Inflammatory Bowel Disease
Inflammatory Bowel Disease (IBD)
Ulcerative colitis and Crohn's disease
• Chronic inflammatory diseases of the
gastrointestinal tract
• No single finding is diagnostic for these
diseases
• Epidemiological, clinical, laboratory,
imaging and pathological characteristics
• Some patients have a clinical picture that
falls between the two diseases
Case
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23 y old female with 6 weeks diarrhea
Liquid stools no blood
Bowel movement at night
Colicky abdominal pain
Fever to 38°C
Loss of appetite
Weight loss 6 kilograms
Case
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Red painful nodules on the lower leg
Painful knee and wrist joints
Previous history of a perianal abcess
Smokes 20 cigarettes a day for 5 years
Brother with Crohn’s disease
Questions
1. Does the patient have inflammatory
bowel disease?
2. How do we diagnose it?
3. How do we treat the patient?
Differential Diagnosis
Small Intestine
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Infections
Malabsorption
Lymphoma
Ulcerative jejenoileitis
Tuberculosis
NSAID enteropathy
Ischemic bowel
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etiology
epidemiological,
clinical,
laboratory,
imaging
pathology
Differential Diagnosis
Colon
• Infection
• Pseudomembranous
colitis
• Radiation colitis
• Ischemic colitis
• Microscopic colitis
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etiology
epidemiological
clinical
laboratory
imaging
pathology
Diagnosis – Building the Picture
Response
to treatment
Pathology
Imaging
Laboratory
Clinical
Epidemiology
IBD
Epidemiology
IBD
Epidemiology
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23 y old
Female
Jewish
Smoker
Brother with Crohn’s
Cause(s) of IBD
• Genetic
• Infection
• Immunological
Genetic Influence
GEOGRAPHICAL
PREVALENCE OF IBD
Clinical
Epidemiology
IBD
Symptoms
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Diarrhea ± mucus, blood
Abdominal pain
Fever
Loss of appetite
Weight loss
Tiredness and weakness
Symptoms (continued)
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Joint pains, arthritis
Mouth ulcers
Skin rash – erythema nodosum
Perianal abscesses and fistuli
Eye inflammation
Laboratory
Clinical
Epidemiology
IBD
Laboratory
• Infection – stool microscopy and culture
• Malabsorption – stool fat (>6g/day)
• Inflammation –
– Erythrocyte sedimentation rate, CRP
– Anemia: iron deficiency, Vit B12 deficiency,
anemia of chronic disease,
• Nutrition – low albumin
p-ANCA and ASCA in IBD
Imaging
Laboratory
Clinical
Epidemiology
IBD
IBD and Imaging
• Is there inflammation in the digestive tract?
– If not – are there any other relevant processes
• What is the distribution of the inflammation?
• What are the characteristics of the
inflammation?
• Take biopsies during imaging?
Small Intestine and Colon
• Duodenum (60 cm long)
– shortest and widest;
• Jejunum (2.5 m long)
– most of digestion & absorption
• Ileum (longest at 3.5 m)
– water and electrolyte absorption
– ends at ileocecal valve
• Colon (1.5 m long)
– water and electrolyte absorption
Differences Between UC and
Crohn’s Disease
Characteristic Features of
Ulcerative Colitis
Crohn’s Disease
Anatomic Distribution
Crohn’s Disease
Consequences of Transmural
Inflammation
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Inflammatory masses
Fistuli
Intestinal obstruction
Perforation
Ulcerative ColitisImaging Modalities
Colon:
• Plain abdominal X-ray
• Colonoscopy
• Barium enema
• (CT)
Ulcerative Colitis
Colon:
• Plain
abdominal Xray
• Colonoscopy
• Barium enema
• (CT)
Normal Barium Enema
Colon:
• Plain abdominal X-ray
• Colonoscopy
• Barium enema
• (CT)
Ulcerative Colitis
BENIGN STRICTURE
Ulcerative Colitis
Colon:
• Plain abdominal Xray
• Colonoscopy
• Barium enema
• (CT)
Crohn’s Disease
Imaging modalities
• Barium studies
– Small bowel follow through and enteroclysis
– Barium enema
• Endoscopy
– Ileoscopy at colonoscopy
– Upper GI endoscopy and enteroscopy
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CT
Ultrasound
Isotope scan
Capsule endoscopy
X-ray Appearance of Crohn’s
Disease
• Barium studies
– Small bowel follow through
and enteroclysis
– Barium enema
• Endoscopy
– Ileoscopy at colonoscopy
– Upper GI endoscopy and
enteroscopy
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CT
Ultrasound
Isotope scan
Capsule endoscopy
Mesenteric Involvement
Jejenitis
Gastro-duodenitis
Crohn’s Colitis
Early Crohn’s Disease-Terminal
Ileum
• Barium studies
– Small bowel follow through and
enteroclysis
– Barium enema
• Endoscopy
– Ileoscopy and colonoscopy
– Upper GI endoscopy and
enteroscopy
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CT
Ultrasound
Isotope scan
Capsule endoscopy
Crohn’s Colitis
Crohn’s Disease
UC
Crohn’s Disease - Enteroscopy
• Barium studies
– Small bowel follow through and
enteroclysis
– Barium enema
• Endoscopy
– Ileoscopy at colonoscopy
– Upper GI endoscopy and
enteroscopy
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CT
Ultrasound
Isotope scan
Capsule endoscopy
Crohn’s Disease
• Small bowel follow through
and enteroclysis – barium
• Ileoscopy at colonoscopy
• Upper GI endoscopy and
enteroscopy
• CT
• Ultrasound
• Isotope scan
• Capsule endoscopy
Crohn’s Disease - CT
Crohn’s Disease
• Small bowel follow through
and enteroclysis – barium
• Ileoscopy at colonoscopy
• Upper GI endoscopy and
enteroscopy
• CT
• Ultrasound
• Isotope scan
• Capsule endoscopy
Video Capsule Endoscopy in IBD
• 17 patients with suspected CD not
diagnosable by conventional methods
• Iron deficiency anemia (9), abdominal pain
(8), diarrhea (7), weight loss (3)
• 12 (70.6%) patients diagnosed as Crohn’s
• Mean duration of symptoms 7.4 years
Fireman et al
Pathology
Imaging
Laboratory
Clinical
Epidemiology
IBD
Differences Between UC and
Crohn’s Disease
Ulcerative colitis and Crohn’s
disease
UC
• Mucosal disease
Crohn’s Disease
• Transmural
inflammation
Crohn’s Disease-Serosal View
Removed Colon
UC
Crohn’s
Distinguishing Features of
Crohn’s Disease
Colorectal Cancer and IBD
RISK OF COLORECTAL
CANCER
FACTORS MODIFYING RISK
OF COLITIS-ASSOCIATED
CANCER
COLONOSCOPIC
SURVEILLANCE FOR
DYSPLASIA
Extraintestinal Manifestations
Aphthous ulcer
Erythema nodosum
Iritis
Crohn’s Perianal Disease
PERIPHERAL ARTHRITIS
Osteopenia
Skin Lesions
Erythema Nodosum
Pyoderma Gangrenosum
Primary Sclerosing Cholangitis
SCLEROSING CHOLANGITIS
Sclerosing Cholangitis- MR
Cholangiography (MRCP)
IBD in Kibbutzim
Crohn’s Disease
25.5/100,000 in 1987 to
65.1/100,000 in 1997
UC
121/100,000 in 1987 to
167/100,000 in 1997