INFLAMMATORY BOWEL DISEASE
ULCERATIVE COLITIS
Etiology
IDIOPATHIC
but risk factors:
• Genetic (HLA-B27)
• Family history,
• Previous intestinal infection,
• use of NSAIDs,
• diet (↑ fat intake),
• Oral contraceptives
• suddenly stopping smoking
(Smoking & appendectomy are
protective factors!)
Pathogenesis:
disruption of epithelial barrier→
↑ permeability for intestinal
bacteria→ activation of
macrophages & secretion of
pro-inflammatory cytokines→
leads to inflammation of the
mucosa → ulceration, edema,
bleeding, and fluid and
electrolyte loss
Clinic
• Rectal bleeding,
• bloody diarrhoea with
mucous
• abdominal pain (crampy)
• Tenesmus
• Urgency/ incontinence
Extra-intestinal:
• General:, fatigue, fever,
weight loss, anemia
• Ocular: uveitis/episcleritis,
• Cutaneous: erythema
nodosum, pyoderma
gangrenosum
• Biliary: primary sclerosing
cholangitis (PSC)
• Skeletal: arthritis (large
joints), ankylosing
spondylitis, sacroiliitis,
osteoperosis
Histology (non-specific):
MONTREAL CLASSIFICATION OF • Increased lamina propria cellularity, basal plasmacytosis, basal lymphoid
aggregates & lamina propria eosinophils
SEVERITY
• Crypt abscesses, crypt branching, shortening, disarray & crypt atrophy
Complications:
• Severe bleeding -Hb <110 even
after transfusion
• Adenocarcinoma
• Toxic megacolon- non
obstructive dilation of colon
>/= 5.5/6cm
• Perforation- mortality of up to
50%
Diagnosis Treatment
Endoscopy (Mayo grading): Induction of Remission:
(1) Mild: erythema, edema/loss of vascular pattern, mild friability Mild:
(2) Moderate: granularity of the mucosa, erosions, friability, contact bleeding, 1. mesalazine (topical +/- oral ) 4g
marked erythema 2. topical steroids
(3) Severe: ulcers, spontaneous bleeding, granularity, absent vascular marking
*Pseudo-polyps can be from stages 1-3 Moderate:
1. mesalazine oral + steroids
2. steroids + azathioprine
3. azathioprine + anti-TNF
(infliximab)
*In UC: mucosal inflammation is continuous (until it stops), and distribution is Severe:
limited to only rectum and colon. 1. iv steroids (prednisone 60mg
for 1w)
MONTREAL CLASSIFICATION OF EXTENT 2. iv cyclosporine (5mg/kg/d for 3
dys) OR iv anti-TNF (infliximab)
3. colectomy, If
a. pts. Unresponsive/intolerant
to multiple modalities of
treatment
b. Complications
c. if not responding to medical
therapy after 10 days
i. Constant deterioration
ii. Initial stabilisation, and
X-ray: dilated loops with air-fluid level secondary to ileus (if free air = later deterioration
perforation), dilation >6cm in case of toxic megacolon, wall edema: iii. Diarrhoea >8x/d
“thumbprinting” sign if acute, “lead-piping sign” if chronic iv. CRP >45mg/ml
Lab:
• CBC- anemia (Hb, iron studies, B12, folate), Maintenance of Remission:
• biochemistry + liver (↓albumin, metabolic acidosis= ↓K+,↑Na+, urea ; If Mesalazine / Azathioprine / Anti-
TNF
cholangitis= ↑ALT, AST, ALP, bilirubin), N/↑ ESR/CRP
→ slowly wean off glucocorticoids
• Stool studies: -ve cultures & C.difficile toxins +
Surgery:
• ↑ fecal calprotectin (shows chronic inflammation in bowel- for screening
• Colectomy + terminal ileostomy
& tx monitoring
• Proctocolectomy
• Immune markers: pANCA (+ve for UC) vs ASCA (+ve for Crohns)
 CHRON’S DISEASE
Risk factors Clinic Diagnosis Treatment
• White, • Prolonged diarrhoea (non-bloody) Can affect any area from mouth to anus, is patchy transmural Induction of Remission:
• Age15-40 or • Abdominal pain (crampy) – in RLQ granulomatous, Mild:
60-80, • Fever, fatigue *Most common area: terminal ileum 1. Oral steroid
• family history • Perianal lesions MONTREAL CLASSIFICATION (budenoside/prednisone-if more
• smoking • Weight loss diffue involvement)
• NSAIDs • Abdominal mass- due to adhesion 2. Mesalazine (5-aminosalicylic
• contraception acid (5-ASA))+ antibiotics
Extra-intestinal:
• Ocular: uveitis/episcleritis, Moderate:
• Cutaneous: erythema nodosum, 1. steroids + azathioprine
• Biliary: primary sclerosing cholangitis (PSC) 2. steroids + methotrexate
• Skeletal: arthritis, ankylosing spondylitis, 3. azathioprine + Anti-TNF
sacroiliitis, osteoporosis (infliximab)
• Renal: Calcium oxalate & uric acid stones
Lab: Severe:
*Patients can have symptoms for many years • CBC- anemia (Hb, iron studies, B12, folate, TIBC), 1. azathioprine + Anti-TNF
prior to diagnosis. • biochemistry + liver (chronic disease=↓albumin, cholesterol, (infliximab)
Ca2+; prolonged diarrhea= ↓Mg2+, PO4-), 2. Tacrolimus
SEVERITY CLASSIFICATION: • ↑ESR/CRP 3. surgery (strictureplasty,
resection, stoma)
Stool studies:
• -ve cultures & C.difficile toxins, Maintenance of Remission:
• ↑ fecal calprotectin* Budesonide / Methotrexate/
• Immune markers: +ve ASCA Mesalazine / Azathioprine/anti-TNF

X-ray- asymmetrical small bowel or colonic dilation with skip Surgery:

areas; calcification; sacroiliitis; intra-abdominal abscesses 1.Abscess drainage
2.seton placement – for fistulas
Colonoscopy: asymmetric and discontinuous lesions, deep 3.Major surgery (Resection)
longtitudinal fissures, cobblestone, crypt inflammation, 4.Stricturoplasty
Complications: atrophic/deep ulcers, scarring, pseudo polypoid masses 5.Stoma (for bowel rest)
• Abscess/ Phlegmon
• Fistulas Biopsy: non-caseating granuloma, atrophous/deep ulcers, symptomatic treatment is important
• Perianal disease cobblestone appearance as well, eg. for pain or diarrhea
• Strictures
• Malabsorption CT abdomen / MRI: skip lesions, bowel wall thickening,
• Anemia surrounding inflammation, abscess, fistulae