Inflammatory Bowel Disease
Dr Alex Tebbett
Epidemiology
Crohn’s: Slightly less common (27-106/100,000) Females 1.2:1,Younger (26)
Ulcerative Colitis: Slightly more common (80-150/100,000) Males 1.2:1, Older (34)
Aetiology
Autoimmune, though specifics largely unknown
1. Genetics Polygenic, HLA DRB, Familial (1 in 5)
2. Host immunology Defective mucosal immune system, Inappropriate response to intraluminal bacteriaby Tcells and cytokines
3. Environmental
Crohn’s: Good hygiene/ developed countriesl. Smokers
Ulcerative Colitis: No relation to hygiene. Non smokers
Pathology
Crohn’s affects the terminal illeum most commonly. It can then extend to Ileocolonic disease where it also involves
the ascending colon. It can present throughout the bowel either as skip lesions or as pancolitis. It can also affect the
large bowel only!
Ulcerative Colitis most commonly presents as proctitis. If it extends proximally from the rectum to involve the
sigmoid and descending colon it becomes left sided colitis. If it extrends to the caecum it is pancolitis. If it also affects
the distal terminal ileum it becomes backwash ileitis.
Macroscopic changes
Crohn’s:
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Ulcerative Colitis:
 Reddened mucosa
 Shallow ulcers
 Inflamed and easily bleeds
Bowel is thickened
Lumen is narrowed
Deep ulcers
Mucusal fissures
Cobblestone
Fistulae
Abscess
Microscopic Changes
Crohn’s:
 Chronic inflammatory cells
o transmural
 Lymphoid hyperplasia
 Granulomas
o Langhan’s cells
Ulcerative Coltis:
 Chronic inflammatory cells
o lamina propria
 Goblet cell depletion
 Crypt abscess
Extraintestinal Manifestations
Eyes:
Joints:
Skin:
Condition
Uveitis
Episcleritis
Conjunctivitis
Type 1 Arthropathy (Pauci)
Type 2 Arthropathy (Poly)
Arthralgia
Ankylosing Spondylitis
Inflammatory back pain
Erythema Nodusum
Pyoderma Gangrenosum
Crohn’s
5%
7%
7%
6%
4%
14%
1.2%
9%
4%
2%
Ulcerative Colitis
2%
6%
6%
4%
2.5%
5%
1%
3.5%
1%
1%
Other extraintestinal manifestations
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Anaemia
Kindney stones
Fatty liver
Gallstones
Venous thrombosis
Other autoimmune disease
Sclerosing cholangitis
Differential Diagnosis
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Each other
Infection (unlikely if >10 days)
IBS
Ileocolonic tuberculosis
Lymphomas
Treating IBD
Induce remission
 Steroids – oral or IV
 Enteral nutrition
 Azathioprine / 6MP (Crohns)
Maintain remission
 Aminosalicylates (UC)
 Azathipreine/ 6MP
 Methorexate
Biologicals generally for Crohn’s only
 Infliximab, adalimumab
 Test for TB first!
UC Flares: Truelove-Witts Criteria:
1.
2.
3.
4.
5.
6.
Crohn’s
1. Azathioprine
2. Methotrexate
3. Cyclosporin
4. Humera
Steroids for flares
Ulcerative Colitis
1. Aminosalicylates
1. Mesalazie
2. Steroids
1. Foam/PR
2. Oral
3. IV
3. Azathiorprine
(Acronym: A STATE)
Anemia less than 10g/dl
Stool frequency greater than 6 stools/day with blood
Temperature greater than 37.5
Albumin less than 30g/L
Tachycardia greater than 90bpm
ESR greater than 30mm/hr
Surgical Management
Indications for surgery in Ulcerative Colitis
 Acute:
 Chronic
o Failure Rx for 3 days
o Poor Rx response
o Toxic dilatation
o Excessive steroid use
o Haemorrhage
o Non compliance Rx
o Perforation
o Risk of cancer
(Acronym: I CHOP)
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Infection
Carcinoma
Haemorrhage
Obstruction
Perforation
Prognosis
UC
 1/3 Single attack
 1/3 Relapsing attacks
 1/3 Progressively worsen requiring colectomy within 20 years
Crohn’s
 Varied prognosis, new biological agents improving
Cancer
 Both have increased risk of colon cancer, though UC>Crohn’s
 Screening colonoscopy done every 2 years after 10 years disease and every year after 20 years disease
IBD for clinical finals
Presenting complaint
Crohn’s:
 Diarrhoea
 Abdominal pain
 Weight loss
 Malaise/lethagy
 Nausea/vomiting
 Low grade fever
 Anorexia
Ulcerative Colitis
 Bloody diarrhoea
 Lower abdominal pain
 +/- mucus
 Malaise/lethargy
 Weight loss
 Apthous ulces in mouth
What else to ask?
