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Introduction
Learning Objective(s)
Inflammatory Bowel
Disease
n. Abbr. IBD
There is NO cure
IBD is a result of an immune response against the bodies own
intestinal system
Most commonly begins in early 20’s to 30’s, but also seen in 50-
80 year old’s (but this peak is mainly for CD)
Not contagious
Cause UNKNOWN
Both are characterized by diarrhea and abdominal pain
Risk Factors
Age and gender:
15-40 years of age
2nd peak 50-80 years of age (CD)
Slight female predominance in CD
Slight male predominance in UC
Genetic susceptibility
Etiology
Unknown but several contributing factors include:
Infectious
Environmental
Diet
Obesity
NSAID or aspirin use (Cyclooxygenase-mediated disruption of the
intestinal epithelial barrier)
It is believed that genetics plays a major role but no specific trigger has
been identified.
First degree relatives 3-20 times more likely to develop IBD
Genetic factors more important in CD than in UC
First confirmed IBD gene (IBD1) confers increased risk of CD
Clinical features of CD demonstrate a heritable pattern with
concordance in disease location
Over 100 distinct susceptibility loci for IBD
Signs include
Fever >101oF/38.6oC
Tachycardia
Abdominal distention
Signs of localized or generalized peritonitis
Leukocytosis
A dilated colon
It may occur anytime during the course of UC but usually occurs early
on
Toxic Megacolon: Presentation
• Depression
• Arthritis
• Liver and kidney disorders including renal stones
• Inflammation of the eye (Anterior Uveitis)
• Skin conditions (Erythema Nodosum / Pyoderma Gangrenosum)
• Bone loss and osteoporosis
• Primary Sclerosing Cholangitis
• Venous and arterial thromboembolism
• Vitamin B12 deficiency
• Spondyloarthropathy and ankylosing spondylitis
Physical Examination
Characteristic history
Typical endoscopic
appearance of the
mucosa
Confirmatory histology
seen on colonic biopsy
Diagnostic Studies for IBD
• Upper GI series with small bowel follow through (SBFT) – initial
study
• Barium enema
• Contrasted CT scan – used more to determine complications of the
disease such as abscesses or fistulas rather than for specific diagnosis
• May show marked thickening of bowel wall in UC, but finding is
nonspecific
• Endoscopy – preferred study
• Small bowel enteroscopy
• Capsule endoscopy
• EGD (ulcerations occur in the stomach and duodenum in 5-10% of
patients with crohn’s disease)
Endoscopy Findings in UC
In mild disease:
A fine granular appearing mucosa
In long-standing disease:
Loss of haustral markings
Shortening of the colon
Tubular appearance of the colon along with pseudopolyps
Endoscopy Findings in CD
IBS
Lactose intolerance
Infectious colitis
Appendicitis
Diverticulitis
Diverticular colitis
Ischemic colitis
Perforating or obstructing carcinoma
Lymphoma
Chronic ischemia
Endometriosis and carcinoid - NB: Can both give a radiologic and clinical
picture that is easily confused with CD of the small bowel
Disease Severity
Asymptomatic remission (CDAI <150) – Patients who are asymptomatic either spontaneously or
after medical or surgical intervention. Patients requiring steroids to remain asymptomatic are not
considered to be in remission but are referred to as being "steroid-dependent”
Mild to moderate Crohn's disease (CDAI 150-220) – Ambulatory patients able to tolerate an oral
diet without dehydration, toxicity, abdominal tenderness, mass, obstruction, or >10 percent weight
loss
Moderate to severe Crohn's disease (CDAI 220-450) – Patients who have failed treatment for mild
to moderate disease or patients with prominent symptoms such as fever, weight loss, abdominal pain
and tenderness, intermittent nausea or vomiting, or anemia
Severe-fulminant disease (CDAI >450) – Patients with persisting symptoms despite conventional
glucocorticoids or biologic agents (infliximab, adalimumab, certolizumab pegol, or natalizumab) as
outpatients, or individuals presenting with high fevers, persistent vomiting, intestinal obstruction,
significant peritoneal signs, cachexia, or evidence of an abscess
For UC
Scores range
form 0-12
Post-
Endoscopy
Medical Treatment
Examples include:
Azathioprine (Imuran) – first to be used
6-mercaptopurine (6-MP) (active metabolite of azathiprine)
Methotrexate – both an immuno-modulater and an anti-inflammatory agent
NB: Need to add folic acid 1 mg/day to decrease adverse effects
Infliximab (Remicade) – anti-TNF therapy
Adalimamab (Humira)- anti-TNF therapy
Hepatitis
Pancreatitis
Probiotics
Lactose avoidance
Medical Treatment: UC Only
5-ASA
suppositories
5-ASA enemas
- Only affects the colon (hence the - May affect any area in the GI
name Colitis) tract from mouth to anus
- Only affects the inner lining of - Is transmural, meaning it can
the mucosa affect all layers of the bowel wall
- Diarrhea is likely to be bloody - Diarrhea usually not bloody
- Surgery can be curative in many - Surgery can be helpful if
cases complications, but not as likely
- Area of inflammation are - Usually has areas of
continuous inflammation interspaced with
areas of normal tissue
Prognosis
Patients who are in remission for one year have an 80 percent chance of
remaining in remission for the subsequent years.
Patients who have active disease within the past year have a 70 percent
chance of remaining active in the forthcoming year and a 50 percent
chance of being in remission within the ensuing three years.
Overall, 13 percent of patients will have a relapse-free course, while 20
percent have annual relapses and 67 percent have a combination of
years in relapse and years in remission within the first eight years after
initial diagnosis.
Fewer than 5 percent will have a continuous course of active disease.
Recurrence of perianal fistulas after medical or surgical therapy is
common (59 to 82 percent).
Effect of IBD on Patient’s Lives
IBD can have significant and severe effects on patients and their
families:
IBD can keep patients from being able to attend school or work
(economical cost)
Increase cost of health insurance or inability to get health insurance
It can keep patients from getting disability or life insurance
Any Questions?
Shane.Apperley@lmunet.edu