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Inflammatory bowel disease (IBD)
Inflammatory bowel disease (IBD) is made up of two separate conditions: Ulcerative colitis
(UC) & Crohn’s disease (CD) - Crohn’s is worse as it can affect the whole GI tract - ‘mouth to
anus’
...
Cause is idiopathic but can be related to
genetic susceptibility
...

* Proctitis (50%) - rectum only
* Left-sided colitis (30%) - rectum + left-side of colon
* Pancolitis (20%) - entire colon
NB: It never spreads proximal/above the ileocecal valve => never enters the small

intestine/ileum (except in backwash ileitis - abnormal ‘spillover’ of UC inflammation into the
terminal ileum)
...
Pseudopolyps & ulcers may also be present
due to inflammation
...

UC is 3x more common in NON-SMOKERS => smoking is protective in UC (whereas
smoking is harmful in Crohn’s) & usually affects 15-30 year olds (affects men & women
the same)
...

Extra-intestinal signs:
* Clubbing
* Aphthous oral ulcers
* Erythema nodosum (red rounded lumps/nodules below the skin surface - most
commonly in the shins)
* Pyoderma gangrenosum (tissue becomes necrotic causing deep ulcers to develop usually in the legs)

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Conjunctivitis
Episcleritis
Iritis
Large joint arthritis
Sacroiliitis
Ankylosing spondylitis (spine & other areas of body become chronically inflamed usually affects back)
Fatty liver
PSC ( Primary sclerosing cholangitis) - inflammation & scarring of the bile ducts can
lead to liver damage & cirrhosis
Cholangiocarcinoma
Nutritional deficits
Amyloidosis - abnormal deposition of amyloid protein in various organs throughout the
Body

Severity can be assessed using Truelove & Witts criteria:
Mild UC

Moderate UC

Severe UC

Motions/day

<4

4-6

>6

Rectal bleeding

Small

Moderate

Large

Temp at 6am

Apyrexial

37
...
8

> 37
...
Difficile toxin) test
* Serological markers - ANCA & ASCA

Imaging
* AXR - No faecal shadows, colonic dilatation, mucosal thickenings/islands
* Erect CXR - abdominal perforation (free air under the diaphragm)
* Barium enema - never do during severe attacks or for diagnosis
* Colonoscopy +/- biopsy - shows extent of disease, inflammatory infiltrate, goblet cell
depletion, mucosal ulcers, glandular distortion, crypt abscesses - best for diagnosis
Endoscopic findings for UC:
* Abnormal erythematous mucosa +/- ulceration
* Uniform inflammation (unlike skip lesions in Crohn’s)
* Mucus in bowel
Complications:
* Bowel perforation
* GI bleeding
* Toxic megacolon (diameter > 6cm)
* Venous thrombosis - give prophylaxis for inpatients
* Colonic carcinoma - intra-epithelial neoplasms may occur in flat, normal looking mucosa
=> surveillance colonoscopy needed every 2/4 years
...
g
...

- Corticosteroids e
...
prednisolone PO or hydrocortisone PR- used when disease does not
quickly respond to 5-ASA
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6 weeks + 5-ASA + 2x daily steroid enemas
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Ciclosporin is
an immunosuppressant & infliximab is an anti-TNFalpha drug (anti-tumour necrosis factor)
that is used to treat autoimmune disease
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20% of pts will need surgery
...


- e
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proctocolectomy + terminal ileostomy
- Colectomy with ileo-anal pouch later
- Total colectomy
- Immunomodulation (suppression of inflammatory processes) is needed when steroids
cannot maintain remission or prolonged use is needed
...
g
...


Crohn’s disease (CD)
Crohn’s disease is a chronic inflammatory bowel condition that can affect any part of the GI tract
from MOUTH TO ANUS (whereas UC only affects rectum + colon)
...
e
...
It is a relapse & remitting
disease => get times of acute exacerbation & times of remission where the disease is not as
active
...

