DISEASES OF LARGE DISEASES OF LARGE INTESTINEINTESTINE

Lykhatska G.V.Lykhatska G.V.

IRRITABLE BOWEL IRRITABLE BOWEL SYNDROMESYNDROME

IRRITABLE BOWEL IRRITABLE BOWEL SYNDROMESYNDROME

-functional disorders-functional disorders,,which which characterized by abdominal paincharacterized by abdominal pain,, defecation disorders without specific defecation disorders without specific organic pathology organic pathology which last more which last more than 12 weeks per yearthan 12 weeks per year

Risk factorsRisk factors

Violations onViolations on diet dietgynecological diseasesgynecological diseasesviolation intestinal microbiocenosisviolation intestinal microbiocenosis

In the pathogenesis, the main role In the pathogenesis, the main role ––intestinal dysmotility and visceral

hypersensitivity

Clinical features of IBSClinical features of IBS

Rome criteria for the Rome criteria for the diagnosis of IBSdiagnosis of IBS

IBSIBS:: SUMMARY SUMMARY

Treatment IBSTreatment IBS Diet 4 and regimen Diet 4 and regimen Antidepressants(amitriptyline 25-50 mg at Antidepressants(amitriptyline 25-50 mg at

bedtime)bedtime) Spasmolytic drugs (dyspatalin 200mg 2 times Spasmolytic drugs (dyspatalin 200mg 2 times

a daya day;;ditsetel 10-50 mg 3 times per day during ditsetel 10-50 mg 3 times per day during 2-4 weeks or more2-4 weeks or more

Laxatives(mukofalkLaxatives(mukofalk,,laktulozalaktuloza,,forlaks)individualforlaks)individuallyly

Antidiarrhea Antidiarrhea drugs(loperamyddrugs(loperamyd,,smekta)individuallysmekta)individually

Psychotherapy(hypnotherapyPsychotherapy(hypnotherapy,,acupuncture)acupuncture) Correction of bowel microflore Correction of bowel microflore

injuries(probiotics-bifi-forminjuries(probiotics-bifi-form,,linexlinex,,symbiter)symbiter)

IBS treatment scheme (with IBS treatment scheme (with prevailing diarrhea)prevailing diarrhea)

Antidiarrhea drugs (loperamid 2-12 Antidiarrhea drugs (loperamid 2-12 mg dailymg daily,,

Cytoprotective drugs (smekta 1-2 Cytoprotective drugs (smekta 1-2 packs 3 times)packs 3 times),,

Enterosorbents(enterosgelEnterosorbents(enterosgel,,poliferan poliferan 1spoon 3 times a day)1spoon 3 times a day)

psychotherapypsychotherapy

IBS treatment scheme (with IBS treatment scheme (with prevailing constipation) prevailing constipation)

Osmotic laxatives (laktuloza 10-30 Osmotic laxatives (laktuloza 10-30 ml 1-2 times a dayml 1-2 times a day,, mukofalk 1-2 mukofalk 1-2 packs 1-3 times a day during meals)packs 1-3 times a day during meals)

Prokinetic drugs(domperidonProkinetic drugs(domperidon,,primer primer 10mg 3 times a day)10mg 3 times a day)

Antidepressants or antagonists (5-Antidepressants or antagonists (5-HT4 receptors 1 tab(6mg)2 times a HT4 receptors 1 tab(6mg)2 times a day before meals)day before meals)

IBS treatment scheme (with pain IBS treatment scheme (with pain syndrom prevailing)syndrom prevailing)

Spasmolytic drugs(duspatalin 200mg Spasmolytic drugs(duspatalin 200mg 2 times a day2 times a day,,ditsetel 50-100mg 3 ditsetel 50-100mg 3 times a day)times a day);;

Antidehressants(amitryptylin 25-Antidehressants(amitryptylin 25-50mg before sleep50mg before sleep,,fluoksetyn 20mg fluoksetyn 20mg once a day)once a day)

ULCERATIVE ULCERATIVE COLITISCOLITIS

EtiologyEtiology

The cause of ulcerative colitis is The cause of ulcerative colitis is unknownunknown

