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DEFINITION: The term inflammatory bowel disease (IBD) covers a group of disorders in which the intestines become inflamed (red and swollen), probably as a result of an immune reaction of the body against its own intestinal tissue OR Inflammatory bowel disease (IBD) is a group of inflammatory conditions of the colon and small intestine. CLASSIFICATION OF IBD: The main forms of IBD are :
1. Crohn's disease and 2. Ulcerative colitis (UC). ULCERATIVE COLITIS is a type of inflammatory bowel disease (IBD) that affects the lining of the large intestine (colon) and rectum. CROHN'S DISEASE is a form of inflammatory bowel disease (IBD). It usually affects the intestines, but may occur anywhere from the mouth to the end of the rectum (anus). ETIOLOGY AND FACTORS: The exact etiology of it is unknown, but certain factors have been found to be associated with the disease, and some hypotheses have been presented. Etiologic factors potentially contributing to it include • • • • • • • genetic factors, immune system reactions, environmental factors, nonsteroidal anti-inflammatory drug (NSAID) use, low levels of antioxidants, psychological stress factors, a smoking history,
and consumption of milk products. PATHOPHYSIOLOGY OF IBD The normal intestine is in steady state of physiologic inflammation having balance between
1. Factors that activate host immune system such as luminal microbes , dietary antigens and endogenous inflammatory stimuli and
amount depend on disease severity Low grade in severe cases Peritoneal irritation. The reason of this variation is unknown In severe cases there may be inflammation of terminal ileum called as “ backwash ileitis” Inflammation. 3. In summary the antigens in the gut due to certain factors lead to uncontrolled inflammation in the crohn’s disease and same is for the ulcerative colitis. fissures. Antigen presenting cells initiate this inflammatory process by activating the T-helper cells and these accelerate the inflammatory process through a number of mechanisms. Leading to severe ulceration in affected area and In the normal intestine antigens are carefully processed by mucosal epithelial cells and are presented to the immune system.g inflammatory T-helper cells release pro inflammatory cytokines such as TNF-α. In the Crohn’s disease the defected mucosal barrier integrity may lead to increased uptake of luminal antigens which can result in uncontrolled inflammation. hemorrhoids. amount depend on disease severity Low grade in severe cases Show peri-anal irritation. abscess Loss in severe cases CROHN’S DISEASE Lower ileum most common but can be anywhere. SIGNS AND SYMPTOMS SIGN AND SYMPTOM Area of intestinal tract affected ULCERATIVE COLITIS Any part of inner most part of colon . patches of normal tissue between affected area and intestinal wall Typically 4 episodes per day Mod to sev tenderness in right lower quadrant Present. The inflammatory cells inflitrate in affected area and as a result abscess occur and goblet cell depletion occurs. continues with no patches Typically 4 episodes per day Lower abdominal cramping Present. It involves genetic susceptibility. For e. The host defenses to down regulate the inflammation and maintain the integrity of the mucosa. the sigmoid and descending colon (left sided colitis) in 40% and whole colon in 20% cases. The cause of initiation is unknown but has its basis for designation as idiopathic.2. failure of immune regulation and triggering microbial flora PATHOPHYSILOGY IN ULCERATIVE COLITIS Ulcerative colitis is confined to the rectum (proctitis) in 40% cases. 4. The TNF α binds to several TNFα receptors in epithelial cells or macrophages and starts pro inflammatory process. granulation and polyps may also form. abdominal or pelvic mass Both occur due to poor absorption Diarrhea Abdominal pain/cramping Blood in stool FEVER Physical examination Weight loss/anorexia .
Appetite Risk of colon cancer Decrease during disease exacerbation Increased Decrease during disease exacerbation Increased DIAGNOSIS OF CROHN’S DISEASE • The diagnosis of Crohn's disease is suspected in patients with fever. and pictures (X-rays) can be taken of the stomach and the small intestines. Barium X-rays can show ulcerations. low blood proteins. When barium is administered through the rectum (barium enema). narrowing. low red blood cell counts (anemia). it sends video images of the lining of the small intestine to a receiver carried on a belt at the waist. When barium is ingested orally (upper GI series) it fills the intestine. COLONOSCOPY BIOPSY VIDEO CAPSULE ENDOSCOPY (VCE) a capsule containing a miniature video camera is swallowed. elevated white blood cell counts and sedimentation rates. As the capsule travels through the small intestine. both of which suggest infection or inflammation 2. abdominal pain and tenderness. 3. DIAGNOSIS OF ULCERATIVE COLITIS STOOL SPECIMENS are collected for analysis to exclude infection and parasites. diarrhea with or without bleeding. and anal diseases • Stool specimen test LABORATORY BLOOD TESTS may show following: 1. pictures of the colon and the terminal ileum can be obtained. since these conditions can cause colitis that mimics ulcerative colitis. low body minerals. and sometimes fistulae of the bowel. due to chronic diarrhea BARIUM X-RAY STUDIES: Barium is a chalky material that is visible by X-ray appears white on X-ray films. The images are downloaded and then reviewed on a computer. .
