INFLAMMATORY BOWEL DISEASES

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INFLAMMATORY BOWEL DISEASES

• Dwarka G. Nath, MD
• Ass Prof of Medicine, UNSoM
• Chief, Gastroenterology Section
• VA Medical Center, Reno, NV

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Q PERTAINING TO IBD, WHICH OF THE FOLLOWING IS
TRUE?

• A. IBD is seen in 50 of first degree
  relatives
• B. Strong concordance by disease category
• C. More common in underdeveloped countries
• D. Flares correlate with life events and/or
  Depression
• E. Concurrent IBS is rare

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Answer is B

• It is B- Individuals with CD tend to have
  family members with CD and Those with UC tend to
  have family members with UC
• Not A- IBD seen in 10-25 of 1st deg relat
• Not C- More common in developed world
• Not D- Not evidence based-only anecdotal
• Not E- upto 30 IBS pts have overlap
  

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Q With respect to UC, Which is FALSE?

• A. Majority have pancolitis at presentation
• B. gt 99 have rectal involvement
• C. More common in non and ex smokers
• D. NSAIDs can lead to relapse
• E. One can manifest PSC without manifest UC
  symptoms

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Answer is A

• It is A- only 20 have pancolitis at onset
• Not B- it is true that Rectum is invariably
• involved in UC
• . Not C- Nicotene is protective for UC
• . Not D True NSAIDs can cause relapse
• . Not E True PSC can manifest without UC
  Symptoms

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Q With respect to Crohns disease, Which is
FALSE?

• A. More common in smokers
• B. Clinical Post-op recurrence is 60
• C. Increased incidence of Sq Cell CA of rectum
  and vulva
• D. GI cancers occur equally in deseased and non
  diseased areas of bowel
• E. pANCA is found less likely than in UC

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Answer is D

• It is D- Diseases Segments have more risk
• Not A- True CD-more common in smokers UC is
  common in non /ex smokers
• Not B- recurs usually at anastamosis in 60 CD
  followed over 15 yrs
• Not C- True incidence of anal/ vulva Sq cancer
  are high
• Not E- pANCA is more common in UC than CD

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Q With regards to IBD, Which generally does not
parallel disease activity?

• A. Erythema Nodosum
• B. Sclerosing Cholangitis
• C. Episcleritis
• D. Peripheral Arthritis
• E. Erythrocyte Sedimentation Rate
• F. CRP

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Answer is B

• It is B- PSC along with Sacroilitis,
  Ankylosing Spondylitis, uveitis DO NOT
  follow disease activity
• They act independ of the disease and need to be
  treated independantly. The onset of any of
  these may predate IBD by several years!
• Not A,C,D,E,F- Erythema Nodosum, Peripheral
  arthritis, episcleritis, ESR, CRP all parallel
  disease activity

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TWO DISTINCT FORMS

• ULCERATIVE COLITIS
• CROHNS DISEASE
• OVERLAP IBD

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ERYTHEMA NODOSUM

• Streptococcal infections- most common cause
• Sarcoidosis
• Idiopathic
• Tuberculosis
• IBD- More association in US than in developing
  countries
• Drugs- OCP, Erythromycin, sulfa,
• Other infections histoplasmosis,
  Coccidiomycosis, Brucellosis, systemic Fungal
  infections, Leprosy, Mycoplasma, chlamidia,
  Gonococcemia
• Allergies
• Pregnancy of OCP
• Vasculitis- Behcets syndrom, SLE variants,
  Pancreatiits, Hodgkins T cell immunodeficincies

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PYODERMA GANGRENOSUM

• Is an Inflammatory skin disease often associated
  with underlying systemic disorder such as IBD,
  Arthritis or Lymphoproliferative disorder
• The eruptions begin as an isolated pustule or
  scattered lesions with rapid progression into
  large ulcers which heals with cribriform scar
• Diagnosis is made after an infectious aetiology
  is excluded

