Lower GI Disease

Imam Suprianto

Gastroentero-Hepatology Division
Of Internal Medicine. Sriwijaya
Medical Faculty.
2009

Inflamatory Bowel Disease

- An immune mediated chronic intestinal condition

- Types : 1. Ulcerative Colitis

2. Crohns Disease
3. Intermediate Colitis

Epidemiology
- Incidence

varies within different geographic area.

- In USA : UC 2,2 to 14,3/100.000
CD 3,1 to 14,6/100.000
- RSCM 2001-2006 : IBD 8,3%
- Hasan Sadikin 2007 : IBD 9,89%
- Sarjito 2007 : IBD 4,4%
- The peak age of onset : 15 and 30 year
- The second peak occur : 60 and 80 year
- Ratio male to female : UC 1 : 1
CD 1,1 : 1

Etiology-Pathogenesis
- Until now the etiology is unclear.
- Basic concept of IBD

Cascade
Inflamation
Protease
Leukotrin

Genetic
Enviroment

Direct Damage
autoimun, viral,
bacteria, protein

Cell

Lymfosit

netrofil

sitokin
macrofag

Clinical Features
- Mayor symptoms : chronic diarrhea with or
without blood, abdominal pain, tenesmus.
- Extra intestinal manifestation : artritis, uveitis,
pioderma gangrenosum, eritema nodosum
- Symptoms correlated with the extend of disease.
- Clinical manifestations of UC are simple than CD
- UC : colon.
CD : mouth to anorectal.

Manifestation Of IBD
1. Acute phase
2. Remision Phase
3. Exacerbation
Use : Disease Activity Index

Clinical Manifestation Of IBD

Clinic

UC

CD

Chronic Diarrhea
Hematoschezia
Abdominal Pain
Abdominal Mass
Fistul
Stenosis
Intestine involved
Rectal involved
Extraintestinal
Megacolon toxic

++
++
+
+/+
+/95%
+
+

++
+
++
++
++
++
++
50%
+
+/-

Pathology of IBD
Pathology

UC

CD

Segmental lesion
Transmural lesion
Granuloma
Fibrosis
Fistula
Anatomy predilection
- ileocaecal
- rectal

+/+
+/-

++
+/++
50%
++
++

+/++

++
+/-

Complication
Ulcerative Colitis :
- Toxic megacolon
- Stricture
- Anal fissure
- Perianal abses
- Malignancy
Chrons Disease :
- Perforation
- Intraabdominal or pelvic Abscess
- Intestinal obstruction
- Massive haemorhage
- Malabsorbtion

normal colon

Ulcerative Colitis

Ulcerative colitis

Crohns disease

Crohns disease

Crohns Disease

Management of IBD
1. Diagnostic
2. Therapeutic
3. Educational
4. Management in primer health care

1.Diagnostic
1.1 Laboratory
- not spesific
- abnormality of Hb, leucosit, LED, trombosit, CRP,
fe serum.
- to evaluated severity of disease and nutrition
status.
1.2 Radiology
- Double contras barium show stricture lesion,
fistul, ulcer, polyp, irregular mucosa
- Contraindication for severe UC

1.3 Endoscopy
- Important role for diagnostic and treatment of IBD.
- Acuracy : 89%
1.4 Histopatology
- UC : crypti abscess, crypti dilatation, Mn
infiltration, Pmn infiltration.
- CD : granulomatous, macrofag and lymfosit
infiltration.

Endoscopy Pattern of IBD

UC

CD

Inflamation
Continues
Skip area
Rectal involved
Cobblestone appearance

+++
+++
+

+
+++
+
+++

Ulcer
In inflamation area
Ileum involved
Discreate
Diameter >1 cm
Deep
Linier
Aphtoid

+++
+
+
+
+
-

+
+++
+++
+++
+++
+++
+++

Pathway of Diagnostic Process of

IBD
Anamnesis
History of illness

Evaluation
clinical illness

Radiology
Colonoscopy
Histopatology

Physical examination

Laboratory
DPL, LED, CRP, Feces, CEA

2. Therapeutic
2.1 Active inflamation
- Corticosteroid, prednison 40-60mg/day
metilprednisolon 0,5 1mg/bw
- Tapering of 8-12 weeks
- 5 ASA : 2-4 gr/day
combined sulfapiridin and aminosalisilat
remision ; 16- 24 weeks
prevent colonrectal cancer

