Colon

dr Putra Hendra SpPD

UNIBA
1. Irritable Bowel Syndrome
(IBS)
2. Inflammatory Bowel
Disease(IBD)
3. Diverticulitis
Irritable Bowel Syndrome
 Functional Disorders
 Functional disorders
 structural nomal
 biochemical normal

 Several functional gastrointestinal disorders

◦ Functional dyspepsia
◦ Irritable bowel syndrome (IBS)
◦ Functional abdominal pain
◦ Abdominal migraine
◦ Aerophagia

4
PATHOGENESIS OF FUNCTIONAL
BOWEL DISEASE

5
Summary

6
 Irritable Bowel Syndrome

Abdominal pain sewaktu defecation dan

membaik setelah defecation
Feses encer dan lebih sering waktu sakit
Merasa belum semua keluar
Mucus per rectum
Visible abdominal distention (bloating)
Labs and sigmoidoscopy negative
 Irritable Bowel Syndrome
Treatment
Reduce stress
Drug therapy
Constipation - bulking agent (psyllium),
lactulose/milk of magnesia
Diarrhea - bulking agent, loperamide,
cholestyramine
Bloating - simethicone (OTC)
Pain/cramping - dicyclomine/Bentyl, Donnatal,
hyoscyamine/Levsin
Diet therapy - eat fiber!
 Diverticular Disease
Diverticulosis

Herniation of the mucosal lining of the

intestine through a defect in the muscular
layer of the intestine
 Diverticular Disease
Diverticulosis
– Characteristic findings on radiologic or
endoscopic exam
– No fever or leukocytosis
– Possibly some intermittent left lower quadrant
pain
– Usually asymptomatic
– Eat more fiber!!!
Diverticular Disease
 Diverticular Disease
Diverticulitis
– Acute abdominal pain
– Constipation or bowel irregularity
– LLQ tenderness and possible mass
– Fever and leukocytosis
– Characteristic radiographic signs
Diverticulosis
 Diverticular Disease
Diverticulitis - Treatment
– Antibiotics
– Liquid diet or NPO
– Can be managed as an outpatient in mild
cases
– NG tube if obstructed
– 10-20% of patients have a recurrence
– Surgery is an option in appropriate cases
Diverticulitis
Inflammatory Bowel Disease
IBD
Inflammatory Bowel Disease
Two major types of IBD
Crohn’s disease
– Incidence - 5 per 100,000 persons
– Prevalence - 90 per 100,000 persons
Ulcerative colitis
– Incidence - 10 per 100,000 persons
– Prevalence - 200 per 100,000 persons
Inflammatory Bowel Disease
Etiology - not clearl.
 genetic predisposition
 environmental exposures.
Crohn’s Disease - affects mouth to anus
melibatkan transmural
Ulcerative colitis – terbatas di colon
hanya melibatkan mucosal
 Aetiology & Pathogenesis
The aetiology of Crohn’s disease is unknown. There are many proposed
pathogenic mechanisms, some of which are represented in this diagram.

Genetic Environmental
susceptibility factors

Host
Immune
Response

Crohn’s Disease

As there is no one cause, it is likely that Crohn’s disease is an outcome of

interactions between genetic predisposition, environmental factors and the
subsequent reaction of the host immune system.
 Environmental Factors
A wide range of environmental factors have been
Environmental
factors found to play a role:

 Smoking – Patients with CD are more likely to have been smokers and
smoking may worsen CD and increase the risk of relapse/surgical intervention.

 Diet – Active CD may improve when a normal diet is changed to a liquid

formula diet.

 Bacterial infection – There is some evidence implicating E. coli, M.

paratuberculosis, the measles virus and L. monocytogenes in the pathogenesis of
CD. This data is controversial and requires further research to clarify.

 Drugs – the oral contraceptive pill has been linked epidemiologically with CD.
Relapse may be precipitated by NSAIDs.
 Immune response
Host Both the potential genetics underlying CD and the
Immune
Response
environmental and host factors surrounding the patient
may be considered as initiating factors for CD, but the
exact aetiology is unknown.

What is known is that mucosal immunity is dysregulated in CD leading to a

prolonged inflammatory response in the gut.

