Upper & Lower GI Diseases Lecture of Gastroentero-Hepatology System, FKUH

INFLAMMATORY BOWEL DISEASE

(IBD)
Level of competent
:1
Centre of Gastroentero-Hepatology, Wahidin Sudirohusodo Hospital
Teaching
Internal Medicine, Faculty of Medicine, Hasanuddin University

Introduction

DEFINITION a chronic
inflammation of the
intestine that is marked by
remission & relapses and
distills clinically into
ulcerative colitis (UC) and
Crohns disease (CD).

CD, initially described in 1932

by Drs Burrill Crohn, Gordon
Oppenheimer,
and
Leon
Ginzburg,
is
an
idiopathic
transmural
chronic
inflammatory disorder affecting
any part of the gastrointestinal
tract.
UC, have been described by Drs
Wilks and Moxon in 1875; is a
diffuse mucosal inflammation
limited to the colon.

Epidemiology

Typicallypresent at a
relative young age, often
in adolescence
The median age of
diagnosis CD and UC is
the third and fourth
decade of life, respectively
Female predominance in
CD and male

Crohns disease (CD) :

Incidence rates were
generally lower and were
broadly similar for men
and women, with rates
for both sexes declining
with increasing age

Ulcerative colitis (UC) :

Incidence rates for men
remaining fairly constant
with increasing age,
whereas for women
decreased.

Pathogenesis

Modifying enviromental
factors (e.g tobacco, OCPs,
appendectomy)

Three major contributory

factors: genetic
susceptibility,
environmental triggers,
and immune activation
Dysregulated mucosal
immune respone to
antigenic components of
the normal commensal
microbiota that reside
within the intestine in a
genetically susceptible
host

Mucos
al
immu
ne
respo
ns
Regulatio
n of
immune
response
?

Commen
sal
Microbial
Antigen
Regulatio
n of
barrier &
bacteria?

Genetics
(e.g.
chromosomes
5 and 16)

T
Regulator
y
response
Th1,Th2 or
Th17
mediated
inflammat
ory
response

Tissue
injury
Clinical
symptom
s

General symptoms

Chronic diarrhea
Abdominal pain &
cramping
Blood in stool
Reduced appetite
Weight loss
Fever

Distiguishing Features of UC & CD

ULCERATIVE COLITIS

CROHNS DISEASE

Pain crampy, lower abdominal,

relived by bowel movement

Pain constant, often in right lower

quadrant (RLQ), not relieved by
bowel movement

Bloody stool

Stool usually not grossly bloody

No abdominal mass

Abdominal mass, often in RLQ

Affect only colon

May affect small & large bowel,

occasionally esophagus &
stomatch

Mucosal disease (granulomas are

not a feature)

Transmural disease (granulomas

found in a minority patients)

Continuous from rectum

May be discontinous (skip area)

DIAGNOSIS
Anamnesis :
sign & simptoms
Onset & course of
symptoms
Growth retardation &
failure to develop sexual
maturity

Physical examination :
Often thin & undernourished,
anemia, tachycardia, low
grade fever, mild-moderate
abdominal tenderness (UC), a
tender mass in RLQ
Toxic megacolon or abscess :
Abdominal distention, rebound
tenderness, absence of bowel
sound & high fever
Extraintestinal manifestation
may be evident :
hepatobiliary, dermatologic,
oral, occular, musculoskeletal,
hematologic

Diagnostic studies

Laboratory : CBC, urinalysis,

serum chemistery,
serologic: ANCA
(Antineutrophil cytoplasmic
Antibodies), ASCA (Ab
Saccharomyces cerevisiae)
Stool examination
Endoscopy LGI + mucosal
biopsy

Plain abdomen, CT
abdomen, CT
enterographycolonography
Pil cam imaging
Barium enema shold not
be performed

COMPLICATIONS
Perforation, abscess,
fistula, obstruction
Anemia,
osteoporosis
Life-threatening
hemorrhage (rare)
Toxic megacolon
Colorectal cancer

DIFFERENTIAL
DIAGNOSIS
Bacterial colitis
(campylobacter, shigella,
salmonella, E.coli)
Clostridium difficileassociated colitis
Parasitic colitis
(amebiasis)
Ischemic colitis
Radiation colitis

Sexual transmitted
colitis (CMV, herpes)
Crohns disease lookalikes (lymphoma,
yersinia, tuberculosis)
GI malignancy
Irritable Bowel
Syndrome (IBS)

GENERAL PRINCIPAL OF THERAPY

Dependent on several
distinct factors : disease
location (eg, ileocecal vs
colonic or proctitis vs
pancolitis), severity (mild,
moderate, or severe), and
complications.
Should be individualized
based on the patients prior
symptomatic response and
tolerance to specific medical
therapies.

Therapy is sequential to
treat acute disease and
then
to
maintain
remission.