2.2 Recurance inflamation

1. 5 ASA/mesalazine
Maintanance dose : 1,5 3 gr/day
for descenden colon to rectosigmoid :
suppositoria-enema.
2. Imunosupresiv
- Metrotexate
- Azathioprine
- 6 Mercaptopurine
- Cyclosporine

3. Antibiotic, probiotic, biologic agent

- infiximab, centrolizumab.
- ciprofloksasin, metronidazol.
4. Lifestyle
2.3 Prevent Complication
2.4 Surgery

Pathway of managemant IBD in

primary health care
Anamnesis and physical examination
suspected IBD
General Treatment
maintenance
5 ASA
respons

not response
5 ASA po +
steroid

refer
not respons

Irritable Bowel Syndrome

- Fungtional bowel disease
- Abdominal pain
- Altered bowel habit
- no abnormality
- Frequency : 10-20% in adult, female predominan

Diagnostic Criteria for IBS (Rome III)

Recurrent abdominal pain at least 3 days per
month in the last 3 month assosiated with 2 or
more of the following :
1. Improvement with defecation
2. Onset assosiated with a change in frequency of
stool.
3. Onset assosiated with a change in form of stool

Types of IBS
1. Pain type.
2. Constipation type.
3. Diarrhea type.
4. Altered pattern

Clinical Features
1. Abdominal Pain
- prerequest clinical feature of IBS
- variable in intensity and location
- pain is exacerbated by eating or emotional stress
and improve by passage of flatus or stool.
- pain frequently episodic and cramp
2. Altered Bowel Habit
- constipation
- diarrhea

3. Gas and Flatulence

- abdominal distention and increased belching or
flatulance.
- most patient have impaired transit and tolerance
of intestinal gas load.
4. Upper gastrointestinal Symptoms
- 25 50% complain dyspepsia, heartburn, nausea,
vomiting.

Differential Diagnostic
- Lactulosa intolerance
- Colonrectal cancer
- Inflamatory bowel disease
- Diverticulitis
- Intestinal obstruction
- Malabsorbtion

Treatment

- Diet
- Pyscotherapy
- Antispasmodic : - Hiosin N butilbromid 3x10mg
- Mebeverin 3 x 13 mg
- Alverine 3 x 30mg
- 5 HT 4 reseptor antagonic : Tegeserod 2 x 6mg
for constipation type.
- loperamide for diarrhea type

Colon Rectal Tumor

Divided 2 : - Colon Cancer
- Polyp Colon
Polyp Colon
Grossly protrusion from the mucosal surface.

Macroscopic :
- Pedunculated polyp
- Sessile polyp
Microscopic :
- non epithelial polyp : limfoid, adiposa, intestine,
- epithelial polyp
Epithelial polyp:
1. Adenoma
2. Hamartoma
3. Inflamatory polyp
4. Hyperplastic polyp

Adenoma :
- tubular, villosa, tubulo-vilosa
- transformed to be malignant
- large polyp to be malignant
Hamartoma
- malformation
- juvenile polyp, peutz jegher syndrome.
- not malignant

Inflamatory polyp
- crohns disease
- ulcerative colitis
- amebiasis
- dysentri basiler
- pedinculated
Hyperplastic polyp
- > 40 years.
- > rectal
- multiple and sessile

Pedinculated polyp colon

Sessile polyp colon

Colon Ca
Epidemiology
- Man : women : 19,4 : 15,3/100.000.
- Incidence high : USA, australia, Europe
- Increase after 50 years
- Second cause of cancer death in USA
- 150.000 new cases each year

Etiology
- complexs interaction between genetic and
environment factors.
- environment factors : macronutrient and
micronutrient.
- genetic factors : - chromosom instability
- microsatelit instability

Stage and prognostic

Stage
Dukes TNM
A
T1N0M0
B1
T1N0M0
B2
T2N0M0
C
T3N1M0
D
T3N2M1

PA
Fase
I
I
II
III
IV

submucosa
muscularis
serosa
lymp node
metastasis

Survival 5 year
>90%
85%
70-80%
35-45%
5%

Clinical Manifestation
- > 50 years
- Bowel habit change
- Hematoschezia
- Obstruction
- Local invasion : tenesmus, hematuria, uretra
obstruction.
- Fistul colon gaster
- Ascites
- Abdominal pain, icteric, portal hypertension.

