Diseases of large and small intestine Lykhatska G.V.

IRRITABLE BOWEL SYNDROME -functional disorders,which characterized by abdominal pain, defecation disorders without specific organic pathology which last more than 12 weeks per year

Risk factors Violations on diet Violations on diet gynecological diseases gynecological diseases violation intestinal microbiocenosis violation intestinal microbiocenosis In the pathogenesis, the main role – In the pathogenesis, the main role – intestinal dysmotility and visceral hypersensitivity

Clinical features of IBS

Rome criteria for the diagnosis of IBS

IBS: SUMMARY

Treatment IBS Diet 4 and regimen Diet 4 and regimen Antidepressants(amitriptyline mg at bedtime) Antidepressants(amitriptyline mg at bedtime) Spasmolytic drugs (dyspatalin 200mg 2 times a day;ditsetel mg 3 times per day during 2- 4 weeks or more Spasmolytic drugs (dyspatalin 200mg 2 times a day;ditsetel mg 3 times per day during 2- 4 weeks or more Laxatives(mukofalk,laktuloza,forlaks)individually Laxatives(mukofalk,laktuloza,forlaks)individually Antidiarrhea drugs(loperamyd,smekta)individually Antidiarrhea drugs(loperamyd,smekta)individually Psychotherapy(hypnotherapy,acupuncture) Psychotherapy(hypnotherapy,acupuncture) Correction of bowel microflore injuries(probiotics-bifi-form,linex,symbiter) Correction of bowel microflore injuries(probiotics-bifi-form,linex,symbiter)

ULCERATIVE COLITIS

Etiology The cause of ulcerative colitis is unknown The cause of ulcerative colitis is unknown

Definition ULCERATIVE COLITIS - A chronic, inflammatory, and ulcerative disease arising in the colonic mucosa, characterized most often by bloody diarrhea ULCERATIVE COLITIS - A chronic, inflammatory, and ulcerative disease arising in the colonic mucosa, characterized most often by bloody diarrhea

ULCERATIVE COLITIS Clinical picture Bloody diarrhea Bloody diarrhea The stools may be watery, may contain mucus, and frequently consist almost entirely of blood and pus The stools may be watery, may contain mucus, and frequently consist almost entirely of blood and pus Abdominal pain Abdominal pain Fever Fever Anorexia Anorexia Weight loss Weight loss Malaise Malaise

The endoscopic spectrum of ULCERATIVE COLITIS includes a) mucosal edema, erythema, loss of vasculature; b) granular mucosa with pinpoint ulceration and friability; c) regenerated (i.e., healed) mucosa with distorted mucosal vasculature; d) regenerated mucosa with typical postinflammatory pseudopolyps

It’s air-contrast radiograph of ULCERATIVE COLITIS, the mucosal pattern is granular with loss of normal haustrations in a diffuse, continuous pattern

Double-contrast barium enema in a patient with Ulcerative Colitis. Total colitis and pseudopolyposis are present.

Ulcerative colitis on barium study

ULCERATIVE COLITIS Complications BleedingToxicmegacolonPerforationColon cancer cancer

ULCERATIVE COLITIS Extracolonic problems Peripheral arthritis Peripheral arthritis Ankylosing spondylitis Ankylosing spondylitis Sacroiliitis Sacroiliitis Anterior uveitis Anterior uveitis Erythema nodosum Erythema nodosum Pyoderma gangrenosum Pyoderma gangrenosum Episcleritis Episcleritis Primary sclerosing cholangitis Primary sclerosing cholangitis

Erythema nodosum on the skin

Erythema nodosum on the leg

Pyоderma gangrenosum seen in UC

Episcleritis in UC

Bilateral episcleritis

CLASSIFICATION OF ULCERATIVE COLITIS according to the degree of expressiveness of clinical manifestations CLASSIFICATION MILDCOURSESEVERECOURSEMODERATE COURSE COURSE

MILDCOURSEMODERATE SEVERECOURSE Defecation frequency <4>6>10 BleedingmildprofuseContinuous Fever- >37,5 ˚C >38,8 ˚C Hemoglobi n g/l >100<100<80 ESR, mm/hour <30>30>50 Albumin, g/l Norm30-40<30

DIFFERENTIAL DIAGNOSIS Crohn's Disease Ulcerative Colitis Small bowel is involved in 80% of cases Disease is confined to the colon. Rectosigmoid is often spared; colonic involvement is usually right-sided. Rectosigmoid is invariably involved; colonic involvement is usually left- sided. Gross rectal bleeding is absent in 15-25% of cases. Gross rectal bleeding is always present. Fistula, mass, and abscess development is common. Fistulas do not occur. Perianal lesions are significant in 25-35%. Significant perianal lesions never occur.

