Inflammatory Bowel
Disease
4th year MS
2009-2010
Khaled Jadallah, MD
Assistant Professor of Medicine
Gastroenterology, Hepatology & Nutrition
Educational Objectives
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Definitions and spectrum of inflammatory bowel
disease (IBD)
Epidemiology of IBD
Etiopathogenesis of IBD
Clinical manifestations of ulcerative colitis (UC)
Clinical manifestations of Crohn’s disease (CD)
Distinguishing features between UC and CD
Diagnostic approach to IBD
Complications of IBD
IBD management
Inflammatory Bowel Disease
IBD include a group of chronic relapsing disorders that
cause inflammation or ulceration in the small and/or
large intestines. IBD is classified as:
 Ulcerative colitis (UC)- causes ulceration and
inflammation of the mucosa of the colon and rectum
 Crohn's disease (CD) - an inflammation that
extends into the deeper layers of the intestinal wall, and
also may affect other parts or layers of the digestive
tract, including the mouth, esophagus, stomach, and
small intestine
Educational Objectives
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Definitions and spectrum of inflammatory bowel
disease (IBD)
Epidemiology of IBD
Etiopathogenesis of IBD
Clinical manifestations of ulcerative colitis (UC)
Clinical manifestations of Crohn’s disease (CD)
Distinguishing features between UC and CD
Diagnostic approach to IBD
Complications of IBD
IBD management
Epidemiology of IBD
Incidence (US)
Age of onset
Male:female ratio
Smoking
Oral contraceptive
Ulcerative colitis Crohn’s disease
11/100 000
7/100 000
15-30 & 60-80
15-30 & 60-80
1:1
1,1-1,8:1
May prevent
disease
May cause disease
No increased risk Relative risk 1,9
Appendectomy
Not protective
Protective
Monozygotic twins 8% concordance 67% concordance
High
Medium
Low
Educational Objectives
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Definitions and spectrum of inflammatory bowel
disease (IBD)
Epidemiology of IBD
Etiopathogenesis of IBD
Clinical manifestations of ulcerative colitis (UC)
Clinical manifestations of Crohn’s disease (CD)
Distinguishing features between UC and CD
Diagnostic approach to IBD
Complications of IBD
IBD management
Nature
Nurture
IBD
Genes
Environment
Educational Objectives
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Definitions and spectrum of inflammatory bowel
disease (IBD)
Epidemiology of IBD
Etiopathogenesis of IBD
Clinical manifestations of ulcerative colitis (UC)
Clinical manifestations of Crohn’s disease (CD)
Distinguishing features between UC and CD
Diagnostic approach to IBD
Complications of IBD
IBD management
Ulcerative Colitis – clinical presentation
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Patients with proctitis usually pass fresh blood or bloodstained mucus either mixed with stool or streaked onto the
surface of normal or hard stool; tenesmus is a feature
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When the disease extends beyond the rectum, blood is
usually mixed with stool or grossly bloody diarrhea may be
noted
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When the disease is severe, patients pass a liquid stool
containing blood, pus, fecal matter
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Other symptoms in moderate to severe disease include:
anorexia, nausea, vomitting, fever, abdominal pain, weight
loss
Ulcerative colitis – macroscopic features
Mucosa is :
- erythematous, has a granular surface that looks like a sand paper
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In more severe diseases:
- hemorrhagic, edematous and ulcerated
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In fulminant disease a toxic colitis or a toxic megacolon may
develop ( wall becomes very thin and mucosa is severely
ulcerated)
UC
Disease Distribution at Presentation
37%
17%
46%
UC – disease severity
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
> 37,5°C
TACHYCARDIA
none
<90 mean
pulse
>90 mean
pulse
UC – disease severity
MILD
ANEMIA
mild
ESR
<30mm
ENDOSCOPIC
APPEARANCE
Erythema,
decreased vascular
pattern, fine
granularity
MODERATE
>75%
SEVERE
<75%
>30mm
Marked erythema,
coarse granularity,
contact bleeding, no
ulceration
Spontaneous
bleeding, ulceration
Educational Objectives
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Definitions and spectrum of inflammatory bowel
disease (IBD)
Epidemiology of IBD
Etiopathogenesis of IBD
Clinical manifestations of ulcerative colitis (UC)
Clinical manifestations of Crohn’s disease (CD)
Distinguishing features between UC and CD
Diagnostic approach to IBD
Complications of IBD
IBD management
CD: Clinical Features
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Abdominal pain, often postprandial