 Rashes
 Mouth ulcers
 Joint/back pain
 Eye problems
 Family history
 Smoking status
Exploring their condition:
 Previous diagnosed?
 How many flares do they get?
 Are they well managed?
 Do they have any concerns about their
treatment?
 Do they see a specialist?
Examination
General Exam
 Weight loss
 Apthous ulcer of mouth
 Anaemia
 Clubbing
Abdominal Exam
 Colostomy bag
 May be some abdominal tenderness, may not.
 May find a RIF mass
 Abscess
 Inflamed loops of bowel
Anything else?
 Rashes on the shins
“I would also like to examine…”
 Anus
 Crohn’s: Odematous tags, fissures or
abscesses
 Ulcerative colitis: usually normal
 PR
 Ulcerative colitis: blood
Investigations
Bedside
 Stool culture: exclude infection
 Sigmoidoscopy
Bloods
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FBC : anaemia and likely raised WCC
Haematemics: type of anaemia
Inflammartory markers
LFT: hypoalbuminaemia is present in severe
disease, hepatic derrangement
Blood cultures (if septicaemia is suspected)
Serological: pANCA (UC)
Imaging
 Plain AXR: helpful in acute attacks
o Thumb printing/ Lead pipe sign
 Barium follow-through in Crohn’s
 CT
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CXR (Perforation)
USS
Special Tests
 Flexible sigmoidoscopy
 Colonoscopy
o But never in severe attacks of UC due
to high risk of perforation
o May be painful in Crohn’s due to anal
fissures
o Diagnostic
o Surveillance
o UC of more than 10 years duration
increased risk of dysplasia and
carcinoma
 OGD
o For Crohn’s: view of terminal illeum
Management
Manage the patient, not just the disease!
 Medications
 Manage extraintestinal manifestations
o Eg B12 deficiency anaemia
 Manage patient’s symptoms
o Eg loperamide for diarrhoea
 Good nutrition, hydration and vitamin supplements
 Psychosocial impact of disease
o Ileostomy/colostomy bag
o Flares and the need for a toilet
Explanation
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Please explain a colonoscopy to the patient
Please explain an OGD to the patient
Please advise the patient on the side effects of steroids
o Prepare an organised list to reel off, it is a very common question!
Please explain the complications of inflixmab
o Keep calm, remember it’s an immnuosupressent!
How to do well in finals questions
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Have a plan on how to answer questions
o Ix: bedside, bloods, imaging, special tests
o Mx: medical, surgical, psychological, social
acute and long term management
Have a reason for each investigation you’d like to do
Treat the person as well as the disease
Don’t ever forget the MDT!
What else could come up….
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Coeliac disease
IBS
Ischaemic colitis
Diverticular disease
Appendicitis
Polyps
Haemorrhoids
Know the side effects of steroids!
Know the difference between colostomy and ileostomy!
Clinical Scenario
29 year old female, one month history of loose watery stools, increasing in frequency to 12 time per day now.
Occasionally stools have blood and slime mixed in with them. Cramping left iliac fossa pain. Feels unwell and
lethargic. On examination, febrile at 38.2. Has a soft abdomen but slightly distended and tender in the left iliac
fossa. PR examination is very painful and reveals fresh blood and mucus on the glove
acute flare of ulcerative colitis
Questions:
 What are your main differential diagnoses for this lady?
 How would you investigate this patient acutely and long term?
 Initial management in acute setting and the long term management?
 Can you compare the clinical presentation and pathological findings for Crohns and UC?
 Can you tell me the effect of smoking on UC and Crohns?
 What scoring system is used for acute UC?
 What are the extra-intestinal manifestations of IBD?