11 imm - lower gi disorders

8/18/2019 11 IMM - Lower GI Disorders

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Inflamatory #owel DiseaseInflamatory #owel Disease

-- An immune mediated chronic intestinal condition An immune mediated chronic intestinal condition

- Types : 1. Ulcerative Colitis- Types : 1. Ulcerative Colitis

. Crohns Disease . Crohns Disease

!. Intermediate Colitis !. Intermediate Colitis


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$pidemiology$pidemiology

-- Incidence varies within di""erent #eo#raphic area.Incidence varies within di""erent #eo#raphic area.

- In U$A : UC % to 1&%!'1((.(((- In U$A : UC % to 1&%!'1((.(((

CD !%1 to 1&%)'1((.((( CD !%1 to 1&%)'1((.(((

- *$C+ ((1-(() : I,D %!- *$C+ ((1-(() : I,D %!

- /asan $adi0in (( : I,D 2%2- /asan $adi0in (( : I,D 2%2

- $ar3ito (( : I,D &%&- $ar3ito (( : I,D &%&

- The pea0 a#e o" onset : 14 and !( year - The pea0 a#e o" onset : 14 and !( year - The second pea0 occur : )( and ( year - The second pea0 occur : )( and ( year

- *atio male to "emale : UC 1 : 1- *atio male to "emale : UC 1 : 1

CD 1%1 : 1 CD 1%1 : 1


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$tiology-%at&ogenesis$tiology-%at&ogenesis

-- Until now the etiolo#y is unclear.Until now the etiolo#y is unclear.- ,asic concept o" I,D- ,asic concept o" I,D

Genetic Direct Dama#e Genetic Direct Dama#e

5nviroment autoimun% viral% 5nviroment autoimun% viral% 6acteria% protein 6acteria% protein

Cascade Cell Lym"ositCascade Cell Lym"osit

In"lamationIn"lamation

7rotease netro"il sito0in7rotease netro"il sito0in

Leu0otrinLeu0otrin

macro"a#macro"a#


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'linical Features'linical Features

- +ayor symptoms : chronic diarrhea with or- +ayor symptoms : chronic diarrhea with orwithout 6lood% a6dominal pain% tenesmus.without 6lood% a6dominal pain% tenesmus.

- 58tra intestinal mani"estation : artritis% uveitis%- 58tra intestinal mani"estation : artritis% uveitis%

pioderma #an#renosum% eritema nodosumpioderma #an#renosum% eritema nodosum

- $ymptoms correlated with the e8tend o" disease.- $ymptoms correlated with the e8tend o" disease.

- Clinical mani"estations o" UC are simple than CD- Clinical mani"estations o" UC are simple than CD

- UC : colon.- UC : colon.

CD : mouth to anorectal. CD : mouth to anorectal.


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Manifestation Of I#DManifestation Of I#D

1. Acute phase1. Acute phase

. *emision 7hase. *emision 7hase!. 58acer6ation!. 58acer6ation

Use : Disease Activity Inde8Use : Disease Activity Inde8


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'linical Manifestation Of I#D'linical Manifestation Of I#D

Clinic UC CDClinic UC CD

Chronic Diarrhea 99 99Chronic Diarrhea 99 99

/ematoscheia 99 9/ematoscheia 99 9 A6dominal 7ain 9 99 A6dominal 7ain 9 99

A6dominal +ass - 99 A6dominal +ass - 99

;istul 9'- 99;istul 9'- 99

$tenosis 9 99$tenosis 9 99

Intestine involved 9'- 99Intestine involved 9'- 99

*ectal involved 24 4(*ectal involved 24 4(

58traintestinal 9 958traintestinal 9 9

+e#acolon to8ic 9 9'-+e#acolon to8ic 9 9'-


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%at&ology of I#D%at&ology of I#D

7atholo#y UC CD7atholo#y UC CD

$e#mental lesion - 99$e#mental lesion - 99Transmural lesion 9'- 9'99Transmural lesion 9'- 9'99

