Done

By Ahmed Z. Alotaibi & Mohammed A. Alshehri

IBD

1. EPIDEMIOLOGY
A. facts
i. Ulcerative colitis incidence peaks during the third decade of life and again in the
seventh decade of life.
ii. Crohn’s disease has a similar bimodal incidence, with most cases occurring
between ages 15 to 30 years and ages 55 to 60 years.
iii. In 15% of patients with inflammatory bowel disease, differentiation between
ulcerative colitis and Crohn’s colitis is impossible; these patients are classified as
having indeterminate colitis.

2. ETIOLOGY
A. Multifactorial
i. Smoking exacerbation of Crohn’s disease “CD”, & breast feeding protective
ii. Family history may play a role because 10% to 30% of cases.
iii. NOD2 Gene ”IBD1” chromosome 16à if in both allelic à40times risk of
development of CD
iv. IBD2 on chromosome 12q & IBD3 on Chromosome 6
v. autoimmune mechanism and/or a defect in the intestinal immune system.
vi. Bacteria, such as Mycobacterium paratuberculosis and Listeria monocytogenes,
and viruses, such as paramyxovirus and measles virus, have been suggested as
etiologic agents in Crohn’s disease.
vii. A defect in the gut mucosal barrier, which increases exposure to intra-luminal
bacteria, toxins, or proinflammatory substances.

 Ulcerative Crohns
colitis disease
1-colon+ rectum +/- Backwash iliitis
2-Mucosa +Submucosa
1-Earliest lesion à aphthous ulcer
2-All GI, +/- spare rectum.

3-Mucosa atrophy + crypt abscess . 3-Transmural.
4-multiple inflammatory pseudopolyps. 4-noncaseating granulomas.
5-the colon may be foreshortened and the 5-deep serpiginous ulcers and a “cobblestone”
mucosa replaced by scar “ lead pipe” in appearance.
CHRONIC ULCERATIVE. 6-Strictures may produce symptoms of obstruction
6-Spares perianal area in CHRONIC CROHNS.
7-The earliest manifestation is mucosal edema 7-involves perianal region.
and loss of vascular pattern 8-skip lesion & fat wrapping :-Pathognomic
8- colonoscopy or barium enema during an 9- rectal sparing occurs in 40%.

acute flare is contraindicatedàthe risk of 10- most common sites of involvementà
perforation. -Terminal ileum and cecum
9-Any stricture àThink malignancy -small bowel
10-pancolic disease risk of Caà -colon&rectum
2% after 10 years. 11-Isolated Anal Crohn’s à 4%
8% after 20 years. 12- surgical therapy is reserved for complications
18% after 30 years. of the disease.
11-Caà arise in areas of flat dysplasia 13- Crohn’s diseaseà present as:
12-Surveillanceà *acute inflammatory process:-
annually after 8 yrs in pancolitis -Associated w/ Fistulas and intra-abd collection
annually after 15 yrs in with left-sided colitis. -Max Medical therapy & TPN àMay cure
13-invasive canceràpresent in up to 20% of -If surgery for fistulaà Resection & anastomosis
patients with low-grade dysplasia for the 1ry inflamed part and only closure of fistula

14-Indication of surgery:- opening in 2nd healthy part
*Emergency à 1-life-threatening hemorrhage -intra-abd collection à CT guided drainage+ABX
2-toxic megacolon “TM” ** chronic fibrotic process:-
3- fulminant colitis “FC” -Associated w/ strictures
-Medical therapy à NEVER CURE
NB:in FC & TMà bowel rest, IVF, broad-
-surgery is either resection or stricturoplasty (see
spectrum ABX, and parenteral
surgical treatment below).

corticosteroidsàfailure to improve within 24hrs
to 48hrsàE1 surgery.
-Balloon Dilatation à valid option in T.ilium

stricture.
*Electiveà 1-intractability
2-side effects to steroids e.g. aseptic 14- recurrence after resection is highà50% after

joint necrosis 10yrs
3-patient at increased risk of colon 15-MC perianal Crohn’s à skin tags
malignancy à especially pancolitis 16- Perianal fistula à usually multiple and lateral.
17- diversion aloneà Will Not Improve Anal&
Perianal Crohn’s.
15- pANCA +ve / ASCA -ve
18- Contraindications of stricturoplasty:-
-Phlegmon
-Peritonitis


-Intraabdominal Abscess

-Impaired Nutritional status
-Dysplasia or Cancer at stricture site

19- pANCA -ve / ASCA +ve
20-common in female

3. EXTRAINTESTINAL MANIFESTATIONS “EIM”

A. 1/4th of crohn’s disease have EIM
B. liver is a common site for EIM
i. Fatty infiltration “Reversible” of the liver is present in 40% to 50% of patients,
and cirrhosis “irreversible” is found in 2% to 5%.
ii. Primary sclerosing cholangitis strongly associated with UC, 40% to 60% of PSC
patients have UC. Only curative treatment of PSC is liver transplant
iii. Pericholangitis à Diagnosed by liver Bx.
iv. Cholangiocarcinoma à early presentation in patient with IBD “20 years earlier”
C. Arthritis
i. 20 times greater in IBD
ii. Improves with IBD treatment
D. Sacroiliitis and ankylosing spondylitis
i. Does NOT improve after treatment
E. Erythema nodosum
i. 5% to 15% of patients with inflammatory bowel disease
ii. Evidence of an active disease
iii. More common in women
iv. raised, red, and predominantly on the lower legs.
F. Pyoderma gangrenosum
i. Uncommon
ii. erythematous plaque, papule, or bleb. “painful”
iii. On pretibial region and occasionally near a stoma.
iv. May be Reversible after surgical resection of bowel.
G. ocular lesions
i. 10 %
ii. develop during an acute exacerbation

4. MEDICAL TREATMENT
medications example General information
Salicylates 1-SulfasalazineàUS - first-line in mild to moderate.
2-5-ASAà CD - inhibit cyclooxygenase and 5-lipoxygenase in the gut mucosa.

