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Inflammatory Bowel DiseaseBy Tutorial 8LEARNING OBJECTIVEDEFINISI, PATOGENESIS, MANIFESTASI KLINIS:ULCERATIVE COLITISCROHNS DIEASESPENATALAKSANAANIDIOPATIKM.O. PATOGENLINGKUNGANGENETIKDIARE DAN PENDARAHANPENURUNAN IMUNITAS

ULSERATIF RMROS/ STRESS OKSIDASINYERI PERUTELEKTROLIT TIDAK SEIMBANGINFLAMASIOSTEOPOROSISNYERI TMJRESORBSI TULANGPENATALAKSANAAN KG Crohns disease Ulcerative colitisExtends into the deeper layers of the intestinal wall, and may affect the mouth, esophagus, stomach, and small intestine. Transmural inflammation and skip lesions.In 50% cases -ileocolic,30% ileal and 20% -colic region. Regional enteritis

causes ulceration and inflammation of the inner lining of the colon and rectum.It is usually in the form of characteristic ulcers or open sores.

TYPESEtiopathogenesisExact cause is unknown.Genetic factorsImmunological factorsMicrobial factorsPsychosocial factorsDietary factor

Ulcerative colitisUlcerative colitis (UC) is a chronic disease of unknown etiology characterized by inflammation of the mucosa and submucosa of the large intestine.The inflammation usually involves the rectum down to the anal margin and extends proximally in the colon for a variable distance.There is no difference between men and women.The worldwide incidence is 0.5~24 new cases per 100 000 individuals, and prevalence is 100~200 cases per 100 000.

Introduction UC: is a form of (IBD). It is a form of colitis, of that includes characteristic ulcers, or open sores, in the colon.The main symptom of active disease is usually diarrhea mixed with blood, of gradual onset. UC is, however, a systemic disease that affects many parts of the body outside the intestine. Because of the name, IBD is often confused with irritable bowel syndrome ("IBS"), a troublesome, but much less serious condition.The five most common symptoms of UC are rectal bleeding, diarrhea, abdominal pain, weight loss, and fever.The clinical presentation of UC depends on the extent of the disease process. Patients usually present with diarrhea mixed with blood and mucus, of gradual onset.They also may have signs of weight loss, and blood on rectal examination.The disease is usually accompanied with different degrees of abdominal pain, from mild discomfort to severely painful cramps.Clinical manifestations Extent of involvement UC is normally continuous from the rectum up the colon. The disease is classified by the extent of involvement, depending on how far up the colon the disease extends:Distal colitis, potentially treatable with enemas:Proctitis: Involvement limited to the rectum. Proctosigmoiditis: Involvement of the rectosigmoid colon, the portion of the colon adjacent to the rectum. Left-sided colitis: Involvement of the descending colon, which runs along the patient's left side, up to the splenic flexure and the beginning of the transverse colon.

Pancolitis: Involvement of the entire colon, extending from the rectum to the cecum, beyond which the small intestine begins.

Extraintestinal features As UC is a systemic disease, patients may present with symptoms and complications outside the colon. These include the following:aphthous ulcers of the mouth .Ophthalmic .Iritis or uveit. Episcleritis.

Patients with ulcerative colitis can occasionally have aphthous ulcers involving the tongue, lips, palate and pharynx CROHNs DISEASE

What is Crohns?inflammatory disease of the intestines that may affect any part of thegastrointestinal tractfrommouthtoanusSymptomsabdominal paindiarrhea(which may be bloody)vomitingweight lossskin rashesarthritis inflammation of the eye

Comparisons of various factors in Crohn's disease and ulcerative colitis Crohn's Disease Ulcerative Colitis Involves terminal ileum Commonly Seldom Involves colon? Involves rectum? Usually Seldom Always Usually Peri-anal involvement Commonl Seldom Bile duct involvement? Not associated Higher rate of Primary sclerosing cholangitis Distribution of Disease Patchy areas of inflammation Continuous area of inflammation Endoscopy Linear and serpiginous (snake-like) ulcers Continuous ulcer Depth of inflammation May be transmural, deep into tissues Shallow, mucosal Fistulae, abnormal passageways between organs Commonly Seldom Biopsy Can have granulomata Crypt abscesses and cryptitis Surgical cure ?

Smoking Often returns following removal of affected part

Higher risk for smokers Usually cured by removal of colon, can be followed by po uchitis Lower risk for smokers Autoimmune disease Generally regarded as an autoimmune disease No consensus Cancer risk? Lower than ulcerative colitis Higher than Crohn's Comparisons of various factors in Crohn's disease and UC (Cont.)Treatment

Lifestyle changes

Diet change

Drugs

SurgeryLifestyle changes

No smokingStress reductionDoing exerciseTaking restDrugs5-ASA agentsGlucocorticoidsAntibioticsImmunosuppresantsBiological therapy

5-ASA Agents

Sulfasalazine (5-aminosalicylic acid and sulfapyridine as carrier substance) Mesalazine (5-ASA), e.g. Asacol, Pentasa Balsalazide (prodrug of 5-ASA) Olsalazine (5-ASA dimer cleaves in colon)

Use In mild to moderate UC & crohns colitisMaintaining remission May reduce risk of colorectal cancer Adverse effects Nausea, headache, epigastric pain, diarrhoea, hypersensitivity, pancreatitis Caution in renal impairment, pregnancy, breast feeding

GlucocorticoidsAnti inflammatory agents for moderate to severe relapses. Inhibition of inflammatory pathwaysBudesonide- 9mg/dl used for 2-3 months & then tapered.Prednisone-40-60mg/dayNo role in maintainence therapy

AntibioticsNo role in active/quienscent UCMetronidazole is effective in active inflammatory,fistulous & perianal CD.Dose-15-20mg/kg/day in 3 divided doses.CiprofloxacinRifaximinImmunosuppresantsThiopurines Azathioprine 6-mercaptopurin Methotrexate CyclosporineCyclosporinePreventing clonal expansion of T cell subsets Use Steroid sparing Active and chronic diseaseSide effects Tremor, paraesthesiae, malaise, headache, gingival hyperplasia, hirsutism Major: renal impairment, infections, neurotoxicity

Other medicationsAnti- diarrheals - Loperamide (Imodium)Laxatives - senna, bisacodyl Pain relievers. acetaminophen (Tylenol). Iron supplements Nutrition