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INFLAMMATORY BOWEL DISEASE

Zulfachmi Wahab
Dept. of Internal Medicine
Dr. Adhyatma Hospital
Semarang

TWO DISTINCT FORMS


AND A SPRECTRUM IN
BETWEEN
ULCERATIVE COLITIS
CROHNS DISEASE
OVERLAP SYNDROMES
MICROSCOPIC COLITIS

EPIDEMIOLOGY & STATASTICS

Estimated prevalence Active cases 100/100,000 of general


population

Estimated approx 1 million cases in US split equally among CD and


UC

More Prevalent in developed/ developing countries

Higher incidence in Ashkanazi Jew decent

Equal distribution among Male :Female

Peak incidence between 10-30 yrs & then a second peak between
6th/7th decade

AETIOLOGY
UNKNOWN
Genetics- approximately 10-15% have a family history of
eg: Ashkanazi jews
Smoking- CD -Yes, Aggrevates
UC- Protective
Developed countries- extreme Hygiene may predispose
(insufficient exposure and challenge of Gut immune
system that makes them susceptible)

Clinical Manifestations- UC
UC typically involves rectum and extends proximally.
At presentation 40 % have proctitis, 40% have left sided, 20% present
with Pancolitis
So Bloody diarrhea, urgency are presenting symptoms
Severe cases i.e. Toxic megacolon can present with fever, weight loss,
tachycardia, failure to thrive, Growth failures and symptoms of systemic
inflamation
Occasionally severe proctitis cases can present with constipation

Upto 20 % can present with extraintestinal symptoms

Clinical Manifestations- CD
Can involve entire GI tract and so symptoms vary
depending on site of involvement
Approximately 30% have SB disease, 40% have ileo-colitis,
30% have colitis and 5% have UGI disease or Anorectal
presentation
Abd pain, Diarrhea, weight loss, Failure to thrive, Growth
retardation- small bowel Disease
Hematochezia, diarrhea in Large bowel disease
Upto 20% have extraintestinal manifestations

Pyoderma_gangrenos um_cribri.lnk

CROHNS DISEASE

FEATURES UC vs CD
Feature
Depth of inflamation
Pattern of disease
Location
Rectal involvement
Ileal disease
Fistulas
Perianal Disease
Granulomas
Overt Bleeding
Malnutrition
Cancer Risk
Tobacco use

UC
Mucosal
Contiguous
Colorectal
Usual
Backwash 10-15%
Rare
Rare
Unlikely
Usual
Unlikely
CRC, Cholangio
Protective

CD
Transmural
Skip areas
Mouth-Anus
less common
Common
Common
Common
10-30% pts
less common
more common
CRC,Sm Bwl
Harmful

Extraintestinal Manifestations &


IBD disease Activity

RELATED to DISEASE ACTIVITY


Erythema Nodosum
arthritis
manifestations

UNRELATED to DISEASE ACTIVITY


Ankylosing Spondylitis/ Axial Arthritis
Sclerosing Cholangitis

RELATION to DISEASE ACTIVITY LESS CLEAR


Pyoderma Gangrenosum
Metabolic Bone Disease
Kidney stones

Peripheral
Ophtholmologic

Primary
Gallstones

LAB FINDINGS
In mild cases Lab findings are NORMAL
Anemia is a common finding from Iron deficiency of Blood loss or B12/
Folate malabsorption in CD
Hypoalbuminemia, metabolic bone disease from malabsorption are
common in CD
Hypokalemia , Metabolic acidosis from severe diarrhea
Acute Phase reactants- ESR, CRP
UC

p ANCA +/ ASCA -

CD

p ANCA -/ ASCA +

PPV 63%
PPV 80%

ENDOSCOPIC HALLMARKS
Disease Invariably of RECTUMUC
Disease in Perineum- fistula/ inflammation- CD
Ileal disease- CD
Skip lesions Vs Continuous disease
Oral involvement- more common in CD

UGI involvement - CD

CROHNS vs PM COLITIS

ULCERATIVE COLITIS
CONTINUOUS INVOLVEMENT

Ch Ulc COLITIS
PSEUDOPOLYPS,

Differential Diagnosis of IBD

Acute Self Limiting Colitis


Bacterial- Toxigenic E Coli, Salmonella
Shigella,Campylobacter, Yersinia, Mycobacterium,N.
Gonorrhea,C.Diff
ParasitesAmoebiasis, Chlamydia Viral----CMV, H.
Simplex

Collagenous/Lymphocytic colitis
Diverticular Dis Associated Colitis
Medication related Colitis--- NSAIDs , Gold
Ischemic Colitis
Radiation Colitis
Appendicitis
Diverticulitis
Neutropenic Enterocolitis/ Typhilitis
Solitary Rectal Ulcer syndrome
Malignancies- Carcinoma/ lymphoma/ leukemia

Microscopic Colitis

Ch Diarrhea with abd pain, mild weight loss


Elderly (70 or >) are more affected
Women have a greater incidence
Association with NSAIDs use suggested
Colonoscopy shows normal mucosa
Biopsy shows inflammatory infiltrates
Unlike UC/ CD crypt distortion is NOT present
Co-existing Celiac sprue should be considered
Treat with Loperamide, Diphenoxylate or Bismuth alone
or in combination
Rarely Cholestyramine, 5 ASA and even steroids may
be considered ( < 5 %patients)

Histopathology features
Crypt Abscess, crypt distortion in UC
Crypt abscess- depth of involvement in CD
Granulomas are found in 30% of CD
Inflamatory infiltrates in MC- NO crypt
distortion noted in MC

Treatment of IBD- UC

Active Disease
Topical therapy for distal disease ie enemas/ suppositoriesASA / Steroid
disease treated with oral mesalamine

Mild

Steroids for severe disease


6 MP /Azathiprine may be used to minimize steroid need
In severe fulminant colitis we may have to use IV steroids,
cyclosporin or infliximab for controll
Surgery will have to be considered if toxic megacolon is
suspeced

Treatment of IBD- UC
Maintenance of Remission
Mild distal disease may not need
maintenance
Severe disease will do better with a low
dose maintenance with ASA
or with
AZA/6MP
Steroids do not have a roll in maitenance

Treatment of IBD- CD
Similar to UC with following exceptions
Smokers should be counselled to stop
5ASA is less effective than in UC
Metronidazole in an option in induction
Steroids for acute flares
Infliximab/ Adalimumab for induction/ maintenance
AZA/ 6MP for maintenance
Surgery fo complications of disease

Thanks 4 U attention