Diarrhea, usually watery
Rectal bleeding
Weight loss
Right lower quadrant pain/palpable mass
Fever
Growth retardation in children
Perirectal fistula
Crohn’s disease – macroscopic features
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Can affect any part of GI tract from the mouth to the anus
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30-40% of patients have small bowel disease alone
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40-55% of patients have both small and large intestines disease
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15-25% of patients have colitis alone
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In 75% of patients with small intestinal disease the terminal
ileum in involved in 90%
Crohn’s Disease:
Anatomic Distribution
Small bowel
alone
(33%)
Ileocolic
(45%)
Frequency of involvement
Most
Least
Colon alone
(20%)
Crohn’s disease – macroscopic features
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CD is a transmural process
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CD is segmental with skip areas in the midst of
diseased intestine
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In one third of patients with CD perirectal
fistulas, fissures, abscesses, anal stenosis are
present
Crohn’s disease – macroscopic features
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Active CD is characterized by focal
inflammation and formation of fistula tracts
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The bowel wall thickens and becomes narrowed
and fibrotic, leading to chronic, recurrent bowel
obstruction
Crohn’s Disease Activity Index
(CDAI)
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Incorporates 8 variables:
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1. liquid or very soft stools /day
2. Abdominal pain & cramping
3. Extraintestinal manifestations
4. Complications
5. Abdominal mass
6. Use of anti diarrheal medications anti7. Hematocrit
8. Body weight
Crohn’s Disease Red Flags
Onset after stopping smoking
 Bleeding only
 Diverticulosis
 Atherosclerosis
 Prolapse
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Extraintestinal Manifestations
of IBD
 Skin
Erythema nodosum
Pyoderma gangrenosum
 Joints
Peripheral arthritis
Sacroileitis
Ankylosing spondylitis
 Eye
Uveitis
Episcleritis
Iritis
 Hepatobiliary complications
Gallstones
PSC
 Renal complications
Nephrolithiasis
Recurrent UTIs
Educational Objectives
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Definitions and spectrum of inflammatory bowel
disease (IBD)
Epidemiology of IBD
Etiopathogenesis of IBD
Clinical manifestations of ulcerative colitis (UC)
Clinical manifestations of Crohn’s disease (CD)
Distinguishing features between UC and CD
Diagnostic approach to IBD
Medical management of IBD
Indications for and role of surgery
Symptoms of IBD
UC vs CD
Feature
UC
CD
Fever
Uncommon
Common
Rectal bleeding
Common
< ½ of patients
Abdominal
tenderness
Abdominal mass
May be present
Common
Uncommon
Common
Abdominal pain
Uncommon
Very common
Weight loss
Uncommon
Common
Tenesmus
Very common
Uncommon
UC vs CD
Complications/Response to Treatment
UC
CD
Fistulas
No
Yes
Small intestine
obstruction
Colonic
obstruction
Response to
antibiotic
Recurrence after
surgery
No
Frequently
Rarely
Frequently
No
Yes
No
Yes
UC vs CD
Different endoscopic features
UC
CD
Rarely
Frequently
Continuous
disease
„Cobblestoning”
Yes
Occasionally
No
Yes
Granuloma on
biopsy
No
Occasionally
Rectal sparing
Criteria for Indeterminate Colitis
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No evidence of small
bowel involvement,
fistula, or perianal
disease
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Absence of
diagnostic criteria for
CD or UC by
microscopy
Differential Diagnosis of Chronic
Diarrhea and Weight Loss
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Colonic diseases
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IBD
Neoplasia
Ischemic bowel
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Pancreatic
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Chronic pancreatitis
Cancer
Cystic fibrosis
Enteropathic
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Celiac disease
Tropical sprue
Lymphoma
Mesenteric ischemia
Whipple’s disease
Hormonal/drugs
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Vipoma
ZES
Medullary CA of thyroid
NSAIDS use
Educational Objectives
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







Definitions and spectrum of inflammatory bowel
disease (IBD)
Epidemiology of IBD
Etiopathogenesis of IBD
Clinical manifestations of ulcerative colitis (UC)
Clinical manifestations of Crohn’s disease (CD)