In CD, a dominant CD4 Th1 reaction is induced. The mechanisms for this are
displayed diagrammatically on the next page.
 Epidemiology

World wide distribution Incidence: 7/100 000

but more common in pop/yr
the West.

The incidence is lower in

Females are non-white races.
affected more Epidemiology
than males
1.2:1 Jews are more affected
than non-Jews

Bimodal age distribution:

20-40 yrs/60-80 yrs The incidence is rising

Prevalence: 100/100 000 pop/yr

 Epidemiology
•Crohn’s disease (CD) is a chronic relapsing inflammatory condition
usually with flare-ups alternating with periods of remission, and an
increasing disease severity and incidence of complications as
time goes on.

•It can affect any part of the gastrointestinal tract from the mouth to the anus.
For typical sites & proportion of patients affected see below:

Extensive Small Terminal Ileum

Bowel – 5% only – 20%

Ileocaecal – 45% Colon only – 25%

Other: anorectal,
gastroduodenual, oral only
– 5%
 Crohn’s Disease
Symptoms
– Right lower quadrant pain and diarrhea,
biasanya intermittent
– Hematochezia (sebagian kecil penderita)
– Low fever and weight loss also possible
– High fever and pain may be indicative of a
complication, e.g., perirectal abscess.
 Crohn’s Disease
Signs
– Abdominal pain , especially RLQ
– Palpable mass in RLQ is possible
– Rectal exam may reveal a perirectal mass
– Abdominal distention
– Peritoneal signs in patients who have
fistulized or ruptured.
 Crohn’s Disease
Complications
– Fistula formation - up to 40% of patients
– Enteroenteric
– Enterovesicular - recurrent UTIs and pneumaturia
– Enterocutaneous - rectovaginal, fistula-in-ano
– Perforation/abscess formation
– Stricture/ small bowel obstruction
– Cancer
– Nutritional deficiencies –
 Diagnosis
Radiology and imaging

Barium follow-through
Colonoscopy, terminal ileoscopy – findings consistent
& biopsy: These allow direct with Crohn’s include
visualisation and allows for a an asymmetrical
biopsy of the mucosa to be alteration in mucosal
taken. This is central to pattern with deep
macroscopic and microscopic ulceration and areas of
diagnosis. narrowing or
stricturing.

Ultrasound & CT
scanning: Can help
define thickness of the
bowel and mesentery
and can be useful to
evaluate disease
progress & chart
fistula formation.
 Diagnosis of IBD

Crohn's disease with the characteristic patchy erythema (left

panel) and ulceration (right panel) that occur next to areas of
normal mucosa. Courtesy of James B McGee, MD. From Uptodate
2007
 Crohn’s Disease
Tablet Enteroscopy
– Swallow a small pill that is a video recorder.
– Records a video image of the small bowel.
– Transmits an image to a video receiver that
then visualizes the small bowel.
 Crohn’s Disease
Lab findings - generally nonspecific
– ESR usually elevated
– Anemia - both low iron from anemia of chronic
disease and low B12 secondary to ileal
involvement or resection
– Leukocytosis
– thrombocytosis
– Hypoalbuminemia
 Lab Findings
p-ANCA Antiglycan
antibodies

Crohn’s Positive in 15% Positive in 75%

Disease

Ulcerative Positive in 85% Positive in 5%

Colitis
 Crohn’s Disease
Classic findings
– Skip lesions - Crohn’s does not affect the
intestinal mucosa in a continuous fashion
– Cobblestoning owing to mucosal fissures
– Luminal narrowing/strictures - string sign
– Fistulas
– Aphthous ulcers
Angular Cheilitis
Aphthous Ulcers
Figure 1 Image of a fissure in ano suspicious for squamous cell carcinoma in a 56-
year-old female patient with ileocolic Crohn's disease

Galandiuk S and Davis BR (2008) Infliximab-induced disseminated histoplasmosis in a patient with Crohn's
disease
Nat Clin Pract Gastroenterol Hepatol doi:10.1038/ncpgasthep1119
Crohn’s Disease
 Crohn’s Disease
Differential diagnosis:
Colonic disease - infectious
– Bacterial colitis - Salmonella, Shigella,
Campylobacter
– Ameba (Amoeba if you’re British)
– CMV
Colonic disease – noninfectiousUlcerative Colitis,
radiation, ischemia
Acute appendicitis with RLQ pain
Ectopic pregnancy, tubo-ovarian abscess/PID
 Intestinal Complications
Anal and perianal complications
•Fissure in ano or fistula in ano
•Haemorrhoids
•Skin tags
•Perianal or ischiorectal abscess
•Anorectal fistulae

Undernutrition
•Caused by reduced food intake, malabsorption, increased protein loss from
inflamed bowel and the increased metabolic demands of being sick.

