bohomolets surgery 4th year lecture #8

LECTURE 8

Inflammatory Bowel Disease (IBD):

Ulcerative Colitis (UC) & Crohn Disease (CD)

National O. Bogomolets Medical University

Faculty Surgery Department N1Kyiv 2008

Prof. Kucher M.

Inflammatory bowel disease (IBD) is a group of inflammatory conditions of the large intestine and, in some cases, the small intestine.The main forms of IBD are ulcerative colitis (UC) and Crohn's disease (CD).

UC

CD

• The main difference between Crohn's disease and UC is the location and nature of the inflammatory changes. Crohn's can affect any part of the gastrointestinal tract, from mouth to anus (skip lesions), although a majority of the cases start in the terminal ileum. Ulcerative colitis, in contrast, is restricted to the colon and the rectum.

• Microscopically, ulcerative colitis is restricted to the mucosa (epithelial lining of the gut), while Crohn's disease affects the whole bowel wall.

• Finally, Crohn's disease and ulcerative colitis present with extra-intestinal manifestations (such as liver problems, arthritis, skin manifestations and eye problems) in different proportions.

• Rarely, a definitive diagnosis of neither Crohn's disease nor ulcerative colitis can be made because of idiosyncrases in the presentation. In this case, a diagnosis of indeterminate colitis may be made

• Ulcerative colitis is an idiopathic form of colitis, that includes characteristic superficial ulcers in the colon’s mucosa

• The main symptom of active disease is usually diarrhea mixed with blood, mucus, and pus

• Ulcerative colitis is usually an intermittent disease, with periods of exacerbated symptoms, and periods that are relatively symptom-free

• Ulcerative colitis is, however, a systemic disease that affects many parts of the body outside the intestine (extracolonic manifestations)

Epidemiology• The incidence of ulcerative colitis in North America is 10-

12 cases per 100,000, – a peak incidence of ulcerative colitis occurring between the ages of

15 and 25. – second peak in incidence occurring in the 6th decade of life. The

disease affects females more than males

• The geographic distribution of ulcerative colitis and Crohn's disease is similar worldwide, with highest incidences in the United States, Canada, the United Kingdom, and Scandinavia. Higher incidences are seen in northern locations compared to southern locations in Europe and the United States.

• As with Crohn's disease, ulcerative colitis is thought to occur more commonly among Ashkenazi Jewish people than non-Jewish people.

UC is a mucosal inflammation:

crypt abscesses

erosion ulcer

A key feature of UC is: -- continuous involvement of rectum &colon -- does not involve ileum

Inflammatorypseudopolyps

Flat displasia

Classification

Ulcerative colitis is normally continuous from the rectum up the colon

Extent of involvement

• Proctitis / proctosigmoiditis

• Left-sided colitis

• Subtotal

• Total involvement (pancolitis)+/- backwash ileatis

Classification

Course:

• Acute disease / culminant

• intermittent course (exacerbations and remossions)

• Permanent / progressive

Endoscopic grades of inflammation activity

• Loss of the vascular appearance of the colon

• Erythema (or redness of the mucosa) and friability of the mucosa (contact bleeding)

• Superficial ulceration, which may be confluent

• Pseudopolyps.

ClassificationSeverity of disease• Mild disease correlates with fewer than four stools daily,

with or without blood, no systemic signs of toxicity, and a normal erythrocyte sedimentation rate (ESR). There may be mild abdominal pain or cramping.

• Moderate disease correlates with more than four stools daily, but with minimal signs of toxicity. Patients may display anemia (not requiring transfusions), moderate abdominal pain, and low grade fever, 38 to 39 °C (99.5 to 102.2 °F).

• Severe disease, correlates with more than six bloody stools a day, and evidence of toxicity as demonstrated by fever, tachycardia, anemia or an elevated ESR.

Classification

Local (colonic) complications

• Toxic megacolon

• Perforation, peritonitis

• Profuse bleeding

• Flat displasia Malignancy

ClassificationExtraintestinal features

• Aphthous ulcers of the mouth• Ophthalmic (involving the eyes):

– Iritis or uveitis, which is inflammation of the iris– Episcleritis

• Musculoskeletal: – Seronegative arthritis, which can be a large-joint oligoarthritis (affecting one or two

joints), or may affect many small joints of the hands and feet– Ankylosing spondylitis, arthritis of the spine– Sacroiliitis, arthritis of the lower spine

• Cutaneous (related to the skin): – Erythema nodosum, – Pyoderma gangrenosum,

• Deep venous thrombosis and pulmonary embolism• Autoimmune hemolytic anemia• Clubbing, a deformity of the ends of the fingers• Primary sclerosing cholangitis, or inflammation of the bile ducts

• Malnutrition and growth retardation in pediatric patients

Local (colonic) complications

Extraintestinal features

Fulminant UC

•BMI <16

•Extraintestinal features

•Complications

Before surgery

5 days after surgery

5 mo after surgery BMI =19.3

The clinical presentation of ulcerative colitis depends on the extent of the disease process.

