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Inflamatory Bowel Disease
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Inflammatory Bowel Disease
Fernando Vega, M.D.
The Spectrum of IBD
Epidemiology
• CD and UC together 1:400
• UC Prevalence 1:500 • UC Incidence 6-12K/annum• CD Prevalence 1:1000• CD Incidence 3-6K/annum
• Peak age of diagnosis 10-40
Symptoms
• Diarrhoea• Tiredness• Abdominal discomfort• Abdominal discomfort• Rectal mucus• Rectal bleeding
Tests for IBD
• Blood tests• Endoscopic tests• Radiological tests• Radiological tests• Microbiological?
CD or UC?• SB, Colon and rarely elsewhere• Patchy inflammation• Linear ulcers• Transmural disease
• Colon only• Continuous inflammation• Continuous ulcers• Superficial disease
• Fistula• 30% Granulomata• Surgery not curative• Smokers worse off
• No fistula• No granulomata• Cured by colectomy• Smokers ?better off
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Blood tests
• Anaemia• Iron , B12 or folate deficiency• ESR/CRP• ESR/CRP
Endoscopy
UC or CD?
Differential Diagnosis: Endoscopic Appearance
UC CDInvolvement of rectum Rectum often sparedDiffuse erythema Asymmetric inflammationContinuous inflammation Discontinuous inflammationMucosal granularity Aphthous ulcerationMucosal friability Linear/serpiginous ulcersUlceration in inflamed mucosa Discrete ulcersPseudopolyps Cobblestoning
Fistulae
Salena BJ, Hunt RH. In: Inflamatory Bowel Disease. From Bench to Bedside. 1994:352-365.
UC: Location and Extent
Percentages based on extent of disease at diagnosis.
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Differential Diagnosis: Colonoscopic Biopsy
UC CDAll samples inflamed Normal samples
Distal biopsy specimens most severe No pattern of inflammation
Mucosal disease Transmural disease
Geller SA. In: Inflammatory Bowel Disease. From Bench to Bedside. 1994:336-351.
Goblet cells reduced Goblet cells may be normal
Crypt abscess Mononuclear infiltrate
Capillary and venule engorgement Lymphangiectasia
No granulation tissue/fibrosis Granulation tissue/fibrosis
No granulomata Granulomata
CD or UC?
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Crohns diseaseCD: Location and Extent
Upper GI
Extraintestinal Manifestations of UC and CD
• Oral Aphthous ulcers • Iritis, uveitis or episcleritis• Seronegative Arthritis, AS• Erythema nodosum• Pyoderma gangrenosum• Thromboembolism• Autoimmune haemolysis• Clubbing PSC• Osteoporosis
Inflamatory Bowel Disease
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Scleritis in IBD
Courtesy of J-F Colombel, MD.
Uveitis in IBD
Courtesy of J-F Colombel, MD.
Sclerosing Cholangitis in IBD
Courtesy of J-F Colombel, MD.
Risk of Bowel Cancer is 1% yearly after 8 years.
• Pancolitis –colonoscope at 8 years post diagnosisEvery 3 years in 2nd decadeEvery 3 years in 2nd decade Every 2 years in 3rd decade and then annually.
Left sided colitis –Colonoscope at 15 years post diagnosis
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Differential Diagnosis of UC• Infection• Ischemia• Diversion,
pseudomembranous, or radiation colitisradiation colitis
• Physical agent• Immunologic etiologies• Systemic disease• CD• Irritable bowel syndrome
Differential Diagnosis of CD
• Lymphoma• Infectious etiologies• Appendicitis• Appendicitis• Diverticulitis• Carcinoma• UC• Coeliac disease
Pseudomembranous colitis
Tuberculous Colitis
Differential Diagnosis: Infectious Colitides
• Bacterial– Campylobacter sp– Salmonella sp– Shigella sp
Clostridium difficile
• Parasitic– Entamoeba histolytica– Schistosomiasis
• Viral– Clostridium difficile– Escherichia coli– Noncholera vibrios– Aeromonas sp– Yersinia enterolitica– Tuberculosis– Histoplasmosis
Surawicz CM. Contemp Intern Med. 1991;3:17-27.
– Cytomegalovirus– Herpes simplex virus type II– Human immunodeficiency
virus
IBD treatment
• Induction of remission• Maintenance• Acute exacerbations• Acute exacerbations• Nutritional aspects• Medical-Surgical interface
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DrugTreatment of UC• Aminosalicylates (PO/PR)• Mesalazine, also known as 5-aminosalicylic acid, 5-ASA, Asacol, Pentasa and Mesalamine. • Sulphasalazine• Balsalazide, also known as Colazal. • Olsalazine, also known as Dipentum.
• Corticosteroids (PO/PR)• prednisolone• hydrocortisone
• Immunosuppressive drugs • 6-mercaptopurine, also known as 6-MP• Azathioprine, also known as Imuran (US) which metabolises to 6-MP. • Cyclosporin• Infliximab
Drug treatment of CD• Aminosalicylates • Mesalazine, also known as 5-aminosalicylic acid, 5-ASA, Asacol, Pentasa and
Mesalamine. • Sulphasalazine
• Antibiotics• Antibiotics• Metronidazole
• Corticosteroids • prednisolone• hydrocortisone
• Immunosuppressive drugs • 6-mercaptopurine, also known as 6-MP• Azathioprine, also known as Imuran (US) which metabolises to 6-MP. • Methotrexate• Infliximab
An ill colitic
• Fever• Tachycardia• Bloody loose stools• Bloody loose stools• ESR• Haemoglobin• Criteria from 1955.
Since 1955Criteria of Trulove and Witts for Assessing
Disease Activity in Ulcerative Colitis7
Mild Activity Severe Activity
Daily bowel movements (no.)
< or = to 5 > 5
Hematochezia Small amounts Large amounts
Temperature < 37.5°C > or = to 37.5°C
Pulse < 90/min > or = 90/min
Erythrocyte sedimentation rate
< 30 mm/h > or = to 30 mm/h
Hemoglobin > 10 g/dl < or = to 10 g/dl
•Patients with fewer than all 6 of the above criteria for severe activity have moderately active disease.
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Natural Course of UC• Recurrence rates vary according to
anatomic extent at diagnosis• Study of 1,161 patients
– 44% had ulcerative proctosigmoiditis36% had substantial colitis– 36% had substantial colitis(left-sided and extensive)
– 18% had pancolitis– In 1.5% the initial disease extent
was unknown
Langholz E et al. Scand J Gastroenterol. 1996;31:260-266.
Natural Course of UC: Proctosigmoiditis
Course Patients (%)Progression of disease 39
Langholz E et al. Scand J Gastroenterol. 1996;31:260-266.
Surgery 12
Natural Course of UC: Pancolitis
Course Patients (%)
Regression 59
P ti l 33Partial 33
Complete 26
Surgery 39
Langholz E et al. Scand J Gastroenterol. 1996;31:260-266.
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Intermittent Course of CD
Mekhjian HS, et al. Gastroenterology. 1979;77:898-906.
CD: Cumulative Probability of Surgery
Mekhjian HS et al. Gastroenterology. 1979;77:907-913.*Kaplan–Meier analysis.
Postsurgical Recurrence of CD
McLeod RS, et al. Gastroenterology. 1997;113:1823-1827.
Recurrence After Surgery in CD
Rutgeerts P et al. Gastroenterology. 1990;99:956-963.