1. Inflammatory Bowel Disease 4th year MS 2009-2010
Khaled Jadallah, MD
Assistant Professor of Medicine
Gastroenterology, Hepatology & Nutrition

2. Educational Objectives
Definitions and spectrum of inflammatory bowel disease (IBD)
Epidemiology of IBD
Etiopathogenesis of IBD
Clinical manifestations of ulcerative colitis (UC)
Clinical manifestations of Crohn’s disease (CD)
Distinguishing features between UC and CD
Diagnostic approach to IBD
Complications of IBD
IBD management

3. Inflammatory Bowel Disease
IBD include a group of chronic relapsing disorders that cause inflammation or ulceration in the small and/or large intestines. IBD is classified as:
Ulcerative colitis (UC)- causes ulceration and inflammation of the mucosa of the colon and rectum
Crohn's disease (CD) - an inflammation that extends into the deeper layers of the intestinal wall, and also may affect other parts or layers of the digestive tract, including the mouth, esophagus, stomach, and small intestine

4. Educational Objectives
Definitions and spectrum of inflammatory bowel disease (IBD)
Epidemiology of IBD
Etiopathogenesis of IBD
Clinical manifestations of ulcerative colitis (UC)
Clinical manifestations of Crohn’s disease (CD)
Distinguishing features between UC and CD
Diagnostic approach to IBD
Complications of IBD
IBD management

5. Epidemiology of IBD Ulcerative colitis Crohn’s disease 11/100 000
Incidence (US)
11/ 7/
Age of onset
15-30 & 60-80
Male:female ratio
1:1
1,1-1,8:1
Smoking
May prevent disease
May cause disease
Oral contraceptive
No increased risk
Relative risk 1,9
Appendectomy
Not protective
Protective
Monozygotic twins
8% concordance
67% concordance

7. High
Medium
Low

8. Educational Objectives
Definitions and spectrum of inflammatory bowel disease (IBD)
Epidemiology of IBD
Etiopathogenesis of IBD
Clinical manifestations of ulcerative colitis (UC)
Clinical manifestations of Crohn’s disease (CD)
Distinguishing features between UC and CD
Diagnostic approach to IBD
Complications of IBD
IBD management

13. Nature
Nurture
IBD
Genes
Environment

16. Educational Objectives
Definitions and spectrum of inflammatory bowel disease (IBD)
Epidemiology of IBD
Etiopathogenesis of IBD
Clinical manifestations of ulcerative colitis (UC)
Clinical manifestations of Crohn’s disease (CD)
Distinguishing features between UC and CD
Diagnostic approach to IBD
Complications of IBD
IBD management

17. Ulcerative Colitis – clinical presentation
Patients with proctitis usually pass fresh blood or blood-stained mucus either mixed with stool or streaked onto the surface of normal or hard stool; tenesmus is a feature
When the disease extends beyond the rectum, blood is usually mixed with stool or grossly bloody diarrhea may be noted
When the disease is severe, patients pass a liquid stool containing blood, pus, fecal matter
Other symptoms in moderate to severe disease include: anorexia, nausea, vomitting, fever, abdominal pain, weight loss

18. Ulcerative colitis – macroscopic features
Mucosa is :
- erythematous, has a granular surface that looks like a sand paper
In more severe diseases:
- hemorrhagic, edematous and ulcerated
In fulminant disease a toxic colitis or a toxic megacolon may develop ( wall becomes very thin and mucosa is severely ulcerated)

19. UC Disease Distribution at Presentation
37%
46%
17%

20. UC – disease severity < 4 per day 4-6 per day >6 per day small
MILD
MODERATE
SEVERE
BOWEL MOVEMENTS
< 4 per day
4-6 per day
>6 per day
BLOOD IN STOOL
small
moderate
Severe
FEVER
none
<37,5°C
> 37,5°C
TACHYCARDIA
<90 mean pulse
>90 mean pulse

21. UC – disease severity mild >75% <75% <30mm >30mm MILD
MODERATE
SEVERE
ANEMIA
mild
>75%
<75%
ESR
<30mm
>30mm
ENDOSCOPIC APPEARANCE
Erythema, decreased vascular pattern, fine granularity
Marked erythema, coarse granularity, contact bleeding, no ulceration
Spontaneous bleeding, ulceration

24. Educational Objectives
Definitions and spectrum of inflammatory bowel disease (IBD)
Epidemiology of IBD
Etiopathogenesis of IBD
Clinical manifestations of ulcerative colitis (UC)
Clinical manifestations of Crohn’s disease (CD)
Distinguishing features between UC and CD
Diagnostic approach to IBD
Complications of IBD
IBD management

25. CD: Clinical Features Abdominal pain, often postprandial
Diarrhea, usually watery
Rectal bleeding
Weight loss
Right lower quadrant pain/palpable mass
Fever
Growth retardation in children
Perirectal fistula

26. Crohn’s disease – macroscopic features
Can affect any part of GI tract from the mouth to the anus
30-40% of patients have small bowel disease alone
40-55% of patients have both small and large intestines disease
15-25% of patients have colitis alone
In 75% of patients with small intestinal disease the terminal ileum in involved in 90%

