• UC & CD are disorders of modern society: their frequency in developed countries has been increasing since the mid-20th century.

• Children: CD is more prevalent than UC

• The highest incidence & prevalence: Northern Europe & North America

• A westernized environment & lifestyle: Smoking, high fat & sugar diets, stress, & high socioeconomic status

• UC: Smoking is associated with milder disease, fewer hospitalization, & a reduced need for medications.

• UC: Appendectomy in early life is associated with a decreased incidence

• CD: Appendectomy in early life is associated with a increased incidence

• Genetic influences: play a greater role in CD than in UC

• Is genetic screening indicated to assess the risk of UC? NO, (given the large number of implicated genes & the small

additive effect of each)

• Human Microbiome project aims to define the composition of the intestinal microbiota in conditions of health & disease.

• The density of microbiota is greater in IBD patients than in healthy control subjects.

• Risk factors for CRC: – Long duration of the disease (regardless of clinical activity)– Extensive involvement– Severe inflammation– A young age at onset– The presence of PSC– Family history of CRC

• Surveillance colonoscopy for patients at risk: there is no clear evidence that such surveillance increases survival.

• Pancolitis: inflammation up to ileocecal valve, with occasional limited involvement of the distal ileum (Backwash ileitis)

• Better detection of suspicious mucosal patterns & dysplasia: Chromoendoscopy, NBI, & autofluorescence imaging

• UC: – Proctitis may present with constipation

– A small area of inflammation surrounding the appendiceal orifice (cecal patch) can be identified in patients with left sided colitis, proctosigmoiditis, or proctitis.

– Cancer: up to 20-30% after 30 years

• CD: – Video capsule endoscopy

– Single balloon enteroscopy

– Double balloon enteroscopy

Pillcam SB capsule (originally named the M2A capsule)

• Indication for surgery:– Failure of medical therapy– Intractable fulminant colitis– Toxic megacolon– Perforation– Uncontrollable bleeding– Intolerable side effects of medication– Stricture that are not amenable to endoscopic

therapy– Unresectable high-grade or multifocal

dysplasia– DALM (Dysplasia associated lesion or mass)– Cancer– Growth retardation in children

• Unlike CD, UC may respond to probiotics:– Escherichia coli strain Nissle 1917 (200 mg/day) – VSL#3 (3600 colony-forming units/day/for 8 weeks)

• Pouchitis: – An inflammation caused by an immune response to the newly

established microbiota in the ileal pouch (dysbiosis).– Metronidazole, ciprofloxacin, rifaximin. – Probiotics can be effective for preventing recurrence. – Pouch failure is a condition requiring pouch excision or permanent

diversion.

• Suppository: Rectum• Foam enema: Proximal sigmoid• Liquid enema: Splenic flexure

• Rectal 5-ASA induces earlier & better results than oral mesalazine in the treatment of active proctitis. In active left-sided colitis there is proximal colonic stasis & fast colonic transit through the inflamed colon. This results in reduced exposure of the distal colon to the oral agent. The combination of both oral & rectally delivered 5-ASA has greater efficacy & speed of response in patients with distal colitis than either administration route used alone.

• Cyclosporine is only a bridge.

• The expanding use of anti-TNFa agents has not decreased the need for colectomy for UC patients.

• Do not forget these etiologies of acute pancreatitis in a patient with IBD: – AZA– 6-MP– 5-ASA– Sulfasalazine– Steroid

• Granuloma may be seen:– CD– TB– Lymphoma– Behcet's disease– Yersinia

• Toxic megacolon: – Colonic distension (supine film >6 cm)

– Plus at least 3 of the following: • T >38ºC• HR >120• Neutrophilic leukocytosis >10,500• Anemia

– PLUS at least 1 of the following:• Dehydration• Altered sensorium• Electrolyte disturbances• Hypotension

Systemic toxicity

Decreased incidence

Smooth muscle inflammation paralyzes dilatation

Hydrocortisone 100 mg/tid-qid Third generation + Metronidazole