git ibd 4th 2012 abstract template

Inflammatory Bowel Disease:

IBD

Dr. Mohammad Shaikhani

CABM,FRCP.

IBD: Definition

Ulcerative colitis

Crohn’s disease (regional enteritis)..

90% Can be differentiated from each other

10% not (indeterminate colitis).

A dysregulated immunologic response to

the local microenvironment of luminal

bacteria.

Genetic predisposition

+

Exact pathophysiology: unknown.2-4/100000

Idiopathic chronic inflammatory

MACROSCOPIC disease of the GIT

of 2 distinct clinical entities:

1

IBD:

Comparison of Features in Ulcerative Colitis and Crohn's Disease

Crohn's DiseaseUlcerative ColitisFeature

TransmuralMucosalDepth of inflammation

Skip areasContiguousPattern of disease

Mouth to anusColorectumLocation

Less commonUsualRectal involvement

CommonBackwash ileitis (15%–

20% of patients)

Ileal disease

CommonRareFistulas

CommonRarePerianal disease

10-30%UnlikelyGranulomas

Less commonUsualOvert bleeding

More commonUnlikelyMalnutrition

Colorectal cancer, small

bowel cancer (depending

on disease location)

Colorectal cancer,

cholangiocarcinoma (if

primary sclerosing

cholangitis is present)

Cancer risk

HarmfulProtectiveTobacco use

Clinical features

Proctitis causing tenesmus (urgency & sense of incomplete evacuation), sometimes causing constipation.

FeverWeight loss( from

inflammation / diarrhea)

Extra-intestinal manifestations & complications.

Physical exam:From mild tenderness toAbdominal distension & rebound

tenderness( toxic megacolon)

Bloody diarrhea

Continuous mucosal disease extends proximally, may involve whole colon (pancolitis)

UC: Clinical features2

Clinical features

Affects any part of GIT frommouth-anus.

Diarrhea caused by SI & Colonic disease.

Diarrhea from SI inflammation, protein lossing enteropathy,Ileal disease or ileal surgical removal.

Hematochesia almost always a sign of colonic disease.

Skip(discontinous) trans-luminal lesions or.

Transluminal leading to strictures & fistulas.

Crohn’s disease: Clinical features2

Fistulas

Enterocutanous fistula.

rectovaginal

Psoas abscess prsenting as limping.

rectovesical.

Abscess.

perianal

Crohn’s disease: Clinical features2

strictures

Present as IO .

Right iliac fossa mass in ileocecal or ileal disease,

Signs of perianal disease as skin tags & anal fistulas.

Present as fever, abdoninal pain,distension,vomiting.

Mostly in TI.

DU or GOO

Crohn’s disease: Clinical features2

Crohn’s Disease

Anatomic distribution

CD activity index

DDx (lymphoma, Yersinea

Enterocolitis, TB)

Extra-intestinal manifestations of IBD

osteopenia

Gall stones

CRC

Cholangio

carcinoma

RENAL

STONES

PSC

others

Arthritis:

A. Peripheral arthritis, usually paralels the disease activity

B. Ankylosing Spondylitis, 1-6%, sacroiliitis,not paralel disease activity.

Ocular lesions:Iritis (uvietis) (0.5-3%), episcleritis, keratitis,

Skin / oral cavity:Erythema nodosum 1-3%>CDPyoderma Gangrenosum 0.6% >UCAphthus stomatitis, metastatic CD.

3

Primary sclerosing cholangitis:

Present with:

High SAP

Jaundice

Biliary obst

PHT

CRC

Higher

incidence of

Cholangitis/CC

80% Have

underlying

IBD

5% of UC

Sometimes in

CD

UDCA

May prevent

CRC

PSC

4

IBD local Complications:

Bleeding

CRC

Depending on

Severity/duration

Toxic

megacolon

fistulas

strictures

CMV Colitis

local

complications

4

IBD local Complications: Toxic mega colon

CT scan:

For follow-up

+

Diagnosis of

Complications

CRC

Depending on

Severity/duration

BE is C/I

BZ/O

perforation risk

Diagnosis:

Clin features+

Plain abd X Ray

Dilation of colon

With

Fulminant colitis

Causes:

IBD

Inf colitis

Ischemic colitis

Toxic

megacolon

Most important

Serious

Complication

Of UC

Management:

Close observation

To consider surgery

If trt fails

Complications of IBD

IBD: Diagnosis/ assessing severity

Amebiais yersinea

CMV

ClostridiumDifficili

Or antibiotic-associated

Cryptosporidia

campylobacter

Infectious colitisExclude infections by GSE/Culture

5

IBD: Diagnosis/ assessing severity

Anemia leockocytosis

HYPOALBUMINEMIA

Increased CRP

High ESR

thrombocytosis

markers of inflammationNon-specific markers of inflammation

5

IBD: Diagnosis/ assessing severity

P-ANCA:In UC 2/3< In CD 15%

In CD 50%< In UC <5%

ASCA

p-ANCA & ASCA is reasonably reliable for the diagnosis

of Crohn disease or ulcerative colitis.

Stool calprotectin: predictive of activity in UC similar to colonoscopy.

