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INFLAMMATORY BOWEL DISEASES

INFLAMMATORY BOWEL DISEASES. INFLAMMATORY BOWEL DISEASES. TWO MAIN FORMS: ULCERATIVE COLITIS - AFFECTS LARGE BOWEL ONLY CROHN’S DISEASE- AFFECTS ANY PART OF GIT. INFLAMMATORY BOWEL DISEASES. INFLAMMATORY BOWEL DISEASES.

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INFLAMMATORY BOWEL DISEASES

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  1. INFLAMMATORY BOWEL DISEASES

  2. INFLAMMATORY BOWEL DISEASES TWO MAIN FORMS: ULCERATIVE COLITIS- AFFECTS LARGE BOWEL ONLY CROHN’S DISEASE- AFFECTS ANY PART OF GIT

  3. INFLAMMATORY BOWEL DISEASES

  4. INFLAMMATORY BOWEL DISEASES • Both idiopathic bowel diseases– it is probable that enviornmental factors operate in a genetically predisposed individual • Disruption of the intestinal integrity allows bacteria & luminal antigens to trigger an immune response

  5. ULCERATIVE COLITIS • Diffuse ulcero-inflammatory disease limited to the colon & affecting only the mucosa & sub mucosa except in more severe cases. • Extends in a continuous fashion proximally from rectum. • No skip lesions

  6. ULCERATIVE COLITIS

  7. ULCERATIVE COLITIS • Proctitis • Proctosigmoiditis • Left sided colitis • Pan ulcerative colitis

  8. EPIDEMIOLOGY • Sex ratio is 1:1. • Uncommon before 10 yrs • Usually diagnosed between 20 & 40 Westernisation of diet has been held responsible as one of the possible causes

  9. AETIOLOGY • Remains unknown • Increased prevalence among first degree relatives • Microbial agents • Milk protein • Smoking protective • Stress

  10. PATHOLOGY • Mostly confined to mucosal & submucosal layers of colon. • 95%cases starts in rectum & spreads proximally. • Confined to colon ,rectum always involved. • In 10% backwash ileits(30 cm)

  11. MACROSCOPICALLY • Inflammed mucosa • Pseudopolyps- (20%) • Undermined edges • Ulcers aligned along long axis • Progressive mucosal atrophy • Severe cases-toxic damage to muscularis & neural plexus.

  12. MACROSCOPICALLY

  13. POLYPS IN ULCERATIVE COLITIS

  14. MICROSCOPICALLY • Mononuclear inflammatory infiltrate in lamina propria. • Crypt abscesses. • Crypts reduced & atrophic. • Goblet cell depletion. • With remission granulation tissue fills ulcer crater. • Submucous fibrosis,architectural disarray-residua of healed disease.

  15. CLINICAL FEATURES • Bloody diarrhea. • Blood stained or purulent rectal discharge. • Lower abdominal cramps. • Course- 1.Relapses & remissions. 2.Fulminant colitis.

  16. Clinical Features(PROCTITIS) • Stool formed or semiformed • Troubled by tenesmus & urgency • Risk of cancer is low • 5-10% spread to rest of colon

  17. CF( LEFT SIDED & TOTAL COLITIS) • Diarrhoea implies active disease proximal to rectum. • 15% left sided colitis • 25% total colitis. • Recurrent severe bloody diarrhoea(20 times/day). • Dehydration,fluid & electrolyte loss. • Anaemia & hypoproteinaemia.

  18. DISEASE SEVERITY • Mild Rectal bleeding or diarrhoea with 4 or few motions/day.no systemic signs. • Moderate More than 4 motions/day No systemic signs. • Severe More than 4 motions/day Signs of systemic illness.

  19. COMPLICATIONS • Acute -toxic dilatation. -perforation. -haemorrhage. • Chronic -cancer -extracolonic manifestations.

  20. CANCER RISK IN UC • Overall risk – 3.5% • Risk increases with age&duration. • More with pancolitis. • Multicentric. • Colon > rectum. • Regular colonoscopic checks in diseases > 10 years. • Epithelial dysplasia – surgery.

  21. EXTRA COLONIC MANIFESTATIONS • Arthritis -large joint polyarthropathy. -sacroilitis & ankylosing spondylitis. • Bile duct cancer • Skin lesions -erethyma nodosum,pyoderma gangrenosum,apthous ulceration. • Eye problems-iritis. • Liver disease-sclerosing cholangitis in 70%.

