INFLAMMATORY BOWEL DISEASE
DEFINITIONS
🟡 refers to two chronic idiopathic inflammatory disorders, ulcerative colitis and Crohn disease.
🟡 indeterminate colitis : a term used when Crohn colitis cannot be distinguished from ulcerative colitis.
🟡 Ulceration from Crohn disease may be transmural and may occur anywhere in the gastrointestinal tract,
represent 10% of patients with inflammatory bowel disease.
🟡 The hallmark of ulcerative colitis is continuous ulceration starting in the rectum and limited to the colon.
most commonly in the distal ileum and proximal colon.
EPIDEMIOLOGY AND RISK FACTOR
🟡 occur at any age, but both have their peak incidence in the second to fourth decade, with a second peak
🟡 no gender preference.
in the seventh decade.
🟡 polygenic disorders, for which family history is a risk factor.
🟡 environmental influences.
A)SMOKING
increase the risk of Crohn’s disease . By contrast, there is an increased risk of UC in non- or ex-smokers
and nicotine has been shown to be an effective treatment in one small clinical trial.
B) NSAIDs :
NSAID ingestion is associated with both the onset of IBD and flares of disease in patients with an
established diagnosis.
C) HYAGINE :
Poor and large families living in crowded conditions have a lower risk of developing CD.
D) NUTRITIONAL FACTOR :
Diet does not affect the course of inflammatory bowel disease.
breast-feeding may provide protection against the development of IBD in offspring.
E) PSYCHOLOGICAL FACTOR :
Factors such as chronic stress and depression seem to increase relapses in patients with quiescent
disease.
F) APPENDECTOMY :
This appears to be ‘protective’ against the development of UC .
By contrast, appendicectomy may increase the risk of development of CD.
CLINICAL MANIFESTATIONS
🟡 extraintestinal complications from the disease itself or medications used to treat disease.
🟡 Arthropathy :
1. Peripheral arthralgias
2. arthritis
3. ankylosing spondylitis
4. sacroiliitis
5. avascular necrosis of the hip and septic arthritis are unusual complications of steroids or other
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immunosuppressive therapies.
risk for renal calculi
1. especially calcium oxalate stones , in the setting of fat malabsorption with Crohn disease in the
small bowel.
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2. Uric acid stones can occur in the setting of severe volume depletion.
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Cheilitis may be a result of iron d ciency anaemia
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Secondary amyloidosis with renal involvement can be a consequence of chronic inflammation.
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Asthma is the most common pulmonary disorder with Crohn disease.
peripheral neuropathy from vitamin B12 deficiency, which may occur as a result of poor absorption owing
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to active small bowel disease or surgical resection.
All Primary sclerosing cholangitis (PSC) patients should be screened for IBD with colonoscopy
🟡 other complications :
1. Toxic megacolon (abdominal distention, diarrhoea,colonic dilation on radiograph)
2. Dehydration
3. Spontaneous abortion
4. premature delivery
5. Protein-losing enteropathy
6. Amyloid
7. Colorectal carcinoma
8. Pancreatitis
9. Phlebitis
10. Vasculitis
11. Ureteric obstruction
12. Fatty liver
13. Cholelithiasis
14. Gallstones : Pigment stones in CD
15. Psoriasis
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16. stomatitis
Assessment of severity of a disease flare :
1. Mild to moderate : able to tolerate oral diet; no dehydration, toxicity, abdominal tenderness, mass or
obstruction; for UC, less than 4 stools per day
2. Moderate to severe : Failed treatment for mild to moderate disease or symptoms of fever, weight
loss, abdominal pain and tenderness, intermittent nausea, vomiting, or anaemia ; moderate UC
(greater than 4 stools per day); severe UC (greater than 6 stools per day with signs of toxicity).
3. Severe : Fulminant. Persisting symptoms despite treatment with steroids or high temperature,
persistent vomiting, intestinal obstruction, rebound tenderness, cachexia, or abscess. Fulminant UC
: greater than 10 bloody stools per day, with signs of toxicity; tenderness, distension, dilated colon,
fever, tachycardia.
CROHN DISEASE
🟡 terminal ileum is affected in about 70% of patients with Crohn disease.
🟡 Symptoms include :
1. abdominal pain, typically in the right lower quadrant , upper abdominal pain (if Gastroduodenal
disease)
2. abdominal tenderness is classically in the right lower quadrant
3. right lower quadrant fullness or a mass
4. diarrhoea
5. hematochezia
6. fatigue
7. fever (in severe disease)
8. weight loss (in severe disease)
9. obstructive symptoms, such as abdominal pain, abdominal distention, and nausea.
