Date post: | 10-Feb-2017 |
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LEARNING OUTCOMES
Describe the disease process of Crohn’s versus Ulcerative Describe the disease process of Crohn’s versus Ulcerative Colitis.Colitis.
Identify the clinical presentation of a patient with Crohn’s Identify the clinical presentation of a patient with Crohn’s Disease and Ulcerative Colitis.Disease and Ulcerative Colitis.
Discuss the various diagnostic workups and how they may Discuss the various diagnostic workups and how they may differentiate Crohn’s & U.C. from other GI ailments.differentiate Crohn’s & U.C. from other GI ailments.
Select appropriate treatments for a patient with Crohn’s Select appropriate treatments for a patient with Crohn’s Disease and Ulcerative Colitis.Disease and Ulcerative Colitis.
DEFINITION
It includes a group of It includes a group of chronic disorders that chronic disorders that cause inflammation or cause inflammation or ulceration in large and ulceration in large and small intestines. small intestines.
TYPES OF IBD
Collagenous colitisCollagenous colitis Lymphocytic colitisLymphocytic colitis Ischemic colitisIschemic colitis Behcet’s syndromeBehcet’s syndrome Infective colitisInfective colitis Intermediate colitisIntermediate colitis
Global Prevalence of IBD
AETIOLOGY
Exact cause is Exact cause is
unknownunknown
Genetic factorsGenetic factors
Immunological factorsImmunological factors
Microbial factorsMicrobial factors
Psychosocial factorsPsychosocial factors
PATHOGENESIS OF IBD
NormalGut
Tolerance-controlled
inflammation
Environmental trigger
(Infection, NSAID, other)
Acute Injury
Complete Healing
Chronic Inflammation
GeneticallySusceptible
HostAcute Inflammation
↓ Immunoregulation, failure of repair or
bacterial clearance
Tolerance
ULCERATIVE COLITIS
UC is an non granulomatous UC is an non granulomatous inflammatory disorder that affects the inflammatory disorder that affects the rectum and extends proximally to affect rectum and extends proximally to affect variable extent of the colon.variable extent of the colon.
It strictly affects the colon and has It strictly affects the colon and has mucosal involvementmucosal involvement
15-40 years (Young adults)15-40 years (Young adults) No variation between sexes No variation between sexes High incidence areas: USA and northern-High incidence areas: USA and northern-
western Europewestern Europe More common in non-smokersMore common in non-smokers
CD is a condition of chronic CD is a condition of chronic granulomatous inflammation potentially granulomatous inflammation potentially involving any location of the GIT from involving any location of the GIT from mouth to anus.mouth to anus.
Crohn’s Disease - affects mouth to anus Crohn’s Disease - affects mouth to anus and has transmural involvementand has transmural involvement
1st peak 15-30 years of age, 2nd peak 1st peak 15-30 years of age, 2nd peak around 60 yaround 60 y
Marginally more common in femalesMarginally more common in females High incidence areas: North America, UK, High incidence areas: North America, UK,
northern Europenorthern Europe More common in smokersMore common in smokers
CROHN’S DISEASE
I B D
PATHOLOGY
CROHN’S DISEASE ULCERATIVE COLITIS
Ileum – most common site Ileum – most common site Transmural Transmural Skip lesionSkip lesion Hose - pipe patternHose - pipe pattern Linear ulcerLinear ulcer Cobble stone app. - of Cobble stone app. - of
mucosamucosa Fat wrapping around Fat wrapping around
bowel bowel
Rectum – most commonRectum – most common
site site Mucosa & sub-mucosaMucosa & sub-mucosa Continuous lesion Continuous lesion Pipe stem colonPipe stem colon Pin point ulcersPin point ulcers Crypt abscess Crypt abscess Pseudopolyps Pseudopolyps
ULCERATIVE COLITIS CROHN’S DISEASE
Abdominal painAbdominal pain Diarrhea Diarrhea Weight lossWeight loss Low grade feverLow grade fever MalabsorptionMalabsorption SteatorrheaSteatorrhea Anorectal lesions, Anorexia, Anorectal lesions, Anorexia,
AnemiaAnemia Malnutrition (weight loss)Malnutrition (weight loss)
DiarrheaDiarrhea Rectal bleedingRectal bleeding TenesmusTenesmus Passage of mucusPassage of mucus Crampy abdominal painCrampy abdominal pain Pain of colonic origin, often left Pain of colonic origin, often left
sided and related to sided and related to defecationdefecation
Relapses and remissions at Relapses and remissions at regular intervals.regular intervals.