Distinguishing features between UC and CD
Diagnostic approach to IBD
Medical management of IBD
Indications for and role of surgery
Diagnostic Approach to Patients
with Suspected IBD
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History……history……history
Clinical exam
Laboratory tests
Radiological imaging
Endoscopy
Special serological testing
Genetic testing
Diagnosis-LAB
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Blood test
CD: Mild anemia, mild leukocytosis, elevated ESR,
elevated CRP, positive ASCA
 UC: Anemia, hypokalemia, hypoalbuminemia,
elevated ESR, elevated LFTs, positive p-ANCA
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Stool analysis
Many WBCs and /or RBCs
 No ova or parasites
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What are the Serological Markers in
IBD?
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pANCA (perinuclear staining pattern)
 Loss of perinuclear pattern after DNAase
 Differentiate from the “other pANCAs”
Antibody against myeloperoxidase
 Antibody against cathepsin G, elastase, lysozyme, and
lactoferrin
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ASCA (anti-Saccharomyces cerevisiae)
 Both IgG and IgA
 Recognize mannose in the cell wall mannan
of Saccharomyces cerevisiae
Why Use Serological Markers in
Clinical Practice?
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Differentiate IBD from functional bowel disorders
Accurately diagnose Crohn’s or UC in a patient with:
 Severe
colitis
 Indeterminate colitis
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Predict disease course or complications in IBD
 CD
phenotype
 Severity of disease
 Risk of pouchitis
Summary
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pANCA and ASCA are specific for UC and CD
respectively
Neither pANCA nor ASCA are sensitive enough to
exclude IBD
In patients with IC, available serological markers do
not accurately predict the subsequent disease course
Antibody profiles can predict disease behavior in
IBD
Diagnostic Approach
Endoscopy
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Endoscopy useful for
Initial diagnosis
 Assessment of severity
 Tissue diagnosis
 F/U during treatment
 Assessment of disease exacerbation
 Surveillance for risk of cancer
 Treatment of certain complications (e.g. strictures)
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Crohn’s Disease
Endoscopic Features
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Asymmetric patchy inflammation
Skip lesions
Rectal sparing
Ulcerations-deep/serpiginous
Cobblestoning-common
Pseudopolyps-rare
Biopsy
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Erosions and normal mucosa
Granulomas in 15 to 35% of specimens
Ulcerative Colitis
Endoscopic Features
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Diffuse involvement
Rectum always diseased
Superficial ulcerations
Friability/bleeding
Flattening/disappearance of haustral folds
Pseudopolyps
No cobblestoning
Bx: No granulomas
Imaging for Crohn Disease
Traditional Techniques
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Abdominal Radiographs
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Barium UGI
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Barium small bowel follow through
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Barium Enteroclysis
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Barium Enema
Imaging for Crohn Disease
Newer Techniques
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CT
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CT Enteroclysis
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CT Enterography
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Magnetic Resonance
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Ultrasound
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Nuclear Medicine
Imaging for Crohns Disease
Summary
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Useful Newer Techniques evolving
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CT Enterography
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Comprehensive evaluation of all bowel & solid organs
Magnetic Resonance
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Useful for ano-rectal disease
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Real-time MR has potential for detection of strictures
Traditional imaging techniques still of value in selected cases
The Capsule (WCE)
WCE
•
•
•
•
•
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Diameter 11mm: Length 26mm
Optical dome: Intestinal illumination by white
light emitting diodes (LED’s)
Lens
Complementary metal-oxide silicone imager
(color camera chip)
Transmitter
Two batteries (silver oxide)