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TWO DISTINCT FORMSAND A SPRECTRUM IN BETWEEN

• ULCERATIVE COLITIS
• CROHNS DISEASE
• OVERLAP SYNDROMES
• MICROSCOPIC COLITIS

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EPIDEMIOLOGY STATASTICS

• Estimated prevalence Active cases 100/100,000
  of general population
• Estimated approx 1 million cases in US split
  equally among CD and UC
• More Prevalent in developed/ developing countries
• Higher incidence in Ashkanazi Jew decent
• Equal distribution among Male Female
• Peak incidence between 10-30 yrs then a second
  peak between 6th/7th decade

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AETIOLOGY

• UNKNOWN
• Genetics- approximately 10-15 have a family
  history of eg Ashkanazi jews
• Smoking- CD -Yes, Aggrevates
  UC- Protective
• Developed countries- extreme Hygiene may
  predispose (insufficient exposure and challenge
  of Gut immune system that makes them susceptible)

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Clinical Manifestations- UC

• UC typically involves rectum and extends
  proximally.
• At presentation 40 have proctitis, 40 have
  left sided, 20 present with Pancolitis
• So Bloody diarrhea, urgency are presenting
  symptoms
• Severe cases i.e. Toxic megacolon can present
  with fever, weight loss, tachycardia, failure to
  thrive, Growth failures and symptoms of systemic
  inflamation
• Occasionally severe proctitis cases can present
  with constipation
• . Upto 20 can present with extraintestinal
  symptoms

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Clinical Manifestations- CD

• Can involve entire GI tract and so symptoms vary
  depending on site of involvement
• Approximately 30 have SB disease, 40 have
  ileo-colitis, 30 have colitis and 5 have UGI
  disease or Anorectal presentation
• Abd pain, Diarrhea, weight loss, Failure to
  thrive, Growth retardation- small bowel Disease
• Hematochezia, diarrhea in Large bowel disease
• Upto 20 have extraintestinal manifestations

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CROHNS DISEASE
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FEATURES UC vs CD

• Feature UC CD
• Depth of inflamation Mucosal Transmural
• Pattern of disease Contiguous Skip areas
• Location Colorectal Mouth-Anus
• Rectal involvement Usual less common
• Ileal disease Backwash 10-15 Common
• Fistulas Rare Common
• Perianal Disease Rare Common
• Granulomas Unlikely 10-30 pts
• Overt Bleeding Usual less common
• Malnutrition Unlikely more common
• Cancer Risk CRC, Cholangio CRC,Sm Bwl
• Tobacco use Protective Harmful

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Extraintestinal Manifestations IBD disease
Activity

• RELATED to DISEASE ACTIVITY Erythema
  Nodosum Peripheral arthritis Ophtholmologi
  c manifestations
• UNRELATED to DISEASE ACTIVITY Ankylosing
  Spondylitis/ Axial Arthritis Primary Sclerosing
  Cholangitis Gallstones
• RELATION to DISEASE ACTIVITY LESS CLEAR
• Pyoderma Gangrenosum Metabolic Bone
  Disease Kidney stones

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LAB FINDINGS

• In mild cases Lab findings are NORMAL
• Anemia is a common finding from Iron deficiency
  of Blood loss or B12/ Folate malabsorption in CD
• Hypoalbuminemia, metabolic bone disease from
  malabsorption are common in CD
• Hypokalemia , Metabolic acidosis from severe
  diarrhea
• Acute Phase reactants- ESR, CRP
• UC? p ANCA / ASCA - ? PPV
  63
• CD ? p ANCA -/ ASCA ? PPV 80

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ENDOSCOPIC HALLMARKS

• Disease Invariably of RECTUMUC
• Disease in Perineum- fistula/ inflammation- CD
• Ileal disease- CD
• Skip lesions Vs Continuous disease
• Oral involvement- more common in CD
• UGI involvement - CD