Granuloma - 4(Granuloma - 4(

;i6rosis 9 99;i6rosis 9 99

;istula 9'- 99;istula 9'- 99 Anatomy predilection Anatomy predilection

- ileocaecal 9'- 99- ileocaecal 9'- 99

- rectal 99 9'-- rectal 99 9'-


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'omplication'omplication

Ulcerative Colitis :Ulcerative Colitis :- To8ic me#acolon- To8ic me#acolon

- $tricture- $tricture

- Anal "issure- Anal "issure

- 7erianal a6ses- 7erianal a6ses- +ali#nancy- +ali#nancy

Chrons Disease :Chrons Disease :

- 7er"oration- 7er"oration

- Intraa6dominal or pelvic A6scess- Intraa6dominal or pelvic A6scess

- Intestinal o6struction- Intestinal o6struction

- +assive haemorha#e- +assive haemorha#e-- +ala6sor6tion


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normal colonnormal colon


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Ulcerative ColitisUlcerative Colitis


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Ulcerative colitisUlcerative colitis


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Crohns diseaseCrohns disease


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Crohns diseaseCrohns disease


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Crohns DiseaseCrohns Disease


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Management of I#DManagement of I#D

1. Dia#nostic1. Dia#nostic

. Therapeutic. Therapeutic

!. 5ducational!. 5ducational

&. +ana#ement in primer health care&. +ana#ement in primer health care


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(.Diagnostic(.Diagnostic

1.1 La6oratory1.1 La6oratory- not spesi"ic- not spesi"ic

- a6normality o" /6% leucosit% L5D% trom6osit% C*7%- a6normality o" /6% leucosit% L5D% trom6osit% C*7%

"e serum."e serum.

- to evaluated severity o" disease and nutrition- to evaluated severity o" disease and nutritionstatus.status.

1. *adiolo#y1. *adiolo#y

- Dou6le contras 6arium show stricture lesion%- Dou6le contras 6arium show stricture lesion%

"istul% ulcer% polyp% irre#ular mucosa"istul% ulcer% polyp% irre#ular mucosa

- Contraindication "or severe UC- Contraindication "or severe UC


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1.! 5ndoscopy1.! 5ndoscopy- Important role "or dia#nostic and treatment o" I,D.- Important role "or dia#nostic and treatment o" I,D.

- Acuracy : 2- Acuracy : 2

1.& /istopatolo#y1.& /istopatolo#y- UC : crypti a6scess% crypti dilatation% +n- UC : crypti a6scess% crypti dilatation% +n

in"iltration% 7mn in"iltration.in"iltration% 7mn in"iltration.

- CD : #ranulomatous% macro"a# and lym"osit- CD : #ranulomatous% macro"a# and lym"osit

in"iltration.in"iltration.


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$ndoscopy %attern of I#D$ndoscopy %attern of I#D

UC CDUC CD In"lamationIn"lamationContinues 999 9Continues 999 9

$0ip area - 999$0ip area - 999

*ectal involved 999 9*ectal involved 999 9

Co66lestone appearance 9 999Co66lestone appearance 9 999

Ulcer Ulcer

In in"lamation area 999 9In in"lamation area 999 9

Ileum involved - 999Ileum involved - 999

Discreate 9 999Discreate 9 999

Diameter


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%at&way of Diagnostic %rocess of%at&way of Diagnostic %rocess of

I#DI#D

Anamnesis Anamnesis /istory o" illness /istory o" illness

5valuation5valuation clinical illness 7hysical e8amination clinical illness 7hysical e8amination

*adiolo#y*adiolo#yColonoscopy La6oratory Colonoscopy La6oratory

/istopatolo#y D7L% L5D% C*7% ;eces% C5A /istopatolo#y D7L% L5D% C*7% ;eces% C5A


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. )&erapeutic. )&erapeutic

.1 Active in"lamation.1 Active in"lamation

- Corticosteroid% prednison &(-)(m#'day- Corticosteroid% prednison &(-)(m#'day metilprednisolon (%4 = 1m#'6w metilprednisolon (%4 = 1m#'6w

