bowel disease

1. Definition it is a conditions characterized by idiopathic chronic
inflammation of bowel.
. Inflammation limited to mucosal layer of colon.
Full thickness inflammation involving any part of the Gl
tract from mouth to anus)

3. CD VS UC

4. EPIDEMIOLO
GY
 It can affect any part of GIT from mouth to anus.
 most common in North America and Northern
Europe with annual incidence of 8 per 100 000.
 Prevalence of around 145 per 100 000 in UK.
 most commonly diagnosed between the ages of 25
and 40 years.
 especially prevalent 3 to 5 times higher in the
ashkenazi Jews.

5. EPIDEMIOLOGY
Cosnes et al, 2011

6. AETIOLOGY
 gut mucosa and the normal gut bacteria becomes deranged,
 Genetic. 10% first deg relatives.50% in monozygotic twins.
 NOD2/CARD15 genes .
 Environmental . jews
 Infection.mycobacterium DNA.M Johne’s disease of cattle.
 Smoking increase risk three fold.cessationeffect equal to
medicine.
 diet high in refined foodstuff.
 sanitation esp in children in childhood.

7. PATHOGENESIS
 increased gut mucosal permeability with ncreased
passage of luminal antigens. an abnormal immune-
mediated response to colonisation of the gut .
 induce a cell-mediated inflammatory response
 release of proinflammatory cytokines
 a defect in suppressor T-cells function.

8. RISK
FACTORS

9. PATHGENESIS OF CD

10. CLINICAL FEATURES
post prandial colicky pain.
• Anorexia, Nausea ,vomiting,
• intermittent Fever,wight loss
• appendicitis
• tender mass inRIF
• intestinal obstruction.
• local or diffuse Peritonitis.
• gall stones
• mild prolong Diarrhea.
• blood in stool.
• anemia,Weight loss common
• fulminant colitis

11.  Gut perforation
 Enterocutaneous fistula.interloop,ileovesical,rectovaginal
fistulaileosigmoid fistula-profuse diarrhoea.
 Periana skin bluish. abscesses and
fistulae,Incontinence,watering-can perineum.
 Rectal bleeding Growth failure
 ‘Metastatic’ CD can occur in the vagina and/or
 skin with nodular ulcers,
 Malnutrition, vitamin deficiencies

12. MANIFESTATIONS
 retarded growthand sexual development in child.
 Amyloidosis.
 osteoporosis
 Joint pain.
 Iritis. uveitis
 aphtous ulcers, dysphagia.
 Sclerosing cholangitis.
 erethema nodosum. pyoderma gangrenosum

14. PATHOLOGY
 terminal ileum is most commonly (65%) alone or with colon
 Colitis alone upto a one-third
 perianal lesions up to 50–75% cases. 25% per cent of
patients
 with small bowel disease, but in 75% of patients with Crohn’s
 colitis.
 characterized by skip lesions, adhesions & fistulas between
gut loops.
 cobblestone appearance on endoscopy and contrast studies.
 fat wrapping of inflamed part of bowel.

15. PATHOLOGY
•areas of normal mucosa in between areas of inflammation
ulcerations WITH mucopurulent exudate..
AREA OF STRICTURING AND PRESTENOTIC DILATATIONS.
• NC l Granuloma in 60%.most common in anorectal disease.
• Submucosal or subserosal lymphoid aggregates.
Fissure,fistula,abscess formation

16. Clinical Features
Clinical Feature Ulcerative Colitis Crohn's
Inflammation Superficial,
continuous
Full thickness, patchy
Mucosal Ulcers
Superficial Deep, linear
Involvement Rectum, colon mouth to anus
Extra-intestinal Yes Yes
Fistulas No Yes
Symptoms Bloody diarrhea, Diarrhea, pain, weight loss

17. Normal colon

19. WORK UP
 BLOOD TESTS
 calprotectin test
 ENDOSCOPY
 ULTRASOUND STUDY
 CT SCAN
 labelled white cell scan
 MR enterography) or enteroclysis