DefinitionDefinition

ULCERATIVE COLITIS -ULCERATIVE COLITIS - A chronic, inflammatory, and A chronic, inflammatory, and ulcerative disease arising in ulcerative disease arising in the colonic mucosa, the colonic mucosa, characterized most often by characterized most often by bloody diarrheabloody diarrhea

ULCERATIVE COLITISULCERATIVE COLITIS Clinical pictureClinical picture

Bloody diarrheaBloody diarrhea The stools may be watery, may contain The stools may be watery, may contain

mucus, and frequently consist almost mucus, and frequently consist almost entirely of blood and pusentirely of blood and pus

Abdominal painAbdominal pain Fever Fever Anorexia Anorexia Weight lossWeight loss MalaiseMalaise

The endoscopic spectrum The endoscopic spectrum of of ULCERATIVE COLITISULCERATIVE COLITIS includesincludesaa) mucosal edema, ) mucosal edema, erythema, loss of erythema, loss of vasculature;vasculature;bb) granular mucosa with ) granular mucosa with pinpoint ulceration and pinpoint ulceration and friability;friability;cc) regenerated (i.e., ) regenerated (i.e., healed) mucosa with healed) mucosa with distorted mucosal distorted mucosal vasculature;vasculature; dd) regenerated mucosa ) regenerated mucosa withwith typical typical postinflammatory postinflammatory pseudopolypspseudopolyps

IIt’t’s air-contrast radiograph of s air-contrast radiograph of ULCERATIVE ULCERATIVE COLITISCOLITIS, the mucosal pattern is granular with , the mucosal pattern is granular with loss of normalloss of normal haustrations in a diffuse, haustrations in a diffuse,

continuous patterncontinuous pattern

ULCERATIVE COLITISULCERATIVE COLITIS

ComplicationsComplications

BleedingBleeding Toxic Toxic megacolonmegacolon

PerforationPerforation ColonColon cancercancer

ULCERATIVE COLITISULCERATIVE COLITIS

Extracolonic problems Extracolonic problems Peripheral arthritisPeripheral arthritisAnkylosing spondylitisAnkylosing spondylitisSacroiliitisSacroiliitisAnterior uveitisAnterior uveitisErythema nodosumErythema nodosumPyoderma gangrenosumPyoderma gangrenosumEpiscleritisEpiscleritis Primary sclerosing cholangitis Primary sclerosing cholangitis

Erythema nodosum on the Erythema nodosum on the sskkinin

Pyоderma gangrenosum Pyоderma gangrenosum seen in UCseen in UC

Episcleritis in UCEpiscleritis in UC

CLASSIFICATION OFCLASSIFICATION OF ULCERATIVE COLITISULCERATIVE COLITIS

according to theaccording to thedegree of expressiveness of clinical degree of expressiveness of clinical

manifestationsmanifestations

CLASSIFICATIONCLASSIFICATION

MILDMILDCOURSECOURSE

MODERATEMODERATE COURSECOURSE

SEVERE SEVERE COURSECOURSE

MILDMILD

COURSECOURSEMODERATEMODERATE

COURSECOURSESEVERE SEVERE

COURSECOURSE

DefecatioDefecation n frequencyfrequency

<4<4 >6>6 >10>10

BleedingBleeding mildmild profuseprofuse ContinuouContinuouss

FeverFever -- >37,5 ˚C>37,5 ˚C >38,8 ˚C>38,8 ˚C

HemogloHemoglobin g/lbin g/l

>100>100 <100<100 <80<80

ESR, ESR, mm/hourmm/hour

<30<30 >30>30 >50>50

Albumin, Albumin, g/lg/l

NormNorm 30-4030-40 <30<30

DIFFERENTIALDIFFERENTIAL DIAGNOSISDIAGNOSISCrohn's Crohn's DiseaseDisease Ulcerative Ulcerative ColitisColitis

Small bowel is involved Small bowel is involved in in 80% 80% of casesof cases

Disease is confined to Disease is confined to the colon. the colon.

Rectosigmoid Rectosigmoid is often is often spared; colonic spared; colonic involvement is usually involvement is usually right-sided. right-sided.

