1. Inflammatory Bowel Disease Crohn’s Disease And Ulcerative Colitis

2. Goals To review the characteristics of the two major inflammatory bowel diseases: Crohn’s Disease and Ulcerative Colitis To review the major ways to image the GI tract in an effort to diagnose and differentiate the two conditions

3. Definition Idiopathic disorders of the GI tract characterized by unexplained patterns of inflammation Characteristic Patterns of Inflammation

4. Epidemiology 1 million patients with IBD Males = Females Crohn’s > Ulcerative Colitis Most patients between 15 and 35 Jewish 5 times more likely to have IBD $2 billion spent annually

5. Patterns of Inflammation Crohn’s Disease Location Can involve the entire gut Predilection for the terminal ileum and Colon Transmural Involvement Ulcerative Colitis Location Only the Colon  Left sides vs Pancolitis Occasionally the bile ducts Histologic Involvement Mucosa only

7. Crohn’s Disease

8. Ulcerative Colitis

9. Pathophysiology Autoimmune etiology Lupus like etiology Early life intestinal infections Hygiene Theory Heredity 15-20% have one sibling Monozygotic twins concordance 44% Multiple Genes are involved (Nod2 on C16) Environmental Occult Infection: mycobacterium, paramyxovirus

10. Signs and Symptoms Abdominal Pain Diarrhea Rectal Bleeding Constitutional Symptoms Arthralgias Skin Rash Anorexia Weight Loss

11. Complications Crohn’s Disease Abcesses Fistulas Obstruction Perianal Disorders Other Malnutrition Anemia Arthritis Kidney Stones Ulcerative Colitis Toxic Megacolon Colon Cancer Other Anemia Arthritis Skin Rash Sclerosing Cholangitis

12. Diagnosis Blood Tests pANCA: CUC ASCA: Crohn’s Imaging Studies Barium Studies CT Endoscopy Colonoscopy

13. Radiology Imaging Tools Plain X-Rays Barium Studies UGI, BE, SBFT, Enterolysis Ultrasound CT

14. Plain X-rays Utility Gas Patterns Calcifications Benefits Inexpensive Easy to do Noninvasive Limitations Limited Detail of hollow organs

15. Example 1

16. Example 2

17. Example 3

18. Barium Studies Indications Evaluation of Hollow Organs Mucosal Evaluation Benefits Relatively inexpensive Easy to do Limitations Patient Resistance to Barium Limited sensitivity Radiation exposure

19. Normal Small Bowel

20. Crohn’s Disease

21. Ultrasound Indications Evaluation of the Biliary Tree, Liver, and Pancreas Benefits Noninvasive No Radiation dose Patient Tolerance Limitations Poor visualization of hollow GI organs Limited visualization in obese or distended patients Immobile (Usually not done at bedside)

22. Gallbladder Ultrasound

23. Nuclear Medicine Studies Indications Liver and Biliary Scanning GI Bleeding Gastric Emptying Benefits Noninvasive Good Patient Compliance Limitations Poor Imaging detail Inconclusive results

24. Example 1 Normal Biliary Imaging

25. Example 2 Cholecystitis

26. GI Bleeding Scans

27. CT Scanning Indications Evaluation of Solid organs, ie: Liver, Pancreas, Spleen Requires IV Contrast Bowel Wall Evaluation Requires Oral Contrast Benefits Easily Done Good Patient Compliance Limitations Hollow organs not visualized in detail Immobile (Cannot be done at bedside)

28. CT Overview

29. Slices

30. Crohn’s Disease

31. Colonoscopy Utility Most accurate method of visualizing the Colon Diagnostic and Therapeutic Benefits “Gold Standard” Low risk of complications Limitations Prep Sedation Cost Video

32. Normal Colonoscopy

33. Colitis

34. Endoscopic Ultrasound Indications Intramural Lesions Differentiation of benign vs malignant Pancreatic Diseases Biliary Disorders Benefits Increased accuracy over standard US and CT Limitations Expensive Advanced training necessary

35. Example 1 Intramural Lesion

36. Example 2 Pancreatic Mass

37. Capsule Endoscopy

39. Conclusions Hollow Organs Bleeding Endoscopy Small Bowel Capsule Endoscopy Pain CT, Ultrasound Solid Organs CT, Ultrasound, EUS Screening Colonoscopy

40. Medical Therapy Corticosteroids Salicylate Preparations Sulfasalazine: Azulfidine Mesalamine: Asacol, Pentasa, Colazal Immune Modulators Azathioprine/6MP Methotrexate Cyclosporin Entocort Infliximab: Remicade Humira

41. Surgical Therapy Only done in the face of surgical complications or medical failure Small Bowel Resections Stricturoplasty Fistula Resections Proctocolectomy

42. Other Therapies Antibiotics Flagyl, Cipro Nicotine Opposite effects in CD and CUC Nutritional Therapy Stress Management Support Groups