Inflammatory bowel disease

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Inflammatory bowel disease

• Michal Holecki, MD, PhD
• Department of Pathophysiology

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Inflammatory bowel disease

• refers to two chronic diseases that cause
  inflammation of the intestines ulcerative
  colitis and Crohn's disease.
• Although the diseases have some features in
  common, there are some important differences.

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Inflammatory bowel disease

• Medical research hasn't determined yet what
  causes inflammatory bowel disease. But
  researchers believe that a number of factors may
  be involved, such as
• environment
• diet
• possibly genetics

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Inflammatory bowel disease

• Current evidence suggests that there's likely
  a genetic defect that affects how our immune
  system works and how the inflammation is turned
  on and off in those people with inflammatory
  bowel disease, in response to an offending agent,
  like
• bacteria
• a virus
• or a protein in food

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Epidemiology of IBD
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Ulcerative colitis microscopic features

• Process is limited to the mucosa and submucosa
  with deeper layer unaffected
• Two major histologic features
• - the crypt architecture of the colon is
  distorted
• - some patients have basal plasma cells and
  multiple basal lymphoid aggregates

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Ulcerative colitis

• is an inflammatory disease of the large
  intestine, also called the colon. In ulcerative
  colitis, the inner lining - or mucosa - of the
  intestine becomes inflamed and develops ulcers
• is often the most severe in the rectal area,
  which can cause frequent diarrhea.

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Ulcerative colitis macroscopic features

• 40-50 of patients have disease limited to the
  rectum and rectosigmoid
• 30-40 of patients have disease extending beyond
  the sigmoid
• 20 of patients have a total colitis
• Proximal spread occurs in continuity without
  areas of uninvolved mucosa

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Ulcerative colitis macroscopic features

• Mucosa is
• - erythematous, has a granular surface that
  looks like a sand paper
• In more severe diseases
• - hemorrhagic, edematous and ulcerated
• In fulminant disease a toxic colitis or a toxic
  megacolon may develop ( wall become very thin and
  mucosa is severly ulcerated)

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Ulcerative colitis clinical presentation

• The major symptoms of UC are
• - diarrhea
• - rectal bleeding
• - tenesmus
• - passage of mucus
• - crampy abdominal pain

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Ulcerative colitis clinical presentation

• Patients with proctitis usually pass fresh blood
  or blood-stained mucus either mixed with stool or
  streaked onto the surface of normal or hard stool
• When the disease extends beyond the rectum, blood
  is usually mixed with stool or grossly bloody
  diarrhea may be noted
• When the disease is severe, patients pass a
  liquid stool containing blood, pus, fecal matter
• Other symptoms in moderate to severe disease
  include anorexia, nausea, vomitting, fever,
  weight loss

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Radiologic change of UC

• Fine mucosal granularity
• Mucosa become thickenned and superficial ulcers
  are seen (collar-button ulcers)
• Loss of haustration

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Ulcerative colitis - complication

• Hemorrhage
• Perforation
• Stricture
• Toxic megacolon (transverse colon with a diameter
  of more than 5,0 cm to 6,0 cm with loss of
  haustration)

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UC disease presentation
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UC disease presentation
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Colonic pseudopolyps
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ulcerative colitisthe left side of the colon is
affected The image shows confluent superficial
ulceration and loss of mucosal architecture.
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Crohns disease

• Crohn's disease differs from ulcerative colitis
  in the areas of the bowel it involves - it most
  commonly affects the last part of the small
  intestine and parts of the large intestine.
• Crohn's disease isn't limited to these areas and
  can attack any part of the digestive tract
• Crohn's disease generally tends to involve the
  entire bowel wall

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Crohns disease macroscopic features

• Can affect any part of GI tract from the mouth to
  the anus
• 30-40 of patients have small bowel disease alone
• 40-55 of patients have both small and large
  intestines disease
• 15-25 of patients have colitis alone
• In 75 of patients with small intestinal disease
  the terminal ileum in involved in 90