Short bowel syndrome

•Develops when extensive bowel resection leads to excessive malabsorption
of fluids, electrolytes and nutrients.

Cancer
•With Crohn’s colitis, there is a increased risk of colorectal carcinoma
•There is an small increased risk of rarer small intestinal and anal cancers
occurring in cites of prolonged inflammation.
 Extra-intestinal complications
There are many systemic associations and complications of CD, most affecting the
liver and biliary tree, joints, skin and eyes:

Sclerosing Cholangitis – occurs in a small

proportion of patients. The pathogenesis is
unknown and the condition is characterised by
an inflammatory obliterative fibrosis of the
biliary tree (the white in the diagram->). It
progresses slowly and a liver transplant is the
only cure.

Ankylosing spondylitis – affects about 5% of patients

with Crohn’s colitis. The patient presents with back
pain and stiffness and the diagnosis can come years
before the CD.
 Extra-intestinal complications
Erythema nodosum – occurs in ~8% of Crohn’s
colitis patients when disease is active. Hot, red
tender nodules appear on the arms and legs and
subside after a few days.

Pyoderma gangrenosum – occurs in ~2% of CD

patients, starting as a small pustule, then
developing into a painful, enlarging ulcer, most
commonly on the leg.

In addition to these conditions, other complications and associations include

episcleritis and uveitis (occuring in 5% of patients with active disease), osteoporosis
(as a consequence of chronic inflammation, malabsortion and treatment with
corticosteroids) and arthropathy.
 Medical management
•Dietary advice and nutritional support including vitamin supplementation to
counter-act any deficiencies that develop.

•Diarrhoea can be controlled by anti-diarrhoeals such as loperamide, codeine

phosphate or co-phenotrope. If the diarrhoea is due to bile acid malabsorption,
then this can be treated with colestyramine.

•Likely to be beneficial in inducing remission:

•Corticosteroids (oral)
•Aminosalicylates
•(azathioprine/mercaptopurine – trade off between benefits and harms)
•Methotrexate
•Infliximab

•Likely to maintain remission:

•Smoking cessation
•(Unknown if the following are effective: enteral nutrition, fish oil, probiotics)

•The BNF information about the drugs on this page can be seen HERE
 Surgical management
•Surgery is indicated for perforation or haemorrhage (emergency) or for small-bowel
obstruction, Crohn's colitis, abscess (intra-abdo and perianal), fistulas and
inflammation unresponsive to medical therapy.

•Approximately 80% of patients with CD will require surgery at some point.

•The principle of surgery is to conserve as much bowel as possible as 60% of

patients need further surgery.

•Surgery is not curative.

In small bowel CD – resection is likely to be beneficial whereby discrete sections are

removed and an end-to-end anastomosis created. The benefits of strictureplasty to
widen a narrowed lumen are unknown at this time.

In colonic CD – segmental and subtotal colectomy is likely

to be beneficial. In a segmental colectomy the part of the
colon affected is removed and an end-to-end anastomosis
created in remaining colon and in a subtotal colectomy the
ileum is sewn/stapled to the sigmoid colon as seen in diagram.
 Prognosis
Mortality
The cumulative mortality is approximately twice that of the general population.
Death is primarily due to sepsis, pulmonary embolism and complications of the
surgery or immunosuppressive agents used as treatments.

Morbidity
The pattern of CD is a lifelong duration with periods of active disease alternating
with periods of remission. The disease causes significant disability with only 75% of
patients being fully capable of work in the first year of disease and 15% of patients
unable to work after 5-10years of the disease.