Distribution of colon rectal ca

- Rectal
- Descenden colon
- Rectosigmoid
- Sigmoid
- Ascenden colon
- Tranversal colon
- Caecum

: 51,5%
: 11,7%
: 9,7%
: 9,7%
: 8,7%
: 6,8%
: 1,9%

Diagnostic
1. Symptoms : hematoschezia, abdominal pain,
decrease body weight, anemia, bowel habit
change.
2. Laboratory : - anemia defisiensi fe
- occult blood in feces
3. Radiology : double contras enema
50%
polyp
4. Colonoscopy : sensitivity 95%
spesifity 99%
5. Histopatology

Treatment
- Kemoprevention : aspirin
NSAID
- Polypectomy : polyp adenomatous
- Hemicolectomy : caecum, ascenden colon,
transversum colon.
- Low anterior resection : rectosigmoid
- Kemotherapy : levamisol
5 FU

Colon Ca

Infection Colitis
Colitis is acute or chronic inflamation of colon.
Divided 2 :
1. Infection colitis : tuberculosis colitis,
pseudomembran colitis, amebiasis colitis,
2. Non infection colitis : ulcerative colitis, crohns
disease, ischemic colitis, radiation colitis, non
spesific colitis

Tuberculosis Colitis
- Due to mycobacterium tuberculosis
- High frequency in growth country

Patogenesis
- Most case caused by mycobacterium
tuberculosis.
- Usually contack with sputum contains M
tuberculosis.
- Relation between high frequency of pulmonary
tuberculosis and tuberculosis colon.

Clinical Features
- chronic abdominal pain
- bloody diarrhea
- constipation
- anoreksia
- fever
- decrease body weight
- intra abdominal mass

Diagnostic
- M tuberculosis : biopsy or microscopic
- Enema : wall thickness, mucosa distorsion,
ulseration, stenosis, mass, pseudopolyp.
- colonoscopy : - narrow lumen, ulceration, edema
and irregular.
- biopsy for cultur and
histopatology.

Differential Diagnosis
- Crohns disease
- Colon Ca
- Amebiasis

Complication
- Bleeding, perforation, obstruction, fistul,
malabsorbtion.
- Obstruction ( 30%).

Treatment
- INH 5 -10 mg/bw
- Etambutol 15-25 mg/bw
- Rifamficin 10mg/bw
- Pyrazinamide 25-35 mg/bw
Surgery if there is complication

Pseudomembran Colitis
- colon inflamation caused by toxin
- formed pseudomembran in mucosa surface.

Etiology
- complication after use antibiotic
- clostridium difficile as bacteria induced.
- supressed normal flora colon

Patogenesis
- Clostridium difficile cause colitis by toxin
mediated
- C difficile produced 2 kinds toxin : A toxin and B
toxin.
- A toxin makes inflamation.

Clinical Features
- appear after the first time antibiotic use or after 6
weeks antibiotic use.
- diarrhea, abdominal pain, fever, edema,
hipoalbuminemia, leukositosis.
- severe : toxic megacolon, perforation, electrolit
imbalance,

Diagnostic
- Diarrhea after antibiotic use
- Colonoscopy : pseudomembran
- Feces cultur : C difficile 95%.
- Elisa : A toxin
DD/ :
Colitis non infection

biopsy

Treatment
- Stop antibiotic
- Mild : metronidazol 4 x 250-500 mg, 7-10 days
- Severe : metronidazol 125 500 mg, 7-14 days

Pseudomembran Colitis

Thanks