- Taperin# o" -1 wee0s- Taperin# o" -1 wee0s

- 4 A$A : -& #r'day- 4 A$A : -& #r'day com6ined sul"apiridin and aminosalisilat com6ined sul"apiridin and aminosalisilat

remision > 1)- & wee0s remision > 1)- & wee0s

prevent colonrectal cancer prevent colonrectal cancer


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. *ecurance in"lamation. *ecurance in"lamation

1. 4 A$A'mesalaine1. 4 A$A'mesalaine

+aintanance dose : 1%4 = ! #r'day +aintanance dose : 1%4 = ! #r'day

"or descenden colon to rectosi#moid : "or descenden colon to rectosi#moid :

suppositoria-enema. suppositoria-enema.

. Imunosupresiv. Imunosupresiv

- +etrote8ate - +etrote8ate - Aathioprine - Aathioprine

- ) +ercaptopurine - ) +ercaptopurine

- Cyclosporine - Cyclosporine


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%at&way of managemant I#D in%at&way of managemant I#D in

primary &ealt& careprimary &ealt& care

Anamnesis and physical e8amination Anamnesis and physical e8amination suspected I,D suspected I,D

General Treatment General Treatment

maintenance not response re"er maintenance not response re"er

4 A$A4 A$A

respons 4 A$A po 9 not respons respons 4 A$A po 9 not respons steroid steroid


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Irrita*le #owel SyndromeIrrita*le #owel Syndrome

- ;un#tional 6owel disease- ;un#tional 6owel disease

- A6dominal pain- A6dominal pain- Altered 6owel ha6it- Altered 6owel ha6it

- no a6normality- no a6normality

- ;re?uency : 1(-( in adult% "emale predominan- ;re?uency : 1(-( in adult% "emale predominan


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Diagnostic 'riteria for I#S +,ome IIIDiagnostic 'riteria for I#S +,ome III

*ecurrent a6dominal pain at least ! days per*ecurrent a6dominal pain at least ! days per

month in the last ! month assosiated with ormonth in the last ! month assosiated with or

more o" the "ollowin# :more o" the "ollowin# :

1. Improvement with de"ecation1. Improvement with de"ecation

. @nset assosiated with a chan#e in "re?uency o". @nset assosiated with a chan#e in "re?uency o"

stool.stool.!. @nset assosiated with a chan#e in "orm o" stool!. @nset assosiated with a chan#e in "orm o" stool


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)ypes of I#S)ypes of I#S1. 7ain type.1. 7ain type.

. Constipation type.. Constipation type.!. Diarrhea type.!. Diarrhea type.

&. Altered pattern&. Altered pattern


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1. A6dominal 7ain1. A6dominal 7ain

- prere?uest clinical "eature o" I,$- prere?uest clinical "eature o" I,$- varia6le in intensity and location- varia6le in intensity and location

- pain is e8acer6ated 6y eatin# or emotional stress- pain is e8acer6ated 6y eatin# or emotional stress

and improve 6y passa#e o" "latus or stool.and improve 6y passa#e o" "latus or stool.

- pain "re?uently episodic and cramp- pain "re?uently episodic and cramp

. Altered ,owel /a6it. Altered ,owel /a6it

- constipation- constipation

- diarrhea- diarrhea


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!. Gas and ;latulence!. Gas and ;latulence- a6dominal distention and increased 6elchin# or- a6dominal distention and increased 6elchin# or

"latulance."latulance.

- most patient have impaired transit and tolerance- most patient have impaired transit and tolerance

o" intestinal #as load.o" intestinal #as load.

