Inflammatory bowel disease

Dr.Abdelkhalig Elhilu
Assistant professor of surgery

Ulcerative colitis

Epidemiology:
Uncommon , mainly in Caucasians, male/female
ratio=1 , mainly affects people 20-40 years.
Cause:
?????? ( Theories- inheritance, infection, stress,
immune disorder, dietary factors).
Clinical presentation:
Diarrhea usually bloody ( up to 20 times/day).
Bloody or purulent rectal discharge.
Urgency of defecation and tenesmus ( proctitis ).
Weight loss.
Dehydration and electrolyte loss and hypoproteinaemia.
Abdominal pain ( serious symptom).
Severity grading:
I. Mild :-rectal bleeding or diarrhea < 4 times/day, absent
systemic symptoms & signs.
II. Moderate :- diarrhea or bleeding > 4 times/day, absent
systemic symptoms & signs.
III. Severe :- > 4 motions/day plus one or more systemic
symptoms ( fever 37.5 ,tacchycardia 90/min,
hypoalbuminaemia less than 3mg/dl, wt loss more than 3
kg.

Complications:
- Acute:
Toxic dilatation of the colon ( severe, all layers, colon
diameter > 6 cm).
Colonic perforation (very high mortality >50%).
Haemorrhage ( uncommon).
- Chronic:
Development of cancer ( 3 - 4 % ).
Extra-alimentary manifestations (skin- erythema
nodosum, pyoderma gangrenosum, aphthous
ulceration. Eye- iritis. Liver- sclerosing cholangitis,
arthritis)
Investigations:
Plain x-ray.
Barium enema (loss of haustrations, granularity ,
pseudopolyps , narrowing).
Sigmoidoscopy.
Colonoscopy and biopsy (extent, DD, monitor
response to treatment).
Stool culture ( Campylobacter, Shigella, Entamoeba,
Clostridium defficile).

UC radiology
 UC colonoscopy

Treatment:
Medical:
Corticosteroids (local or systemic).
5-aminosalicylic acid (5-ASA).
Surgical:
For complications ( proctocolectomy with ileostomy or
colectomy with ileorectal anastomosis/pouch): –
I. Toxic dilatation.
II. Perforation.
III. Haemorrhage.
IV. Severe uncontrolled disease with anaemia.
V. Steroid dependent disease.
VI. Dysplasia and malignant change.
VII. Extra-intestinal manifestations.
 Crohn’s Disease

Epidemiology:
Most common in North America & Northern Europe.
Slightly commoner in females.
Affects mainly people 25 – 40 years.
Cause:
?????? ( Theories: Mycobacterium paratuberculosis,
vasculitis, genetic factors )

Pathology:
Can affect the GIT from mouth to anus.
The ileum is mostly affected followed by the anus.
Characterized by skip lesions.
Macroscopically – fibrosis, thickening and narrowing
of the bowel, mucosal oedema and ulcerations
( cobble stone appearance)
Trans mural inflammation, inflammatory masses,
adhesions, mesenteric abscesses, mesenteric
thickening, enlarged mesenteric lymph nodes.
Microscopically – aphthous ulcers , focal areas of
chronic inflammation involving all layers of the
intestine, non-caseating granulomas.
Clinical features:
Depends on the area involved.
Acute:
Resemble acute appendicitis.
Usually there is diarrhea.
Perforation and peritonitis ( rare ).
Acute colitis ± toxic dilatation.
Chronic:
Mild diarrhea.
Intestinal colic.
RIF pain or mass.
Intermittent fever, anaemia, wt loss ( common ).
Perianal abscesses, fissures, ulcers and fistulae.
Obstructive symptoms.
Internal fistulae symptoms.

Investigations:
Radiology – barium enema, small bowel enema,
sinograms, CT scan, MRI.
Sigmoidoscopy and colonoscopy.
Laboratory tests – CBC, serum albumin etc
Treatment:
Medical:
Steroids ( local & systemic ).
5-ASA, monoclonal antibody (infliximab).
Immune modulators ( Azathioprine ).
Antibiotics (anal disease and inflammatory RIF mass).
Nutritional support.
Surgical:
Indications –bleeding, recurrent intestinal obstruction,
perforation, intestinal fistulae, fulminant colitis, perianal
disease, malignant change.
Ileocaecal resection, segmental resection,
stricturoplasty,colectomy and ileorectal
anastomosis,temporary ileostomy, proctocolectomy,
drainage of perianal abscesses.
Intra-operatively