inflammatory bowel disease. inflammatory bowel disease (ibd) ulcerative colitis and crohn's...
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Inflammatory Bowel Disease
Inflammatory Bowel Disease (IBD) Ulcerative colitis and Crohn's disease
• Chronic inflammatory diseases of the gastrointestinal tract
• No single finding is diagnostic for these diseases
• Epidemiological, clinical, laboratory, imaging and pathological characteristics
• Some patients have a clinical picture that falls between the two diseases
Case
• 23 y old female with 6 weeks diarrhea• Liquid stools no blood• Bowel movement at night• Colicky abdominal pain• Fever to 38°C• Loss of appetite• Weight loss 6 kilograms
Case
• Red painful nodules on the lower leg
• Painful knee and wrist joints
• Previous history of a perianal abcess
• Smokes 20 cigarettes a day for 5 years
• Brother with Crohn’s disease
Questions
1. Does the patient have inflammatory bowel disease?
2. How do we diagnose it?
3. How do we treat the patient?
Differential DiagnosisSmall Intestine
• Infections • Malabsorption• Lymphoma• Ulcerative jejenoileitis• Tuberculosis• NSAID enteropathy• Ischemic bowel
– etiology– epidemiological, – clinical, – laboratory, – imaging– pathology
Differential DiagnosisColon
• Infection• Pseudomembranous
colitis• Radiation colitis• Ischemic colitis• Microscopic colitis
– etiology– epidemiological– clinical– laboratory– imaging– pathology
Diagnosis – Building the Picture
Epidemiology
Clinical
Laboratory
Imaging
Pathology
Response to treatment
IBD
Epidemiology IBD
Epidemiology
• 23 y old
• Female
• Jewish
• Smoker
• Brother with Crohn’s
Cause(s) of IBD
• Genetic• Infection• Immunological
Genetic Influence
GEOGRAPHICAL PREVALENCE OF IBD
Epidemiology
Clinical
IBD
Symptoms
• Diarrhea ± mucus, blood• Abdominal pain• Fever• Loss of appetite• Weight loss• Tiredness and weakness
Symptoms (continued)
• Joint pains, arthritis
• Mouth ulcers
• Skin rash – erythema nodosum
• Perianal abscesses and fistuli
• Eye inflammation
Epidemiology
Clinical
Laboratory
IBD
Laboratory
• Infection – stool microscopy and culture
• Malabsorption – stool fat (>6g/day)
• Inflammation – – Erythrocyte sedimentation rate, CRP– Anemia: iron deficiency, Vit B12 deficiency,
anemia of chronic disease,
• Nutrition – low albumin
p-ANCA and ASCA in IBD
Epidemiology
Clinical
Laboratory
Imaging
IBD
IBD and Imaging
• Is there inflammation in the digestive tract?– If not – are there any other relevant processes
• What is the distribution of the inflammation?
• What are the characteristics of the inflammation?
• Take biopsies during imaging?
Small Intestine and Colon • Duodenum (60 cm long)
– shortest and widest; • Jejunum (2.5 m long)
– most of digestion & absorption• Ileum (longest at 3.5 m)
– water and electrolyte absorption– ends at ileocecal valve
• Colon (1.5 m long)– water and electrolyte absorption
Differences Between UC and Crohn’s Disease
Characteristic Features of Ulcerative Colitis
Crohn’s DiseaseAnatomic Distribution
Crohn’s DiseaseConsequences of Transmural
Inflammation
• Inflammatory masses• Fistuli• Intestinal obstruction• Perforation
Ulcerative Colitis-Imaging Modalities
Colon:
• Plain abdominal X-ray
• Colonoscopy
• Barium enema
• (CT)
Ulcerative Colitis
Colon:• Plain
abdominal X-ray
• Colonoscopy• Barium enema• (CT)
Normal Barium Enema
Colon:• Plain abdominal X-ray• Colonoscopy• Barium enema• (CT)
Ulcerative Colitis
BENIGN STRICTURE
Ulcerative Colitis
Colon:• Plain abdominal X-
ray• Colonoscopy• Barium enema• (CT)
Crohn’s Disease Imaging modalities
• Barium studies– Small bowel follow through and enteroclysis– Barium enema
• Endoscopy– Ileoscopy at colonoscopy– Upper GI endoscopy and enteroscopy
• CT• Ultrasound• Isotope scan• Capsule endoscopy
X-ray Appearance of Crohn’s Disease
• Barium studies– Small bowel follow through
and enteroclysis– Barium enema
• Endoscopy– Ileoscopy at colonoscopy– Upper GI endoscopy and
enteroscopy• CT• Ultrasound• Isotope scan• Capsule endoscopy
Mesenteric Involvement
Jejenitis
Gastro-duodenitis
Crohn’s Colitis
Early Crohn’s Disease-Terminal Ileum
• Barium studies– Small bowel follow through and
enteroclysis– Barium enema
• Endoscopy– Ileoscopy and colonoscopy– Upper GI endoscopy and
enteroscopy• CT• Ultrasound• Isotope scan• Capsule endoscopy
Crohn’s Colitis
Crohn’s Disease
UC
Crohn’s Disease - Enteroscopy• Barium studies
– Small bowel follow through and enteroclysis
– Barium enema• Endoscopy
– Ileoscopy at colonoscopy– Upper GI endoscopy and
enteroscopy• CT• Ultrasound• Isotope scan• Capsule endoscopy
Crohn’s Disease
• Small bowel follow through and enteroclysis – barium
• Ileoscopy at colonoscopy• Upper GI endoscopy and
enteroscopy• CT• Ultrasound• Isotope scan• Capsule endoscopy
Crohn’s Disease - CT
Crohn’s Disease
• Small bowel follow through and enteroclysis – barium
• Ileoscopy at colonoscopy• Upper GI endoscopy and
enteroscopy• CT• Ultrasound• Isotope scan• Capsule endoscopy
Video Capsule Endoscopy in IBD
• 17 patients with suspected CD not diagnosable by conventional methods
• Iron deficiency anemia (9), abdominal pain (8), diarrhea (7), weight loss (3)
• 12 (70.6%) patients diagnosed as Crohn’s
• Mean duration of symptoms 7.4 years
Fireman et al
Epidemiology
Clinical
Laboratory
Imaging
Pathology
IBD
Differences Between UC and Crohn’s Disease
Ulcerative colitis and Crohn’s disease
UC• Mucosal disease
Crohn’s Disease• Transmural
inflammation
Crohn’s Disease-Serosal View
Removed Colon
UC Crohn’s
Distinguishing Features of Crohn’s Disease
Colorectal Cancer and IBD
RISK OF COLORECTAL CANCER
FACTORS MODIFYING RISK OF COLITIS-ASSOCIATED
CANCER
COLONOSCOPIC SURVEILLANCE FOR
DYSPLASIA
Extraintestinal Manifestations
Erythema nodosumAphthous ulcer
Iritis
Crohn’s Perianal Disease
PERIPHERAL ARTHRITIS
Osteopenia
Skin LesionsErythema Nodosum Pyoderma Gangrenosum
SCLEROSING CHOLANGITIS
Primary Sclerosing Cholangitis
Sclerosing Cholangitis- MR Cholangiography (MRCP)
IBD in Kibbutzim Crohn’s Disease UC
25.5/100,000 in 1987 to
65.1/100,000 in 1997
121/100,000 in 1987 to
167/100,000 in 1997
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