&. Upper #astrointestinal $ymptoms&. Upper #astrointestinal $ymptoms

- 4 = 4( complain dyspepsia% heart6urn% nausea%- 4 = 4( complain dyspepsia% heart6urn% nausea%

vomitin#.vomitin#.


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Differential DiagnosticDifferential Diagnostic

- Lactulosa intolerance- Lactulosa intolerance

- Colonrectal cancer - Colonrectal cancer - In"lamatory 6owel disease- In"lamatory 6owel disease

- Diverticulitis- Diverticulitis

- Intestinal o6struction- Intestinal o6struction

- +ala6sor6tion- +ala6sor6tion


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)reatment)reatment

-- DietDiet- 7yscotherapy- 7yscotherapy- Antispasmodic : - /iosin 6util6romid !81(m#- Antispasmodic : - /iosin 6util6romid !81(m#

- +e6everin ! 8 1! m# - +e6everin ! 8 1! m#

- Alverine ! 8 !(m# - Alverine ! 8 !(m#- 4 /T & reseptor anta#onic : Te#eserod 8 )m#- 4 /T & reseptor anta#onic : Te#eserod 8 )m#

"or constipation type. "or constipation type.

- loperamide "or diarrhea type- loperamide "or diarrhea type


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'olon ,ectal )umor 'olon ,ectal )umor

Divided : - Colon Cancer Divided : - Colon Cancer

- 7olyp Colon - 7olyp Colon

%olyp 'olon%olyp 'olon

Grossly protrusion "rom the mucosal sur"ace.Grossly protrusion "rom the mucosal sur"ace.


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+acroscopic :+acroscopic :

- 7edunculated polyp- 7edunculated polyp

- $essile polyp- $essile polyp

+icroscopic :+icroscopic :

- non epithelial polyp : lim"oid% adiposa% intestine%- non epithelial polyp : lim"oid% adiposa% intestine%

- epithelial polyp- epithelial polyp

5pithelial polyp:5pithelial polyp:

1. Adenoma1. Adenoma

. /amartoma. /amartoma!. In"lamatory polyp!. In"lamatory polyp

&. /yperplastic polyp&. /yperplastic polyp


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Adenoma : Adenoma :

- tu6ular% villosa% tu6ulo-vilosa- tu6ular% villosa% tu6ulo-vilosa- trans"ormed to 6e mali#nant- trans"ormed to 6e mali#nant

- lar#e polyp to 6e mali#nant- lar#e polyp to 6e mali#nant

/amartoma/amartoma- mal"ormation- mal"ormation

- 3uvenile polyp% peut 3e#her syndrome.- 3uvenile polyp% peut 3e#her syndrome.

- not mali#nant- not mali#nant


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In"lamatory polypIn"lamatory polyp

- crohns diseasecrohns disease

- ulcerative colitisulcerative colitis

- ame6iasis- ame6iasis

- dysentri 6asiler - dysentri 6asiler - pedinculated- pedinculated

/yperplastic polyp/yperplastic polyp

- < &( years.- < &( years.- < rectal- < rectal

- multiple and sessile- multiple and sessile


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7edinculated polyp colon7edinculated polyp colon


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$essile polyp colon$essile polyp colon


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'olon 'a'olon 'a

$pidemiology$pidemiology

- +an : women : 12%& : 14%!'1((.(((.- +an : women : 12%& : 14%!'1((.(((.- Incidence hi#h : U$A% australia% 5urope- Incidence hi#h : U$A% australia% 5urope

- Increase a"ter 4( years- Increase a"ter 4( years

- $econd cause o" cancer death in U$A- $econd cause o" cancer death in U$A

- 14(.((( new cases each year - 14(.((( new cases each year


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$tiology$tiology

- comple8s interaction 6etween #enetic and- comple8s interaction 6etween #enetic and

environment "actorsenvironment "actors..

- environment "actors : macronutrient and- environment "actors : macronutrient andmicronutrient.micronutrient.