28. Crohn’s Disease: Anatomic Distribution
Small bowel alone (33%)
Ileocolic (45%)
Frequency of involvement
Colon alone (20%)
Least
Most

29. Crohn’s disease – macroscopic features
CD is a transmural process
CD is segmental with skip areas in the midst of diseased intestine
In one third of patients with CD perirectal fistulas, fissures, abscesses, anal stenosis are present

30. Crohn’s disease – macroscopic features
Active CD is characterized by focal inflammation and formation of fistula tracts
The bowel wall thickens and becomes narrowed and fibrotic, leading to chronic, recurrent bowel obstruction

33. Crohn’s Disease Activity Index (CDAI)
Incorporates 8 variables:
1. liquid or very soft stools /day
2. Abdominal pain & cramping
3. Extraintestinal manifestations
4. Complications
5. Abdominal mass
6. Use of anti diarrheal medications anti-
7. Hematocrit
8. Body weight

34. Crohn’s Disease Red Flags
Onset after stopping smoking
Bleeding only
Diverticulosis
Atherosclerosis
Prolapse

35. Extraintestinal Manifestations of IBD
Skin
Erythema nodosum
Pyoderma gangrenosum
Joints
Peripheral arthritis
Sacroileitis
Ankylosing spondylitis
Eye
Uveitis
Episcleritis
Iritis
Hepatobiliary complications
Gallstones
PSC
Renal complications
Nephrolithiasis
Recurrent UTIs

46. Educational Objectives
Definitions and spectrum of inflammatory bowel disease (IBD)
Epidemiology of IBD
Etiopathogenesis of IBD
Clinical manifestations of ulcerative colitis (UC)
Clinical manifestations of Crohn’s disease (CD)
Distinguishing features between UC and CD
Diagnostic approach to IBD
Medical management of IBD
Indications for and role of surgery

47. Symptoms of IBD UC vs CD Feature UC CD Fever Uncommon Common
Rectal bleeding
< ½ of patients
Abdominal tenderness
May be present
Abdominal mass
Abdominal pain
Very common
Weight loss
Tenesmus

48. UC vs CD Complications/Response to Treatment
Fistulas No
Yes
Small intestine obstruction
Frequently
Colonic obstruction
Rarely
Response to antibiotic
Recurrence after surgery

49. UC vs CD Different endoscopic features
Rectal sparing
Rarely
Frequently
Continuous disease
Yes
Occasionally
„Cobblestoning” No
Granuloma on biopsy

50. Criteria for Indeterminate Colitis
No evidence of small bowel involvement, fistula, or perianal disease
Absence of diagnostic criteria for CD or UC by microscopy

51. Differential Diagnosis of Chronic Diarrhea and Weight Loss
Colonic diseases
IBD
Neoplasia
Ischemic bowel
Pancreatic
Chronic pancreatitis
Cancer
Cystic fibrosis
Enteropathic
Celiac disease
Tropical sprue
Lymphoma
Mesenteric ischemia
Whipple’s disease
Hormonal/drugs
Vipoma
ZES
Medullary CA of thyroid
NSAIDS use

52. Educational Objectives
Definitions and spectrum of inflammatory bowel disease (IBD)
Epidemiology of IBD
Etiopathogenesis of IBD
Clinical manifestations of ulcerative colitis (UC)
Clinical manifestations of Crohn’s disease (CD)
Distinguishing features between UC and CD
Diagnostic approach to IBD
Medical management of IBD
Indications for and role of surgery

53. Diagnostic Approach to Patients with Suspected IBD
History……history……history
Clinical exam
Laboratory tests
Radiological imaging
Endoscopy
Special serological testing
Genetic testing

54. Diagnosis-LAB Blood test Stool analysis
CD: Mild anemia, mild leukocytosis, elevated ESR, elevated CRP, positive ASCA
UC: Anemia, hypokalemia, hypoalbuminemia, elevated ESR, elevated LFTs, positive p-ANCA
Stool analysis
Many WBCs and /or RBCs
No ova or parasites

55. What are the Serological Markers in IBD?
pANCA (perinuclear staining pattern)
Loss of perinuclear pattern after DNAase
Differentiate from the “other pANCAs”
Antibody against myeloperoxidase
Antibody against cathepsin G, elastase, lysozyme, and lactoferrin
ASCA (anti-Saccharomyces cerevisiae)
Both IgG and IgA
Recognize mannose in the cell wall mannan of Saccharomyces cerevisiae

56. Why Use Serological Markers in Clinical Practice?
Differentiate IBD from functional bowel disorders
Accurately diagnose Crohn’s or UC in a patient with:
Severe colitis
Indeterminate colitis
Predict disease course or complications in IBD
CD phenotype
Severity of disease
Risk of pouchitis

57. Summary pANCA and ASCA are specific for UC and CD respectively
Neither pANCA nor ASCA are sensitive enough to exclude IBD
In patients with IC, available serological markers do not accurately predict the subsequent disease course
Antibody profiles can predict disease behavior in IBD