Calprotectin seems to be a sensitive marker of intestinal inflammation. iron studies. and C-reactive protein(another sign of inflammation). This test alone. so elevated levels suggest inflammatory bowel disease in the right setting. BLOOD TESTS may show anemia and an elevated white blood cell count or sedimentation rate (commonly referred to as sed rate). liver function tests. An elevated white blood cell count and sed rate both reflect ongoing inflammation in the colon. STOOL TEST: There is some evidence that a stool test for a protein called calprotectin could be useful in identifying patients who would benefit from colonoscopy. They include: . cannot distinguish between different diseases causing the inflammation so should be used with caution. OTHER BLOOD TESTS may also be checked including monitoring the kidney function. COLONOSCOPY ---BARIUM ENEMA X-RAY (less accurate)-VIDEO CAPSULE ENDOSCOPY TREATMENT CROHN’S DISEASE Anti inflammatory drugs as Corticosteroids Immunosuppressants Antibiotics Other medications Surgery ULCERATIVE COLITIS Anti inflammatory drugs Antibiotics Immunomodulators Surgery TREATMENT FOR CROHN’S DISEASE ANTI-INFLAMMATORY DRUGS Anti-inflammatory drugs are often the first step in the treatment of inflammatory bowel disease. however.
Infliximab finds TNF in your bloodstream and removes it before it causes inflammation in your intestinal tract. Natalizumab (Tysabri). Neoral. they can be used for short-term (three to four months) symptom improvement and to induce remission. Blocking these molecules is thought to reduce chronic inflammation that occurs when they bind to your intestinal cells. but they target your immune system rather than directly treating inflammation Azathioprine (Imuran) and mercaptopurine (Purinethol). Sulfasalazine (Azulfidine). Rowasa). Infliximab works by neutralizing tumor necrosis factor (TNF). Mesalamine (Asacol. Certolizumab pegol (Cimzia). This drug is for adults and children with moderate to severe Crohn's disease. ANTIBIOTICS Antibiotics can reduce the amount of drainage and sometimes heal fistulas and abscesses in people with Crohn's disease. . Sandimmune). sometimes used for people with Crohn's disease who don't respond well to other medications. CORTICOSTEROIDS. These are the most widely used for IBD Infliximab (Remicade). IMMUNE SYSTEM SUPPRESSORS These drugs also reduce inflammation. In moderate to severe inflammatory bowel disease that doesn't respond to other treatments. while the immune system suppressors can help maintain remission. often used to help heal Crohn's-related fistulas. This potent drug. Methotrexate (Rheumatrex). Cyclosporine (Gengraf. which can trigger symptoms Frequently prescribed antibiotics include: Metronidazole (Flagyl). Corticosteroids aren't for long-term use. Adalimumab (Humira). Ciprofloxacin (Cipro). But. OTHER MEDICATIONS : Anti-diarrheals. Corticosteroids also may be used with an immune system suppressor — the corticosteroids can induce remission. This drug works by inhibiting certain immune cell molecules — integrins — from binding to other cells in your intestinal lining. Researchers also believe antibiotics help reduce harmful intestinal bacteria and suppress the intestine's immune system.
Immunomodulators increasingly are becoming important treatments for patients with severe ulcerative colitis who do not respond adequately to anti-inflammatory agents. Apriso Rowasa enema) that need direct contact with the inflamed tissue in order to be effective. Laxatives. and mesalamine (Pentasa. Topical 5-ASAcompounds such as sulfasalazine (Azulfidine). methotrexate (Rheumatrex.Removal of a diseased segment of the small intestine that is causing obstruction. azathioprine (Imuran). Neoral). cyclosporine (Gengraf. Systemic corticosteroids have predictable side effects with long term use. EXTRA INTESTINAL COMPLICATIONS • • • JOINTS AND BONES: 10% have relapse as arthropathy . TREATMENT FOR ULCERATIVE COLITIS ANTI-INFLAMMATORY AGENTS 1. Lialda. Asacol. Examples of immunomodulators include 6-mercaptopurine (6MP). Vitamin B-12 shots. IMMUNOMODULATORS 1. Drainage of pus from abdominal and peri-rectal abscesses. Iron supplements. SURGERY 1.5% have ankylosing spondolytis SKIN: Edema occurs in 8% and gangrenosum in 2 % OCULAR: 5% develop episcleritis (intense burning and itching with localised area of blood vessels) .olsalazine (Dipentum). This procedure also eliminates the risk of developing colon cancer. Removal of the colon and rectum is the only permanent cure for ulcerative colitis. Systemic anti-inflammatory medications such as corticosteroids that decrease inflammation throughout the body without direct contact with the inflamed tissue. ANTIBIOTICS SURGERY: Surgery for ulcerative colitis usually involves removing the entire colon and the rectum. Resection of internal fistulae (such as a fistula between the colon and bladder) that are causing infections. Trexall). 2. Pain relievers.
