcinoma risk increases in
patients with Crohn,s disease.
• Typically, these cancers arise in segments of long-
term active disease & segments of bypassed bowel.
• Annual surveillance with colonoscopy is
recommended in patients with Crohn,s colitis.
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22. Laboratory findings
CBC:
leukocytosis , thrombocytosis, Anemia.
Marked leukocytosis suggests complication with
abscess.
ESR and CRP are usually elevated.
Hypoalbuminemia, anemia and leukocytosis are
suggestive of sever disease.
Iron studies may reveal iron deficiency anemia
Imaging:Endoscopy, Barium enema, CT scan and
MRI
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23. Cont’d…
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25. Differential Diagnosis
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26. Management
• Sulfasalazine and other 5-ASA agents are the main
stay of therapy for the IBDs.
• Other treatment options include Glucocorticoids,
Antibiotics, Azathioprine and 6-mercaptopurine,
Methotrexate, Cyclosporine, Tacrolimus and other
biologic agents like Anti-TNF therapies.
• Surgical Therapy
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