58. Diagnostic Approach Endoscopy
Endoscopy useful for
Initial diagnosis
Assessment of severity
Tissue diagnosis
F/U during treatment
Assessment of disease exacerbation
Surveillance for risk of cancer
Treatment of certain complications (e.g. strictures)

61. Crohn’s Disease Endoscopic Features
Asymmetric patchy inflammation
Skip lesions
Rectal sparing
Ulcerations-deep/serpiginous
Cobblestoning-common
Pseudopolyps-rare
Biopsy
Erosions and normal mucosa
Granulomas in 15 to 35% of specimens

63. Ulcerative Colitis Endoscopic Features
Diffuse involvement
Rectum always diseased
Superficial ulcerations
Friability/bleeding
Flattening/disappearance of haustral folds
Pseudopolyps
No cobblestoning
Bx: No granulomas

65. Imaging for Crohn Disease Traditional Techniques
Abdominal Radiographs
Barium UGI
Barium small bowel follow through
Barium Enteroclysis
Barium Enema

66. Imaging for Crohn Disease Newer TechniquesCT
CT Enteroclysis
CT Enterography
Magnetic Resonance
Ultrasound
Nuclear Medicine

67. Imaging for Crohns Disease Summary
Useful Newer Techniques evolving
CT Enterography
Comprehensive evaluation of all bowel & solid organs
Magnetic Resonance
Useful for ano-rectal disease
Real-time MR has potential for detection of strictures
Traditional imaging techniques still of value in selected cases

68. The Capsule (WCE)

69. WCE Diameter 11mm: Length 26mm
Optical dome: Intestinal illumination by white light emitting diodes (LED’s)
Lens
Complementary metal-oxide silicone imager (color camera chip)
Transmitter
Two batteries (silver oxide)

70. GE Junction
Duodenum
Jejunum
Ileocecal Valve

72. Educational Objectives
Definitions and spectrum of inflammatory bowel disease (IBD)
Epidemiology of IBD
Etiopathogenesis of IBD
Clinical manifestations of ulcerative colitis (UC)
Clinical manifestations of Crohn’s disease (CD)
Distinguishing features between UC and CD
Diagnostic approach to IBD
Complications of IBD
IBD management

73. IBD-Complications GI Bleeding Toxic megacolon Perforation
Thromboembolic phenomena
Fistulas/fissures
Abscess
Strictures/obstruction
Malabsorption/malnutrition
Cancer

77. Best Protection
Surveillance colonoscopy
Procto-colectomy (for UC)

78. Descending Colon Stricture

79. Colonic Strictures Consider nonsurgical management if:
Endoscopically accessible
Multiple prior resections
Shorter strictures (less than 5 cm)
Steroid injection if significant inflammation

81. Fistula: Definition
A communication between two epithelial-lined organs.
Lifetime risk of fistula in CD:30%

82. Perianal Fistula
Pretreatment
2 Weeks
10 Weeks
18 weeks

83. Educational Objectives
Definitions and spectrum of inflammatory bowel disease (IBD)
Epidemiology of IBD
Etiopathogenesis of IBD
Clinical manifestations of ulcerative colitis (UC)
Clinical manifestations of Crohn’s disease (CD)
Distinguishing features between UC and CD
Diagnostic approach to IBD
Complications of IBD
IBD management

84. Goals of Therapy for IBD
Inducing remission
Maintaining remission
Restoring and maintaining nutrition
Maintaining patient’s quality of life
Prevention of complications
Surgical intervention (selection of optimal time for surgery)

85. Inductive Therapies For UC For CD Aminosalicylates Corticosteroids
Cyclosporin
For CD
Antibiotics
Anti-TNF

86. Maintenance Therapies
Immunosupressors
Azathioprine
6-MP
Methotrexate
Aminosalicylates
Anti-TNF
NOT corticosteroids

87. IBD Management Summary
There is no “one size fits all” to IBD therapy
Therapy and decision making are tailored to the individual
Algorithms are based upon available evidence
Evidence is in constant flux
Success of algorithms depends upon optimization of each step of therapy and considerable judgment about each outcome
Skillful application of medical therapy makes all the difference in outcomes

88. Surgery for IBD General Concepts
Majority will need surgery: 78% over twenty years
Surgery generally indicated for complications of disease
Surgery must be directed at area of bowel responsible for complication

89. Indications for Surgery
Intestinal obstruction (most common)
Intractability/steroid dependence
Non-healing fistula/Abscess
Toxic megacolon/Free perforation
Uncontrollable GI bleeding
Severe perianal disease
Cancer
Growth retardation (children)
Severe uncontrollable extraintestinal manifestations

90. Management of IBD Summary
The goals of therapy are
Relieve symptoms
Prevent relapse
Correct nutritional deficiencies
Control inflammation
Prevent complications, especially colon cancer
Treatment depends on
􀂃 Type of disease
􀂃 Site of disease
􀂃 Disease severity
Treatment may include drugs , nutrition supplements , surgery or a combination of these options