inflammatory bowel disease
Post on 11-May-2015
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Inflammatory Bowel Disease
Dr. Rahul Arora
Inflammatory bowel disease (IBD) is an immune-mediated chronic intestinal condition. Ulcerative colitis (UC) and Crohn's disease (CD) are the two major types of IBD.
Inflammatory Bowel DiseaseIntroduction
Etiology and Pathogenesis
A consensus hypothesis is that in genetically predisposed individuals, both exogenous factors (e.g., normal luminal flora and multiple pathogens like Salmonella sp., Shigella sp., Campylobacter sp., Clostridium difficile ) and host factors (e.g., intestinal epithelial cell barrier function, innate and adaptive immune function) cause a chronic state of dysregulated mucosal immune function that is further modified by specific environmental factors (e.g., smoking and psychosocial factors).
Defective Immune Regulation in IBDIn normals, tolerance may be responsible for the lack of immune responsiveness to dietary antigens and the commensal flora in the intestinal lumen. In IBD this suppression of inflammation is altered, leading to uncontrolled inflammation. The mechanisms of this regulated immune suppression are incompletely known.During the course of infections in the normal host, full activation of the gut-associated lymphoid tissue occurs but is rapidly superseded by dampening the immune response and tissue repair. In IBD this process may not be regulated normally.
The Inflammatory Cascade in IBD
Inflammatory cytokines, such as IL-1, IL-6, and TNF, have diverse effects on tissues. They promote fibrogenesis, collagen production, activation of tissue metalloproteinases, and the production of other inflammatory mediators.
Clinical PresentationInflammatory bowel disease
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 mean >37.5°C mean
Tachycardia None <90 mean pulse >90 mean pulse
Anemia Mild >75% 75%
Sedimentation rate <30 mm >30 mm
Endoscopic appearance
Erythema, decreased vascular pattern, fine granularity
Marked erythema, coarse granularity, absent vascular markings, contact bleeding, no ulcerations
Spontaneous bleeding, ulcerations
Ulcerative Colitis: Disease Presentation
Different Clinical, Endoscopic, and Radiographic Features
Ulcerative Colitis Crohn's Disease
Clinical
Gross blood in stool Yes Occasionally
Mucus Yes Occasionally
Systemic symptoms Occasionally Frequently
Pain Occasionally Frequently
Abdominal mass Rarely Yes
Significant perineal disease
No Frequently
Fistulas No Yes
Small-intestinal obstruction
No Frequently
Colonic obstruction Rarely Frequently
Response to antibiotics No Yes
Recurrence after surgery No Yes
ANCA-positive Frequently Rarely
ASCA-positive Rarely Frequently
Endoscopic
Rectal sparing Rarely Frequently
Continuous disease Yes Occasionally
"Cobblestoning" No Yes
Granuloma on biopsy No Occasionally
Radiographic
Small bowel significantly abnormal
No Yes
Abnormal terminal ileum Occasionally Yes
Segmental colitis No Yes
Asymmetric colitis No Yes
Stricture Occasionally Frequently
Infectious Etiologies
Bacterial
Salmonella
Shigella
Toxigenic Escherichia coli
Campylobacter
Yersinia
Clostridium difficile
Gonorrhea
Chlamydia trachomatis
Mycobacterial
Tuberculosis
Mycobacterium avium
Parasitic
Amebiasis
Isospora
Hookworm
Viral
Cytomegalovirus
Herpes simplex
HIV
Fungal
Histoplasmosis
Candida
Aspergillus
Diseases that Mimic IBD
Noninfectious Etiologies
Inflammatory
Diversion colitis
Collagenous/lymphocytic colitis
Ischemic colitis
Radiation colitis/enteritis
Solitary rectal ulcer syndrome
Eosinophilc gastroenteritis
Neutropenic colitis
Beçhet's syndrome
Graft-versus-host disease
Neoplastic
Lymphoma
Metastatic carcinoma
Carcinoma of the ileum
Carcinoid
Familial polyposis
Drugs and Chemicals
NSAIDs
Phosphasoda
Cathartic colon
Gold
Oral contraceptives
Cocaine
Chemotherapy
IBD is associated with variety of extraintestinal manifestation.
Almost one-third of the patients have at least one.
Extraintestinal manifestation Dermatologic
1.Erythema nodosum occurs in up to 15% of CD patients and 10% of UC patients
The lesions of EN are hot, red, tender nodules measuring to 5cm in diameter and are found on the anterior surface of the legs, ankles, calves, thighs and arms
2. Pyoderma gangrenosum (PG) seen in 1 to 12% of UC patients and is less common in CD colitis.
may occur years before the onset of bowel symptoms.
Lesions are common on the dorsal surface of the feet and legs but may occur on the arms, chest and even face.
pyoderma vegetans, pyostomatitis vegetans, Sweet's syndrome, and metastatic CD.
Psoriasis affects 5–10% of patients with IBD and is unrelated to bowel activity.
Perianal skin tags are found in 75–80% of patients with CD, especially those with colon involvement.
Oral mucosal lesions, seen often in CD and rarely in UC, include aphthous stomatitis and "cobblestone" lesions of the buccal mucosa.