GE Junction
Jejunum
Duodenum
Ileocecal Valve
Educational Objectives









Definitions and spectrum of inflammatory bowel
disease (IBD)
Epidemiology of IBD
Etiopathogenesis of IBD
Clinical manifestations of ulcerative colitis (UC)
Clinical manifestations of Crohn’s disease (CD)
Distinguishing features between UC and CD
Diagnostic approach to IBD
Complications of IBD
IBD management
IBD-Complications
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GI Bleeding
Toxic megacolon
Perforation
Thromboembolic phenomena
Fistulas/fissures
Abscess
Strictures/obstruction
Malabsorption/malnutrition
Cancer
Best Protection
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Surveillance colonoscopy
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Procto-colectomy (for UC)
Descending Colon Stricture
Colonic Strictures
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Consider nonsurgical management if:
Endoscopically accessible
 Multiple prior resections
 Shorter strictures (less than 5 cm)
 Steroid injection if significant inflammation
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Fistula: Definition
A communication between two epithelial-lined organs.
Lifetime risk of fistula in CD:30%
Perianal Fistula
Pretreatment
2 Weeks
10 Weeks
18 weeks
Educational Objectives









Definitions and spectrum of inflammatory bowel
disease (IBD)
Epidemiology of IBD
Etiopathogenesis of IBD
Clinical manifestations of ulcerative colitis (UC)
Clinical manifestations of Crohn’s disease (CD)
Distinguishing features between UC and CD
Diagnostic approach to IBD
Complications of IBD
IBD management
Goals of Therapy for IBD
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Inducing remission
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Maintaining remission
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Restoring and maintaining nutrition
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Maintaining patient’s quality of life
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Prevention of complications
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Surgical intervention (selection of optimal time
for surgery)
Inductive Therapies
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For UC
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Aminosalicylates
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Corticosteroids
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Cyclosporin
For CD
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Aminosalicylates
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Corticosteroids
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Antibiotics
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Anti-TNF
Maintenance Therapies
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Immunosupressors
Azathioprine
 6-MP
 Methotrexate
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Aminosalicylates
Anti-TNF
NOT corticosteroids
IBD Management
Summary
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There is no “one size fits all” to IBD therapy
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Algorithms are based upon available evidence
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Therapy and decision making are tailored to the individual
Evidence is in constant flux
Success of algorithms depends upon optimization of
each step of therapy and considerable judgment about
each outcome
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Skillful application of medical therapy makes all the
difference in outcomes
Surgery for IBD
General Concepts
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Majority will need surgery: 78% over twenty
years
Surgery generally indicated for complications of
disease
Surgery must be directed at area of bowel
responsible for complication
Indications for Surgery
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Intestinal obstruction (most
common)
Intractability/steroid dependence
Non-healing fistula/Abscess
Toxic megacolon/Free
perforation
Uncontrollable GI bleeding
Severe perianal disease
Cancer
Growth retardation (children)
Severe uncontrollable
extraintestinal manifestations
Management of IBD
Summary
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The goals of therapy are
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Treatment depends on
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Relieve symptoms
Prevent relapse
Correct nutritional deficiencies
Control inflammation
Prevent complications, especially colon cancer
􀂃 Type of disease
􀂃 Site of disease
􀂃 Disease severity
Treatment may include drugs , nutrition supplements ,
surgery or a combination of these options