DIFFERENTIAL DIAGNOSIS Crohn's Disease Ulcerative Colitis On x-ray, bowel wall is affected asymmetrically and segmentally, with "skip areas" between diseased segments. Bowel wall is affected symmetrically and uninterruptedly from rectum proximally (ahaustral Colon). Endoscopic appearance is patchy, with discrete ulcerations separated by segments of normal- appearing mucosa. Inflammation is uniform and diffuse (continuous superficial inflammation with granular)

DIFFERENTIAL DIAGNOSIS Crohn's Disease Ulcerative Colitis Microscopic inflammation and fissuring extend transmurally; lesions are often highly focal in distribution. Inflammation is confined to mucosa (diffuse, continuous, superficial inflammation) except In severe cases. Epithelioid (sarcoid-like) granulomas detected in bowel wall or lymph nodes in 25-50% of cases (pathognomonic). Typical epithelial granulomas do not occur.

ULCERATIVE COLITIS Treatment Diet № 4 Diet № 4 Aminosalicilates (Sulfasalazine, Salofalk) Aminosalicilates (Sulfasalazine, Salofalk) Corticosteroid therapy (Budesonid, Prednizolon) Corticosteroid therapy (Budesonid, Prednizolon) Immunosuppressive drugs (Azathioprine) Immunosuppressive drugs (Azathioprine) Antidiarrheal drugs - loperamide, Anticholinergics, digestive enzymes, transfusions, vitamin Antidiarrheal drugs - loperamide, Anticholinergics, digestive enzymes, transfusions, vitamin therapy

DISEASES OF SMALL INTESTINE Crohns disease Crohn’s disease

Definition CROHN’S DISEASE A nonspecific chronic transmural inflammatory disease that most commonly affects the distal ileum and colon but may occur in any part of the GI tract. CROHN’S DISEASE A nonspecific chronic transmural inflammatory disease that most commonly affects the distal ileum and colon but may occur in any part of the GI tract.

PLAN CROHN’S DISEASE (CD) Etiology and Etiology and Epidemiology of CROHN’S DISEASE Pathology of CROHN’S DISEASE Pathology of CROHN’S DISEASE Clinical picture of CROHN’S DISEASE Clinical picture of CROHN’S DISEASE Diagnosis of CROHN’S DISEASE Diagnosis of CROHN’S DISEASE Differential Diagnosis of CROHN’S DISEASE Differential Diagnosis of CROHN’S DISEASE Prognosis of CROHN’S DISEASE Prognosis of CROHN’S DISEASE Treatment of CROHN’S DISEASE Treatment of CROHN’S DISEASE

Etiology The fundamental cause of Crohn's disease is unknown The fundamental cause of Crohn's disease is unknown

The spectrum of CROHN DISEASE presentations includes gastroduodenitis, jejunoileitis and ileitis, ileocolitis, colitis 7% 33% 45% 15%

CROHN’S DISEASE Clinical picture Abdominal pain (77%) Abdominal pain (77%) Chronic diarrhea (73%) Chronic diarrhea (73%) Bleeding (22%) Bleeding (22%) Anal Fistulas (16%) Anal Fistulas (16%) Anorexia Anorexia A right lower quadrant mass or fullness A right lower quadrant mass or fullness

CROHN’S DISEASE Extraintestinal manifestations Weight loss (54%) Weight loss (54%) Fever (35%) Fever (35%) Anemia (27%) Anemia (27%) Peripheral arthritis (16%) Peripheral arthritis (16%) Ophtalmic diseases ( Episcleritis, 10%) Ophtalmic diseases ( Episcleritis, 10%) Aphthous stomatitis Aphthous stomatitis Erythema nodosum (2%) Erythema nodosum (2%) Pyoderma gangrenosum Pyoderma gangrenosum

Endoscopic spectrum of CD includes a) aphthous ulcerations amid normal colonic mucosal vasculature; b) deeper, punched- out ulcers in ileal mucosa; c) a single colonic linear ulcer; d) deep colonic ulcerations forming a stricture.