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Distribution of gastrointestinal Crohn's disease.
Based on data from American Gastroenterological
Association.
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Crohns disease macroscopic features

• CD is a transmural process
• CD is segmental with skip areas in the midst of
  diseased intestine
• In one third of patients with CD perirectal
  fistulas, fissures, abscesses, anal stenosis are
  present

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Crohns disease macroscopic features

• mild disease is characterized by
• aphtous or small superficial ulcerations
• In more active disease
• stellate ulcerations fuse longitudinally and
  transversely to demarcate island of mucosa that
  are histologically normal
• Cobblestone appearance is characteristic of CD
  (both endoscopically and by barium radiography)

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Crohns disease macroscopic features

• Active CD is characterized by focal inflammation
  and formation of fistula tracts
• The bowel wall thickens and becomes narrowed and
  fibrotic, leading to chronic, recurrent bowel
  obstruction

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Crohns disease macroscopic features

• Aphtoid ulceration and focal crypt abscesses with
  loose aggregation of macrophages which form
  granulomas
• Transmural inflammation that is accompanied by
  fissures that penetrate deeply into the bowel wall

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serpiginous ulcer, a classic finding in Crohn's
disease
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Crohns disease sign and symptoms

• Ileocolitis
• - right lower quadrant pain and diarhhea
• - palpable mass, fever and leucocytosis
• - pain is colickly and relieved by defecation
• Jejunoileitis
• - inflammatory disease is associated with loss
  of digestive and absorptive surface

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Crohns disease sign and symptoms

• Colitis and perianal disease
• - low grade fever, malaise, diarrhea, crampy
  abdominal pain, sometimes hematochezia
• - pain is caused by passage of fecal material
  through narrowed and inflamed segments of large
  bowel
• Gastroduodenal disease
• - nusea, vomiting, epigastric pain
• - second portion of duodenum is more commonly
  involved than the bulb

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Endoscopic image of Crohn's colitis showing deep
ulceration.
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IBD is associated with variety of extraintestinal
menifestation. Almost one-third of the patients
have at least one.
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Extraintestinal manifestation

Dermatologic 1. Erythema nodosum occurs in up to
15 of CD patients and 10 of UC patients The
lesions of EN are hot, red, tender nodules
measuring to 5cm in diameter and are found on the
anterior surface of the legs, ankles, calves,
thighs and arms 2. Pyoderma gangrenosum (PG) is
seen in 1 to 12 of UC patients and is less
common in CD colitis. PG may occur years before
the onset of bowel symptoms. Lesions are common
on the dorsal surface of the feet and legs but
may occur on the arms, chest and even face.
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Extraintestinal manifestation

• Rheumatologic
• Peripherial arthritis developes in 15 to 20
  of IBD patients, is more common in CD.
• It is asymmetric, polyarticular and
  migratory.
• Most often affects large joints of the upper
  and lower extremities
• Ankylosing spondylosis (AS) occurs in 10 of
  IBD.
• Sacroilitis is symetrical, occurs equally in
  UC and CD, often asymptomatic

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Extraintestinal manifestation

• Ocular
• The incidence of ocular complications in IBM
  patients is 1 to 10
• The most common is conjunctivitis, anterior
  uveitis, episcleritis
• Symptoms include ocular pain, photophobia,
  blurred vision, headache

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Extraintestinal manifestation

• Urologic
• The most frequent genitourinary complications
  are calculi, ureteral obstruction, fistulas
• The highest frequency of nephrolithiasis
  (10-20) occurs in patients with CD.

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Patients with IBD have an increased prevelance of
osteoporosis secondary to vitamin D deficiency,
calcium malabsorbtion, malnutrition,
corticosteroid use More common cardiopulmonary
manifestations include endocarditis, myocarditis,
pleuropericarditis and interstitial lung disease.
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Different clinical features
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Different clinical features
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Different endoscopic features