inflammatory bowel disease

(IBD)
Dr. Elsayed Abdelmaksood Khalil
Prof. of internal Medicine,
Gastroentrology unit
Mansoura University

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 Inflammatory bowel disease (IBD)
chronic non-specific inflammation of the GI
tract : IBD commonly refers to ulcerative
colitis and Crohn's disease .
Although the diseases have some features in
common, there are some important
differences:
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Ulcerative colitis ( UC) is an
inflammatory disease of the large
intestine only (rectum alone, left
sided colon, or the whole colon).
The small intestine is never involved, except
in a few of these patients there is
inflammation of the distal terminal
ileum (backwash ileitis), the
mucosa - of the intestine
becomes inflamed and develops
ulcers. UC is often most severe in
.the rectal area
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Crohn's disease (CD) can attack any part of
the digestive tract, most commonly affects the
last part of the small intestine (called the
terminal ileum) and parts of the large intestine
but the rectum may be spared and be relatively
normal. Crohn's disease causes inflammation
that extends much deeper into the layers of the
intestinal wall . Crohn's disease generally tends
to involve the entire bowel wall.
health problems may occur outside the
digestive system. the disease may show signs
of inflammation elsewhere in the body, such
as in the joints, eyes, skin, and liver. Skin tags
that look like hemorrhoids or abscesses may
also develop around the anus.

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Features Crohn Disease Ulcerative Colitis
Skip areas Common Never

Transmural
Common Occasional
involvement
Rectal sparing Common Never
Perianal
Common Never
involvement
Fistulas Common Never
Strictures Common Occasional
Granulomas Common Occasional
IBD occurs most frequently in people ages 15 to
30, but it can also affect younger children and
older people. And there are significantly more
reported cases in western Europe and North
America than in other parts of the world.
Causes
The etiology of IBD is unknown.
Environmental, infectious, genetic,
autoimmune, and host factors have been
suspected. Interactions among these factors
may be more important. smoking may
enhance the development of Crohn's
disease. The onset of UC occasionally
appears to coincide with smoking cessation
 Diagnoses
History and clinical examination
Blood tests may be done to determine if there
are signs of inflammation, which are often
present with the disease.
Barium study of the intestines
ColonoscopIC examination

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 History
Patients with UC most commonly present with bloody diarrhea,
whereas patients with CD usually present with nonbloody
diarrhea.
Abdominal pain cramping and weight loss occur in more
severe cases.
The greater the extent of colon involvement, the more likely
the patient is to have diarrhea. Patients might have formed
stools if their disease is confined to the rectum. Rectal
urgency or tenesmus reflects inflamed rectum.

As the degree of inflammation increases, systemic

symptoms develop, including low-grade fever, malaise,
nausea, vomiting, sweats, and arthralgias.
Fever, dehydration, and abdominal tenderness develop in
severe UC, reflecting progressive inflammation into deeper
layers of the colon.
The presentation of CD is generally more insidious than
that of UC, with ongoing abdominal pain, anorexia,
diarrhea, weight loss, and fatigue.
Grossly bloody stools, while typical of UC, are less
common in CD.
One half of patients with CD present with perianal
disease (eg, fistulas, abscesses).
Occasionally, acute right lower quadrant pain and fever
may be noted, mimicking appendicitis.
CD with gastroduodenal involvement may mimic peptic
ulcer disease and can progress to gastric outlet
obstruction.
Commonly, the diagnosis is established only after
several years of recurrent abdominal pain, fever, and
diarrhea.
Crohn's disease may present as an
emergency with acute right iliac fossa pain
mimicking acute appendicitis. Examination of
the anus to look for anal tags, fissures, or
perianal abscesses.In ulcerative colitis the
anus is usually normal.
 Clinical examination
Fever, tachycardia, dehydration, and toxicity may occur. Pallor
may be noted,
signs of localized peritonitis, although abdominal tenderness
is common..
Patients with CD may develop a mass in the right lower
quadrant.
The rectal examination often reveals bloody stool
Complications (eg, perianal fissures or fistulas, abscesses,
rectal prolapse) may be observed in up to 90% of patients
with CD.
Include in the examination a search for extraintestinal
manifestations, such as iritis, episcleritis, arthritis, and
dermatologic involvement.
 Barium study of the intestines
This procedure involves the use of a thick white solution ,
which shows up white on an X-ray film, In CD a small bowel
follow through shows deep ulcerations and areas of
narrowing (string sing) largely confined to the ileum. Skip
lesions with normal bowel between are also seen also, rectal
sparing are noted in CD.
CD Barium enema also shows
ulcerations which is usually patchy.
In UC barium enema may reveal a shortened colon, with
loss of haustrations and destruction of the mucosal pattern
(ie, lead pipe colon).

