INFLAMMATORY BOWEL

DISEASE
 Inflammatory bowel disease
(IBD) :

Is a term used to represent tow

distinctive disorders of idiopathic
chronic intestinal inflammation

These disorders are :

Crohn disease and Ulcerative colitis
 - A 3rd, less-common category,
Indeterminate colitis, represents
∼10% of pediatric patients
In general , inflammatory bowel disease
characterized by :

- Poorly understood etiologies

- Unpredictable exacerbations and

remissions

-Onset in preadolescent/adolescent or
early adulthood
 - About 25% of patients present
before 20 years of age
- IBD may begin as early as the 1st year of
life
 Etiology and
pathogenesis

The exact cause is unknown but there

is a contributing or associated factors :

- Genetic factors
- Immunological factors
- Environmental factors
 - HLA DR2 related genes are
associated with ulcerative
clolitis
- HLA DR5 related genes are associated with
chron disease
- If one family member is affected the risk
is
(( 7-30 % ))

- if both parents are affected the risk is

(( more than
35 % ))
Immunologic
al factors
- Defective regulation of immunesuppression
( defective physiologic inflammatory response )

-A perinuclear antineutrophil antibody (pANCA)

is found in ∼70% of patients with ulcerative
colitis compared with <20% of those with Crohn
disease
Environmental factors :

- IBD is more common in developed contries

-Cigarette smoking is a risk factor for Crohn

disease but paradoxically protects against
ulcerative colitis

- No single infectious agent is reported

PATHOLOGICAL FEATURES

- MACROSCOPIC
 Ulcerative colitis
( macroscopic
features )
• Affect the rectum and colon
• Affect the inner lining
• Spread in continuity
• Superficial ulcers and
pseudopolyps
 Crohn disease
( macroscopic
features )
• Can affect any part of the
GIT
• Transmural
• Segmental with skip lesions
• Cobblestone appearance
Presentation and clinical
features
- It is usually possible to distinguish
between ulcerative colitis and
Crohn disease by the clinical
presentation and radiologic,
endoscopic, and histopathologic
findings
 - It is not possible to make a
definitive diagnosis in ∼10% of
patients with chronic colitis; this
disorder is
called indeterminate colitis
- Occasionally, a child initially believed to have
ulcerative colitis on the basis of clinical findings is
subsequently found to have Crohn colitis :

-This is particularly true for the youngest patients,

because Crohn disease in this patient population can
more often manifest as exclusively colonic
inflammation, mimicking ulcerative colitis
 Intestinal symptomes in ulcerative
colitis
-Blood, mucus, and pus in the stool as well as
diarrhea are the typical presentation of ulcerative
colitis

-Tenesmus, urgency, cramping abdominal pain

(especially with bowel movements), and
nocturnal bowel movements are common

-The mode of onset ranges from insidious with

gradual progression of symptoms to acute and
fulminant
Fulminant colitis

- Fever
- severe anemia
- Hypoalbuminemia
- Leukocytosis
- More than 5 bloody stools per day For 5
days
 Intestinal symptomes in crohn
disease
-Patients with small bowel disease are more likely
to have an obstructive pattern (most commonly
with right lower quadrant pain) characterized by
fibrostenosis

-Patients with colonic disease are more likely to

have symptoms resulting from inflammation
(diarrhea, bleeding, cramping)
-In contrast to ulcerative colitis, perianal disease
is common (tags, fistula, abscess)

-Gastric or duodenal involvement may be

associated with recurrent vomiting and epigastric
pain

-Partial small bowel obstruction, usually secondary

to narrowing of the bowel lumen from
inflammation or stricture, can cause symptoms of
cramping abdominal pain (especially with meals),
borborygmus, and intermittent abdominal
distention
-Systemic signs and symptoms are more common in
Crohn disease than in ulcerative colitis. Fever,
malaise, and easy fatigability are common

-Growth failure with delayed bone maturation and

delayed sexual development can precede other
symptoms by 1 or 2 yr and is at least twice as
likely to occur with Crohn disease as with
ulcerative colitis
 Children can present with growth
failure as the only manifestation
of Crohn Disease
Causes of growth failure include :
- Inadequate caloric intake
- Suboptimal absorption or excessive loss of nutrients
- The effects of chronic inflammation on bone metabolism
and
appetite
- The use of corticosteroids during treatment
 Diagnosi
s
- Laboratory
- Barium and radiological
studies
- Endoscopy
- Biopsy
Note
:

In case of ulcerative colitis , if

symptomes are suggestive and the
duration is less than 3 weeks , infection
must be excluded before diagnosis
Infections in the differential diagnosis
:
- Campylobacter jejuni
- Yersinia enterocolitica
- Clostridium difficile
- Shigella
- Entamoeba
histolytica
- Giardia lamblia
 Laboratory
findings :
- Elevation of inflammatory
markers :
- CRP
- ESR
- Platelets
- leukocytes
-Anemia either due blood loss or anemia of
chronic disease

- Hypoalbuminemia
 Barium enemas and radiological
studies
-In ulcerative colitis its not diagnostic but
suggestive and shows :
- superficial ulcers
- pipe stem appearance due loss of haustrations
-In crohn disease radiologic studies are necessary
for the entire GI tract ,,, plain films , enemas and
contrast small bowel follow through may show :
- Ulceration
- Narrowing
- Stricturing
 - In Crohn disease CT and MR
enterography and small bowel
ultrasound are increasingly being
used to assess for intestinal wall
thickening and extraluminal
findings such as abscesses or fistulas
 Endoscopy and
biopsy
- Can establish the diagnosis
-Estimate the stage and severity of
the disease
- Delinate the treatment options
 Treatmen
t

1-medical
2-
surgical
3-
support
Medica
l
Ulcerative colitis

-A medical cure for ulcerative colitis is not

available; treatment is aimed at controlling
symptoms and reducing the risk of recurrence

-About 20-30% of patients have

spontaneous improvement in symptoms

-Most children are in remission within 3 mo; however,

5- 10% continue to have symptoms unresponsive to
treatment beyond 6 mo
Crohn disease

-The specific therapeutic modalities used depend on

geographic localization of disease, severity of
inflammation, age of the patient, and the presence
of complications (abscess)

-Antibiotics such as metronidazole are used for

infectious complications and are first line therapy
for perianal disease
 - Unfortunately, up to 50% of
children with Crohn disease either
become refractory to
corticosteroid therapy or become
dependent on daily dosing and
quickly experience flare of the
disease when the dose is decreased
Drugs used in both diseases
:
1- aminosalicylates ( 5-ASA )

- sulfasalazine ( 50-75 mg/kg/24 hr )

Because of poor tolerance and hypersensitivity ,
sulfasalazine is used less commonly than other, better
tolerated preparations (mesalamine, 50-100
mg/kg/day; balsalazide 110-175 mg/kg/day)
-These preparations have been shown to effectively
treat active ulcerative colitis and to prevent
recurrence.

-It is recommended that the medication be

continued even when the disorder is in remission.

-These medications might also decrease the lifetime

risk of colon cancer
-Approximately 5% of patients have an allergic
reaction to aminosalicylates , manifesting as rash,
fever, and bloody diarrhea, which can be difficult to
distinguish from symptoms of a flare of ulcerative
colitis

-Hypersensitivity to the sulfa component is the

major side effect of sulfasalazine and occurs in 10-
20% of patients
 - Aminosalicylates can also be given
in enema or suppository form and
is especially useful for proctitis

- Oral and rectal 5-ASA has been shown to be

more effective than just oral 5-ASA for distal
colitis
 2-
Probiotics
-Probiotics have been shown to be effective in
adults for maintenance of remission for ulcerative
colitis, although they have not been shown to
induce remission during an active flare

-The most promising role for probiotics has been to

prevent pouchitis, a common complication
following surgery
- The efficacy of probiotics in treatment of
Crohn disease is controversial
 3-
corticosteroids
-most commonly, oral prednisone : 1-2 mg/kg/24 hr
(40- 60 mg maximum dose)

-moderate to severe pancolitis or colitis that

is unresponsive to 5-ASA therapy

-With severe colitis, the dose can be divided twice

daily and can be given intravenously
 medication for acute flares, but
they are not appropriate
maintenance medications due to
loss of effect and side effects

- Steroids have not been shown to change

disease course or promote healing of mucosa
-Budesonide, a corticosteroid with local anti-
inflammatory activity on the bowel mucosa is also
used for mild to moderate ileal or ileocecal disease

-More effective than mesalamine in the treatment

of active ileocolonic disease but is less effective
than prednisone

-Although less effective than traditional

corticosteroids, it cause less steroid-related side
effects
Hydrocortisone enemas are used
to treat proctitis but they are
probably not effective as 5-ASA
Steroids side effects include :