CROHN’S DISEASE DIAGNOSIS x-ray: Barium enema x-ray may show reflux of barium into the terminal ileum with irregularity, nodularity, stiffness, wall thickening, and a narrowed lumen. A small-bowel series with spot x-rays of the terminal ileum usually most clearly shows the nature and extent of the lesion. An upper GI series without small-bowel follow-through usually misses the diagnosis. x-ray: Barium enema x-ray may show reflux of barium into the terminal ileum with irregularity, nodularity, stiffness, wall thickening, and a narrowed lumen. A small-bowel series with spot x-rays of the terminal ileum usually most clearly shows the nature and extent of the lesion. An upper GI series without small-bowel follow-through usually misses the diagnosis.

X-ray showing abnormal terminal ileum in Crohn's disease

Barium contrast X-ray showing a narrowed segment with Crohn's disease (arrowheads) Barium contrast X-ray showing a narrowed segment with Crohn's disease (arrowheads) Barium contrast X-ray showing a narrowed segment with Crohn's disease (arrowheads)

Laboratory findings Laboratory findings are nonspecific: Laboratory findings are nonspecific: -anemia, -leukocytosis, -hypoalbuminemia, - ↑ ESR, C-reactive proteins. Elevated alkaline phosphatase and γ- glutamyltranspeptidase accompanying colonic disease often reflect primary sclerosing cholangitis.

CROHN’S DISEASE DIFFERENTIAL DIAGNOSIS Ulcerative colitis Ulcerative colitis Acute appendicitis Acute appendicitis Pelvic inflammatory disease Pelvic inflammatory disease Ectopic pregnancy Ectopic pregnancy Ovarian cysts Ovarian cysts Cancer of the cecum Cancer of the cecum Lymphosarcoma Lymphosarcoma Systemic vasculitis Systemic vasculitis Radiation enteritis Radiation enteritis Ileocecal TB Ileocecal TB AIDS-related oppor­ tunistic infections (cytomegalovirus) AIDS-related oppor­ tunistic infections (cytomegalovirus)

DIFFERENTIAL DIAGNOSIS Crohn's Disease Ulcerative Colitis Small bowel is involved in 80% of cases Disease is confined to the colon. Rectosigmoid is often spared; colonic involvement is usually right-sided. Rectosigmoid is invariably involved; colonic involvement is usually left- sided. Gross rectal bleeding is absent in 15-25% of cases. Gross rectal bleeding is always present. Fistula, mass, and abscess development is common. Fistulas do not occur. Perianal lesions are significant in 25-35%. Significant perianal lesions never occur.

The typical perianal skin tag of Crohn's Disease

Episcleritis due to Crohn disease

DIFFERENTIAL DIAGNOSIS Crohn's Disease Ulcerative Colitis On x-ray, bowel wall is affected asymmetrically and segmentally, with "skip areas" between diseased segments. Bowel wall is affected symmetrically and uninterruptedly from rectum proximally (ahaustral Colon). Endoscopic appearance is patchy, with discrete ulcerations separated by segments of normal- appearing mucosa. Inflammation is uniform and diffuse (continuous superficial inflammation with granular)

DIFFERENTIAL DIAGNOSIS Crohn's Disease Ulcerative Colitis Microscopic inflammation and fissuring extend transmurally; lesions are often highly focal in distribution. Inflammation is confined to mucosa (diffuse, continuous, superficial inflammation) except In severe cases. Epithelioid (sarcoid-like) granulomas detected in bowel wall or lymph nodes in 25-50% of cases (pathognomonic). Typical epithelial granulomas do not occur.

Enterocutaneous fistulae in Chrohn's disease

CROHN’S DISEASE Treatment Diet № 4 Diet № 4 Aminosalicilates (Sulfasalazine, Salofalk) Aminosalicilates (Sulfasalazine, Salofalk) Corticosteroid therapy (Budesonid, Prednizolon) Corticosteroid therapy (Budesonid, Prednizolon) Immunosuppressive drugs (Azathioprine) Immunosuppressive drugs (Azathioprine) Antibacterial drugs (metronidazole, Nifuroxazide Antibacterial drugs (metronidazole, Nifuroxazide Symptomatic treatment (antidiarrheal drugs - loperamide, Anticholinergics) Symptomatic treatment (antidiarrheal drugs - loperamide, Anticholinergics)