powerpoint: chronic inflammatory disordes
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CHRONIC INFLAMMATORY DISORDES OF THE BOWEL
IBD- ETIOLOGY
IBD: ulcerative colitis and Crohns
Etiology ? obscure: separated diseases or different facets of the same disease
IBD- ETIOLOGY
Chronic inflammation of the bowel wall- diarrhea
Dietary factors, infective agents and autoimmunity- proposed in the etiology of IBD.
ULCERATIVE COLITIS ACUTE INFLAMMATORY ATTACK
Loose blood-stained stools streaked with mucus Severe diarrhea- 20 loose stools/day The urge to defecate is the worst sy. Dehydration, electrolyte disturbances Anemia due to blood loss Progressive dilatation- paralytic colon
TOXIC MEGACOLONHigh fever, tachycardia, hypotension Dehydration, severe anemia Plain abdo.X ray- colon diameter>6 cm. indicates imminent perforation Instant barium enema- if diagnosis is in doubt, colonoscopy is CI. Severe distension- perforation- fecal peritonitis EMERGENCY TOTAL COLECTOMY
ULCERATIVE COLITIS CLINICAL FEATURES
Intestinal symptoms
Extraintestinal symptoms Concomitant diseases
Diarrhea with blood, mucus and pus Abdominal pain, tenesmus, cramps Tenderness mostly in the LIF Anemia, fever, weight loss Arthritis, erythema nodosum, eye sy. Primary sclerosing cholangitis Secondary amyloidosis Ankylosing spondylitis
CLINICAL SEVERITY OF THE ATTACK- UC
Mild attack Mild diarrhea < 4/day, blood and mucus No fever, no tachycardia, no anemia
Moderate attack 5-8 motions/day
Severe attack > 8 motions/day Blood loss- anemia, hb.< 10g/dl Fever, tachycardia
PLAIN ABDO-X RAY GROSSLY DISTENDED COLON
TOXIC MEGACOLON
TOXIC MEGACOLON
BARIUM ENEMA- ULCERATIVE COLITIS: the haustral pattern is lost, irregular mucosa thickening and deep ulcers
BARIUM ENEMA- UC : stenosis of the ascending and transverse colon, lost of haustral pattern
BARIUM ENEMA-UC: narrowed bowel, haustral pattern lost, mucosa irregularly thickened and ill-defined
TOXIC MEGACOLON INTRAOPERATIVE VIEW
ULCERATIVE COLITIS MULTIPLE BLEEDING ULCERS
UC- red mucosa, the tendancy for the inflammed tissue to throw itself up into inflammatory pseudopolyps
TOTAL COLECTOMY DONE FOR CLINICALLY SEVERE INTRACTABLE CHRONIC ULCERATIVE COLITISMULTIPLE INFLAMMATORY PSEUDOPOLYPS
Laboratory findings ulcerative colitis
Disease activity ESR,WBC, HB, Total protein Orosomucoid, C-reactive protein
Deficiencies Albumin Hb. Iron, electrolyte abnormalities
Exclusion of infectious causes Stool culture Mucosa biopsy
ULCERATIVE COLITIS COMPLICATIONS
PERFORATION AND PERITONITIS TOXIC MEGACOLON RESISTANCE TO MEDICAL THERAPY DEVELOPMENT OF COLORECTAL CANCER: LONG STANDING UC>10 YEARS INVOLVEMENT OF THE WHOLE COLON PRESENCE OF SEVERE DYSPLASIA
ULCERATIVE COLITIS RADIOLOGICAL FINDINGS
Diffuse granularity of mucosa Deep and undermining ulcers Loss of normal haustral pattern Tubular appearance Pseudopolyps
ENDOSCOPY ULCERATIVE COLITIS
Acute attack Diffuse erythema Granularity and friability of the mucosa Hemorrhage, mucus, pus Shallow, confluent ulceration Pseudopolyps
Inactive stage Pale, red atrophic mucosa Sporadic pseudopolyps
SIGMOIDOSCOPIC GRADING OF MUCOSAL APPEARANCES IN U C
Grade I- normal mucosa Grade II- hyperemic mucosa Grade III- bleeding on light contact or spontaneously Grade IV- severe change with an excess of mucus, pus, mucosal hemorrhage and ulcers
ULCERATIVE COLITIS MANAGEMENT
The choice of treatment depends on: The severity of attacks The amount of colon involved The extent of chronic symptoms The risk of long-term complications
ULCERATIVE COLITIS TREATMENT
Local corticosteroids preparations Systemic corticosteroids Oral sulphasalazine Anti-diarrheal agents: codeine phosphate or loperamide and bulking agents, methylcelulose- reduce stool frequency High protein diet, oral iron drugs Surgical removal
MEDICAL THERAPY OF THE ACUTE ATTACK- U C
Mild attack Mesalazina(5-ASA) 2g/day, pills/sup.
