Inflammatory Bowel Disease 4 th year MS 2009-2010

1. Inflammatory Bowel Disease4th year MS2009-2010 Khaled Jadallah, MD Assistant Professor of Medicine Gastroenterology, Hepatology & Nutrition

2. Educational Objectives • Definitions and spectrum of inflammatory bowel disease (IBD) • Epidemiology of IBD • Etiopathogenesis of IBD • Clinical manifestations of ulcerative colitis (UC) • Clinical manifestations of Crohn’s disease (CD) • Distinguishing features between UC and CD • Diagnostic approach to IBD • Complications of IBD • IBD management

3. Inflammatory Bowel Disease • IBD include a group of chronic relapsing disorders that cause inflammation or ulceration in the small and/or large intestines. IBD is classified as: • Ulcerative colitis (UC)- causes ulceration and inflammation of the mucosa of the colon and rectum • Crohn's disease (CD)- an inflammation that extends into the deeper layers of the intestinal wall, and also may affect other parts or layers of the digestive tract, including the mouth, esophagus, stomach, and small intestine

4. Educational Objectives • Definitions and spectrum of inflammatory bowel disease (IBD) • Epidemiology of IBD • Etiopathogenesis of IBD • Clinical manifestations of ulcerative colitis (UC) • Clinical manifestations of Crohn’s disease (CD) • Distinguishing features between UC and CD • Diagnostic approach to IBD • Complications of IBD • IBD management

5. Epidemiology of IBD

7. High Medium Low

8. Educational Objectives • Definitions and spectrum of inflammatory bowel disease (IBD) • Epidemiology of IBD • Etiopathogenesis of IBD • Clinical manifestations of ulcerative colitis (UC) • Clinical manifestations of Crohn’s disease (CD) • Distinguishing features between UC and CD • Diagnostic approach to IBD • Complications of IBD • IBD management

13. Nature Nurture IBD Genes Environment

16. Educational Objectives • Definitions and spectrum of inflammatory bowel disease (IBD) • Epidemiology of IBD • Etiopathogenesis of IBD • Clinical manifestations of ulcerative colitis (UC) • Clinical manifestations of Crohn’s disease (CD) • Distinguishing features between UC and CD • Diagnostic approach to IBD • Complications of IBD • IBD management

17. Ulcerative Colitis – clinical presentation • Patients with proctitis usually pass fresh blood or blood-stained mucus either mixed with stool or streaked onto the surface of normal or hard stool; tenesmus is a feature • When the disease extends beyond the rectum, blood is usually mixed with stool or grossly bloody diarrhea may be noted • When the disease is severe, patients pass a liquid stool containing blood, pus, fecal matter • Other symptoms in moderate to severe disease include: anorexia, nausea, vomitting, fever, abdominal pain, weight loss

18. Ulcerative colitis – macroscopic features • Mucosa is : - erythematous, has a granular surface that looks like a sand paper • In more severe diseases: - hemorrhagic, edematous and ulcerated • In fulminant disease a toxic colitis or a toxic megacolon may develop ( wall becomes very thin and mucosa is severely ulcerated)

19. UCDisease Distribution at Presentation 37% 46% 17%

20. UC – disease severity

21. UC – disease severity

24. Educational Objectives • Definitions and spectrum of inflammatory bowel disease (IBD) • Epidemiology of IBD • Etiopathogenesis of IBD • Clinical manifestations of ulcerative colitis (UC) • Clinical manifestations of Crohn’s disease (CD) • Distinguishing features between UC and CD • Diagnostic approach to IBD • Complications of IBD • IBD management

25. CD: Clinical Features • Abdominal pain, often postprandial • Diarrhea, usually watery • Rectal bleeding • Weight loss • Right lower quadrant pain/palpable mass • Fever • Growth retardation in children • Perirectal fistula

26. Crohn’s disease – macroscopic features • Can affect any part of GI tract from the mouth to the anus • 30-40% of patients have small bowel disease alone • 40-55% of patients have both small and large intestines disease • 15-25% of patients have colitis alone • In 75% of patients with small intestinal disease the terminal ileum in involved in 90%

28. Crohn’s Disease:Anatomic Distribution Small bowelalone(33%) Ileocolic(45%) Frequency of involvement Colon alone(20%) Least Most

29. Crohn’s disease – macroscopic features • CD is a transmural process • CD is segmental with skip areas in the midst of diseased intestine • In one third of patients with CD perirectal fistulas, fissures, abscesses, anal stenosis are present

30. Crohn’s disease – macroscopic features • Active CD is characterized by focal inflammation and formation of fistula tracts • The bowel wall thickens and becomes narrowed and fibrotic, leading to chronic, recurrent bowel obstruction

33. Crohn’s Disease Activity Index(CDAI) • Incorporates 8 variables: • 1. liquid or very soft stools /day • 2. Abdominal pain & cramping • 3. Extraintestinal manifestations • 4. Complications • 5. Abdominal mass • 6. Use of anti diarrheal medications anti- • 7. Hematocrit • 8. Body weight

34. Crohn’s Disease Red Flags • Onset after stopping smoking • Bleeding only • Diverticulosis • Atherosclerosis • Prolapse

35. Extraintestinal Manifestations of IBD • Skin • Erythema nodosum • Pyoderma gangrenosum • Joints • Peripheral arthritis • Sacroileitis • Ankylosing spondylitis • Eye • Uveitis • Episcleritis • Iritis • Hepatobiliary complications • Gallstones • PSC • Renal complications • Nephrolithiasis • Recurrent UTIs

46. Educational Objectives • Definitions and spectrum of inflammatory bowel disease (IBD) • Epidemiology of IBD • Etiopathogenesis of IBD • Clinical manifestations of ulcerative colitis (UC) • Clinical manifestations of Crohn’s disease (CD) • Distinguishing features between UC and CD • Diagnostic approach to IBD • Medical management of IBD • Indications for and role of surgery

47. Symptoms of IBDUC vs CD

48. UC vs CDComplications/Response to Treatment

49. UC vs CDDifferent endoscopic features

50. Criteria for Indeterminate Colitis • No evidence of small bowel involvement, fistula, or perianal disease • Absence of diagnostic criteria for CD or UC by microscopy