INFLAMMATORY BOWEL DISEASE

(IBD)
Upper & Lower GI Diseases Lecture of Gastroentero-Hepatology System, FKUH
Centre of Gastroentero-Hepatology, Wahidin Sudirohusodo Hospital Teaching
Internal Medicine, Faculty of Medicine, Hasanuddin University
Level of competent : 3A
Introduction
Inflammatory bowel diseases (IBD) is
a chronic inflammation of the
intestine that is marked by remission
& relapses and distills clinically into
ulcerative colitis (UC) and Crohns
disease (CD).
IBD occur all over the world, but
they appear more frequently in
western industrialized countries.
CD, initially described in 1932
by Drs Burrill Crohn, Gordon
Oppenheimer, and Leon
Ginzburg, is an idiopathic
transmural chronic inflammatory
disorder affecting any part of
the gastrointestinal tract.
UC, have been described by Drs
Wilks and Moxon in 1875; is a
diffuse mucosal inflammation
limited to the colon.
Epidemiology
Crohns disease (CD) :
Incidence rates were generally
lower and were broadly similar
for men and women, with rates
for both sexes declining with
increasing age
Typicallypresent at a relative
young age, often in adolescence
The median age of diagnosis CD
and UC is the third and fourth
decade of life, respectively
Female predominance in CD and
male predominance in UC
Pathogenesis
Three major contributory factors:
genetic susceptibility,
environmental triggers, and
immune activation
Dysregulated mucosal immune
respone to antigenic components
of the normal commensal
microbiota that reside within the
intestine in a genetically
susceptible host
Modifying enviromental factors (e.g
tobacco, OCPs, appendectomy)
Mucosal
immune
respons
Commensal
Microbial
Antigen
Genetics
(e.g. chromosomes
5 and 16)
Regulation
of immune
response?
Regulation
of barrier &
bacteria?
Clinical
symptoms
Tissue injury
Th1,Th2 or
Th17
mediated
inflammatory
response
T Regulatory
response
General symptoms
Chronic diarrhea
Abdominal pain &
cramping
Blood in stool
Reduced appetite
Weight loss
Fever
Distiguishing Features of UC & CD
ULCERATIVE COLITIS CROHNS DISEASE
Pain crampy, lower abdominal, relived by
bowel movement
Pain constant, often in right lower quadrant
(RLQ), not relieved by bowel movement
Bloody stool Stool usually not grossly bloody
No abdominal mass Abdominal mass, often in RLQ
Affect only colon May affect small & large bowel,
occasionally esophagus & stomatch
Mucosal disease (granulomas are not a
feature)
Transmural disease (granulomas found in a
minority patients)
Continuous from rectum May be discontinous (skip area)
DIAGNOSIS
Anamnesis :
sign & simptoms
Onset & course of symptoms
Growth retardation & failure to
develop sexual maturity
Physical examination :
Often thin & undernourished,
anemia, tachycardia, low grade
fever, mild-moderate abdominal
tenderness (UC), a tender mass
in RLQ
Toxic megacolon or abscess :
Abdominal distention, rebound
tenderness, absence of bowel
sound & high fever
Extraintestinal manifestation
may be evident : hepatobiliary,
dermatologic, oral, occular,
musculoskeletal, hematologic
Diagnostic studies
Laboratory : CBC, urinalysis,
serum chemistery,
serologic: ANCA (Antineutrophil
cytoplasmic Antibodies), ASCA
(Ab Saccharomyces cerevisiae)
Stool examination
Endoscopy LGI + mucosal biopsy
Plain abdomen, CT abdomen, CT
enterography-colonography
Pil cam imaging
Barium enema shold not be
performed
COMPLICATIONS
Perforation, abscess,
fistula, obstruction
Anemia, osteoporosis
Life-threatening
hemorrhage (rare)
Toxic megacolon
Colorectal cancer
DIFFERENTIAL DIAGNOSIS
Bacterial colitis
(campylobacter, shigella,
salmonella, E.coli)
Clostridium difficile-
associated colitis
Parasitic colitis (amebiasis)
Ischemic colitis
Radiation colitis
Sexual transmitted colitis
(CMV, herpes)
Crohns disease look-alikes
(lymphoma, yersinia,
tuberculosis)
GI malignancy
Irritable Bowel Syndrome
(IBS)
GENERAL PRINCIPAL OF THERAPY
Dependent on several distinct
factors : disease location (eg,
ileocecal vs colonic or proctitis
vs pancolitis), severity (mild,
moderate, or severe), and
complications.
Should be individualized based
on the patients prior
symptomatic response and
tolerance to specific medical
therapies.
TREATMENT
Diet and nutrition
Drugs :
5-Aminosalicylates : sulfasalazine 1-4g/day twice daily, mesalamine 2-
4g/day 3-4times daily, olsalazine 1-3g/day twice daily
Steroids oral-iv in CD : budesonide 9mg/d, prednisone/ methylprednisolone
40-60mg/d
Antibiotics : ciprofloxacin 500mg twice daily, metronidazole 1-1.5g/d (in CD
with perianal disease)
Immunomodulators : azatioprine2-2.5mg/kg/d or mercaptopurine 1-
1.5mg/kg/d, methotrexate 15-25mg im once daily (inchronic active &
steroid dependent)
Anti-Tumor Necrosis Factor (TNF) : Infliximab 5mg/kg at week 0,2,6
Surgery : due to complication
Prognosis
75% have to surgery
25% can managed using
medical therapy (UC)
Risk for CRC 8-10 years
later
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