  22. INVESTIGATIONS • Plain x-ray abdomen • Often shows the severity. • Colon diameter > 6 cm toxic megacolon. • Mucosal islands may be seen. • Small bowel loops in right lower quadrant indicates severity.

  23. X-RAY The colon appears shorter than normal and has lost its haustral pattern.

  24. TOXIC MEGACOLON

  25. INVESTIGATIONS • Barium enema principal signs are • Loss of haustrations. • Mucosal changes. • Pseudopolyps. • Narrow contracted colon.

  26. BARIUM ENEMA GRANULAR MUCOSA

  27. BARIUM ENEMA PSEUDOPOLYPS OF DESCENDING COLON

  28. BARIUM ENEMA SHORT COLON , SMOOTH HAUSTRATIONS & NARROW LUMEN

  29. BARIUM ENEMA Inflammation of the transverse and descending colon - The haustration of the colon became smooth.The lumen of the descending colon is narrow.

  30. SIGMOIDOSCOPY • Early cases & mild disease. • Initial findings are of proctitis- -hyparaemic mucosa,bleeds on touch, pus like exudate. • Later-tiny ulcers which appear to coalesce.

  31. COLONOSCOPY & BIOPSY • Establish extent of inflammation. • Distingush ulcerative colitis & crohn’s disease. • Monitor response to treatment. • Assessment of malignant change. not usually done in acute cases.

  32. TREATMENT • Dietary management • Pharmacological management • Surgical management

  33. MEDICAL TREATMENT

  34. TREATMENT • Basic -high fibre diet. -anti diarrhoeal agents. -patient education & support. • 1st linetherapy-anti inflammatory drugs. • 2nd linetherapy-other immunosupressive agents.

  35. CORTICOSTEROIDS • Po/IV/Enema • Prompt anti-inflammatory action • Faster than 5 Amino Salisylic Acid • Not useful in maintaining remission

  36. 5 AMINOSALISYLIC ACID • Oral/enema/suppository • Indusing remission,long term maintenance • Local antiinflammatory agent • Sulfasalazine-5ASA+sulfapyridine • Asacol-mesalazine+acrylic resin

  37. IMMUNOSUPPRESSANTS • Resistant or frequent relapses • Azathioprine,cyclosporin ,methotrexate • Azathioprine-inhibits DNA synthesis & lymphocyte proliferation • Cyclosporin-blocks cytotoxic T cell activation • Methotrexate-binds dihydrofolate reductase

  38. MEDICAL TREATMENT ACUTE ATTACK Corticosteroids most useful. -locally or systemically. 5-ASA derivatives -mesalazine or osalazine. -locally or systemically. -maintains remission rather than treating an acute attack.

  39. MEDICAL TREATMENT MILD ATTACKS • Usually responds to rectally administered steroids. • More extensive disease-oral prednisolone 20-40mg/day over 3-4 weeks. • Sulfasalazine 1gm TID or newer 5-ASA compounds concurrently.

  40. MEDICAL TREATMENT MODERATE ATTACKS • Oral prednisolone 40mg/day. • Twice daily steroid enemas. • 5-ASA

  41. MEDICAL TREATMENT SEVERE ATTACKS • Medical emergency. • Look for signs of peritonism. • Abdominal girth,liver dullness. • Plain x-ray abdomen daily. • Fluid & electrolyte balance,stool chart • Anaemia corrected & nutrition.

  42. MEDICAL TREATMENT SEVERE ATTACKS(contd..) • Maintained nill per mouth. • IV hydrocortisone 100-200mg qid. • Rectal infusion of prednisolone. • Some are treated with azathioprine or cyclosporin. • No improvement in 5-7 days- Surgery must be considered.

  43. INDICATIONS FOR SURGERY • Severe disease not responding to medical management • Chronic disease • Steroid dependent disease • Risk of neoplastic changes • Extra intestinal manifestations • Severe haemorrhage or stenosis causing obstruction

  44. SURGICAL OPTIONS • NON RESTORATIVE 1.Proctocolectomy 2.Conservative proctocolectomy • RESTORATIVE 1.1 or 2 stage ileoanel pouch 2. Colectomy & ileorectal anastomosis

  45. OPERATIONS EMERGENCY • First aid procedure- total abdominal colectomy & ileostomy • Rectum closed just beneath the skin • Histology of the resected colon

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