Barium enema is contraindicated in patients with moderate-

to-severe colitis because it risks perforation or precipitation of
a toxic megacolon.
colonoscope, this instrument is a long, tube inserted
through the anus and attached to a TV monitor. This
procedure is called a colonoscopy, which allows the
doctor to see inflammation, bleeding, or ulcers on
the wall of the colon. During the exam, a biopsy
must be done

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A microscope (Crohn's disease three is an
increase in chronic inflammatory cells and
lymphoid hyperplasia non caseating granuloma
may be present , in ulcerative colitis he
mucosa shows a chronic inflammatory cell
infiltrate in the lamina propria. Crypt abscesses
and goblet cell depletion are also seen)
 Extraintestinal complications
occur in approximately20% of patients with IBD .In some cases,
they may be more problematic than the bowel disease itself.
Joints: Peripheral arthritis, usually migratory and monoarticular,
tends to parallel disease activity but may antedate it. Ankylosing
.spondylitis is associated with HLA-B27
Ocular: Episcleritis, conjunctivitis and Iritis
Dermatologic: Erythema nodosum, pyoderma gangrenosum,
.aphthous ulcers and vasculitis
Liver and biliary tree: pericholangitis, chronic active hepatitis,
cirrhosis, primary sclerosing cholangitis, bile duct carcinoma and
Gallstones
Hypercoagulable state
 Complications
Perforation and toxic megacolon
Suspect toxic megacolon in a patient with fulminant UC,
especially if the number of daily stools has declined sharply
without a corresponding improvement in symptoms. The
abdomen is typically distended, tender, and tympanitic. The
best method of diagnosing toxic megacolon is through the use
of plain radiography.
Strictures usually are benign but can lead to obstruction.
Fistulas and abscesses are much more common in CD
Massive hemorrhage occurs in fewer than 1% of patients.
Cancer risk increases with extent and duration of the disease
Amyloid
 Treatment
Drug treatment is the main method for relieving the
symptoms of both ulcerative colitis and Crohn's
disease.. Some patients requrie only symptomatic
treatment.
Drugs Affecting Motility: Antidiarrheal drugs such as
loperamide (Imodium) or diphenoxylate (Lomotil) can
have some beneficial effects. Antispasmodic drugs
have also been used in some cases.
Metronidazole can be used alone or in combination
with corticosteroids. It is an antibiotic and also inhibits
the immune system.
 Anti-inflammatory drugs
Sulfasalazine and mesalamine containing
compounds are the drugs of choice . are effective
for treating acute UC and for maintaining its
remission; they are also beneficial in mildly to
moderately active CD when the colon is involved.
Sulfasalazine has not been clearly shown to
maintain remission in CD.
Corticosteroids:These agents are the treatments
of choice for an acute IBD attack; administer IV in
severe disease.
Do not use steroids for maintaining remission
because of their lack of efficacy and potential
complications
Immunosuppressants agents: Azathioprine and
Cyclophosphamide: These agents are useful as
steroid-sparing agents, in healing fistulas, or
when the patient has serious contraindications
to surgery. They are used in patients refractory
to or unable to tolerate steroids. Some agents,
including azathioprine and its metabolite, 6-
mercaptopurine, have been useful in CD
complicated by recurrent rectal fistulas or
perianal disease; response can take up to 6
months. Methotrexate has also been tried.

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Tumor necrosis factor alpha
inhibitors: Infliximab (Remicade),
given intravenously, consists of
monoclonal antibodies to TNF-alpha.

most common mistakes in treating

inflammatory bowel disease is to
stop medication too early.
 Surgery
In Crohn's disease, doctors make every attempt
to avoid surgery because of the recurring nature
of the disease. There's also a concern that an
aggressive surgical approach to Crohn's disease
will cause further complications, such as short
bowel syndrome.
 In the case of ulcerative colitis, removal of
the colon (large intestine) may be
necessary, along with a surgical
procedure called an ileoanal
anastomosis (also called an ileoanal
pull-through) in which doctors form a
pouch from the small bowel to collect
stool in the pelvis. This allows the stool to
pass through the anus
 Thank
You
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