TREATMENT

Surgery : due to complication

Diet and nutrition

Drugs :
5-Aminosalicylates : sulfasalazine 1-4g/day twice daily, mesalamine
2-4g/day 3-4times daily, olsalazine 1-3g/day twice daily
Steroids oral-iv in CD : budesonide 9mg/d, prednisone/
methylprednisolone 40-60mg/d
Antibiotics : ciprofloxacin 500mg twice daily, metronidazole 1-1.5g/d
(in CD with perianal disease)
Immunomodulators : azatioprine2-2.5mg/kg/d or mercaptopurine 11.5mg/kg/d, methotrexate 15-25mg im once daily (inchronic active
& steroid dependent)
Anti-Tumor Necrosis Factor (TNF) : Infliximab 5mg/kg at week 0,2,6

Prognosis

75% have to surgery

25% can managed
using medical
therapy (UC)
Risk for CRC 8-10
years later

References

Avunduk C. Inflammatory Bowel Disease. In Manual of Gastroenterology diagnosis & therapy. 4 th Edition.
Lippincott Williams & Willkins. 2009;pp244-263.
Blumberg RS. Inflammatory Bowel Disease : Imunologic considerations. In Current diagnosis & treatment
Gastroenterology, Hepatology & Endoscopy. Ed by Greenberger NJ, Blumberg RS, Burakoff R. Lange McGraw-Hill
companies, 2009,pp11-21.
Burakoff R, Hande S. Inflammatory Bowel Disease : Medical considerations. In Current diagnosis & treatment
Gastroenterology, Hepatology & Endoscopy. Ed by Greenberger NJ, Blumberg RS, Burakoff R. Lange McGraw-Hill
companies. 2009;pp22-33.
Inflammatory Bowel Disease. MIMS Gastroenterology Indonesia. 2 nd Edition. CMP Medica. 2009/2010.
Lower Gastrointestinal Tract Inflammatory bowel disease. In Atlas of Gastrointestinal Endoscopy and Related
Pathology . Ed by Klaus Schiller F.R. Cockel R,. Hunt RH. Blackwell Science Ltd, 2002; pp 270-289.
Paradowski TJ, Ciorba M. Inflammatory Bowel Disease. In The Washington Manual Gastroenterology
Subspeciality Consult. 2nd Edition. Ed by Gyawali CP, Henderson KE, De Fer TM. Lippincott Williams & Willkins.
2008;pp127-139.
Riegler G, de Leone A. IBD: Epidemiology and Risk Factors. In Inflammatory Bowel Disease and Familial
Adenomatous Polyposis, Clinical Management and Patients Quality of Life. Ed by Delaini GG. Springer-Verlag
Italy. 2006
Shanahan F. Ulcerative colitis. In Clinical Gastroenterology and Hepatology. Ed by Weinstein WM, Hawkey CJ,
Bosch J et al. Elsevier Mosby. 2005; pp.343-358.
Vermeire S, Rutgeerts P. Crohns Disease. In Clinical Gastroenterology and Hepatology. Ed by Weinstein WM,
Hawkey CJ, Bosch J et al. Elsevier Mosby. 2005; pp.359-376.

Level of
competent : 3A

IRRITABLE BOWEL
SYNDROME (IBS)
Centre of Gastroentero-Hepatology, Wahidin Sudirohusodo
Hospital Teaching
Internal Medicine, Faculty of Medicine, Hasanuddin University

Definition
Recurrent abdominal pain or discomfort at least 3
days per month in the last 3 months associated
with 2 or more of the following : (ROME III criteria)
improved with defecation
onset associated with a change in frequency of
stool
onset associated with a change in form
(appearance) of stool

Epidemiology

Mostly between the ages 20

and 40 years
20% consult a physician,
only a small percentage
visit a gastroenterologist
> 60% have psychological
disturbances (anxiety,
somatoform, personality
disorders or chronic pain
syndrome); 35% have a
history of sexual abuse
(women)

The most common functional

bowel disorder and effects
predominantly women (70%
patients)

Can cause great discomfort,

sometimes intermittent or
continous,for many decades
in patients life and can have
significantly negative impact
on quality of life

Pathogenesis
IBS can be cause by many factors,such as :
Disturbed bowel motility
Visceral hypersensitivity
Bacterial overgrowth /postinfective IBS
(Shigella, salmonella, campylobacter)
Stress response : psychological problems

CLASSIFICATION
based solely on stool
consistency and not
frequency, urgency and
straining (The Rome III ) :
1. IBS with constipation
(IBS-C)
2. IBS with diarrhea (IBSD)
3. Mixed IBS (IBS-M)
4. Unsubtype IBS
Alarm feature indicate that
the diagnosis might not be
IBS

Clinical Findings
SYMPTOMS AND SIGN :
Abdominal pain or discomfort
that is linked to bowel
function
Not explained by biochemical
or structural abnormalities
With symptoms onset at least
6 month

Diagnosis
Symptom & sign
Laboratory : CBC, Thyroid stimulating
hormone & serologies, stool test
Endoscopy of LGI

Differential Diagnosis
Lactose
intolerance
Food intolerance
Infections
Celiac disease
Tropical sprue
Small bowel
bacterial

IBD
Microscopic colitis

Complications
Decreased QOL
Time off work & school
Personal expense of medication &
physician visits
Psychological problem (depression &
anxiety)

Treatment
Dietary modification
Fiber supplements
Physichotherapy

Pharmacologic agents : antidiarrheal, enemas &

suppositories, laxantive,antispamotics, tricyclic
antidepressants, selective serotinin reuptake
inhibitors (SSRIs = citalopram, fluoxetine), serotinin
receptor, probiotics

Colitis 3A

Dysentry Bacilli 4

Carcinoma Colon 2

Necrotizing enterocolitis
1

Proctitis 3A