Infammatory bowel

diseases

Dr Yasser Mahrous
-Idiopathic: UC, crohn`s

- Ischemic colitis

- Bilharzial colitis

- Amaebiasis

- TB

- Shigellosis
 Ulcerative colitis
A chronic, inflammatory, and ulcerative disease
arising in the rectal and colonic mucosa,
characterized most often by bloody diarrhea.
 Aetiology
The cause of ulcerative colitis is unknown.
Evidence suggests that a genetic predisposition
leads to an unregulated intestinal immune
response (neutophilic or lymphocytic) to an
environmental, dietary, or infectious agent.
 Epidemiology
1. Age : Bimodal
2. Sex: More in females
3. More in urban areas , developed
countries and colder climates
4. More in jews (4-5 times)
5. More in non smokers
Pathology
-Site:
- rectum :40%
- left colon: 30%
- pancolitis:20-30%
-Macroscopic:
-Mucosa is granular, edematous, friable,
ulcerations and pseudopolyps
-Microscopic:
Infiltration of mucosa with plasma cells
,PMNL and lymphocytes, Crypt abscess
 Clinical picture
• Remissions and exacerbations of bloody diarrhea

• Mild cases: Proctitis and distal colitis

• Moderate cases (Left sided colitis): pain, fever, diarrhea,

bleeding,and anemia

• Severe cases (Fulminant): severe bleeding, severe

diarrhea, and severe abdominal pain and shock.

• Complicated cases: colonic dilatation and toxic

megacolon.
:Extraintestinal manifestations
1. Joints ( sacroiliitis, ankylosing
spondylitis)
2. Skin (pyoderma gangrenosa, erythema
nodosum)
3. Eye (iritis and uveitis)
4. Liver (sclerosing cholangitis, gall stones)
5. Hypercoagulable states
6. Urinary complications (stones, ureteric
obstruction)
 :Complications

1. Infectious colitis
2. Toxic megacolon
3. Massive hge and perforation
4. Cancer colon
 Diagnosis:
1. Stool analysis
2. ESR
3. Barium enema
4. Colonoscopic picture and biopsy
5. Upper endoscopy and enteroscopy
6. Capsule enteroscopy
normal
 :Differential diagnosis
- crohn`s disease Severe perianal disease, rectal sparing,
absence of bleeding, and asymmetric or segmental involvement of the
colon indicate Crohn's rather than ulcerative colitis

- Bilharzial coloitis
- Amaebiasis
- TB
- Shigellosis
- Ischemic colitis
- Contraceptive pills induced colitis
- Cancer colon
- Pseudomembanous colitis
:Treatment
 Diet
1. No known dietary substances cause activation of IBD

2. Lactose intolerance is common in persons with Crohn

disease or ulcerative colitis

3. Nothing by mouth (status NPO) or liquid diet can

hasten the reduction of inflammation

4. Parenteral alimentation may be needed.

Step 1:
Step 1a (aminosalicylate preparations): sulfasalazine , mesalamine ,
balsalazide , and olsalazine.

Treating flares of IBD and for maintaining remission.

More effective in persons with ulcerative colitis than in persons with

Crohn disease.

Step 1b (antibiotics):
metronidazole , ciprofloxacin and Rifaximin are the most commonly used
.antibiotics in persons with IBD
Step 2 (Corticosteroids)

•Corticosteroids are rapid-acting anti-inflammatory

agents used in the treatment of IBD. Indications are for
acute flares of disease only; corticosteroids have no
role in the maintenance of remission.

•Corticosteroids may be administered intravenously (ie,

methylprednisolone, hydrocortisone), orally (ie,
prednisone, prednisolone, budesonide,
dexamethasone), or topically (ie, enema, suppository,
or foam preparations.
 Step 3(immune modifiers )
•The immune modifiers 6-MP and azathioprine are used in
patients with IBD in whom remission is difficult to maintain with
the aminosalicylates alone.

•Immune modifiers work by causing a reduction in the

lymphocyte count, and because of that mechanism of action,
their onset of action is relatively slow (typically 2-3 mo).

•They are used most commonly for refractory disease; they are
also used as primary treatment for fistulae and the maintenance
of remission in patients intolerant of aminosalicylates.

• Use of these agents mandates monitoring of blood parameters;

 Step 3a (immune modifiers )

Infliximab (Remicade) is an anti–TNF-alpha

monoclonal antibody administered by
. infusion

It is administered as 3 separate infusions of

5 mg/kg at weeks 0, 2, and 6, often followed
by doses every 8 weeks for maintenance of
. remission
 Step 4 (experimental agents )
•Methotrexate (12.5-25 mg/wk orally or intramuscularly)

•Thalidomide (50-300 mg/d orally)

•Interleukin 11 (1 mg/wk subcutaneously)

•Cyclosporine A at a dose of 2-4 mg/kg/d intravenously

•Nicotine patch (14-21 mg/d via topical patch)

•Probiotics

•Heminthic therapy.
Neuropeptides including substance P,
corticotropin-releasing hormone, neurotensin,
vasoactive intestinal peptide, and galanin. The
available evidence is that neuropeptide
blockade may be considered a therapeutic
approach in both Crohn's disease and
ulcerative colitis
•Leukotriene synthetase inhibitors, which are currently
in phase III trials. One of these inhibitors, zileuton
(Zyflo), has been shown to be effective in inflammatory
bowel disease. Its demonstrated efficacy is similar to
that of the 5-ASA preparations.

Tacrolimus (FK506; Prograf), an immunosuppressant

similar to cyclosporine but with better oral absorption,
was shown to be beneficial in patients with complex
proximal small-bowel Crohn's disease.