Inflammatory bowel disease

Definition:
-Inflammatory disease of the GI tract. The two inflammatory bowel diseases
include

Crohn's disease (regional enteritis)

ulcerative colitis.

- Causes of IBD are unknown but may be due to deregulated autoimmune

processes against intestinal flora with environmental factors contributing.
- Extraintestinal manifestations of IBD

Aphthous ulcers
Pyoderma Gangrenosum (necrotic tissue that causes ulcers in the leg)
Iritis (painful inflammation of the iris)
Erythema nodosum (Inflammation of the fact cells under the skin
resulting in red lumps or nodules)
Sclerosing cholangitis (destruction of the bile duct)
Arthritis, Ankylosin spondylitis (inflammatory disease of the axial
skeleton)
Clubbing of fingers
Kidney (amyloid deposits, nephrotic syndrome)

History:

Ask about abdominal pain (SOCRATES)

Change in bowel habits (diarrhea/ constipation/ frequency/ quality/
quantity/ timing)
Tenesmus
Change in stool color / presence of mucus.
Change in urinating habits (abstinence/ change in color/ quantity/
urgency/ burning) \
Fatigue
Weight loss
fever/chills
Sweat
Ask about extraintestinal symptoms.
Family History / Past medical / Surgical History/ alcohol/ smocking.

Differential diagnosis:

Crohn's vs ulcerative colitis

Infectious colitis
Ischemic colitis
irritable bowel syndrome
Diverticulitis
Zollinger Ellison syndrome
colon cancer
ischemic bowel.

IBD
Incidence

Ulcerative colitis
More common 10/100000

Crohn's disease
Less common 3-6/100000

Sex

Male > female

Female> male

Distribution

Bimodal: 20 to 35y - 50 to 65

Bimodal: 25 to 40 - 50 to
65

Initial symptoms

Bloody diarrhea
(hallmark), fever, weight
loss

Abd pain, diarrhea,

weight loss, anal disease

Anatomic
distribution

COLON ONLY

Route of spread

Almost always involves the

rectum and spreads
proximally in a continuous
route without skip areas
Mucosa/ submucosa only

Mouth to anus:
small bowel (20%)
Small bowel and colon
(40%)
Colon only (30%)
Small bowel, colon, or both
with Skip areas of normal
bowel

Bowel
involvement
Anal
involvement

Uncommon

Full thickness
Common (fistulae,
abscess, fissures, ulcers)

Rectal
involvement

100%

Rare

Mucosal findings

1.
2.
3.
4.

Granular flat mucosa

ulcers
Crypt abscess
dilated mucosal
vessels
5. Pseudopolyps

1.
2.
3.
4.
5.
6.

Diagnostic tests

1. Colonoscopy
2. Barium enema (lead
pipe appearance)
3. UGI with small bowel
follow through (R/O
crohn's)
4. stool cultures

1.

1.
2.
3.
4.
5.
6.

1. fistula/abscess
(fistulas because
crohn's is
transmural)
2. perforation
3. stricture
4. toxic megacolon
5. Obstruction
6. cancer risk

Complications

Cancer
toxic megacolon
colonic perforation
hemorrhage
obstruction
cancer risk

2.
3.
4.

Aphtoid ulcers
Granulomas
Linear ulcers
Transverse fissures
Swollen mucosa
Full thickness wall
involvement
Colonoscopy with
biopsy
(cobblestoning)
Barium enema
UGI with small bowel
follow through
stool cultures

Toxic megacolon: Toxic patient --> sepsis, febrile, abdominal pain

Megacolon--> acutely and massively distended colon
Surgery:
- Ulcerative colitis:
1. Total proctocolectomy, distal rectal mucosectomy, and ileoanal pull
through
2. Total proctocolectomy and Brooke ileostomy.
- Inflammation of the ileoanal pull through may occur --> pouchitis --> treat
with metronidazole.
- Crohn's Disease:
-The most common indication for surgery in patients with crohn's disease is
small bowel obstruction.

- During bowel resection for Crohn's disease we only need grossly negative
margins.
-CD: Surgery (not curative) most commonly performed in cases of disease
complications of the disease; generally consists of conservative resection
(eg, potential stricturoplasty vs resective surgery) to preserve bowel length
in case future additional surgery needed

Medications for IBD:

Step I Aminosalicylates (oral, enema, suppository formulations): For

treating flares and maintaining remission; more effective in UC than in
CD. Sulfasalazine--> has an active metabolite: 5'aminosalicylate
which is released in the colon

Step IA Antibiotics: Used sparingly in UC (limited efficacy, increased

risk for antibiotic-associated pseudomembranous colitis); in CD, most
commonly used for perianal disease, fistulas, intra-abdominal
inflammatory masses. PO metronidazole: treatment of choice for
perianal crohn's disease.

Step II Corticosteroids (intravenous, oral, topical, rectal): For acute

disease flares only. Infliximab: Antibody directed against tumor
necrosis factor alpha.

Step III Immunomodulators: Effective for steroid-sparing action in

refractory disease; primary treatment for fistulas and maintenance of
remission in patients intolerant of or not responsive to
aminosalicylates. 6 mercaptopurine, azathioprine, mesalamine

Step IV Clinical trial agents: Tend to be disease-specific (ie, an agent

works for CD but not for UC, or vice versa)

- Enemas is a unique medication route option for ulcerative colitis.