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Dr. Elsayed Abdelmaksood Khalil Prof. of internal Medicine, Gastroentrology unit Mansoura University
Inflammatory bowel disease (IBD)
chronic non-specific inflammation of the GI tract : IBD commonly refers to ulcerative colitis and Crohn's disease . Although the diseases have some features in common, there are some important differences:
Ulcerative colitis ( UC) is an inflammatory disease of the large intestine only (rectum alone, left sided colon, or the whole colon).
The small intestine is never involved, except
in a few of these patients there is inflammation of the distal terminal ileum (backwash ileitis), the mucosa - of the intestine becomes inflamed and develops ulcers. UC is often most severe in .the rectal area
Crohn's disease (CD) can attack any part of the digestive tract, most commonly affects the last part of the small intestine (called the terminal ileum) and parts of the large intestine but the rectum may be spared and be relatively normal. Crohn's disease causes inflammation that extends much deeper into the layers of the intestinal wall . Crohn's disease generally tends to involve the entire bowel wall.
health problems may occur outside the digestive system. the disease may show signs of inflammation elsewhere in the body, such as in the joints, eyes, skin, and liver. Skin tags that look like hemorrhoids or abscesses may also develop around the anus.
Features Skip areas Transmural involvement Rectal sparing Perianal involvement Fistulas Strictures Granulomas
Crohn Disease Common Common Common Common Common Common Common
Ulcerative Colitis Never Occasional Never Never Never Occasional Occasional
IBD occurs most frequently in people ages 15 to 30, but it can also affect younger children and older people. And there are significantly more reported cases in western Europe and North America than in other parts of the world.
Causes The etiology of IBD is unknown. Environmental, infectious, genetic, autoimmune, and host factors have been suspected. Interactions among these factors may be more important. smoking may enhance the development of Crohn's disease. The onset of UC occasionally appears to coincide with smoking cessation
Diagnoses History and clinical examination Blood tests may be done to determine if there are signs of inflammation, which are often present with the disease. Barium study of the intestines ColonoscopIC examination
History Patients with UC most commonly present with bloody diarrhea, whereas patients with CD usually present with nonbloody diarrhea. Abdominal pain cramping and weight loss occur in more severe cases. The greater the extent of colon involvement, the more likely the patient is to have diarrhea. Patients might have formed stools if their disease is confined to the rectum. Rectal urgency or tenesmus reflects inflamed rectum. As the degree of inflammation increases, systemic symptoms develop, including low-grade fever, malaise, nausea, vomiting, sweats, and arthralgias. Fever, dehydration, and abdominal tenderness develop in severe UC, reflecting progressive inflammation into deeper layers of the colon.
The presentation of CD is generally more insidious than that of UC, with ongoing abdominal pain, anorexia, diarrhea, weight loss, and fatigue. Grossly bloody stools, while typical of UC, are less common in CD. One half of patients with CD present with perianal disease (eg, fistulas, abscesses). Occasionally, acute right lower quadrant pain and fever may be noted, mimicking appendicitis. CD with gastroduodenal involvement may mimic peptic ulcer disease and can progress to gastric outlet obstruction. Commonly, the diagnosis is established only after several years of recurrent abdominal pain, fever, and diarrhea.
Crohn's disease may present as an emergency with acute right iliac fossa pain mimicking acute appendicitis. Examination of the anus to look for anal tags, fissures, or perianal abscesses.In ulcerative colitis the anus is usually normal.
Clinical examination Fever, tachycardia, dehydration, and toxicity may occur. Pallor may be noted, signs of localized peritonitis, although abdominal tenderness is common.. Patients with CD may develop a mass in the right lower quadrant. The rectal examination often reveals bloody stool Complications (eg, perianal fissures or fistulas, abscesses, rectal prolapse) may be observed in up to 90% of patients with CD. Include in the examination a search for extraintestinal manifestations, such as iritis, episcleritis, arthritis, and dermatologic involvement.