- Growth retardation
- Adrenal suppression
- Cataracts
- Osteopenia
- Aseptic necrosis of the head of the
femur
- Glucose intolerance
- Risk of infection
 4-
Immunomodulators
- Most commonly azathioprine (2.0-2.5 mg/kg/day)
or
6-mercaptopurine (1-1.5 mg/kg/day)

-Less commonly cyclosporine (which has been

associated with improvement in some children
with severe or fulminant colitis ) or thiopurine

-For children with disease resistant or

requiring frequent corticosteroid therapy
Methotrexate is another immunomodulator that is
effective in the treatment of active Crohn’s disease
and has been shown to improve height velocity in the
1st year of administration.

-The advantages include once-weekly dosing by either

subcutaneous or oral route and a more-rapid onset
of action (6-8 wk) than azathioprine or 6-
mercaptopurine.

-Folic acid is usually administered concomitantly

to decrease medication side effects
Side effects of immunomodulators include :

- Flu-like symptoms
- Bone marrow suppression
- Liver and lung inflammation
- Lymphoproliferative disorders mainly from
thiopurine
 5- Anti tumor necrosis factor
antibodies
- Most commonly Infliximab (5 mg/kg IV)

-The use of anti-TNFs in UC has demonstrated efficacy

in achieving steroid-free remission and mucosal
healing, and in changing the natural history
(colectomies)
 - Infliximab has been shown to be
effective for induction and
maintenance therapy in patients
with moderate to severe disease

- Infliximab is also effective in cases of fulminant

colitis
-The onset of action of infliximab is quite rapid and it
is initially given as 3 infusions over a 6 wk period (0,
2,
and 6 wk)

-The durability of response to infliximab is variable

and can be as short as 4-8 wk, making maintenance
therapy necessary
Diet therapy in crohn
disease
Exclusive enteral nutritional
therapy ( elemental or polymeric
diets )

-The use of a complete liquid diet, with the exclusion

of normal dietary components for a defined period of
time, as a therapeutic measure to induce remission in
active Crohn disease , Is an effective primary as well as
adjunctive treatment

-Because elemental diets are relatively unpalatable,

they are administered via a nasogastric or
gastrostomy infusion, usually overnight
-This intervention also results in mucosal healing,
nutritional improvements and enhanced bone
health

- Children can participate in normal daytime

activities

-A major disadvantage of this approach is that

patients are not able to eat a regular diet , In
addition, perianal and colon disease does not
respond well
High-calorie oral supplements

- Although effective , are often not tolerated because

of early satiety or exacerbation of symptoms
(abdominal pain, vomiting, or diarrhea)
Surgica
l
Ulcerative colitis

Colectomy is performed for :

- Intractable disease
- Complications of therapy
-Fulminant disease that is unresponsive to
medical management
Crohn disease

-Surgical therapy should be reserved for very

specific indications

-Recurrence rate after bowel resection is high (>50%

by 5 yr); the risk of requiring additional surgery
increases with each operation
Surgery is the treatment of choice for :

-Localized disease of small bowel or colon that

is unresponsive to medical treatment
- Bowel perforation
-Fibrosed stricture with symptomatic partial
small bowel obstruction
- Intractable bleeding
 Suppor
t
-Psychosocial support is an important part
of therapy for this disorder
Prognosi
s
Ulcerative colitis

-The course of ulcerative colitis is marked

by remissions and exacerbations

-Most children with this disorder respond initially

to medical management
 - Beyond the 1st decade of disease,
the risk of development of colon
cancer begins to increase rapidly. The
risk of colon cancer may be
diminished with surveillance
colonoscopies beginning after 8-10 yr
of disease
Crohn disease

-Crohn disease is a chronic disorder that is

associated with high morbidity but low mortality

-Symptoms tend to recur despite treatment and

often without apparent explanation

-Up to 15% of patients with early growth retardation

secondary to Crohn disease have a permanent
decrease in linear growth
-Resection of terminal ileum can result in bile
acid malabsorption with diarrhea and vitamin
B12 malabsorption

-The risk of colon cancer in patients with long-standing

Crohn colitis approaches that associated with
ulcerative colitis, and screening colonoscopy after 10
years of colonic disease is indicated
Thank
you