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Inflammatory Bowel Disease

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Inflammatory Bowel Disease Ulcerative Colitis Crohn Disease Non specific type Ulcerative Colitis Ulcerative Colitis Remitting & relapsing disease Unknown etiology ... – PowerPoint PPT presentation

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Title: Inflammatory Bowel Disease


1
Inflammatory Bowel Disease
  • Ulcerative Colitis
  • Crohn Disease
  • Non specific type

2
Ulcerative Colitis
3
Ulcerative Colitis
  • Remitting relapsing disease
  • Unknown etiology
  • LaRGE bowel involvement
  • No skip lesion as in Crohn disease
  • Backwash ileitis may involve terminal ileum
  • Can arise if extensive colonic involvement
  • Incidence 10/100,000 (crohn 5/100,000)
  • Genetic component
  • First degree relative 20 to 30 folds increased
    risk
  • HLA DR2 10-20
  • ankylosing spondylitis HLA B27
  • primary sclerosing cholangitis HLA B8

4
Disease involvement
  • Rectum
  • most common site affected
  • Anal disease
  • Rare, usually mild form unlike crohn disease
  • Symptoms
  • Urgency may even have urge incontinence
  • Diarrhoea
  • Anaemia
  • Malnutrition, growth retardation
  • Toxic megacolon ( acute abdomen)
  • Colonic Ca

5
Extra alimentary manifestation 25
  • Arthropathy
  • Large Joints disease activity related
    (commonest joint affected)
  • Ankylosing Spondilitis
  • Sacroileitis
  • Liver (Rx for colonic disease is ineffective in
    controlling these)
  • Fatty degeneration
  • Chronic active hepatitis cirrhosis
  • Primary scleorsing cholangitis 4
  • Cholangiocarcinoma (rare)
  • Skin
  • Pyoderma gangrenosum - U.C. gt crohn (ulcerative
    colitis more common then crohns disease)
  • Erythema nodosum crohn gt U.C.
  • Eye
  • Uveitis scaring visual impairment
  • episcleritis
  • Cancer
  • 0 in 10 years
  • 10 in 20 years
  • gt20 in 30 years

6
Endoscopic FeaturesNon specific
  • Lost of vascular pattern
  • Due to mucosal oedema, the normal vascular
    pattern is no longer seen
  • Fine granularity
  • Pseudopolyps
  • Contact bleeding / erythema
  • Frank ulceration
  • Muscoal degeneration

7
Radiological FeaturesNon specific
  • Lost of pattern (e.g. haustration)
  • Pseudopolyps
  • Granularity
  • Ulcer
  • Strictures
  • Fistula (more common in Crohn disease)

Radiological Images provide you a permanent
record for future reference
8
HistopathologyDefinitive
  • Limited to mucosa only
  • Except in fulminant case which may involve
    muscularis propria
  • In assessing the severity of the disease, look at
    the
  • Extend of neutrophil infiltration
  • No. of crypt abscess

Optimal site for Bx if no obvious disease segment
found on colonoscopy 7 cm from anal verge
posterior wall
9
BacteriologyDifferential Diagnosis
  • Campylobacter
  • Similar microscopic appearance it need special
    technique to identify the organism
  • Shigella
  • E coli
  • Amoebiasis
  • Cytomegalovirus

10
Medical Rx
  • Anti-inflammatory
  • Steroid prednisolone
  • 5 AminoSalicylic Acid
  • Sulfasalazine (oldest)
  • Salazoprin
  • Bone marrow depression
  • Oligospermia
  • Mesalazin
  • Pentasa
  • Dipentum
  • Immuno-suppression
  • Azathioprine
  • Cyclosporin
  • Immune Modulator
  • Interferon
  • Infliximab
  • For fistula disease
  • Antibiotic
  • Metronidazole
  • Ciprofloxacin
  • Antimotility
  • Lomotil
  • Codeine

