1. IBD Inflammatory Bowel Disease
Dr. László Orosz
Surgical Department
University Of Debrecen

2. IBD
Crohn’s Disease
Ulcerative colitis

3. Suspicion of IBD Diarrhoea for more than 4 weeks
Opening the bowels more than twice a day
wet/fluid-like stool
Abdominal pain
Stool containing blood, mucus or pus

4. Ulcerative colitis
Chronic inflammatory bowel disease that is only localised in the mucus membrane of the colon/rectum.
There are ulcers and signs of inflammation in the rectum and the colon. It is a recurrent disease.
Diarrhoea, bloody stool, crampy abdominal pain, weight loss, loss of appetite
Diffuse ulceration in colon mucus membrane, crypt abscess, infiltration.

5. Crohn’s disease
Chronic, segmental or multy-segmental. All the layers of the intestine is affected
Both small intestines and the colon might be affected
Cramp-like abdominal pain, weight loss, diarrhoea, fever
Local inflammation, micro-erosions, fissures, granuloma, fistulas , infiltrations, lymphatic vessel enlargement

9. Localisation Ulcerative Colitis Sigmoid-rectum 54% Left colon 27%
Pancolitis %
Crohn’s disease
Small intestine and colon 50%
Ileitis %
Colitis %
Anorectal %

10. Distribution of gastrointestinal Crohn's disease.

11. Epidemiology
Young age
Incidence has not changed in the recent years
Crohn’s disease: 6/100000
Ulcerative Colitis: 2-3/ in the developped countries
10-20 x frequent in afected families
genetical predisposition: In1996-ban Hugot et al found IBD1 locus on the 16 chromosome, which predispose for CD, IBD2 that predispose for CU

13. Ethiology
Unknown!!
Infective: herpes, measeles, E. coli, M. paratuberculosis
Genetic background: familiar disposition
Diet?
Immune system: autoimmune?
Emmotional status

14. Symptoms Ulcerative Coilits Crohn’ disease Bleeding 80% 22%
Diarrhoea % %
Abdominal pain 47% %
Fistulas % %
Weight-loss % %
Fever % %
Anaemia % %
Joint pain % %
Eye symptoms % %

15. Extraintestinal symptoms
Arthritis, polyarthritis %
Erythema nod., Pyoderma gangr %
Fatty liver, Chr. Active hepatitis, PSC %
Iridocyclitis, Uveitis %
Oral, stomatitis aphtosa %
Alveolitis, lung fibrosis <1%

17. Diagnostics: Crohn’s disease
Colonscopy, (biopsy) capsule-endoscopy
X-ray, Barium anema and meal
UH, CT
Laboratory (blood) tests ( Sedimentation, WBC, CRP, liver enzymes, stool culture )

19. Endoscopy image of colon showing serpiginous ulcer, a classic finding in Crohn's disease

21. Crohn's disease can mimic ulcerative colitis on endoscopy
Crohn's disease can mimic ulcerative colitis on endoscopy. This endoscopic image is of Crohn's colitis showing diffuse loss of mucosal architecture, friability of mucosa in sigmoid colon and exudate on wall, all of which can be found with ulcerative colitis.

22. Endoscopic image of colon cancer identified in the sigmoid colon (anatomy) on screening colonoscopy for Crohn's disease.

23. Diagnostics: Ulcerative colitis
Colonscopy, (biopsy) capsule-endoscopy
X-ray, Barium anema and meal
UH, CT
Laboratory (blood) tests ( Sedimentation, WBC, CRP, liver enzymes, stool culture )

26. Endoscopic image of a sigmoid colon afflicted with ulcerative colitis
Endoscopic image of a sigmoid colon afflicted with ulcerative colitis. Note the vascular pattern of the colon granularity and focal friability of the mucosa.

27. Colonic pseudopolyps of a patient with intractable ulcerative colitis
Colonic pseudopolyps of a patient with intractable ulcerative colitis. Colectomy specimen.

28. Patients with ulcerative colitis can occasionally have aphthous ulcers involving the tongue, lips, palate and pharynx

29. Endoscopic image of ulcerative colitis affecting the left side of the colon. The image shows confluent superficial ulceration and loss of mucosal architecture. Crohn's disease may be similar in appearance, a fact that can make diagnosing UC a challenge.

30. Biopsy sample (H&E stain) that demonstrates marked lymphocytic infiltration (blue/purple) of the intestinal mucosa and architectural distortion of the crypts.

31. H&E stain of a colonic biopsy showing a crypt abscess, a classic finding in ulcerative colitis

32. Medical therapy Pentasa Steroids, imuran, (budesonid)
Anti-TNF-alfa (Remicade)
Ciprofloxacin, metronidazol
Nutritional advices

33. Crohn’s disease: Therapy
Acute fulminate: exclusion of abscess than Steroid mg, wide spectrum antibiotics
Subacute disease: Steroid in decreasing dosage Budenofalk, sulfasalazin, Pentasa, Salofalk, metronidasol
Chronic: constant low dose steroid, Imuran, 5-aminosalicyl

34. Ulcerative colitis :Therapy
Acute inflammation: Steroid, antibioticum, 5-ASA
Chronic : 5-ASA, Imuran

35. Crohn’s disease: complications
Stenosis, ileus (bowel obstruction)
Fistula formation
Abscess formation
Bleeding
Toxic megacolon
Malignant transformation

37. Ulcerative colitis: complications
Stenosis, ileus (bowel obstruction)
bleeding
Perforation, abscess formation, peritonitis
Toxic megacolon
Malignant transformation

38. Crohn’disease: Surgical therapy
Maximally conservative !!!
Resection (preserving as much small intestine as possible!)
Srticturopalsty (small intestine)

47. Toxic megacolon

48. Ulcerative colitis: Surgical treatment
In acute case:
Hartmann procedure
Proctocolectomy
Elective operation:
Proctocolectomy with ileostomy
Total colectomy with ileo-rectal anastomosis
Proctocolectomia , ileo-analis anastomisis with ileum pauch
Proctocolectomia, Koch-reservoir

49. Colon J-pouch

50. J-pouch

51. IPAA