inflamatory bowel diseas-w

8/3/2019 Inflamatory Bowel Diseas-W

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Inflammatory Bowel DiseaseInflammatory Bowel Disease

David S. Kauvar, MDDavid S. Kauvar, MDCPT, MC, USACPT, MC, USA

Department of General SurgeryDepartment of General Surgery

Brooke Army Medical CenterBrooke Army Medical Center

Fort Sam Houston, TXFort Sam Houston, TX


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OutlineOutline

OverviewOverview

EpidemiologyEpidemiology

Clinical featuresClinical features

EtiologyEtiology

PathologyPathology

WorkupWorkup

Medical and Surgical TherapyMedical and Surgical Therapy


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OverviewOverview

Two similar but distinct diagnosesTwo similar but distinct diagnoses

Ulcerative ColitisUlcerative Colitis

Confined to ColonConfined to Colon

Crohn's DiseaseCrohn's Disease

Small/Large BowelSmall/Large Bowel Intestinal and ExtraIntestinal and Extra--Intestinal featuresIntestinal features

Medical and Surgical TherapyMedical and Surgical Therapy


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EpidemiologyEpidemiology


Prevalence 60/100KPrevalence 60/100K

Incidence 6/100KIncidence 6/100K

Industrial NationsIndustrial Nations

White, JewishWhite, Jewish

Men = WomenMen = Women

Onset 15Onset 15--40 y40 y

5% after 60 y5% after 60 y

Crohn'sCrohn's Prevalence 10Prevalence 10--

70/100K70/100K

Incidence 1Incidence 1--6/100K6/100K

Industrial NationsIndustrial Nations

Jewish, Educated,Jewish, Educated,

UrbanUrban

Men = WomenMen = Women

1515--30 y, 5530 y, 55--60 y60 y

Both carry increased risk of colon cancer

Risk is proportional to duration of active disease


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Distinguishing Clinical FeaturesDistinguishing Clinical Features


Bloody diarrheaBloody diarrhea

ContinuousContinuous

colitiscolitis

Rectum toRectum toCecumCecum

Crohn'sCrohn's

NonNon--bloodybloody

diarrheadiarrhea

Perianal diseasePerianal disease

DiscontinuousDiscontinuous

ColitisColitis

Skip lesionsSkip lesions

anywhere inanywhere in

GI tractGI tract


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PresentationPresentation

Ulcerative ColitisUlcerative Colitis 60% Mild Colitis60% Mild Colitis

Bloody DiarrheaBloody Diarrhea

Abdominal painAbdominal pain

25% Moderate Colitis25% Moderate Colitis

AnemiaAnemia

MalnutritionMalnutrition

15% Severe Colitis15% Severe Colitis Toxic MegacolonToxic Megacolon

PerforationPerforation

SepsisSepsis

Crohn'sCrohn's

NonNon--Bloody DiarrheaBloody Diarrhea

Abdominal PainAbdominal Pain

Weight LossWeight Loss

1010--20% Appendicitis20% Appendicitis

2525--50% Peri50% Peri--AnalAnal

DiseaseDisease StrictureStricture--ObstructionObstruction

Fistula with AbscessFistula with Abscess

Can mimic AppendicitisCan mimic Appendicitis


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CrohnsCrohns


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ExtraExtra--Intestinal FindingsIntestinal Findings((Either DiseaseEither Disease))

CutaneousCutaneous PyodermaPyoderma

gangrenosumgangrenosum

Erythema nodosumErythema nodosum

OcularOcular ConjunctivitisConjunctivitis

EpiscleritisEpiscleritis

UveitisUveitis

IritisIritis

IridocyclitisIridocyclitis

MusculoskeletalMusculoskeletal

ArthritisArthritis

AnkylosingAnkylosing

SpondilitisSpondilitis BiliaryBiliary

Primary SclerosingPrimary Sclerosing

CholangitisCholangitis

All except Biliary can improve in Ulcerative Colitis

once the Colon is removed


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Pyoderma GangrenosumPyoderma Gangrenosum


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Erythema Nodosum


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Conjunctivitis

EpiscleritisUveitis

Iritis

Iridocyclitis


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Ankylosing Spondylitis


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Primary SclerosingPrimary Sclerosing

CholangitisCholangitis


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EtiologyEtiology

Ulcerative Colitis & Crohn'sUlcerative Colitis & Crohn's

InfectionInfection

Immune (auto?)Immune (auto?)

GeneticGenetic

Environmental factorsEnvironmental factors

No one really knows for sureNo one really knows for sure


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Bacteria & VirusesBacteria & Viruses


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DNA Repair and Class II MHC Genes

99--10% of UC patients have an affected family member10% of UC patients have an affected family member


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Immune dysfunctionImmune dysfunction

in the bowel wallin the bowel wall

InappropriateInappropriate

cytokine productioncytokine production


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PathologyPathology


ContinuousContinuous

Rectum toRectum toCecumCecum

MucosalMucosal

Crypt AbscessesCrypt Abscesses

Lead pipeLead pipe

PseudopolypsPseudopolyps

Crohn'sCrohn's

DiscontinuousDiscontinuous

TransmuralTransmural

Skip LesionsSkip Lesions-- LipsLips

to Anusto Anus

GranulomasGranulomas

Creeping fatCreeping fat

CobblestoneCobblestone

Fistulas, StricturesFistulas, Strictures


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RectumCecum


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CrohnsCrohns


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Crohn's strictureCrohn's stricture


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Crohn's Colon UlcerCrohn's Colon Ulcer


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Crohn's EnterocolonicCrohn's EnterocolonicFistulaFistula


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Crohn'sCrohn's

stricture withstricture with

obstructionobstruction


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Crohn's skip lesionsCrohn's skip lesions



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The Workup of IBDThe Workup of IBD


HistoryHistory

ColonoscopyColonoscopy

BiopsyBiopsy

SBFTSBFT

CT ScanCT Scan

Crohn'sCrohn's

HistoryHistory


BiopsyBiopsy

SBFTSBFT CT ScanCT Scan

Pill Cam?Pill Cam?


