RCSI Royal College of Surgeons in Ireland Coláiste Ríoga na Máinleá in Éirinn

Title Inflammatory Bowel Disease

Class Senior Cycle II

Course Surgery
 LEARNING OBJECTIVES

• List the types of inflammatory bowel disease (IBD)

• Describe the pathophysiology and clinical features of
ulcerative colitis (UC) and Crohn’s disease
• Discuss the investigations and treatment options for IBD
• List the extra-intestinal manifestations of IBD
 INFLAMMATORY BOWEL DISEASE

• Crohn’s disease
– Affects any part of the GI tract

• Ulcerative Colitis (more common)

–Affects the large bowel only

• Indeterminate Colitis
–Inflammation of the large bowel with features of UC and CD

• 25-40% develop extra intestinal manifestations

 ULCERATIVE COLITIS

• Affects the mucosa and submucosa of the large bowel

only

• Rectum is always involved

• In 20% of cases the terminal ileum is also involved “

back wash Ileitis”
 PATHOPHYSIOLOGY

• Mucosal Ulcers and crypt abscesses form.

• Intact and oedematous mucosa projects into the bowel lumen

(pseudopolyposis).

• Subsequent fibrosis from chronic inflammation leads to loss of

colonic haustra (lead pipe colon).

• Predisposes to dysplastic change and adenocarcinoma

development.
 CLINICAL FEATURES

• Bloody diarrhoea
• Tenesemus
• Weight and appetite loss
• Electrolyte imbalance (hypokalemia)
• Systemically unwell
• Toxic megacolon
– Massively dilated colon with patchy necrosis
– Perforation imminent unless colectomy is performed
• Extraintestinal manifestations
TOXIC MEGACOLON
 INVESTIGATIONS

Endoscopy:

Mucosal inflammation of
colon and rectum

Biopsy shows typical

pathological features of
UC
 INVESTIGATIONS

Barium Enema can

detect:
•Loss of haustra
•Pseudopolyps
•“Lead- pipe” colon
 INVESTIGATIONS

Computed Tomography
(CT scan):
• Diffusely thickened
colonic walls
suggestive of
ulcerative colitis
 TREATMENT

• Conservative (medical)
– Local
– Systemic

• Surgical
– Emergency
– Elective
 TREATMENT

Medical Surgical
• Local therapy • Subtotal colectomy with
– Steroid enemas,foams ileostomy
• Systemic steroids • Panproctocolectomy with
• 5-ASA preparations permanent ileostomy
• 6-mercaptopurine • Restorative
• Infliximab proctocolectomy with ileo-
anal pouch, Park’s pouch
 CROHN’S DISEASE

• Chronic, non-caseating granulomatous disease

• Full thickness inflammatory process that can affect any part of

the GIT

• Onset in teens and twenties

• Prevalence is 200/100,000

• More common in Caucasians

 PATHOPHYSIOLOGY

• Small Bowel ----------------------------------------------50%

• Large and Small Bowel both--------------------------50%

• Large Bowel alone---------------------------------------20%

• Perianal disease -----------------------------------------30%

• Upper Gastrointestinal tract----------------------------15%

 CLINICOPATHOLOGICAL FEATURES
• Mucosal inflammation:
– Diarrohea
– Growth retardation in children from malnutrition
– Severe malabsorption in case of small bowel inflammation

• Transmural Inflammmation
– Crohn’s disease of the terminal ileum may mimic appendicitis
– Serosal inflammation may cause different bowel segments to
adhere to each other. May eventually lead to :
• Adhesions
• Perforation
• Fistulae
 CLINICOPATHOLOGICAL FEATURES

• Perianal problems:
– Painless superficial ulcers

– Dense fibrous anal strictures

– Rectovesical or rectovaginal fistuale

– Complex anal fistulae

– Severe cases : perineum can have multiple sinuses with dense

fibrotic skin (watering can perineum)
 CLINICOPATHOLOGICAL FEATURES

• Upper GI involvement:
– Oral ulcers

– Dysphagia

– Gastric outlet obstruction

 INVESTIGATIONS
• Endoscopy
– Upper and lower (for diagnosis)

• Small bowel enema

– Can detect strictures
– String sign of Kantor if terminal ileum is involved

• CT scan of the abdomen and pelvis with contrast

– Can demonstrate fistulae and abscess
• MRI
– Can assess complex perianal disease
 INVESTIGATIONS

Endoscopy:

Cobble stone appearance with

normal intervening mucosa
 INVESTIGATIONS

Small bowel enema:

“String sign of Kantor” showing

terminal ileal stricture
 INVESTIGATIONS

CT Abdomen:

Showing a terminal
ileal stricture
 INVESTIGATIONS

• MR enteroclysis
– Effective to document small bowel strictures in young patients

• Fistulography
– Demonstrates anatomy and helps in surgical planning for
complex fistulae
 TREATMENT

• Medical
– Corticosteroids
– 5-aminosalicylates
– Immunomodulatory agents:
• Azathioprine , 6- mercaptopurine, cyclosporin
– Monoclonal antibody targeting TNF-alpha
• Infliximab

• Surgery
– Not a cure for CD
– Only focuses on disease related complications
 MOST COMMON SURGICAL PROCEDURES

Aim is to preserve as much bowel length as possible

• Ileocecal resection

• Segmental bowel resection

• Colectomy and Ileorectal anastomosis

• Subtotal colectomy and ileostomy

• Strictureplasty
 EXTRAINTESTINAL MANIFESTAIONS OF IBD

System/organ complication
Skin Erythema nodosum, pyoderma
gangrenosum, acute inflammatory
dermatitis, psoriasis, oral ulcers
Musculoskeletal Arthritis, ankylosing spondylitis,
osteoporosis
Hepatobiliary Sclerosing cholangitis
Eye Uveitis, episcleritis, corneal ulcers
Other less common Gallstones, pancreatitis, renal calculi