Moderate attack PDN 60mg/day, 5-ASA
Severe attack IV nutrition, fluids, blood transfusion IV steroids 5-ASA Broad spectrum antibiotics
ULCERATIVE COLITIS SURGERY
Required in 20% of pts. with UC Fulminant cases- urgent colectomy Toxic megacolon Hemorrhage Perforation
Malignant change Chronic disabling symptoms: Intractable diarrhea with urgency, Failure to maintain adequate nutrition
ULCERATIVE COLITIS SURGERY
Proctocolectomy with ileostomy Colectomy+ ileo-rectal anastomosis Need for long-life annual endoscopic examination of the remnant rectum
Total colectomy, mucosal proctectomy, ileoanal anastomosis
CROHNS DISEASE
Chronic relapsing inflammatory disease of the GI tract Potentially affects any part of the tract, usually affects the small bowel Terminal ileum is most commonly affected- terminal ileitis May affect one or more GI segments with intervening parts completely spared
CROHNS DISEASE
Large bowel is affected in at least 25% of cases, either alone or in association with disease elsewhere May affect the perineal region With each exacerbation, old or new areas may become involved
PATHOPHYSIOLOGY CROHNS DISEASE
Inflammation extends diffusely through the entire thickness of the bowel wall. The wall becomes grossly thickened by inflammatory edema The epithelium remains largely intact but is criss-crossed by deep fissured ulcers- cobblestone surface appearance
PATHOPHYSIOLOGY CROHNS DISEASE
Granulomas containing multinucleate giant cells are scattered througout the inflammed bowel wall Granulomas are diagnostic feature Longstanding inflammation leads to progressive fibrosis of the thickened bowel wall- elongated strictures
EFFECTS OF MUCOSAL INFLAMMATION
Diarrhea streaked with mucus and blood if the colon is involved Luminal narrowing- partial obstruction- grumbling and colicky abdominal pain Pain is the predominant feature in Crohns disease
BARIUM FOLLOW THROUGH SMOOTH NARROWING OF THE TERMINAL ILEUM
CROHNS DISEASE
CROHNS DISEASE
COLONIC CROHNS DISEASE ENDOSCOPIC VIEW
COLONIC CROHNS DISEASE COBBLESTONING
EFFECTS OF MUCOSAL INFLAMMATION
Extensive disease- malabsorbtion: protein malnutrition, iron and folate vit.B12 deficiency, anemia and diarrhea In kids- marked growth retardation Diminished recirculation of bile saltsgall stone formation
EFFECTS OF TRANSMURAL INFLAMMATION
Transmural inflammation may progress to surrounding structures Inflammation of parietal peritoneumlocalized peritonitis Tough, fibrotic postinflammatory adhesions Localized abscess formation- free perforation is rare
EFFECTS OF TRANSMURAL INFLAMMATION
Fistulas may develop: Gastro-colic fistula- fecal vomiting Ileo-rectal fistula- diarrhea Entero-vesical fistula- severe UTI, pneumaturia Entero-vaginal fistula- vaginal passage of feces Entero-cutaneous fistula
BARIUM ENEMA COLO-INTESTINAL CROHNS FISTULA
PERIANAL INFLAMMATION
Common in Crohns disease Recurrent perianal abscesses Characteristic bluish, boggy piles Anal fissures
PERIANAL CROHNS DISEASE
SYSTEMIC FEATURES
Non-gastrointestinal manifestations: Arthropathy Eye disorders Skin lesions
EXTRADIGESTIVE SIGNS- IBD
PERIANAL INFLAMMATION
Multiple fistulae commonly develop between rectum and perianal skinpepper pot perineum Paradoxically, this is more common associated with small bowel disease than colorectal disease
CLINICAL PICTURE
Abdominal pain Weight loss General malaise Diarrhea is less distressing and less likely to contain blood Generalized wasting and anemia Tenderness, inflammatory mass, scars from previous surgery
CLINICAL PICTURE
Perineal and rectal examination
Rectoscopy
DIFFERENTIAL DIAGNOSIS ULCERATIVE COLITIS
Infectious colitis: salmonella, shigella, clostridium difficile Crohns disease of the colon Ischemic colitis Radiation colitis Malignancy of the colon
APPROACH TO INVESTIGATION
USS of the abdomen Isotope scan. indium-labelled WBC Barium enema Barium follow-through Videocapsule endoscope
CROHNS DISEASE MANAGEMENT
Corticosteroids Metronidazol- perianal disease Elemental diets TPN with complete bowel rest Sulphasalazine Anti-diarrheal drugs
CROHNS DISEASE SURGICAL MANAGEMENT
INDICATIONS: Acute exacerbation unresponsive to steroids Acute complications:abscess, perforation, major hemorrhage Intolerable long-term symptoms Entero-cutaneous or internal fistulas
CROHNS DISEASE SURGICAL MANAGEMENT
Resection of the diseased segment Panproctocolectomy with ileostomy Abscess drainage with resection Fistulectomies
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