20. LABORATORY TESTS
CBC,RFT,LFT,CRP.
ESR-elevated
Anemia
Leukocytosis
hypoalbuminemia
Stool RE

21. Colonoscopy

25. CT Enterography

26. MEDICAL TREATMENT

27. MEDICAL TREATMENT
1-CORTICOSTEROID
 moderate to severe disease,RAPID remission in
70–80% of cases .
 short courses only,Not used for maintenance.
 Prednisone (40-60 mg/day) acute episode.
 Budesonide ileal or right-side colonic disease
 usually replaced with immunomodulatory agents
 adrenal suppression.

28. MEDICAL TREATMENT
2-ASA AGENTS
 Mesalamine. small bowel
 Mesalazine Asacol,Pentasa
 Olsalazine (5-ASA dimer cleaves in colon)
 limited efficacy in small bowel CD

29. MEDICAL TREATMENT
3-immunosuppressive agents .
AZATHIOPURINE-6MP used for CURRENTLY
STD maintenance therapy,Inhibit cell-mediated
responses
TPMT activity TEST, myelosuppression
Cyclosporine 80% remission.

30. MEDICAL TREATMENT.
4-MONOCLONAL ANTIBODIES
 currently widely used for induction and maintenance.
 also appear to be effective treatments for perianal disease
 early and aggressive THERAPY at high risk for early RECURRENCE.
 Suppress cell mediated immunity,
1ST Gen MAB. Infliximab. TNF BLOCKER.ESP pediatric CD.
2ND-Gen MAB adalimumab. TNF-α blocker. SC 1-2 WKLY
3-RD GEN MAB. integrin Ab. vedulizumab and etrolizumab
binds α4β7 and α4β1 receptors .ptevent WBCs
migration at site inflammation.
COSTLY,,MALIG
Contraindications Active infection, tuberculosis ,history of malignancy

31. MEDICAL TREATMENT
 Antibiotics. metronidazole peripheral neuropathy,
ciprofloxacin Achilles tendinitis and tendon rupture ESP
IN PERIANAL
 Antidiarrheal Agents. Loperamide,diphenoxylate.
 Bile acid sequestrants .cholestyramine, colestipol
 Anticholinergic agents.dicyclomine,hyoscyamine,
propantheline

32. MEDICAL TREATMENT
NUTRITIONAL SUPPORT
 Elemental diet or parenteral nutrition REMISSION IN 80%
 enteral tube or even intravenous feeding

33. SURGERY IN CD
 70% of patients with CD will require a bowel
resection in the first decade
 fundamental principle is to preserve healthy gut and
to maintain adequate function

34. INDICATIONS OF SURGERY IN CD
recurrent intestinal obstruction.
persistent or massive acute bleeding.
perforation of the bowel.
failure of medical therapy.
steroid dependent disease.
intestinal fistula.
perianal disease (abscess, fistula, stenosis).
malignant change.

35. OPERATIONS DONE FOR CD
 Strictureplasty
 Ileocaecal resection
 Segmental resection
 Proctectomy and proctocolectomy.
 Colectomy and ileorectal anastomosis
 Subtotal colectomy and ileostomy
 Temporary loop ileostomy.

36. INDICATIONS OF DELAYED
ANASTOMOSIS OR ILEOSTOMY
 Intra-abdominal septic compli_x0002_cations are more
common if
 current high-dose steroid therapy (≥10mg prednisolone
for ≥4 weeks before surgery);
 current preoperative monoclonal antibody therapy;
 preoperative significant weight loss (>10% premorbid
weight).
 pre-existing abdominal sepsis (notably abscess or fistula);
 serum albumin <32 g/L.

37. APPROACH
 ‘step-up’ approach. ESTB TO NEWER.
 TOP-DOWN APPROACH. NEWER TO ESTB