inadequate fluids. IBS is a syndrome or collection of symptoms rather than a disease. and constipation. DIFFERENCE B/W IBD AND IBS Inflammatory bowel disease (IBD) is a collective term that refers to chronic. Typically. and bloody stools. poor nutrition. usually on the right side of the lower abdomen. On occasion. discomfort. Common sites of involvement include the rectum & recto-sigmoid area Inflammation Inflammation may occur in patches Inflammation is continuous throughout affected areas . diarrhea. ileitis. Perinuclear antineutrophil cytoplasmic antibodies (P-ANCA) are seen in IBD. causing an overlapping type of inflammatory bowel disease Signs and symptoms in Irritable Bowel Syndrome Irritable bowel syndrome (IBS) is a condition of spastic colon. the colon is more sensitive and contracts more readily than it does in other people. and inflammatory white blood cells are seen in the colon mucosa. fever. The most common sites include the small intestine. Irritable bowel syndrome (IBS) is a common functional gastrointestinal disorder causing increased contractions or spasms of the colon or rectum. symptoms of IBS are often linked to stress. weight loss. and proctitis. autoimmune. Increased chances of cholangiocarcinoma. It is not an inflammatory disorder. mainly ulcerative colitis and Crohn ‘s disease. right abdomen. and poor eating habits. although IBD may also be referred to as colitis. In people with IBS. and stomach Ulcerative Colitis Ulcerative Colitis is characterized by chronic inflammation of the colon and does not involve the small intestine. So increased ALP and GGT. inflammatory diseases of the bowel. enteritis. abdominal pain. Signs and symptoms in Inflammatory Bowel Disease Patients with inflammatory bowel disease have symptoms of diarrhea. such as eating too fast or not relaxing after a meal.• BILIARY SYSTEM: 5% develop it by infection proceeding biliary tree and causing strictures and fibrosis. colon. abdominal pain. fibromyalgia. and other disorders. feeling of a mass or fullness in the lower. Symptoms of IBS include chronic abdominal pain. signs and symptoms of both ulcerative colitis and Crohn’s disease both occur in patients. the inflammatory process begins at the rectum and spreads. In these conditions. DIFFERENCE B/W CROHN’S DISEASE AND ULCERATIVE COLITIS Difference Location Crohn's Disease Crohn's Disease is characterized by inflammation involving all layers of the bowel wall in any part of the gastro-intestinal tract. Symptoms of IBS often occur in people with systemic lupus erythematosus.
cramping or swelling Anemia Fever Gastrointestinal bleeding Joint pain Malabsorption Persistent or recurrent diarrhea Stomach ulcers Vomiting Abdominal pain or discomfort Anemia caused by severe bleeding Bloody diarrhea Dehydration Fatigue Fever Joint pain Loss of appetite Malabsorption Rectal bleeding Urgent bowel movements Weight loss Weight loss treatment Corticosteroids (budesonide.prednisolone) Aminosalicylates(sulphasalazine) immunosupressants(azathioprine. surgery to remove diseased sections of bowel may provide some relief from symptoms. the removal of that organ (called a colectomy) is considered a "cure." . merceptopurine) Biological therapies infliximab adalimumab Corticosteroids (budesonide. but the disease tends to recur Because the inflammation only occurs in the large intestine in ulcerative colitis.prednisolone) Aminosalicylates(sulphasalazine) immunosupressants(azathioprine. but they do not extend beyond the inner lining Bleeding from the rectum during bowel movements Appearance Bleeding Bleeding from the rectum during bowel movements is not common Symptoms Abdominal pain. merceptopurine) Biological therapies infliximab adalimumab Surgical therapy For patients with Crohn's disease.Pain Pain is commonly experienced in the lower right abdomen Colon wall may be thickened and may have a rocky appearance Ulcers along the digestive track are deep and may extend into all layers of the bowel wall Pain is common in the lower left part of the abdomen Colon wall is thinner and shows continuous inflammation Mucus lining of large intestine may have ulcers.