People with CD are also more at risk of developing certain cancers and other
complications as mentioned under the clinical features section of this module.
Ulcerative Colitis
 Ulcerative Colitis
Symptoms
– Bloody diarrhea
– Crampy abdominal pain
– Tenesmus - urgent feeling of needing to
evacuate to the rectum.
– Fever, weight loss also possible
– 15-25% have extra-intestinal manifestations
 Ulcerative Colitis
Signs
– LLQ pain - mild to severe
– Can be very ill in patients with toxic
megacolon: fever, tachycardia, orthostasis
 Ulcerative Colitis
Lab Findings - as in Crohn’s, nonspecific
– ESR usually elevated in active disease
– Mild anemia
– Leukocytosis
– Thrombocytosis (acute phase reactant)
– Stool studies negative (culture, C.diff toxin,
O&P)
 Ulcerative Colitis
Imaging Studies
– As disease affects the rectum and extends
proximally, flexible sigmoidoscopy/endoscopy
can be the definitive study. This allows for
direct visualization and biopsy sampling.
– Contrast radiography/ACBE may show
mucosal changes and distal ulcers.
– Classic long-standing finding is the lead pipe
colon.
Lead pipe colon
Ulcerative Colitis
Ulcerative Colitis
Ulcerative Colitis
 Ulcerative Colitis
Differential Diagnosis
– Infection: Campylobacter, Shigella,
Salmonella, Yersinia, E. coli 0157:H7,
amebiasis, Clostridium difficile
– Noninfectious: Crohn’s disease, ischemic
colitis, radiation colitis
– Immunocompromised host: CMV, HSV, GC,
Blastocystis hominis, Chlamydia
 Ulcerative Colitis
Complications
– Toxic Megacolon: 15-50% mortality
– Perforation
– Cancer: increasing risk of dysplasia with
increased time from onset of disease.
Time from onset: 20 30
Risk of cancer 5-13% 13-34%
 Ulcerative Colitis
Prognosis
– Severity of disease is somewhat predictive of the
future course and the need for colectomy.
– In one study, the colectomy rate was 24% at 10 years
and 30% at 25 years.
– Rate of colectomy is much higher in patients with
pancolitis. Those with isolated ulcerative proctitis
have essentially the same cancer risk as the baseline
population.
– Of note, total colectomy is 100% curative!
 Summary
Ulcerative Colitis Crohn’s
Clinical findings
– Perianal Disease Rare Common (1/3 pts)
– Fistulas Rare Common (up to 40%)
– Abscess Rare 20%
– Stricture Rare Common
Colonoscopy findings
– Rectal involvement Always Usually spared
– Pattern Continuous from rectum Skip lesions
Radiologic findings
– Ileal involvement Rare, backwash ileitis 75%
Histologic findings
– Depth of inflammation Mucosa to submucosa Transmural
– Granulomas Uncommon 20% of biopsies
 IBD - Rx
Education
Support groups
Psychologic therapy as indicated
Oral sulfa drugs for IBD
 IBD - Rx
Corticosteroids - extremely useful for
treating acute flares and in maintaining
remission in moderate to severe disease.
Start Solu-medrol at 125mg IV q6hr, then
switch to po Prednisone at 40-60mg qD.
Taper over 8-12 weeks if possible.
 IBD - Rx
Immunosuppressive drugs
– Azathioprine and 6-Mercaptopurine
Purine analogs that may inhibit T cell function
– Infliximab (Remicade ®)and other TNF
inhibitors
Tumor Necrosis Factor (TNF)
Antibiotics - acute treatment
– metronidazole/Flagyl - covers anaerobic
bacteria. Especially useful in perirectal disease.
 Corticosteroids
Side Effects
Cushingoid Psychosis
appearance Aseptic necrosis of
Osteoporosis bone/hip
Hypertension Neuropathy
Diabetes Myopathy
Peptic ulcer
Extra-intestinal Manifestations
of IBD
Reactive arthropathy - present with active
disease
Episcleritis - seen more commonly in
Crohn’s disease
Erythema Nodosum - Crohn’s > UC
Pyoderma Gangrenosum - UC > Crohn’s
Extra-intestinal Manifestations
of IBD
Sacroiliitis - 10% patients with IBD.
Association with HLA-B27
Scleritis and uveitis
Primary sclerosing cholangitis - usually
with UC
Erythema
Nodosum
Pyoderma Gangrenosum