Rectosigmoid Rectosigmoid is is invariably involved; invariably involved; colonic involvement is colonic involvement is usually left-sided.usually left-sided.

Gross rectal bleeding is Gross rectal bleeding is absent in absent in 15-25% 15-25% of of cases.cases.

Gross rectal bleeding is Gross rectal bleeding is always present.always present.

Fistula, mass, and Fistula, mass, and abscess development is abscess development is common.common.

Fistulas do not occur.Fistulas do not occur.

Perianal Perianal lesions are lesions are significant in significant in 25-35%.25-35%.

Significant perianal Significant perianal lesions never occur.lesions never occur.

DIFFERENTIALDIFFERENTIAL DIAGNOSISDIAGNOSISCrohn's Crohn's DiseaseDisease Ulcerative Ulcerative ColitisColitis

On x-ray, bowel wall is On x-ray, bowel wall is affected affected asymmetrically and asymmetrically and segmentally, with segmentally, with "skip areas" between "skip areas" between diseased segments.diseased segments.

Bowel wall is affected Bowel wall is affected symmetrically and symmetrically and uninterruptedly from uninterruptedly from rectum proximally rectum proximally ((ahaustralahaustral ColonColon).).

Endoscopic Endoscopic appearance is patchy, appearance is patchy, with discrete with discrete ulcerations separated ulcerations separated by segments of by segments of normal-appearing normal-appearing mucosa.mucosa.

Inflammation is uniform Inflammation is uniform and diffuse (and diffuse (continuous continuous superficial superficial inflammationinflammation

with granularwith granular))

DIFFERENTIALDIFFERENTIAL DIAGNOSISDIAGNOSISCrohn's Crohn's DiseaseDisease Ulcerative Ulcerative ColitisColitis

Microscopic Microscopic inflammation and inflammation and fissuring extend fissuring extend transmurally; lesions transmurally; lesions are often highly focal are often highly focal in distribution.in distribution.

Inflammation is Inflammation is confined to mucosaconfined to mucosa ((ddiffuse, continuous, iffuse, continuous, superficial superficial inflammationinflammation) except In ) except In severe cases.severe cases.

Epithelioid Epithelioid (sarcoid-(sarcoid-like) granulomas like) granulomas detected in bowel wall detected in bowel wall or lymph nodes in or lymph nodes in 25-25-50% 50% of cases of cases (pathognomonic).(pathognomonic).

Typical epithelial Typical epithelial granulomas do not granulomas do not occur.occur.

ULCERATIVE COLITISULCERATIVE COLITIS TreatmentTreatment

Diet Diet № № 44 Aminosalicilates (Aminosalicilates (SulfasalazineSulfasalazine, ,

Salofalk)Salofalk) Corticosteroid Corticosteroid therapy (Budesonid, therapy (Budesonid,

Prednizolon)Prednizolon) Immunosuppressive drugsImmunosuppressive drugs

(Azathioprine)(Azathioprine) Antidiarrheal drugsAntidiarrheal drugs - - loperamide, loperamide,

Anticholinergics, digestive enzymes, Anticholinergics, digestive enzymes, transfusions, vitamin transfusions, vitamin therapy

DISEASES OF SMALL DISEASES OF SMALL INTESTINE INTESTINE

CROHN’S CROHN’S DISEASEDISEASE

DefinitionDefinition

CROHN’S CROHN’S DISEASE DISEASE A nonspecific chronic transmural A nonspecific chronic transmural inflammatory disease that most inflammatory disease that most commonly affects the distal ileum commonly affects the distal ileum and colon but may occur in any and colon but may occur in any part of the GI tract.part of the GI tract.