Barium study of the intestines This procedure involves the use of a thick white solution , which shows up white on an X-ray film, In CD a small bowel follow through shows deep ulcerations and areas of narrowing (string sing) largely confined to the ileum. Skip lesions with normal bowel between are also seen also, rectal sparing are noted in CD. Barium enema also shows CD ulcerations which is usually patchy. In UC barium enema may reveal a shortened colon, with loss of haustrations and destruction of the mucosal pattern (ie, lead pipe colon). Barium enema is contraindicated in patients with moderateto-severe colitis because it risks perforation or precipitation of a toxic megacolon.
colonoscope, this instrument is a long, tube inserted through the anus and attached to a TV monitor. This procedure is called a colonoscopy, which allows the doctor to see inflammation, bleeding, or ulcers on the wall of the colon. During the exam, a biopsy must be done
A microscope (Crohn's disease three is an increase in chronic inflammatory cells and lymphoid hyperplasia non caseating granuloma may be present , in ulcerative colitis he mucosa shows a chronic inflammatory cell infiltrate in the lamina propria. Crypt abscesses and goblet cell depletion are also seen)
Extraintestinal complications occur in approximately20% of patients with IBD .In some cases,
they may be more problematic than the bowel disease itself. Joints: Peripheral arthritis, usually migratory and monoarticular, tends to parallel disease activity but may antedate it. Ankylosing .spondylitis is associated with HLA-B27 Ocular: Episcleritis, conjunctivitis and Iritis Dermatologic: Erythema nodosum, pyoderma gangrenosum, .aphthous ulcers and vasculitis Liver and biliary tree: pericholangitis, chronic active hepatitis, cirrhosis, primary sclerosing cholangitis, bile duct carcinoma and Gallstones Hypercoagulable state
Complications Perforation and toxic megacolon Suspect toxic megacolon in a patient with fulminant UC, especially if the number of daily stools has declined sharply without a corresponding improvement in symptoms. The abdomen is typically distended, tender, and tympanitic. The best method of diagnosing toxic megacolon is through the use of plain radiography. Strictures usually are benign but can lead to obstruction. Fistulas and abscesses are much more common in CD Massive hemorrhage occurs in fewer than 1% of patients. Cancer risk increases with extent and duration of the disease Amyloid
Treatment Drug treatment is the main method for relieving the symptoms of both ulcerative colitis and Crohn's disease.. Some patients requrie only symptomatic treatment. Drugs Affecting Motility: Antidiarrheal drugs such as loperamide (Imodium) or diphenoxylate (Lomotil) can have some beneficial effects. Antispasmodic drugs have also been used in some cases. Metronidazole can be used alone or in combination with corticosteroids. It is an antibiotic and also inhibits the immune system.
Anti-inflammatory drugs Sulfasalazine and mesalamine containing compounds are the drugs of choice . are effective for treating acute UC and for maintaining its remission; they are also beneficial in mildly to moderately active CD when the colon is involved. Sulfasalazine has not been clearly shown to maintain remission in CD. Corticosteroids:These agents are the treatments of choice for an acute IBD attack; administer IV in severe disease. Do not use steroids for maintaining remission because of their lack of efficacy and potential complications
Immunosuppressants agents: Azathioprine and Cyclophosphamide: These agents are useful as steroid-sparing agents, in healing fistulas, or when the patient has serious contraindications to surgery. They are used in patients refractory to or unable to tolerate steroids. Some agents, including azathioprine and its metabolite, 6mercaptopurine, have been useful in CD complicated by recurrent rectal fistulas or perianal disease; response can take up to 6 months. Methotrexate has also been tried.
necrosis factor alpha inhibitors: Infliximab (Remicade), given intravenously, consists of monoclonal antibodies to TNF-alpha.
common mistakes in treating inflammatory bowel disease is to stop medication too early.
Surgery In Crohn's disease, doctors make every attempt to avoid surgery because of the recurring nature of the disease. There's also a concern that an aggressive surgical approach to Crohn's disease will cause further complications, such as short bowel syndrome.
In the case of ulcerative colitis, removal of the colon (large intestine) may be necessary, along with a surgical procedure called an ileoanal anastomosis (also called an ileoanal pull-through) in which doctors form a pouch from the small bowel to collect stool in the pelvis. This allows the stool to pass through the anus
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