1. Inflammatory Bowel disease
By Dr Khaled Ahmad, md, facs, fasmbs

2. Inflammatory bowel disease
Inflammatory Bowel disease is comprised of 2 major disorders
Ulcerative Colitis
Crohn disease

3. Inflammatory bowel disease
Ulcerative colitis :
Chronic inflammatory condition
Relapsing and remitting episodes of inflammation limited to mucosal layer of colon.

4. Inflammatory bowel disease
Ulcerative colitis :
Involves the rectum and typically extends in a proximal and continuous fashion to involve other portions of the colon.

5. Inflammatory bowel disease
Crohn disease:
Transmural inflammation and by skip lesions.

6. Inflammatory bowel disease
Crohn disease:
May lead to fibrosis and strictures and to obstructive clinical presentations
Transmural inflammation results in sinus tracts, giving rise to microperforations and fistulae.

7. Inflammatory bowel disease
Crohn disease:
Involves the entire GI tract from mouth to perianal area
Most commonly affected area = Ileum + proximal colon
Phenotype of Crohn disease : inflammatory, structuring or penetrating

8. Inflammatory bowel disease

9. Inflammatory bowel disease

10. Inflammatory bowel disease
Pathophysiology
Exact mechanism for IBD not well understood, though to be related to combination of factors in gut, including:
Damage to epithelial mucin proteins and tight junctions,
Breakdown of homeostatic balance between host’s mucosal immunity and enteric microflora
Genetic polymorphisms in toll-like receptors (TLRs)
Disrupted homeostatic balance between regulatory and effector T-cells

11. Inflammatory bowel disease
Epidemiology
Prevalence of Ulcerative colitis in adults in the USA = 238 per population
Prevalence of Crohn Disease in adults in the USA = 201 per population.
Incidence and prevalence of Crohn disease and ulcerative colitis appear to be lower in Asia and the Middle East

12. Inflammatory bowel disease
Risk Factors
Age and gender (Onset between years)
Slight Female predominance in Crohn Disease especially in later adolescence and early adulthood
Slight male predominance in ulcerative colitis

13. Inflammatory bowel disease
Risk Factors
Racial and ethnicity (Incidence lower in black and Hispanic populations compared to whites)
Genetic susceptibility (10-25% of individuals with IBD have a first degree relative with Crohn or ulcerative colitis)

14. Inflammatory bowel disease
Risk Factors
Smoking
Associated with an increased risk of Crohn disease
Paradoxically lower risk for milder disease in ulcerative colitis
Current as well as past smokers are more likely to develop Crohn disease than those who never smoked.
Smoking may also increase the risk of recurrence of Crohn disease

15. Inflammatory bowel disease
Risk Factors
Diet (Western style diet : processed, fried and sugary food associated with an increased risk of developing Crohn disease.
Physical activity associated with a decrease in risk of Crohn Disease
Obesity (accumulation of intra-abdominal fat may contribute to mucosal inflammation)
Infections (imbalance in the gut microbiome may contribute to the developing of IBD)

16. Inflammatory bowel disease
Risk Factors
For UC : Hx of prior GI infections, e.g. Shigella, Salmonella, Campylobacter, during adulthood double risk of developing UC, thought to be changes in gut flora triggering chronic inflammatory process
Weak associations between NSAIDs, OCPs and increased risk of UC

17. Inflammatory bowel disease
Ulcerative colitis : Clinical manifestation
Diarrhea, may be associated with blood
Bowel movement frequent and small in volume
Symptoms : colicky abdominal pain, urgency, tenesmus, incontinence
Onset : gradual, symptoms are progressive over several weeks
Patients may have fever, fatigue and weight loss

18. Inflammatory bowel disease
Ulcerative colitis : Clinical manifestation
Diagnosis based on presence of chronic diarrhea for more than 4 weeks
Evidence of chronic colitis on endoscopy and biopsy
Exclusion of other causes of colitis by history, lab studies

19. Inflammatory bowel disease
Ulcerative colitis : Clinical manifestation
Montreal classification used to categorize extent and severity of disease
E1 (proctitis): inflammation limited to the rectum
E2 (left-sided; distal): inflammation limited to the splenic flexure
E3 (pancolitis): inflammation extends to the proximal splenic flexure
S0 (remission): no symptoms
S1 (mild): four or less stools per day (with or without blood), absence of systemic symptoms, normal inflammatory markers
S2 (moderate): four stools per day, minimum signs of systemic symptoms
S3 (severe): six or more bloods per day, pulse rate of ≥90 beats per min, temperature ≥37·5°C, ESR >30
Extraintestinal manifestations are more commonly seen in UC than CD
include aphthous oral ulcers, iritis/uveitis/episcleritis, seronegative arthritis, ankylosing spondylitis, sacroiliitis, erythema nodosum, pyoderma gangreosum, autoimmune hemolytic anemias and primary sclerosing cholangitis

20. Inflammatory bowel disease
Ulcerative colitis : Diagnosis
Based on clinical symptoms confirmed by objective findings from endoscopic and histologic examinations
Initial w/u must r/o infectious and non-infectious causes of diarrhea
Endoscopic features
loss of vascular pattern, erythema, granular and friable mucosa, erosions, ulcerations and spontaneous bleedings
Pathologic features
distortion of crypt architecture, crypt abscess, infiltration of lamina propria w/ plasma cells, eosinophils, lymphocytes, lymphoid aggregates and mucin depletion