Patients usually present with diarrhea mixed with blood and mucus, of gradual onset.

They also may have signs of weight loss, and blood on rectal examination. The disease is usually accompanied with different degrees of abdominal pain, from mild discomfort to severely painful cramps.

The following conditions may present in a similar manner as ulcerative colitis, and should be excluded:

• Crohn's disease• Infectious colitis, which is typically detected on stool

cultures • Pseudomembranous colitis, or Clostridium difficile-

associated colitis, bacterial upsets often seen following administration of antibiotics

• Ischemic colitis, inadequate blood supply to the intestine, which typically affects the elderly

• Radiation colitis in patients with previous pelvic radiotherapy

• Chemical colitis resulting from introduction of harsh chemicals into the colon from an enema or other procedure.

Diagnosis and workup

General• A complete blood count is done to check for anemia; thrombocytosis,

a high platelet count, is occasionally seen• Electrolyte studies and renal function tests are done, as chronic

diarrhea may be associated with hypokalemia, hypomagnesemia and pre-renal failure.

• Liver function tests are performed to screen for bile duct involvement: primary sclerosing cholangitis.

• X-ray, barium enema• Urinalysis

• Stool culture, to rule out parasites and infectious causes.• Erythrocyte sedimentation rate can be measured, with an elevated

sedimentation rate indicating that an inflammatory process is present.• C-reactive protein can be measured, with an elevated level being

another indication of inflammation.

UC: barium enema, endoscopy, biopsy

Medical treatment:

• Aminosalicylates. In 1977 Mastan S.Kalsi et al determined that 5-aminosalicyclic acid (5-ASA and

mesalazine) was the therapeutically active compound in sulfasalazine

Brand name formulations include– Mesalazine, Asacol, Pentasa, Mezavant, Lialda, and

Salofalk.– Sulfasalazine, also known as Azulfidine.– Balsalazide - Disodium, also known as Colazal.– Olsalazine, also known as Dipentum.

• Corticosteroids– Cortisone, Prednisone, Prednisolone, Hydrocortisone– Methylprednisolone– Beclometasone Budesonide - under the brand name of Entocort

• Immunosuppressive drugs– Mercaptopurine, ( 6-Mercaptopurine, 6-MP and Purinetho)l.– Azathioprine, ( Imuran, Azasan or Azamun, which metabolises to 6-

MP).– Methotrexate, which inhibits folic acid– Tacrolimus

• Biological treatment– Infliximab– Visilizumab – Helminthic Therapy (There are currently two closely related treatments

available, either inoculation with Necator americanus, commonly known as hookworms, or Trichuris Suis Ova, (TSO) commonly known as Pig Whipworm Eggs.)

Indications for Surgery

Absolute Relative

1.Fulminant colitis

2. Local complications: - toxic megacolon - massive haemorrhage - frank perforation - peritonitis3. carcinoma

4. growth retardation in pediatric patients

1. Progressive course of dis.

2. Intractebilitydespite maximal medical therapy

3. Flat displasia ІІ-ІІІ gr.

4. Pseudopolyposis, extracolonic manifestations

Operative management

Terminal

ileostomy

J-pouch-rectal

anastomosis

J- or S-pouch-anal

anastomosis

Steps:1. Sigmoid mobilization.

2. AMI transsection.

3. Presacral dissection.

4. Pelvic nerves preserving.

5. Rectovaginal septum dissection.

6. Rectosigmoid transsection

(1st stage).

Steps:6. Splenic flexure

mobilization.

7. Lesser sac entering.

8. A et V CM

transsection.

Steps:9. Ileocolic mobilization.

10. Lateral attachment & hepatic flexure mobilization.

11. Extracorporeal

J-pouch formation.

12. Rectum stump transanal evagination to perineum and supraanal

transsection.

13. J-pouch-rectum circular anastomosis.

Steps:1. Extracorporeal S-pouch formation.

2. Transanal mucosectomy, Ileoanal anastomosing.

.