- require direct contact to affect mucosa.
- available in suppositories.

Antibiotics Metronidazole. - improves Crohn’s colitis and perianal disease (for 4 weeks)
Fluoroquinolone. -1st line in perianal disease
-antibiotics are not used to treat ulcerative colitis.
-only used in fulminant colitis or toxic megacolon.

Corticosteroids Budesonide. - either oral or parenteral.

Beclomethasone. -Induce Remission but don’t prevent relapse
Dipropionate. - for an acute exacerbation.
- 75% to 90% of patients will improve.
- should be limited to the shortest course possible due to side effects.
- careful use in childrenà potential adverse effect on growth.
- Failure to wean à relative indication for surgery.
- Corticosteroid enemasà effective for proctitis and proctosigmoiditis.
- Corticosteroid enemas à less side effects than systemic.

Immunomodulating -Azathioprine -onset of action of these drugs takes 6 to 12 weeks

Agents “Imuran”à No need -decrease proliferation of inflammatory cell, and prevent relapse.
to stop before -use in patient not responding to salicylate or steroid dependent or refractory to
Surgery steroids.
6-mercatopurine (6- -Azathioprine side effect à Bone marrow suppression
MP). -Helps tapering Corticoid dependent patients.
-Cyclosporine. -concomitant use of corticosteroids is required.
- Methotrexate -(Cyclosporine)not routinely used to treat inflammatory bowel disease.
- Cyclosporineà will improve acute flare of IBD in 80% of patients.
- Improvement is generally apparent within 2 weeks after use of Cyclosporine
- Avoid Long-term use cyclosporine due its toxicities (e.g., nephrotoxicity,
hirsutism, gum hypertrophy).
- Methotrexateà is a folate antagonist, more than 50% of patients will improve

Biologic Agents -Infliximab
-adalimumab “Humira”à
Controversial Studies to stop
or not to stop before surgery
-based on inhibition of tumor necrosis factor alpha (TNF-α).
-Not used in an ongoing sepsis or intra-abd collection
- improve treatment for steroid-refractory inflammatory bowel disease.
- anti-TNF-α therapy may also be beneficial in treating the extraintestinal
manifestations.
-Infliximabà monoclonal antibody directed against TNF-α.
- Infliximabà use in moderate to severe Crohn’s disease.
- Infliximabà Drug of choice patients with perianal Crohn’s disease.
- Infliximabà Recurrence is common after stopping infliximab.
- Infliximabà require infusions on a bimonthly basis.
- Adalimumabà treatment of steroid-refractory ulcerative colitis

5. SURGICAL MANAGEMENT
Ulcerative Colitis Crohn’s disease

Emergency:- Iliocecal Crohn’s:-

1-TM, FC, or Colon Bleedingà Isolated disease to the area à Resect and anastomose.
* Total Abdominal colectomy + end ileostomy +/-
Small bowel Strictures:-
Mucus Fistulaà definitive surgery delayed
afterwards.
-Isolated short à Resection & anastomosis at normal
** IF patient is severely ill and unstableà appearing bowel, no need for frozen
-loop ileostomy. -If length of bowel is looked afterà Stricturoplasty:-
-or decompressive colostomy. -Heineke-Mickuliczà <7cm w/ NO Fistula
2-Massive Rectal Bleedà
-Judd stricturoplastyà <7cm W/ FISTULA
proctectomy + permanent ileostomy or an ileal
-Moskel-Walske-Neumayerà <7cm w/ Diameter
pouch–anal anastomosis.
discrepancy
-Finneyà >7 cm and ≤15 cm
Elective:- choose one -side-to-side isoperistaltic stricturoplastyà Multiple
1-Total proctocolectomy with end ileostomy. short strictures clustered over a lengthy segment.
2-restorative proctocolectomy with ileal pouch–anal *Duodenal strictures +Intra-mesenteric abscessà G-J
anastomosis. Bypass
3-Abdominal colectomy + ileorectal anastomosisà
only for a patient with indeterminate colitis and Crohn’s Colitis:-
rectal sparing. same as US in E1 and elective, EXCEPT in elective case
Segmental colectomy may be appropriate if rest of

colon is normal.
Anal & Perianal Crohn’s:-
-Skin tags and Hemorrhoid à No excision unless
Extremely Symptomatic
-Perianal AbscessàI&D THEN ABX along w/ Anti TNF
-Fissureà Conservative, SLIC à R.Contraindicated.
-FistulaàLiberal use of non-cutting setons.
-Rectovaginal fistula “RV”à rectal or vaginal mucosal
advancement flap. PROCTECTOMYàfor Highly
symptomatic RV fistula.

Indeterminate Colitis
-15% of patients with inflammatory bowel disease.
-The indications for surgery are the same as those for ulcerative colitis.
-a total abdominal colectomy with end ileostomy may be the best initial procedure:-
1- If pathology show US à Completion + ileal pouch–anal anastomosis procedure.
2- If pathology Undetermined or Crohn’s Colitisà completion proctectomy with end ileostomy
*Ileal pouch–anal reconstruction may also be considered in crohn’s colitis with the understanding that the
pouch failure rate is between 15% and 20%.

This was done in hopes to finish early and watch Deadpool 2