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