Steps:2nd stage restorative

J-pouch-rectum

anastomosis, 6 months

after total colectomy with

ileostomy:

no adhesions!!! rectal stump is free in

pelvic cavity; transillumination of the

rectal stump; rectal stump dissection.

• Crohn's disease (also known as regional enteritis) is a chronic, episodic, inflammatory bowel disease (IBD) that affects any part of the entire wall of the bowel or intestines. Crohn's disease can affect any part of the gastrointestinal tract from mouth to anus; as a result, the symptoms of Crohn's disease vary among afflicted individuals. The disease is characterized by areas of inflammation with areas of normal lining between in a symptom known as skip lesions.

• Although the cause of Crohn's disease is not known,

• it is believed to be an autoimmune disease that is genetically linked (Mutations in the CARD15 gene (also known as the NOD2 gene) are associated with Crohn's disease)

• The highest relative risk occurs in siblings, affecting males and females equally.

• Smokers are three times more likely to get Crohn's disease.

CD: affected areas

Pathology

Pathology

CD clinical manifestations

4 typical clinical forms:– In case of terminal ileum involvement ---- like

appendicitis– In case of colon involvement (> 20% ) ---- like UC– Perianal fistulas, abscess– Extraintestinal features

Lennard-Jones algorithm for CD differentiation

• 1) Segmental involvement of the colon;

• 2)Macroscopically non-involved mucosa surrounding affected segments;

• 3)terminal ileitis

• 4)Deep snake-like) ulcers

• 5) Fistulas

• 6) Anal- / Peri-anal involvement

• 7)Granulomas

Diagnosis “ CD” in case: of any 3 criterias (1-6) or

In case of 7-th + any one (1-6)

CD diagnosisCD diagnosis

CD diagnosisCD diagnosis

W.R.Best CDAI

• Remission (CDAI<150);

• Mild (150<CDAI>250);

• moderate (250<CDAI>350);

• Severe (CDAI>350).

Local complications

Indications for Surgery

• Intractability• Intestinal obstruction• Intra-abdominal abscess• Fistulas• Fulminant colitis• Toxic megacolon• Massive bleeding• Cancer• Growth retardation• Extracolonic Manifestations

• Crohn's cannot be cured by surgery, though it is used when partial or a full blockage of the intestine occurs.

• Surgery may also be required for complications such as obstructions, fistulas and/or abscesses, or if the disease does not respond to drugs within a reasonable time.

• After the first surgery, Crohn's usually shows up at the site of the resection though it can appear in other locations.

• After a resection, scar tissue builds up which causes strictures. A stricture is when the intestines becomes too small to allow excrement to pass through easily which can lead to a blockage.

• After the first resection, another resection may be necessary within five years

• What is Microscopic Colitis? • Microscopic Colitis (MC) is the term used to cover two types of bowel inflammation that affect the colon (large

bowel) called Collagenous Colitis and Lymphocytic Colitis. Both these conditions cause watery diarrhoea. MC is classified as a type of Inflammatory Bowel Disease (IBD), but is different from and not usually as severe as the better known types of IBD, Crohn’s Disease and Ulcerative colitis (UC). However, MC appears to be more common than was previously believed, but this may simply be due to greater awareness and better diagnosis of the condition.

• MC gets its name because the large bowel lining looks normal or nearly normal to the naked eye during colonoscopy (a test to look inside your large bowel) and normal on x-ray examination and can only be seen when tissue samples are taken from the colon and examined under the microscope.

• What is the difference between Collagenous and Lymphocytic Colitis? • There is not much difference between Collagenous Colitis and Lymphocytic Colitis and they tend to have the same

symptoms. • Collagenous Colitis (CC) is the term used when a thickened band of tissue made of a protein, called collagen, often

together with an increased number of white blood cells called lymphocytes, are found just beneath the lining of the colon. Lymphocytes are part of the body’s defence system to fight infection and disease. The condition was first described in 1976 by a Swedish pathologist, Dr CG Lindstrom.

• A few years later Dr NW Read described a similar type of colitis, which came to be called Lymphocytic Colitis (LC) by Dr AJ Lazenby. It is similar to CC having a large number of lymphocytes, but there is no continuous band of thickened collagen.

• There has been some debate about whether these two conditions are individual diseases or two stages of one disease. There have been several cases where over time the diagnosis has changed from one to the other.

• How does Microscopic Colitis affect the working of the colon? • When the colon becomes inflamed with MC it becomes less efficient at absorbing the liquid from the stools, resulting

in a larger volume of watery stools. At the same time the inflamed colon cannot hold as much waste as normal, leading to more frequent bowel actions.