Inflammatory Bowel Disease

Background
Inflammatory bowel disease (IBD)
commonly refers to:
ulcerative colitis (UC) and
Crohn disease (CD)

which are chronic inflammatory disease

of the GI tract of unknown etiology
 Inflammatory Bowel Disease

Background
Crohn disease is also referred to as:
regional enteritis
terminal ileitis or
granulomatous ileocolitis
 Inflammatory Bowel Disease

Pathophysiology
Increasing evidence suggests that, at least
in CD, there is a defect in the function of
the intestinal immune system

As a consequence:▼
►there is a breakdown of the defense
barrier of the gut, which, in turn, results
in ► exposure of the mucosa to
microorganisms or their products
 Inflammatory Bowel Disease

Pathophysiology
In UC, inflammation always begins in
the rectum, extends proximally a
certain distance, and then abruptly
stops

A clear demarcation exists between

involved and uninvolved mucosa
 Inflammatory Bowel Disease
Pathophysiology
The rectum is always involved in UC, and no
"skip areas" are present

UC primarily involves ▼
the mucosa and
the submucosa
with formation of:
crypt abscesses and
mucosal ulceration
 Inflammatory Bowel Disease

Illustration: UC without skip areas

UC
The mucosa typically appears granular and
friable
 Inflammatory Bowel Disease
Pathophysiology
In severe cases (UC)

►1) In more severe cases, pseudopolyps

form, consisting of areas of hyperplastic
growth with swollen mucosa

2) Inflammation and necrosis can

extend below the lamina propria to
involve the submucosa and the circular
and longitudinal muscles, although this
is unusual
 Inflammatory Bowel Disease

• Illustration: pseudopolyps
 Inflammatory Bowel Disease

Pathophysiology
UC remains confined to the rectum in
approximately 25% of cases

In the remainder of cases, UC spreads

proximally and contiguously

Pancolitis occurs in 10% of patients

 Inflammatory Bowel Disease

Pathophysiology
UC
The small intestine is never involved,
except when the distal terminal
ileum is inflamed in a superficial
manner, referred to as backwash
ileitis
 Inflammatory Bowel Disease

Pathophysiology
CD
The most important pathologic feature is
involvement of all layers of the bowel,
not just the mucosa and the
submucosa, as is characteristic of UC
 Inflammatory Bowel Disease
Pathophysiology
CD is discontinuous, with skip areas
interspersed between one or more
involved areas
 Inflammatory Bowel Disease

CD with skip areas (large intestine)

CD
 Inflammatory Bowel Disease

Pathophysiology
The 3 major patterns of involvement in CD are:
(1) disease in the ileum and cecum, occurring
in 40% of patients

(2) disease confined to the small intestine,

occurring in 30% of patients and

(3) disease confined to the colon, occurring

in 25% of patients
 Inflammatory Bowel Disease
Pathophysiology
CD causes 3 patterns of
involvement:

(1) inflammatory disease

(2) strictures and

(3) fistulas
 Inflammatory Bowel Disease

Pathophysiology
Extraintestinal manifestations of IBD
include:
iritis
episcleritis
arthritis and
skin involvement
as well as pericholangitis and
sclerosing cholangitis
 Inflammatory Bowel Disease

Mortality/Morbidity
The most common causes of death in IBD
are:
peritonitis with sepsis
malignancy
thromboembolic disease and
complications of surgery
 Inflammatory Bowel Disease

Mortality/Morbidity
Toxic megacolon, one of the most dreaded
complications of UC, can lead to:
perforation
sepsis
shock and
death
 Inflammatory Bowel Disease

• Illustration: toxic mega colon

 Inflammatory Bowel Disease

Mortality/Morbidity

Malnutrition and chronic anemia are

observed in long-standing CD

Children with CD or UC can exhibit

growth retardation
 Inflammatory Bowel Disease
Race
Incidence among whites is approximately 4 times
that of other races

Sex
Incidence is slightly greater in females than in
males

Age
Incidence peaks in the second and third decades
of life
 Inflammatory Bowel Disease
CLINICAL
History
Patients with ulcerative colitis (UC) most
commonly present with bloody diarrhea

Whereas patients with Crohn disease (CD)

usually present with nonbloody diarrhea
 Inflammatory Bowel Disease

CLINICAL
History

Abdominal pain and cramping

fever and

weight loss occur in more severe

cases
 Inflammatory Bowel Disease

CLINICAL
History
Remember
The greater the extent of colon involvement, the
more likely the patient is to have diarrhea

Rectal urgency or tenesmus reflects reduced

compliance of the inflamed rectum
CLINICAL
History
As the degree of inflammation increases,
systemic symptoms develop, including:
low-grade fever
malaise
nausea
vomiting
sweats and
arthralgias
 Inflammatory Bowel Disease

CLINICAL
History
Fever
Dehydration and
abdominal tenderness

►develop in severe UC, reflecting progressive

inflammation into deeper layers of the
colon
 Inflammatory Bowel Disease
CLINICAL
History
The presentation of CD is generally more
insidious than that of UC, with ongoing:
abdominal pain
anorexia
diarrhea
weight loss and
fatigue
 Inflammatory Bowel Disease
CLINICAL
History
Grossly bloody stools, while typical of UC, are less
common in CD

One half of patients with CD present with perianal

disease:
Example:
Fistulas
abscesses
 Inflammatory Bowel Disease
CLINICAL
History
► Occasionally, acute right lower quadrant
pain and fever may be noted, mimicking
appendicitis
► Commonly, the diagnosis is established
only after several years of:
recurrent abdominal pain
fever, and
diarrhea