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Genetic influences : play a greater role in CD than in UC

UC & CD are disorders of modern society : their frequency in developed countries has been increasing since the mid-20 th century. Children : CD is more prevalent than UC The highest incidence & prevalence : Northern Europe & North America

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Genetic influences : play a greater role in CD than in UC

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  1. UC & CD are disorders of modern society: their frequency in developed countries has been increasing since the mid-20th century. • Children:CD is more prevalent than UC • The highest incidence & prevalence: Northern Europe & North America • A westernized environment & lifestyle:Smoking, high fat & sugar diets, stress, & high socioeconomic status • UC:Smoking is associated with milder disease, fewer hospitalization, & a reduced need for medications. • UC:Appendectomy in early life is associated with a decreased incidence • CD:Appendectomy in early life is associated with a increased incidence

  2. Genetic influences: play a greater role in CD than in UC • Is genetic screening indicated to assess the risk of UC? NO, (given the large number of implicated genes & the small additive effect of each) • Human Microbiome project aims to define the composition of the intestinal microbiota in conditions of health & disease. • The density of microbiota is greater in IBD patients than in healthy control subjects.

  3. Risk factors for CRC: • Long duration of the disease (regardless of clinical activity) • Extensive involvement • Severe inflammation • A young age at onset • The presence of PSC • Family history of CRC • Surveillance colonoscopy for patients at risk: there is no clear evidence that such surveillance increases survival. • Pancolitis: inflammation up to ileocecal valve, with occasional limited involvement of the distal ileum (Backwash ileitis) • Better detection of suspicious mucosal patterns & dysplasia:Chromoendoscopy, NBI, & autofluorescence imaging

  4. UC: • Proctitis may present with constipation • A small area of inflammation surrounding the appendiceal orifice (cecal patch) can be identified in patients with left sided colitis, proctosigmoiditis, or proctitis. • Cancer:up to 20-30% after 30 years • CD: • Video capsule endoscopy • Single balloon enteroscopy • Double balloon enteroscopy

  5. Pillcam SB capsule (originally named the M2A capsule)

  6. Indication for surgery: • Failure of medical therapy • Intractable fulminant colitis • Toxic megacolon • Perforation • Uncontrollable bleeding • Intolerable side effects of medication • Stricture that are not amenable to endoscopic therapy • Unresectable high-grade or multifocal dysplasia • DALM (Dysplasia associated lesion or mass) • Cancer • Growth retardation in children

  7. Unlike CD, UC may respond to probiotics: • Escherichia coli strain Nissle 1917 (200 mg/day) • VSL#3 (3600 colony-forming units/day/for 8 weeks) • Pouchitis: • An inflammation caused by an immune response to the newly established microbiota in the ileal pouch (dysbiosis). • Metronidazole, ciprofloxacin, rifaximin. • Probiotics can be effective for preventing recurrence. • Pouch failure is a condition requiring pouch excision or permanent diversion.

  8. Suppository: Rectum • Foam enema: Proximal sigmoid • Liquid enema: Splenic flexure • Rectal 5-ASA induces earlier & better results than oral mesalazine in the treatment of active proctitis. In active left-sided colitis there is proximal colonic stasis & fast colonic transit through the inflamed colon. This results in reduced exposure of the distal colon to the oral agent. The combination of both oral & rectally delivered 5-ASA has greater efficacy & speed of response in patients with distal colitis than either administration route used alone. • Cyclosporine is only a bridge. • The expanding use of anti-TNFa agentshas not decreased the need for colectomy for UC patients.

  9. Do not forget these etiologies of acute pancreatitis in a patient with IBD: • AZA • 6-MP • 5-ASA • Sulfasalazine • Steroid • Granuloma may be seen: • CD • TB • Lymphoma • Behcet's disease • Yersinia

  10. Systemic toxicity • Toxic megacolon: • Colonic distension (supine film >6 cm) • Plus at least 3 of the following: • T>38ºC • HR >120 • Neutrophilic leukocytosis >10,500 • Anemia • PLUS at least 1 of the following: • Dehydration • Altered sensorium • Electrolyte disturbances • Hypotension Decreased incidence Smooth muscle inflammation  paralyzes  dilatation Hydrocortisone 100 mg/tid-qid Third generation + Metronidazole

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