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CROHNS vs PM COLITIS
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ULCERATIVE COLITISCONTINUOUS INVOLVEMENT
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Ch Ulc COLITISPSEUDOPOLYPS,
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Differential Diagnosis of IBD

• Acute Self Limiting Colitis Bacterial-
  Toxigenic E Coli, Salmonella Shigella,Campylob
  acter, Yersinia, Mycobacterium,N.
  Gonorrhea,C.Diff ParasitesAmoebiasis,
  Chlamydia Viral----CMV, H. Simplex
• Collagenous/Lymphocytic colitis
• Diverticular Dis Associated Colitis
• Medication related Colitis--- NSAIDs , Gold
• Ischemic Colitis
• Radiation Colitis
• Appendicitis
• Diverticulitis
• Neutropenic Enterocolitis/ Typhilitis
• Solitary Rectal Ulcer syndrome
• Malignancies- Carcinoma/ lymphoma/ leukemia

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Microscopic Colitis

• Ch Diarrhea with abd pain, mild weight loss
• Elderly (70 or gt) are more affected
• Women have a greater incidence
• Association with NSAIDs use suggested
• Colonoscopy shows normal mucosa
• Biopsy shows inflammatory infiltrates
• Unlike UC/ CD crypt distortion is NOT present
• Co-existing Celiac sprue should be considered
• Treat with Loperamide, Diphenoxylate or Bismuth
  alone or in combination
• Rarely Cholestyramine, 5 ASA and even steroids
  may be considered ( lt 5 patients)

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Histopathology features

• Crypt Abscess, crypt distortion in UC
• Crypt abscess- depth of involvement in CD
• Granulomas are found in 30 of CD
• Inflamatory infiltrates in MC- NO crypt
  distortion noted in MC

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Treatment of IBD- UC

• Active Disease Topical therapy for distal
  disease ie enemas/ suppositories- ASA /
  Steroid Mild disease treated with oral
  mesalamine
• Steroids for severe disease
• 6 MP /Azathiprine may be used to
  minimize steroid need
• In severe fulminant colitis we may have to use
  IV steroids, cyclosporin or infliximab for
  controll
• Surgery will have to be considered if toxic
  megacolon is suspeced

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Treatment of IBD- UC

• Maintenance of Remission
• Mild distal disease may not need
  maintenance Severe disease will do
  better with a low dose maintenance with ASA or
  with AZA/6MP
• Steroids do not have a roll in maitenance

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Treatment of IBD- CD

• Similar to UC with following exceptions
• Smokers should be counselled to stop 5ASA is
  less effective than in UC Metronidazole in an
  option in induction
• Steroids for acute flares
• Infliximab/ Adalimumab for induction/ maintenance
• AZA/ 6MP for maintenance
• Surgery fo complications of disease

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QUESTION?

• If you donot have any here are some of your MKSAP
  questions

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Case 69 yo man has a 6 wk h/o loose bowels with
urgency, mucous and BRBPR

• He underwent resection of rectosig cancer 14
  months ago.
• 2/14 LN positive, no distant mets
• Chemo and XRT given post op
• 2weeks ago he received Levofloxin for a comm aq
  pneumonia which resolved
• PE- unremarkable, PR-blood tinged mucous
• Flex Sig- Friable granular mucosa with a few
  telangiectasia in distal rectum

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QWhich of the following is the most likely
diagnosis?

• A. Recurrent Rectal Cancer
• B. Radiation Colitis
• C. Ischemic colitis
• D. Ulcerative colitis
• E. C. Diff colitis

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Answer is B Radiation Colitis

• It is B- flex sig findings of telangiectasia
• Not A- Atypical for endoscopy to be neg
• Not C- ischemic colitis is usually acute here we
  have a 6 weeks history
• Not D-age of onset, no ulcerations makes it less
  likely
• Not E- symptoms started prior to ABx therapy

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