FEATURES MILD MODERATE SEVERE FULMINANTStool frequency
< 4 4 - 6 > 6 > 10
Blood in stools
Intermittent
Intermediate
Frequent Continuous
Pulse < 90 90 - 100 > 100 > 110Haematocrit
Normal 3 - 40 < 30 Req. Transfusion
Weight loss - %
None 1-10% > 10% Req. TPN
Temperature
Normal 99 - 100 > 100 > 100
ESR < 20 20 - 30 > 30 > 30 Albumin Normal 3 – 3.5 < 3.5 Severe
CLINICAL GRADING – U C
COMPLICATIONS
CROHN’S DISEASE ULCERATIVE COLITIS
Obstruction Obstruction Peritonitis Peritonitis Perianal Perianal
abscessabscess
Toxic megacolon Toxic megacolon Massive HgeMassive Hge Fistula-in-ano Fistula-in-ano
EXTRA – INTESTINAL COMPLICATIONS - BOTH
MalnutritionMalnutrition Pancreatitis Pancreatitis Amyloidosis Amyloidosis Anaemia Anaemia Intracranial Intracranial
Thromboembolic events Thromboembolic events DVT DVT
INVESTIGATIONS
CCRP - RP - increasedincreased ESRESR - - increasedincreased Platelet ct - Platelet ct -
increasedincreased HHb b - decreased- decreased LeukocytosisLeukocytosis HypoalbuminemiaHypoalbuminemia
Endoscopy Endoscopy Colonoscopy Colonoscopy HistopathologyHistopathology RadiologyRadiology Serology Serology tests tests Microbiological Microbiological
stool test stool test
ULCERATIVE COLITIS CROHN’S DISEASE
Hose – pipe colon Hose – pipe colon Toxic megacolon Toxic megacolon Loss of haustrations Loss of haustrations
Rose-thorn Rose-thorn appearance appearance
String sign of String sign of KantorKantor
Straightening of Straightening of bowel bowel
ULCERATIVE COLITIS CROHN’S DISEASE
“Creeping Fat”
DIFFERENTIAL DIAGNOSIS
Chronic infectious colitisChronic infectious colitis Ischemic colitisIschemic colitis DiverticulitisDiverticulitis Irritable Bowel SyndromeIrritable Bowel Syndrome Amoebic colitis Amoebic colitis Intestinal tuberculosis Intestinal tuberculosis D / D – R I F – Mass D / D – R I F – Mass Colon CancerColon Cancer
GENERAL MEASURES
Correction of anemia.Correction of anemia. Fluid & electrolyte Fluid & electrolyte
supplementation.supplementation. Nutrition ( high protein, Nutrition ( high protein,
carbohydrate ,vitamin, but low carbohydrate ,vitamin, but low fat diet ) ,TPNfat diet ) ,TPN
Sedatives and tranquilizers.Sedatives and tranquilizers. Psychological counselingPsychological counseling
DEFINITIVE TREATMENT
AcuteAcute - Induce remission - Induce remission
Chronic - Maintenance of Chronic - Maintenance of
remissionremission
SurgicalSurgical - Correct complications - Correct complications
ACUTE THERAPY
IV +/- PO Hydrocortisone or IV +/- PO Hydrocortisone or MethylprednisoloneMethylprednisolone
Rectal +/- Oral 5-ASA; Rectal +/- Oral 5-ASA; SulfasalazinesSulfasalazines
BSA +/- Metronidazole BSA +/- Metronidazole IV Cyclosporine 2-4 mg/kgIV Cyclosporine 2-4 mg/kg Bowel RestBowel Rest
CHRONIC THERAPY
Goals:Goals:
Remission of bowel Remission of bowel
inflammationinflammation
1-4 BM/day with mucosal 1-4 BM/day with mucosal
healinghealing
Prevention of strictures, Prevention of strictures,
fistulas, fistulas,
other complicationsother complications
Prevention of need for surgeryPrevention of need for surgery
CROHN’S DISEASE
Failure of medical therapyFailure of medical therapy Recurrent obstructionRecurrent obstruction PerforationPerforation Fistula / Abscess / StrictureFistula / Abscess / Stricture HemorrhageHemorrhage Steroid dependency diseaseSteroid dependency disease Growth retardation (children)Growth retardation (children) Malignant changeMalignant change
INDICATIONS - SURGERY
SURGERY
REFERENCES
“DIAGNOSIS OF DISEASES OS OFTEN EASY; OFTEN DIFFICULT & OFTEN
IMPOSSIBLE”