21. Inflammatory bowel disease
Ulcerative colitis : Complications
Complications include severe bleeding, toxic megacolon, perforation, strictures and the development of dysplasia and colorectal cancer

22. Inflammatory bowel disease
Ulcerative colitis
Double contrast barium enema
Demonstrates extensive mucosal
Ulceration and inflammation
Throughout the colon

23. Inflammatory bowel disease
Ulcerative colitis : Treatment
Ulcerative proctitis : 5-ASA to induce remission
Suppositories alone are effective in managing proctitis
Proctosigmoiditis require enemas + suppositories

24. Inflammatory bowel disease
Ulcerative colitis : Treatment
Left-sided colitis, extensive colitis or pancolitis
Mildly or moderately active left-sided colitis/extensive/pancolitis : combination therapy with oral 5- ASA medications, rectal 5-ASA or steroid suppositories, and 5- ASA or steroid enemas or foam preparations
Failure to respond to combination therapy with oral 5-ASA medications and topical 5-ASA and steroids : Oral glucocorticoids (Glucocorticoids should be tapered after the patient has been stable for 2-4 weeks).

25. Inflammatory bowel disease
Ulcerative colitis : Treatment

26. Inflammatory bowel disease
Ulcerative colitis : Treatment
Surgical treatment required in approximately 20-30% of patients. Surgery is generally curative in UC.
Emergency: Life-threatening complications related to fulminant disease unresponsive to medical treatment
Urgent: Severe disease admitted to hospital and not responding to intensive medical treatment
Elective: Refractory disease intolerant to long-term maintenance treatments or colorectal cancer.

27. Inflammatory bowel disease
Ulcerative colitis :Prevention and screening
UC patients at increased risk of colorectal cancer
2% after 10 years, 8% after 20 years and 18% after 30 years
Screening colonoscopy beginning at 8 years after disease onset
Following initial colonoscopy, subsequent screening depends on extent of disease
Proctitis/proctosigmoditis: Follow specific age guidelines for surveillance of colorectal cancer
Left-sided colitis/pancolitis: Every 1-2 years
UC w/ Primary sclerosing cholangitis = PSC: Annually from time of dx of PSC
Risk factors for Colorectal cancer
Duration and extent of disease
Endoscopic and histologic severity of inflammation

28. Inflammatory bowel disease
Crohn Disease : Epidemiology
Genetic factors
Family hx well established as one of the strongest risk factors for development for CD
Environmental factors
Lifestyle factors such as tobacco use, sedentary lifestyle, exposure to air pollution, and consumption of western diet
Infectious factors
CD often occurs after infectious gastroenteritis

29. Inflammatory bowel disease
Crohn Disease : Clinical presentation
Unlike in UC, Crohn’s disease can affect any portion of the GI tract
Common presenting symptoms
abdominal pain, bloody or watery diarrhea, incontinence, fistulas and perianal symptoms. Extracolonic GI involvement associated with aphthous ulcers, dysphagia, upper abdominal pain and vomiting.
Patients with CD may have hx of other autoimmune disorders,

30. Inflammatory bowel disease
Crohn Disease : Clinical presentation
Montreal classification used to categorize CD
L-classification: Defines extent of disease
L1: Disease confined to terminal ileum
L2: Disease confined to clon
L3: Disease involving ileum and colon
L4: Disease involving upper GI tract
L4+L3: Disease involving upper GI tract and distal disease
B-classification: Defines phenotype
B1: Without stricture formation, non-penetrating
B2: Stricturing
B3: Penetrating
B3p: Perinally penetrating

31. Inflammatory bowel disease
Crohn Disease : Diagnosis
Clinical diagnosis based on history findings with objective findings from history and laboratory studies
As with UC, must r/o important non-infectious causes (IBS, Behcet’s syndrome blood vessel inflammation ) and infectious causes (Yersinia, enteroviruses etc.) that mimic CD
Endoscopy is gold standard for diagnosis
Radiologic tests may assist in diagnosis
CT/MRI enterography or enteroclysis
Abdominal U/S
Biomarkers can also be used
CRP, lactoferrin and calprotectin

32. Inflammatory bowel disease
Crohn Disease : Treatment
All patients with CD should be counseled to quit smoking
As with UC, initial medical treatment depends on phenotype, disease activity, comorbidities and other individual characteristics of patient
In most cases, short course of antibotics, steroids, or anti-TNF agent, e.g. infliximab, adalimumab, combined with thiopurines or methotrexate for long-term maintenance
5-ASA derivatives, which are mainstay of UC, have shown to be less useful in treatment of CD
Superiority of combination of thiopurines and TNF blockers
No current consensus on optimal length of therapy
Unlike in UC, surgery is not curative in CD

33. Inflammatory bowel disease
Crohn Disease : Prevention/screening
Regular screen for active infection
tuberculosis, infections hepatitis, CMV, HIV and C. difficile
Colorectal cancer screening
In patients with more than a third of colon affected (Montreal classification L3), first screening colonoscopy should occur 8 years after onset, repeated every 1-2 years once remission achieved, and every 1-3 years once normal.
Patients with Primary sclerosing cholangitis (PSC) should undergo annual screenings