- #enetic "actors : - chromosom insta6ility- #enetic "actors : - chromosom insta6ility

- microsatelit insta6ility - microsatelit insta6ility


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Stage and prognosticStage and prognostic

$ta#e 7A $urvival 4 year $ta#e 7A $urvival 4 year

Du0es T+ ;aseDu0es T+ ;ase A T1(+( I su6mucosa


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'linical Manifestation'linical Manifestation

- < 4( years- < 4( years

- ,owel ha6it chan#e- ,owel ha6it chan#e

- /ematoscheia- /ematoscheia

- @6struction- @6struction- Local invasion : tenesmus% hematuria% uretra- Local invasion : tenesmus% hematuria% uretra

o6struction.o6struction.

- ;istul colon #aster - ;istul colon #aster

- Ascites- Ascites- A6dominal pain% icteric% portal hypertension.- A6dominal pain% icteric% portal hypertension.


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Distri*ution of colon rectal caDistri*ution of colon rectal ca

- *ectal : 41%4- *ectal : 41%4

- Descenden colon : 11%- Descenden colon : 11%

- *ectosi#moid : 2%- *ectosi#moid : 2%

- $i#moid : 2%- $i#moid : 2%

- Ascenden colon : %- Ascenden colon : %

- Tranversal colon : )%- Tranversal colon : )%- Caecum : 1%2- Caecum : 1%2


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DiagnosticDiagnostic

1. $ymptoms : hematoscheia% a6dominal pain%1. $ymptoms : hematoscheia% a6dominal pain%

decrease 6ody wei#ht% anemia% 6owel ha6itdecrease 6ody wei#ht% anemia% 6owel ha6it

chan#e.chan#e.. La6oratory : - anemia de"isiensi "e. La6oratory : - anemia de"isiensi "e

- occult 6lood in "eces - occult 6lood in "eces

!. *adiolo#y : dou6le contras enema 4(!. *adiolo#y : dou6le contras enema 4(

polyppolyp&. Colonoscopy : sensitivity 24&. Colonoscopy : sensitivity 24

spesi"ity 22spesi"ity 22

4. /istopatolo#y4. /istopatolo#y


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)reatment)reatment

- emoprevention : aspirin- emoprevention : aspirin

$AID $AID

- 7olypectomy : polyp adenomatous- 7olypectomy : polyp adenomatous

- /emicolectomy : caecum% ascenden colon%- /emicolectomy : caecum% ascenden colon%

transversum colon.transversum colon.

- Low anterior resection : rectosi#moid- Low anterior resection : rectosi#moid

- emotherapy : levamisol- emotherapy : levamisol

4 ;U 4 ;U


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Colon CaColon Ca


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Infection 'olitisInfection 'olitis

Colitis is acute or chronic in"lamation o" colon.Colitis is acute or chronic in"lamation o" colon.

Divided :Divided :

1. In"ection colitis : tu6erculosis colitis%1. In"ection colitis : tu6erculosis colitis%pseudomem6ran colitis% ame6iasis colitis%pseudomem6ran colitis% ame6iasis colitis%

. on in"ection colitis : ulcerative colitis% crohns. on in"ection colitis : ulcerative colitis% crohns

disease% ischemic colitis% radiation colitis% nondisease% ischemic colitis% radiation colitis% non

spesi"ic colitisspesi"ic colitis

) * l i ' liti)u*erculosis 'olitis


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)u*erculosis 'olitis)u*erculosis 'olitis

- Due to myco6acterium tu6erculosis- Due to myco6acterium tu6erculosis- /i#h "re?uency in #rowth country- /i#h "re?uency in #rowth country

%atogenesis%atogenesis

- +ost case caused 6y myco6acterium- +ost case caused 6y myco6acterium

tu6erculosis.tu6erculosis.

- Usually contac0 with sputum contains +- Usually contac0 with sputum contains +tu6erculosis.tu6erculosis.