Other Dermatologic Manifestations:
Extraintestinal manifestation Rheumatologic Peripherial arthritis developes in 15 to 20% of IBD
patients, is more common in CD. It is asymmetric, polyarticular and migratory. Most often affects large joints of the upper and lower
extremities
Ankylosing spondylosis (AS) occurs in 10% of IBD.
Sacroilitis is symetrical, occurs equally in UC and CD, often asymptomatic
Extraintestinal manifestation
Ocular The incidence of ocular complications in IBM
patients is 1 to 10% The most common is conjunctivitis, anterior
uveitis, episcleritis Symptoms include: ocular pain, photophobia,
blurred vision, headache
Extraintestinal manifestation
Urologic The most frequent genitourinary complications
are: calculi, ureteral obstruction, fistulas The highest frequency of nephrolithiasis (10-
20%) occurs in patients with CD.
HepatobiliaryCholelithiasis Primary Sclerosing Cholangitis (PSC)
Metabolic bone disorderPatients with IBD have an increased prevelance of osteoporosis secondary to vitamin D deficiency, calcium malabsorption, malnutrition, corticosteroid use.
Thromboembolic Disorders venous and arterial thrombosis
Other DisordersMore common cardiopulmonary manifestations include endocarditis, myocarditis, pleuropericarditis and interstitial lung disease. secondary or reactive amyloidosis. Pancreatitis
Management of Ulcerative Colitis Acute to induce remission1. oral +- topical 5-ASA2. +- oral corticosteroids eg 40mg prednisolone3. Azathioprine (Chronic active)4. iv steroids/Colectomy/ cyclosporin (severe) Maintaining remission1. oral +- topical 5-ASA2. +- Azathioprine (frequent relapses)
Management of Crohn’s Disease
Acute to induce remission1. oral high dose5-ASA2. +- oral corticosteroids 3. Azathioprine (Chronic active)4. Methotrexate (intolerant of azathioprine)5. iv steroids/ metronidazole/elemental
diet/surgery/infliximab Maintaining remission1. Smoking cessation2. oral 5-ASA limited role3. +- Azathioprine (frequent relapses)4. Methotrexate (intolerant of azathioprine)5. Infliximab infusions (8 weekly)
Inflammatory Bowel DiseaseNursing care
Report Sign/Symptoms of patients
Provide emotional support
Skin careRecord frequency of
stools and typeMonitor bowel
soundsVitals and I/O
Watch for dehydration
Monitor Hydration & Electrolytes
Weigh dailyDietary consultWatch for
complicationsIf OR, follow
routine
Oral 5-ASA PreparationPreparation Formulation Delivery Dosing Per Day
Azo-bondSulfasalazine (500 mg) (Azulfadine)
Sulfapyridine-5-ASA
Colon 3–6 g (acute)2–4 g (maintenance)
Olsalazine (250 mg) (Dipentum)
5-ASA-5-ASA Colon 1–3 g
Balsalazide (750 mg) (Colazal)Aminobenzoyl-alanine-5-ASA
Colon 6.75–9 g
Delayed-ReleaseMesalamine (400, 800 mg) (Asacol)
Eudragit S (pH 7) Distal ileum-colon
2.4–4.8 g (acute)1.6–4.8 g (maintenance)
Claversal/Mesasal/Salofalk (250, 500 mg)
Eudragit L (pH 6) Ileum-colon 1.5–3 g (acute)1.5–3 g (maintenance)
Sustained-Release
DRUGS DOSAGE
CORTICOSTEROIDSPrednisone 40–60 mg/day
Budesonide 9 mg/day, then tapered
IMMUNOSUPPRESANTSAzathioprine 2.0–3.0 mg/kg per day
6-Mercaptopurine
1.0–1.5 mg/kg per day(oral)
Methotrexate
25 mg/week per orally
Cyclosporin 2–4 mg/kg per day intravenously
Infliximab(Anti-TNF Antibody)
5 mg/kg per day intravenously
THANK YOU
Differential diagnosis of painful defecation
•Colonic/rectal disorders:1. Infectious agent (bacterial, viral, parasitic) 2. Constipation 3. Colitis or proctitis (inflammation of the colon / rectum). 4. Cancer or polyp 5. Foreign bodies •Perineal(around the anus) disorders:
1. Anal sac abscess or cancer 2. Perineal hernia •Abdominal cavity masses•Pelvic masses or fractures•Prostate disorders
However, in an IBD patient, the normal flora is likely perceived as if it were a pathogen. Anaerobic organisms, particularly Bacteroides and Clostridia species, and some aerobic species such as Escherichia may be responsible for the induction of inflammation. Psychosocial factors can contribute to worsening of symptoms.
Exogenous Factors
Colonic pseudopolyps
DRUGS USED IN IBD1. Prednisone is usually started at doses
of 40–60 mg/d for active UC that is unresponsive to 5-ASA therapy.
2. Budesonide is used for 2–3 months at a dose of 9 mg/d, then tapered.
3. Azathioprine (2.0–3.0 mg/kg per day) 4. 6-MP (1.0–1.5 mg/kg per day)5. MTX (25 mg/week) is effective in
inducing remission and reducing glucocorticoid dosage; 15 mg/week is effective in maintaining remission in active CD.
6. Cyclosporin is most effective given at 2–4 mg/kg per day intravenously in severe UC
7. intravenous infliximab (5 mg/kg)
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