Inflammatory Bowel Disease

INTRODUCTION

• IBD is an idiopathic disease , probably involving an immune reaction of the body to its own intestinal tract

• Crohn’s disease (CD)

• Ulcerative colitis (UC)

INTRODUCTION

• CD is a condition of chronic granulomatous inflammation potentially involving any location of the GIT from mouth to anus.

• UC is an non granulomatous inflammatory disorder that affects the rectum and extends proximally to affect variable extent of the colon.

EPIDEMIOLOGY

• UC:

15-40 yrs (Young adults)No variation between between men and women or

between socioeconomic groupHigh incidence areas: USA and northern-western

EuropeMore common in non-smokers

EPIDEMIOLOGY CD

1st peak 15-30 years of age, 2nd peak around 60 y

Marginally more common in females

High incidence areas: North America, UK,northern

Europe

More common in smokers

ETIOLOGY

• Immunology

• Initiating pathogen

• Environmental Factors

• Genetic factors

SYMPTOMS UC:

• Rectal bleeding or bloody diarrhea

• Pain of colonic origin, often left sided and related to defecation

CD:

• Diarrhea

• Recurrent abdominal pain

• Anorectal lesions, Anorexia, Anemia

• Malnutrition (weight loss)

• Fever

INVESTIGATIONS

• Endoscopy

• Colonoscopy

• Histopathology

• Radiology

• Hematological tests and microbiological stool test for

infection

UC CD

ESR elevation

Hypoalbuminemia

Anaemia

Electrolyte imbalance

Leucocytosis

ESR ↑

Hypoalbuminemia

Anaemia

LABORATORY INVESTIGATION

Feature UC CD

Location Only colon GIT

Anatomic

distribution

Continuous, begins

distally

Skip lesions

Rectal involvement Involved in >90% Rectal spare

Gross bleeding Universal Only 25%

Peri-anal disease Rare 75%

Fistulization No Yes

Granulomas No 50-75%

DISTINGUISHING CHARACTERISTICS OF CD AND UC

Feature CD UC

Transmural inflammation Yes Uncommon

Granulomas 50-75% No

Fissures Common Rare

Fibrosis Common No

Submucosal inflammation Common Uncommon

PATHOLOGIC FEATURES OF CD AND UC

UC CD

Collar button ulcers Nodularity

Granularity

RADIOLOGIC FEATURES OF CD AND UC

PATHOPHYSIOLOGY

• Bacterial antigens are taken up by specialized M cells, pass between leaky epithelial cells or enter the lamina propria through ulcerated mucosa

• After processing they are presented on type 1 T-helper cells by antigen presenting cells (APC) in the lamina propria.

• T-cell activation and differentiation results in Th1 T cell mediated cytokine response

• With the secretion of cytokines including gamma interferon (IFNƴ)

PATHOPHYSIOLOGY

• Further amplification of T cells perpetuates the inflammatory process with activation of non immune cells and release of the important cytokines.

• Eg: IL-12, IL-23, IL-1, IL-6 and tumor necrosis factor (TNF)

• These pathways occur in all normal individual exposed to inflammatory insults and this is self limiting in healthy subjects

• In genetically predisposed persons, dysregulation of innate immunity may trigger inflammatory bowel disease.

MANAGEMENT OF IBD

Non-pharmacological

• Initial tretment is nonoperative Stop Smoking (for crohn’s disease)

• Nutrition

PHARMACOLOGICAL

• Aminosalicilates (5-ASA): sulfasalazine, mesalazine, olsalazine

• Corticosteroids : Budesonide, presnisolone, methylprednisolone

• Immunosuppressants: azathioprine , 6-mercaptopurine

• Antibiotics : metronidazole, ciprofloxacin

• Anti diarrhoals : loperamide, Diphenoxylate & atropine

PHARMACOLOGICAL

• Antispasmodic agent: Dicyclomine

• Immunoglobulin - İnfliximab

• Miscellaneous( Total or supplementary parenteral

nutrition, fish oils, sodium cromoglycate, lidocaine,

nicotine trans dermally)

• Surgical management