10. dysphagia
11. odynophagia
12. chest pain
13. heartburn.
14. Rectal examination may reveal skin tags, haemorrhoids, fissure, abscesses and fistulae.
15. Perianal pain and discharge ,
16. Oral ulcers
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17. Peritoneal signs may occur when penetrating Crohn disease causes intestinal perforation.
External fistulas, which present with symptoms of fluid discharge from the cutaneous opening, can be
enterocutaneous or perianal. Internal fistulas can be enteroenteric, rectovaginal, or enterocolonic.
ULCERATIVE COLITIS
🟡 extent of disease :
1. 14 to 37% of patients have pancolitis
2. 36 to 41% have disease extending beyond the rectum
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3. 44 to 49% have proctosigmoiditis
Symptoms include :
1. hematochezia
2. diarrhoea
3. tenesmus
4. production of excessive mucus
5. urgency to defecate
6. abdominal pain.
7. constipation (in proctitis or proctosigmoiditis)
8. difficulty defecating (in proctitis or proctosigmoiditis)
9. fever (in severe disease)
10. weight loss (in severe disease)
11. nausea and vomiting (because of abdominal pain)
12. fatigue )because of anemia)
13. peripheral edema (because of hypoalbuminemia).
DIFFERENTIAL DIAGNOSIS
DIAGNOSIS
LABORATORY TEST
1. Increased CRP
2. Increased ESR
3. leukocytosis
4. anaemia
5. thrombocytosis
6. Faecal calprotectin elevated. (useful for disease monitoring in IBD).
7. Peripheral antineutrophil cytoplasmic antibody (p-ANCA) is elevated in 60% of patients with CD or
UC.
8. Anti–Saccharomyces cerevisiae antibody is elevated in 80% of CD patients.
🟡 pANCA may be positive in UC. This is contrary to CD, where pANCA is usually negative and positive
🟡 Stool studies for ova and parasites, culture, and C. difficile should be obtained to rule out infection
ASCA.
RADIOLOGY
🟡 Barium enema can show mucosal granularity or ulceration (in UC)
🟡 inflammation of the colonic wall is detected on ultrasound, as is the presence of free fluid within the
🟡 Small-bowel series may show ulcerations in between normal mucosa, fistulas (“cobblestoning”), or
abdominal cavity.
🟡 MRI with enterography is also helpful in evaluating CD, particularly of the small intestine.
strictures (in CD)
🟡 CT scan of abdomen and pelvis or CT enterography can also be useful in some cases
MRI of the pelvis is helpful in evaluating rectal or perirectal disease and fistula.
🟡 Radionuclide scans with indium- or technetium-labelled leukocytes are used in some centres to identify
small intestinal and colonic disease inflammation and to localise extraintestinal abscesses.
ENDOSCOPY:
🟡 Colonoscopy in CD :
● in patients presenting with severe disease (in whom a limited unprepared sigmoidoscopy should be
carried out).
● f ings vary from mild, patchy, superficial (aphthoid) ulceration to more widespread, larger and
deeper ulcers that produce a cobblestone appearance
● Endoscopic assessment of the terminal ileum is essential in all patients with suspected CD.
● Two biopsies should be performed in five areas, including the rectum and terminal ileum.
🟡 Capsule endoscopy is used in CD patients when radiological examination is normal. A patency capsule
assessment is often performed first to exclude strictures of the small bowel that would constitute a
contraindication to subsequent capsule endoscopy.
🟡 Colonoscopy in UC :
● Endoscopy with mucosal biopsy is the ‘gold standard’ investigation for the diagnosis of UC.
● allows assessment of disease activity and extent.
● chromoendoscopy is used to diagnose dysplasia , In patients with long-term colitis.
● Full colonoscopy should not be performed in severe attacks of disease for fear of perforation;
instead, a limited unprepared flexible sigmoidoscopy should be used to confirm diagnosis.
UPPER GIT ENDOSCOPY IN CD :
🟡 performed in all patients at diagnosis to define the extent of disease accurately as a guide to prognosis.
and to exclude oesophageal and gastroduodenal disease in patients with relevant symptoms
MANAGEMENT
TREATMENT OF CD
TREATMENT OF UC