- There are SKIP LESIONS which means the inflammation is not continuous like in UC - some
areas of bowel are left unaffected
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- Men & women are equally likely to be affected but Crohn’s tends to be more common in
DEVELOPED COUNTRIES - it is also a disease of young people with presentation mostly at 2040years
...
The first larger peak occurs at ages 15 - 30
years
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- Smoking increases risk of development X 3/4 (unlike UC where smoking is protective)
...
g
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10% - colovesical (colon - bladder), colovaginal (colon vagina), perianal, enterocutaneous
- Bowel perforation
Colon cancer
Fatty liver disease
PSC (primary sclerosing cholangitis)
Cholangiocarcinoma
Renal stones
Osteomalacia
Malnutrition
Amyloidosis

Investigations:
Bloods:

- FBC - anemia
- CRP & ESR - inflammatory markers
...
The liver often switches to making CRP-type proteins instead of Albumin

-

U&Es - dehydration due to diarrhea/vomiting
LFTs - fatty liver disease?
Stool culture & Microscopy - check for Clostridium difficile, Campylobacter, E
...

ASCA (anti-Saccharomyces cerevisiae antibodies) - antibodies to the yeast S
...


- p-ANCA ( perinuclear antineutrophil cytoplasmic antibody) - more common in UC than
Crohn’s
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- Small bowel enema - detects ileal disease
- Capsule endoscopy - camera pill
- Barium enema - rarely used but can show: Cobblestone mucosa, ‘rose thorn’ ulcers, +/colon strictures Colonoscopy is preferred to barium enema
...
g
...
Perhaps more effective in treatment of UC
...
g
...
g
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It takes 6-10 weeks to work
...


- TNF-alpha inhibitors (tumour necrosis factor) - e
...
Infliximab, adalimumab - TNF-alpha
plays a large role in the pathogenesis of Crohn’s => TNF inhibitors can lower disease activity
...
Effects may be short term, but treatment can be repeated in 8 weeks
...

- Methotrexate - it is an abortifacient => used in abortions to terminate early pregnancies & also
used to treat cancer
...

- Enteral nutrition (EN) - feeding a diet containing all necessary supplements
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- Antibiotics e
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rifaximin
Surgical
- 50 - 80% Need >1 surgery in their lifetime
...
Ileostomy, colectomy resection of the bowel
...

Types of bowel surgery/resection:
1) Left hemi colectomy - When only the left side of the colon is removed (hemi= half)

2) Transverse Colectomy - when only the middle part of the colon is removed (the transverse
colon)

3) Right hemi colectomy - When only the right side of the colon is removed (hemi = half)

4) Sigmoid colectomy - When only the sigmoid colon is removed
...
Sometimes to give the bowel time to heal, the bowel is brought
out as an opening in the front of the abdominal wall - this is called a stoma
...

The stoma is usually temporary & the ends of the bowel are joined back together a few months
later in another operation - this is called a stoma reversal
...
Surgery to
remove the whole colon is called a total colectomy
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Severe attacks:
- Patient looks systemically unwell
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Metrondiazole PO or IV - antibiotic (SEs alcohol intolerance & irreversible neuropathy)
Monitor vital signs & record stool frequency & consistency on stool chart
Physical exam daily & daily U&Es, CRP, FBC, ESR & plain AXR
If improving after 5 days consider switching to PO prednisolone
If NOT improving after 5 days consider TNF-alpha inhibitors (infliximab, adalimumab)
Perianal disease - Occurs in 50% of patients
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- Consider if possible abdominal sepsis present (especially if abdominal pain present investigation with USS, CT & MRI)
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- Actinomycosis - bacterial infection that causes suppurative & granulomatous inflammation
- Amyloidosis
- Bowel carcinoma

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Diverticulitis
Coeliac disease
IBS
Behcet’s disease (BD) - systemic vasculitis disease that causes inflammation of small blood
vessels => causing ulceration of mucous membranes & ocular problems
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