Inflammatory Bowel Disease

1. Inflammatory Bowel Disease Ulcerative Colitis Crohn Disease Non specific type

2. Ulcerative Colitis

3. 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

4. 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

5. 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. > crohn (ulcerative colitis more common then crohn’s disease) • Erythema nodosum – crohn > U.C. • Eye • Uveitis – scaring – visual impairment • episcleritis • Cancer • 0% in 10 years • 10% in 20 years • >20% in 30 years • Proportional to the duration and severity of the disease

6. 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

7. 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

8. 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

9. BacteriologyDifferential Diagnosis • Campylobacter • Similar microscopic appearance… it need special technique to identify the organism • Shigella • E coli • Amoebiasis • Cytomegalovirus

10. 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 Medical Rx 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

11. 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

12. 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

13. 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

14. 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

15. Fistula Mx • Nutritional support • Psychological support • Mobilize the patient • Antibiotic • Immune Modulator • Infliximab

16. Fistula • Internal 40% • Vagina • Bladder • Small bowel • Large bowel • External 40% • Mixed 20%

17. 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 Anal FistulaDifficult Problem to Mx

18. 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

19. 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

20. It is important to remember there may be situation in which one cannot differentiate ulcerative colitis from crohn’s 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.