- *elation 6etween hi#h "re?uency o" pulmonary- *elation 6etween hi#h "re?uency o" pulmonary

tu6erculosis and tu6erculosis colon.tu6erculosis and tu6erculosis colon.


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'linical Features'linical Features-- chronic a6dominal painchronic a6dominal pain- 6loody diarrhea- 6loody diarrhea

- constipation- constipation

- anore0sia- anore0sia- "ever - "ever

- decrease 6ody wei#ht- decrease 6ody wei#ht

- intra a6dominal mass- intra a6dominal mass


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- + tu6erculosis : 6iopsy or microscopic- + tu6erculosis : 6iopsy or microscopic

- 5nema : wall thic0ness% mucosa distorsion%- 5nema : wall thic0ness% mucosa distorsion%

ulseration% stenosis% mass% pseudopolyp.ulseration% stenosis% mass% pseudopolyp.- colonoscopy : - narrow lumen% ulceration% edema- colonoscopy : - narrow lumen% ulceration% edema

and irre#ular. and irre#ular.

- 6iopsy "or cultur and- 6iopsy "or cultur and

histopatolo#y. histopatolo#y.


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Differential DiagnosisDifferential Diagnosis

-- Crohns diseaseCrohns disease- Colon Ca- Colon Ca

- Ame6iasis- Ame6iasis

'omplication'omplication- ,leedin#% per"oration% o6struction% "istul%- ,leedin#% per"oration% o6struction% "istul%

mala6sor6tion.mala6sor6tion.

- @6struction !(E.- @6struction !(E.


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)reatment)reatment-- I/ 4 -1( m#'6wI/ 4 -1( m#'6w- 5tam6utol 14-4 m#'6w- 5tam6utol 14-4 m#'6w

- *i"am"icin 1(m#'6w- *i"am"icin 1(m#'6w- 7yrainamide 4-!4 m#'6w- 7yrainamide 4-!4 m#'6w

$ur#ery i" there is complication$ur#ery i" there is complication

'% d * ' liti


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%seudomem*ran 'olitis%seudomem*ran 'olitis

- colon in"lamation caused 6y to8in- colon in"lamation caused 6y to8in- "ormed pseudomem6ran in mucosa sur"ace.- "ormed pseudomem6ran in mucosa sur"ace.

$tiology$tiology

- complication a"ter use anti6iotic- complication a"ter use anti6iotic

- clostridium di""icile as 6acteria induced.- clostridium di""icile as 6acteria induced.- supressed normal "lora colon- supressed normal "lora colon


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%atogenesis%atogenesis

- Clostridium di""icile- Clostridium di""icile cause colitis 6y to8incause colitis 6y to8in

mediatedmediated

- C di""icile produced 0inds to8in : A to8in and ,- C di""icile produced 0inds to8in : A to8in and ,

to8in.to8in.

- A to8in ma0es in"lamation.- A to8in ma0es in"lamation.


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- appear a"ter the "irst time anti6iotic use or a"ter )- appear a"ter the "irst time anti6iotic use or a"ter )

wee0s anti6iotic use.wee0s anti6iotic use.- diarrhea% a6dominal pain% "ever% edema%- diarrhea% a6dominal pain% "ever% edema%

hipoal6uminemia% leu0ositosis.hipoal6uminemia% leu0ositosis.

- severe : to8ic me#acolon% per"oration% electrolit- severe : to8ic me#acolon% per"oration% electrolit

im6alance%im6alance%


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- Diarrhea a"ter anti6iotic use- Diarrhea a"ter anti6iotic use

- Colonoscopy : pseudomem6ran 6iopsy- Colonoscopy : pseudomem6ran 6iopsy

- ;eces cultur : C di""icile 24.- ;eces cultur : C di""icile 24.- 5lisa : A to8in- 5lisa : A to8in

DD /DD /

Colitis non in"ectionColitis non in"ection


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7seudomem6ran Colitis7seudomem6ran Colitis


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Than0sThan0s

11 imm - lower gi disorders

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