Inflammatory Bowel Disease

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Inflammatory Bowel Disease

• Ulcerative Colitis
• Crohn Disease
• Non specific type

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Ulcerative Colitis
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Ulcerative Colitis

• Remitting relapsing disease
• Unknown etiology
• LaRGE bowel involvement
• No skip lesion as in Crohn disease
• Backwash ileitis may involve terminal ileum
• Can arise if extensive colonic involvement
• Incidence 10/100,000 (crohn 5/100,000)
• Genetic component
• First degree relative 20 to 30 folds increased
  risk
• HLA DR2 10-20
• ankylosing spondylitis HLA B27
• primary sclerosing cholangitis HLA B8

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Disease involvement

• Rectum
• most common site affected
• Anal disease
• Rare, usually mild form unlike crohn disease
• Symptoms
• Urgency may even have urge incontinence
• Diarrhoea
• Anaemia
• Malnutrition, growth retardation
• Toxic megacolon ( acute abdomen)
• Colonic Ca

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Extra alimentary manifestation 25

• Arthropathy
• Large Joints disease activity related
  (commonest joint affected)
• Ankylosing Spondilitis
• Sacroileitis
• Liver (Rx for colonic disease is ineffective in
  controlling these)
• Fatty degeneration
• Chronic active hepatitis cirrhosis
• Primary scleorsing cholangitis 4
• Cholangiocarcinoma (rare)
• Skin
• Pyoderma gangrenosum - U.C. gt crohn (ulcerative
  colitis more common then crohns disease)
• Erythema nodosum crohn gt U.C.
• Eye
• Uveitis scaring visual impairment
• episcleritis
• Cancer
• 0 in 10 years
• 10 in 20 years
• gt20 in 30 years

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Endoscopic FeaturesNon specific

• Lost of vascular pattern
• Due to mucosal oedema, the normal vascular
  pattern is no longer seen
• Fine granularity
• Pseudopolyps
• Contact bleeding / erythema
• Frank ulceration
• Muscoal degeneration

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Radiological FeaturesNon specific

• Lost of pattern (e.g. haustration)
• Pseudopolyps
• Granularity
• Ulcer
• Strictures
• Fistula (more common in Crohn disease)

Radiological Images provide you a permanent
record for future reference
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HistopathologyDefinitive

• Limited to mucosa only
• Except in fulminant case which may involve
  muscularis propria
• In assessing the severity of the disease, look at
  the
• Extend of neutrophil infiltration
• No. of crypt abscess

Optimal site for Bx if no obvious disease segment
found on colonoscopy 7 cm from anal verge
posterior wall
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BacteriologyDifferential Diagnosis

• Campylobacter
• Similar microscopic appearance it need special
  technique to identify the organism
• Shigella
• E coli
• Amoebiasis
• Cytomegalovirus

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Medical Rx

• Anti-inflammatory
• Steroid prednisolone
• 5 AminoSalicylic Acid
• Sulfasalazine (oldest)
• Salazoprin
• Bone marrow depression
• Oligospermia
• Mesalazin
• Pentasa
• Dipentum
• Immuno-suppression
• Azathioprine
• Cyclosporin
• Immune Modulator
• Interferon
• Infliximab
• For fistula disease

• Antibiotic
• Metronidazole
• Ciprofloxacin
• Antimotility
• Lomotil
• Codeine

5 aminosalicylic acid is the active moiety, not
the sulfapyridine which is the main causes for
most of the drug complications, in
Sulfasalazine.. This lead to the development of
the newer 5 ASA agents
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Surgery for UC

• Prophylactic Colectomy
• For long term disease
• For severity /activity of the disease
• For histological indication
• Any displasia on biopsy is indicative for surgery
  
• Mild dysplasia 54 chance of harboring
  malignancy somewhere
• High grade dysplasia 67 chance of harboring
  malignancy somewhere
• Emergency Colectomy
• Toxic megacolon
• Perforation
• Other interventions
• Fistula formation
• Abscess collection

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Surgery for UC

• Procto-colectomy with
• Ileoanal anastomosis
• Ileo-J pouch
• to recreate reservoir to replace the resected
  rectum
• End ileostomy
• Gold standard
• Curative treatment for the disease
• Others
• Total colectomy
• Still need surveillance for the rectal mucosa

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Crohn Disease

• Remitting relapsing disorder
• Transmural inflammation
• Non caseating granulomata
• Giant cell formation
• Anyway along the GI tract
• Skip lesions with normal segment of bowel in
  between
• Anal disease common

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Crohn disease

• Fistula
• Spontaneous
• Less likely to heal
• Post Operative
• May heal spontaneously since disease segment
  theoretically has been removed
• Likely to require surgery if
• Fail to close with conservative Rx in 6 to 12 wks
• Fistula originate from a disease segment of the
  bowel
• Fistula originate from anastomotic leakage with
  more than 50 circumferential breakdown
• Distal obstructive lesion i.e stricture

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Fistula Mx

• Nutritional support
• Psychological support
• Mobilize the patient
• Antibiotic
• Immune Modulator
• Infliximab

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Fistula

• Internal 40
• Vagina
• Bladder
• Small bowel
• Large bowel
• External 40
• Mixed 20

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Anal FistulaDifficult Problem to Mx

• Types
• Simple anal fistula
• Usually trasnsphincteric type of fistula, high or
  low
• Vagina-anal fistula
• Vesicle-anal fistula
• Complicated anal fistula
• With multiple fistula tracts
• High recurrence Rate

• Surgery
• Loose long term seton drainage
• (seton insert a plastic rubber through the
  fistula track)
• Rectal Advancement Flap
• Ano-cutaneous Advancement Flap
• Vagina Flap
• Gracilis Transposition Flap
• Stoma diversion

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CrohnSurgery

• Laparotomy
• Accurately measure the remaining length of bowel
• Accurately documented the segment of bowel
  involve, its length and nature of involvement
• Maximum Conservation of bowel length is required

Microscopic disease at resection margin does not
has any impact on the recurrence of the disease
It is most important to avoid short gut syndrome
which will result in significant morbidity or
even mortality
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Surgery for IBD

• Stricturoplasty
• Need to rule out malignancy first
• Large bowel resections
• Segmental resection
• For localise disease segment (crohn disease)
• Fistula
• Stricture
• Total colectomy ileorectal anastomosis
• Preserve normal sphincter function
• For patient with minimal anorectal disease
• Total Colectomy ileostomy
• Still need surveillance for the rectum
• Panproctocolectomy ileostomy
• Gold standard for UC
• Perineal wound healing problem common
• Restorative Proctocolectomy
• Contraindicate in Crohn disease
• Creating ileo-pouch to act as reservoir
• Pouchitis severe, eventually need excision as well

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• It is important to remember there may be
  situation in which one cannot differentiate
  ulcerative colitis from crohns disease in
  patients where the histological features are not
  conclusive. which will be called the mixed type
  of inflammatory bowel disease. However, the
  management is still the same. considering the
  medical therapy plus surgical intervention when
  indications arise.