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Ulcerative Colitis:Ulcerative Colitis:

PseudopolypsPseudopolyps


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Chrons: Severe UlcersChrons: Severe Ulcers


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SBFTSBFT


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Crohn's: Stricture/ObstructionCrohn's: Stricture/Obstruction


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Crohn's: Stricture


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Crohn's: Entero-Colonic

Fistula


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CAT ScanCAT Scan


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Crohns: CT appearanceCrohns: CT appearance


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Ulcerative Colitis: Pneumatosis IntestinalisUlcerative Colitis: Pneumatosis Intestinalis

in toxic Megacolonin toxic Megacolon


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TreatmentTreatment

MedicalMedical

Similar for both diseasesSimilar for both diseases

SurgicalSurgical

Can provide a cure for UCCan provide a cure for UC

Only palliative for CrohnsOnly palliative for Crohns


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Medical TherapyMedical Therapy

UCUC 55--ASAASA

SteroidsSteroids

AntibioticsAntibiotics

ChemotherapyChemotherapy

AzathioprineAzathioprine

CyclosporineCyclosporine

MethotrexateMethotrexate Biologics?Biologics?

RemicadeRemicade

Crohn'sCrohn's 55--ASAASA

SteroidsSteroids

BedesonideBedesonide ChemotherapyChemotherapy

AzathioprineAzathioprine

CyclosporineCyclosporine

MethotrexateMethotrexate FlagylFlagyl

BiologicsBiologics

InfliximabInfliximab


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55--ASA MedsASA Meds

Similar to aspirinoral and intraluminal


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SteroidsSteroids

AntiAnti--inflammatory activityinflammatory activity----oral and intraluminaloral and intraluminal


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Antibiotics/AntiviralsAntibiotics/Antivirals

Uncertain role in both diseasesUncertain role in both diseases


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ChemotherapyChemotherapy

ImmunosuppressiveImmunosuppressive effects


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BiologicsBiologics

TargetedImmune Modulation TherapyTargetedImmune Modulation Therapy


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Surgery in UCSurgery in UC

CurativeCurative Disease confined to ColorectalDisease confined to Colorectal

mucosamucosa

IndicationsIndications Failure of Medical TherapyFailure of Medical Therapy

Eliminate cancer riskEliminate cancer risk

Improve extracolonic diseaseImprove extracolonic disease Total ProctoTotal Procto--ColectomyColectomy

Anastomosis vs StomaAnastomosis vs Stoma


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Total ProctocolectomyTotal Proctocolectomy

No stoma, temporary stoma, permanent stomaNo stoma, temporary stoma, permanent stoma


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End IleostomyEnd Ileostomy


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JJ--Pouch ReconstructionPouch Reconstruction


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JJ--Pouch ReconstructionPouch Reconstruction


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Surgery in CrohnsSurgery in Crohns

Treat complications and symptomsTreat complications and symptoms

IndicationsIndications

Obstruction, fistula, abscess, bleedingObstruction, fistula, abscess, bleeding

LongLong--term pancolitis (cancer risk)term pancolitis (cancer risk)

OperationsOperations

Stricturoplasty, resection, bypass,Stricturoplasty, resection, bypass,

drainagedrainage

Guiding principle: Preserve BowelGuiding principle: Preserve Bowel

LengthLength


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Surgery in CrohnsSurgery in Crohns

Recurrent DiseaseRecurrent Disease

60% @ 5y60% @ 5y

95% @ 20y95% @ 20y

Need for more SurgeryNeed for more Surgery

20% @5y20% @5y

33% @10y33% @10y

50% @20y50% @20y


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Take Home PointsTake Home Points


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PresentationPresentation

Ulcerative ColitisUlcerative Colitis Bloody DiarrheaBloody Diarrhea

No PeriNo Peri--Anal diseaseAnal disease

Toxic MegacolonToxic Megacolon

CrohnsCrohns

Non Bloody DiarrheaNon Bloody Diarrhea Abdominal pain/obstructionAbdominal pain/obstruction

PeriPeri--Anal diseaseAnal disease


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PathologyPathology


Continuous; Rectum to CecumContinuous; Rectum to Cecum

Confined to mucosaConfined to mucosa

CrohnsCrohns

Discontinuous; Small BowelDiscontinuous; Small Bowel

Full thicknessFull thickness


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WorkupWorkup

Both UC and CrohnsBoth UC and Crohns

H & PH & P

Colonoscopy, BiopsyColonoscopy, Biopsy

Small Bowel follow throughSmall Bowel follow through

CT ScanCT Scan


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TreatmentTreatment


Medical TherapyMedical Therapy

Surgery is curativeSurgery is curative

CrohnsCrohns

Surgery for complications onlySurgery for complications only

Preserve Bowel lengthPreserve Bowel length


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Thank You.Thank You.

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