PLANPLANCROHN’S CROHN’S DISEASE DISEASE (CD)(CD)

Etiology and Etiology and

Epidemiology of Epidemiology of CROHN’S CROHN’S DISEASEDISEASE Pathology of Pathology of CROHN’S CROHN’S DISEASEDISEASE Clinical picture of Clinical picture of CROHN’S CROHN’S DISEASEDISEASE Diagnosis of Diagnosis of CROHN’S CROHN’S DISEASEDISEASE Differential Diagnosis of Differential Diagnosis of CROHN’S CROHN’S

DISEASEDISEASE Prognosis of Prognosis of CROHN’S CROHN’S DISEASEDISEASE Treatment of Treatment of CROHN’S CROHN’S DISEASEDISEASE

EtiologyEtiology

The fundamental cause of The fundamental cause of Crohn's disease is unknownCrohn's disease is unknown

DISEASES OF SMALL DISEASES OF SMALL INTESTINE INTESTINE

The spectrum of The spectrum of CROHN DISEASECROHN DISEASE presentations includes presentations includes

gastroduodenitis, jejunoileitis and gastroduodenitis, jejunoileitis and ileitis, ileocolitis, ileitis, ileocolitis, ccolitisolitis

7% 33%

45% 15%

CROHN’S CROHN’S DISEASEDISEASE Clinical pictureClinical picture

Abdominal pain (77%)Abdominal pain (77%) Chronic diarrhea (73%)Chronic diarrhea (73%) Bleeding (22%) Bleeding (22%) Anal Fistulas (16%)Anal Fistulas (16%) Anorexia Anorexia A right lower quadrant mass or A right lower quadrant mass or

fullnessfullness

CROHN’S CROHN’S DISEASEDISEASE Extraintestinal Extraintestinal manifestationsmanifestations Weight loss (54%)Weight loss (54%)

Fever (35%)Fever (35%) Anemia (27%)Anemia (27%) Peripheral arthritisPeripheral arthritis (16%) (16%) Ophtalmic diseases Ophtalmic diseases

((Episcleritis,Episcleritis, 10%) 10%) Aphthous stomatitisAphthous stomatitis Erythema nodosum (2%)Erythema nodosum (2%) Pyoderma gangrenosumPyoderma gangrenosum

Endoscopic Endoscopic sspectrum of Cpectrum of CDD includesincludes a) a) aphthous aphthous ulcerations amid ulcerations amid normal colonic normal colonic mucosalmucosal vasculature;vasculature; b) b) deeper, punched-deeper, punched-out ulcers in ileal out ulcers in ileal mucosa; mucosa; cc)) a single colonic a single colonic linear ulcer;linear ulcer; dd)) deep colonic deep colonic ulcerations ulcerations forming a forming a stricture.stricture.

CROHN’S CROHN’S DISEASEDISEASEDIAGNOSISDIAGNOSIS

x-rayx-ray:: Barium enema x-ray may Barium enema x-ray may show reflux of barium into the show reflux of barium into the terminal ileum with irregularity, terminal ileum with irregularity, nodularity, stiffness, wall thickening, nodularity, stiffness, wall thickening, and a narrowed lumen. A small-and a narrowed lumen. A small-bowel series with spot x-rays of the bowel series with spot x-rays of the terminal ileum usually most clearly terminal ileum usually most clearly shows the nature and extent of the shows the nature and extent of the lesion. An upper GI series without lesion. An upper GI series without small-bowel follow-through usually small-bowel follow-through usually misses the diagnosis.misses the diagnosis.

X-ray showing abnormal X-ray showing abnormal terminal ileum in Crohn's terminal ileum in Crohn's

diseasedisease

Laboratory findingsLaboratory findingsLaboratory findings are nonspecificLaboratory findings are nonspecific::

--anemia,anemia,

--leukocytosis,leukocytosis,

--hypoalbuminemia, hypoalbuminemia,

- - ↑↑ ESR, C-reactive proteins. ESR, C-reactive proteins.

Elevated alkaline phosphatase and γ-Elevated alkaline phosphatase and γ-glutamyltranspeptidase glutamyltranspeptidase accompanying colonic disease often accompanying colonic disease often reflect primary sclerosing cholangitis.reflect primary sclerosing cholangitis.