Immunological markers of inflammationImmunological markers of inflammation

5

Omp-C Abs&

Cbir1 Abs

Predict classical

CD

Stool

Calprotectin

In UC/CD

IBD: Diagnosis/ assessing severity

UC:EXTENT/Severity

complications

Diagnosis ofColonic disease

CD

Colonoscopic findingsColonoscopic findings

5

BiopsyFor H.PathoConfirmation

BiopsyFor H.PathoConfirmation

Rutgeerts Endoscopic Scoring System

– neoterminal ileum

I,1 I,3

I,4

Actuarial analysis of symptomatic recurrence in patients stratified according

to severity of endoscopic lesions

IBD: Diagnosis/ assessing severity

Plain abdomenfor toxic

Megacolon& IO

BARIUM

CTenterography

VCE for SICD

Radiological findingsRadiological findings

5

ENTEROCLYSISFOR CD

MRIIn Pelvic CD

Management:

Medical: immune-modulating drugs.

Surgical:

Surgery needed for :

25-35% UC; total colectomy with ileal pouch anastomosis.

& 70% CD (local resections of local complications) with 40-50%

requiring recurrent intervention.

Urgent Surgery Elective Surgery

Ongoing hemorrhage Failure of medical therapy

Toxic megacolon Intolerable side effect of medical therapy

Colonic perforation Development of dysplasia

Fulminant ulcerative colitis Carcinoma

Colonic stricture

Growth retardation in children

Emergency Operation Elective Operation

±Subtotal colectomy with end ileostomy Panproctocolectomy with

permanent end ileostomy (simple and curative)

Panproctocolectomy with permanent end

ileostomy

Subtotal colectomy with ileorectal

Anastomosis (rarely performed)

Proctocolectomy with continent

ileostomy (Kock pouch) - Rarely performed

Panproctocolectomy with IPAA

with or without diverting ileostomy (CI in

Crohn’s disease)

Surgery for UC : Indications

Surgery for CD:Indications

Urgent Surgery Elective Surgery

Perforation Stricture

Abscess Fistula

Uncontrollable hemorrhage Malignancy

Toxic megacolon Malnutrition

Bowel obstruction Poorly controlled despite management

Extra-intestinal manifestations

Treatment :Medication & surgery

Medication Indication Side Effects

5-ASA (sulfasalazine, olsalazine,

balsalazide, mesalamine:

oral, rectal UC: induction/maintenance

CD (weak): induction/maintenance

Inters nephritis (rare

Diarrhea (olsalazine)

Medication Indication Side Effects

Antibiotics: Metronidazole, Ciprofloxacin CD: perianal/ colonic disease

Metronidazole:PN

, metallic taste, antabuse effect

Ciprofloxacin: arthropathy, seizure)

Medication Indication Side Effects

CS (oral, IV, rectal) UC/CD: induction, not maintenance

Acne, moon facies, truncal obesity, osteoporosis, osteonecrosis, DM, hypertension, cataracts, inf

Budesonide CD (ileal/R colon): induction Minimal CS effects

Medication Indication Side Effects

Methotrexate CD: induction/maintenance

Bone marrow suppression, hepatotoxicity, pulmonitis

6-MP, Azathioprine UC/CD: steroid withdrawal, maintenance

Pancreatitis, fever, infection, leukopenia, hepatotoxicity, lymphoma

Anti–TNF-α: Infliximab UC/CD: induction/maintenance

Infusion reaction, tuberculosis reactivation, demyelination, infection,HF,Lymphoma.

Adalimumab UC/CD: induction/maintenance

Cyclosporine UC: steroid refractory

Hypertension, nephro &neurotoxicity

Therapeutic Pyramid for Active UC

Severe

Moderate

Mild

Systemic Corticosteroids

Aminosalicylates

Surgery

Oral SteroidsAZA/6-MP

Cyclosporine

Infliximab

Ulcerative Colitis: Mild to ModerateAcute flare

Exclude enteric

pathogen

Extensive

Oral 5-ASA

Response

adequate

Response

inadequate

Maintain

oral 5-ASA

Response

adequateConsider

increased dose

Response

inadequate

Oral steroid

Response

inadequate

Oral 5-ASA Response

inadequate

Consider rectal therapy

(5-ASA and/or steroid)

Patient willing to

take rectal therapyPatient unwilling

to take rectal

therapy

Response

adequate

Maintain

L sided

Ulcerative Colitis: Moderate to Severe

Moderate

Oral steroid

Taper

Successful

Maintain on

5-ASA and observe

Inadequate response

Adequate response

Unsuccessful

IV Steroid

6MP/AZA

Success

Maintain

6-MP/AZA

Response

Failure

Consider

CyA

No

response

Colectomy

Inadequate response

Severe

Infliximab

Response

Maintain

infliximab

No

response

Biologic era in IBD management:

Healing of refractory ulceration/fistula with Infliximab

van Dullemen HM et al. Gastroenterology. 1995;109:129.

Pretreatment 4 Weeks posttreatment

Pretreatment 2 Weeks

10 Weeks 18 weeks

Present DH, et al. N Engl J Med. 1999;340

New Approaches to Therapeutic Intervention in Crohn’s Disease?

The “Step-up” vs “Top-down” Trial

Corticosteroids

Corticosteroids

Corticosteroids

+ (episodic) IFX

IFX +

AZA

+ AZA/MTX

+ IFX

AZA, azathioprine; IFX, infliximab; MTX, methotrexate.