5 aminosalicylic acid is the active moiety, not
the sulfapyridine which is the main causes for
most of the drug complications, in
Sulfasalazine.. This lead to the development of
the newer 5 ASA agents
11
Surgery for UC
  • Prophylactic Colectomy
  • For long term disease
  • For severity /activity of the disease
  • For histological indication
  • Any displasia on biopsy is indicative for surgery
  • Mild dysplasia 54 chance of harboring
    malignancy somewhere
  • High grade dysplasia 67 chance of harboring
    malignancy somewhere
  • Emergency Colectomy
  • Toxic megacolon
  • Perforation
  • Other interventions
  • Fistula formation
  • Abscess collection

12
Surgery for UC
  • Procto-colectomy with
  • Ileoanal anastomosis
  • Ileo-J pouch
  • to recreate reservoir to replace the resected
    rectum
  • End ileostomy
  • Gold standard
  • Curative treatment for the disease
  • Others
  • Total colectomy
  • Still need surveillance for the rectal mucosa

13
Crohn Disease
  • Remitting relapsing disorder
  • Transmural inflammation
  • Non caseating granulomata
  • Giant cell formation
  • Anyway along the GI tract
  • Skip lesions with normal segment of bowel in
    between
  • Anal disease common

14
Crohn disease
  • Fistula
  • Spontaneous
  • Less likely to heal
  • Post Operative
  • May heal spontaneously since disease segment
    theoretically has been removed
  • Likely to require surgery if
  • Fail to close with conservative Rx in 6 to 12 wks
  • Fistula originate from a disease segment of the
    bowel
  • Fistula originate from anastomotic leakage with
    more than 50 circumferential breakdown
  • Distal obstructive lesion i.e stricture

15
Fistula Mx
  • Nutritional support
  • Psychological support
  • Mobilize the patient
  • Antibiotic
  • Immune Modulator
  • Infliximab

16
Fistula
  • Internal 40
  • Vagina
  • Bladder
  • Small bowel
  • Large bowel
  • External 40
  • Mixed 20

17
Anal FistulaDifficult Problem to Mx
  • Types
  • Simple anal fistula
  • Usually trasnsphincteric type of fistula, high or
    low
  • Vagina-anal fistula
  • Vesicle-anal fistula
  • Complicated anal fistula
  • With multiple fistula tracts
  • High recurrence Rate
  • Surgery
  • Loose long term seton drainage
  • (seton insert a plastic rubber through the
    fistula track)
  • Rectal Advancement Flap
  • Ano-cutaneous Advancement Flap
  • Vagina Flap
  • Gracilis Transposition Flap
  • Stoma diversion

18
CrohnSurgery
  • Laparotomy
  • Accurately measure the remaining length of bowel
  • Accurately documented the segment of bowel
    involve, its length and nature of involvement
  • Maximum Conservation of bowel length is required

Microscopic disease at resection margin does not
has any impact on the recurrence of the disease
It is most important to avoid short gut syndrome
which will result in significant morbidity or
even mortality
19
Surgery for IBD
  • Stricturoplasty
  • Need to rule out malignancy first
  • Large bowel resections
  • Segmental resection
  • For localise disease segment (crohn disease)
  • Fistula
  • Stricture
  • Total colectomy ileorectal anastomosis
  • Preserve normal sphincter function
  • For patient with minimal anorectal disease
  • Total Colectomy ileostomy
  • Still need surveillance for the rectum
  • Panproctocolectomy ileostomy
  • Gold standard for UC
  • Perineal wound healing problem common
  • Restorative Proctocolectomy
  • Contraindicate in Crohn disease
  • Creating ileo-pouch to act as reservoir
  • Pouchitis severe, eventually need excision as well

20
  • It is important to remember there may be
    situation in which one cannot differentiate
    ulcerative colitis from crohns disease in
    patients where the histological features are not
    conclusive. which will be called the mixed type
    of inflammatory bowel disease. However, the
    management is still the same. considering the
    medical therapy plus surgical intervention when
    indications arise.
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