CROHN’S CROHN’S DISEASEDISEASEDIFFERENTIALDIFFERENTIAL DIAGNOSISDIAGNOSIS

Ulcerative colitis Ulcerative colitis Acute Acute

appendicitisappendicitis Pelvic Pelvic

inflammatory inflammatory diseasedisease

Ectopic Ectopic pregnancypregnancy

Ovarian cystsOvarian cysts

Cancer of the cecumCancer of the cecumLymphosarcomaLymphosarcomaSystemic vasculitisSystemic vasculitisRadiation enteritisRadiation enteritis Ileocecal TBIleocecal TB AIDS-related oppor AIDS-related oppor

tunistic infections tunistic infections ((cytomegalovirus) cytomegalovirus)

DIFFERENTIALDIFFERENTIAL DIAGNOSISDIAGNOSISCrohn's Crohn's DiseaseDisease Ulcerative Ulcerative ColitisColitis

Small bowel is involved Small bowel is involved in in 80% 80% of casesof cases

Disease is confined to Disease is confined to the colon. the colon.

Rectosigmoid Rectosigmoid is often is often spared; colonic spared; colonic involvement is usually involvement is usually right-sided. right-sided.

Rectosigmoid Rectosigmoid is is invariably involved; invariably involved; colonic involvement is colonic involvement is usually left-sided.usually left-sided.

Gross rectal bleeding is Gross rectal bleeding is absent in absent in 15-25% 15-25% of of cases.cases.

Gross rectal bleeding is Gross rectal bleeding is always present.always present.

Fistula, mass, and Fistula, mass, and abscess development is abscess development is common.common.

Fistulas do not occur.Fistulas do not occur.

Perianal Perianal lesions are lesions are significant in significant in 25-35%.25-35%.

Significant perianal Significant perianal lesions never occur.lesions never occur.

The typical perianal skin The typical perianal skin tag of Crohn's tag of Crohn's DiseaseDisease

DIFFERENTIALDIFFERENTIAL DIAGNOSISDIAGNOSISCrohn's Crohn's DiseaseDisease Ulcerative Ulcerative ColitisColitis

On x-ray, bowel wall is On x-ray, bowel wall is affected affected asymmetrically and asymmetrically and segmentally, with segmentally, with "skip areas" between "skip areas" between diseased segments.diseased segments.

Bowel wall is affected Bowel wall is affected symmetrically and symmetrically and uninterruptedly from uninterruptedly from rectum proximally rectum proximally ((ahaustralahaustral ColonColon).).

Endoscopic Endoscopic appearance is patchy, appearance is patchy, with discrete with discrete ulcerations separated ulcerations separated by segments of by segments of normal-appearing normal-appearing mucosa.mucosa.

Inflammation is uniform Inflammation is uniform and diffuse (and diffuse (continuous continuous superficial superficial inflammationinflammation

with granularwith granular))

DIFFERENTIALDIFFERENTIAL DIAGNOSISDIAGNOSISCrohn's Crohn's DiseaseDisease Ulcerative Ulcerative ColitisColitis

Microscopic Microscopic inflammation and inflammation and fissuring extend fissuring extend transmurally; lesions transmurally; lesions are often highly focal are often highly focal in distribution.in distribution.

Inflammation is Inflammation is confined to mucosaconfined to mucosa ((ddiffuse, continuous, iffuse, continuous, superficial superficial inflammationinflammation) except In ) except In severe cases.severe cases.

Epithelioid Epithelioid (sarcoid-(sarcoid-like) granulomas like) granulomas detected in bowel wall detected in bowel wall or lymph nodes in or lymph nodes in 25-25-50% 50% of cases of cases (pathognomonic).(pathognomonic).

Typical epithelial Typical epithelial granulomas do not granulomas do not occur.occur.

Enterocutaneous fistulae in Enterocutaneous fistulae in Chrohn'sChrohn'sdiseasedisease

CROHN’S CROHN’S DISEASEDISEASETreatmentTreatmentDiet Diet № № 44

Aminosalicilates (Aminosalicilates (SulfasalazineSulfasalazine, , Salofalk)Salofalk)

Corticosteroid Corticosteroid therapy (Budesonid, therapy (Budesonid, Prednizolon)Prednizolon)

Immunosuppressive drugsImmunosuppressive drugs (Azathioprine)(Azathioprine)

Antibacterial drugs (metronidazole, Antibacterial drugs (metronidazole, NifuroxazideNifuroxazide

Symptomatic treatmentSymptomatic treatment (antidiarrheal drugs(antidiarrheal drugs - - loperamide, loperamide, Anticholinergics)Anticholinergics)