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04-May-18

Inflammatory bowel disease

1

04-May-18

Inflammatory bowel
disease guidelines,
students are expected to
fully understand IBS and it’s
management
...

• These mediators are targets for therapeutic
interventions
...

• Inflammation is more severe distaly
• In a long standing pancolitis, the bowel can become
shortened and ‘pseudopolyps’ develop which are
normal or hypertrophied residual mucosa within
areas of atrophy
...

• Both acute and chronic inflammatory cells
infiltrate the lamina propria and the crypts
(cryptitis)
...

• Goblet cells loose their mucus and in the long
run, glands become distorted
• Dysplasia characterised by heaping of cells
within the crypts and increased mitotic rate may
herald development of colon cancer

Crohn’s disease
•Sites commonly involved in order of
frequency, terminal ileum and right side of
colon, colon alone, terminal ileum alone,
ileum and jejunum
...

• These may penetrate through the bowel wall to
initiate abcesses or fistulas involving the bowel,
bladder, uterus, vagina and the skin of the
perineum
...


Clinical features
ULCERATIVE COLITIS
• Bloody diarrhoea
• The first attack is the most severe and there
after the disease is followed by relapses and
remissions
• Emotional stress, intercurrent infections,
gastroenteritis, antibiotics or NSAIDs may
provoke a relapse
• Proctitis causes rectal bleeding and mucus
discharge sometimes accompanied by
tenesmus
...


•Some patients pass frequent small volume
fluid stools while others are constipated and
pass pellety stools
...

•Patient is toxic with fever, tachycardia and
signs of peritoneal inflammation

On examination
•Evidence of weight loss, anaemia with
glossitis and angular stomatitis
•Abdominal tenderness mostly marked over
the area of inflammation
•Abdominal mass – due to matted loops of
thickened bowel or an intra abdominal
abcess may occur
...


CROHN’S DISEASE
• Abdominal pains, diarrhoea and weight loss
• ileal crohn’s disease may cause sub acute or even acute
intestinal obstruction waterly diarrhoea
•
•
•
•

Weight loss
Patients avoid food since eating provokes pain
Malabsorption – fats, protein or vitamin deficiency
Many patients present with symptoms of small bowel and
colonic disease
...

CONDITIONS WHICH CAN MIMIC ULCERATIVE OR CROHN’S COLITIS

INFECTIVE
BACTERIAL
• Salmonella

VIRAL

• Shigella • Herpes simplex
• Campylobacter jejuni

• Cytomegalovirus

• E
...
Full blood count
• Anaemia resulting from bleeding
• Malabsorption of iron, folic acid or vitamin
B12
2
...

5
...

•Ultrasound may identify thickened small
bowel loops and abcess development in
crohn’s disease

Differential diagnosis of small bowel
crohn’s disease
•Other causes of right iliac fossa mass
•Caecal carcinoma
•Appendix abcess
•Infection (tuberculous, Yersinia,
actinomycosis)
•Mesenteric adenitis
•Pelvic inflammatory disease
•lymphoma
Investigations cont
...
Bacteriology
• Stool microscopy, culture and examination
• Clostridium difficile toxin
• Ova and cysts
• Blood cultures
• Serological tests
4
...

• Crohn’s disease – patchy inflammation with discrete,
deep ulcers
• Colonoscopy may show active inflammation with
pseudopolyps or a complicating carcinoma

management
• Both ulcerative colitis and crohn’s disease are life long conditions
and have important psychological implications; specialist nurses,
counsellors and patient support groups have key roles in
education, reassurance and coping
...
Aminosalicylates [mesalazine (Asacol, Salofalk,
Pentasa, Mezavant) Olsalazine, sulfasalazine,
balsalazide]
MOA; Modulate cytokine release from bowel
mucosa
They are delivered to colon by 1 of 3
mechanisms
i
...

Time dependent (Pentasa)
iii
...
Corticosteroids (prednisolone, hydrocortisone,
Budesonide)
MOA ; Antiinflammatory

Treatment cont
...
Anti TNF antibodies (Infliximab and
adalimumab) – suppress inflammation and
induce apoptosis of inflammatory cells
7
...
Antidiarrhoeal agents (codeine phosphate,
loperamide, lomotil)
MOA; Reduce gut motility and small bowel
secretion
Loperamide improves anal function
...
Thiopurines (Azathioprine, 6-mercaptopurine)
MOA; immunomodulation by inducing T-cell
apoptosis
Azathioprine is metabolised in the liver to
6mercaptopurine then by thiopurine
methyltransferase (TPMT) to thioguanine
nucleotides
4
...
Ciclosporin – suppresses T-cell expansion

ULCERATIVE COLITIS
• Active proctitis
• Mild to moderate disease – mesalazine enemas or
suppositories combined with oral mesalazine are
effective 1st line therapy
...

• Active left sided or extensive ulcerative colitis
• High dose aminosalicylate combined with topical
aminosaicylate and corticosteroid
• Oral prednisolone is indicated when initial
aminosalicylate therapy is ineffective

• Severe ulcerative colitis
• In patient management
• Joint monitoring by the physician and the
surgeon
• Correct dehydration - -IV fluids
• Nutritional support
• IV corticosteroids (Methylprednisolone 60mg
or Hydrocortisone 400mg per day) given as a
constant infusion

• Topical and oral aminosalicylates (Their value in
severe disease is unclear)
• Non – response to corticosteroids – IV
ciclosporin or infliximab
...


cont
...


Crohn’s disease

Crohn’s disease

cont
...

• Patients who relapse more than once a year
should be treated with Thiopurines
• Patients who are intolerant of or resistant to
Thiopurines are managed with methotrexate
combined with folic acid
• Chronic use of corticosteroids should be avoided
as this leads to osteoporosis and other side
effects without preventing relapse

• Fistulas and perianal disease
• Are often associated with sepsis
• Manage by first defining the site of fistulation by
imaging
...


Indications for surgery in ulcerative
colitis
1
...
Failure of medical therapy
• Dependence upon oral corticosteroids
• Complications of drug therapy

3
...
Disease complications unresponsive to medical
therapy
• Arthritis
• Pyoderma gangrenosum

5
...


1
...
Haemorrhage
3
...


4
...
Extra intestinal (systemic)
• Occur during the active phase of inflammatory bowel disease
➢Conjuctivitis
➢Iritis
➢Episcleritis
➢Mouth ulcers
➢Fatty liver
➢Liver abcess (portal pyemia)
➢Mesenteric or portal vein thrombosis
➢Venous thrombosis

➢Arthralgia of large joints
➢Erythema nodosum
➢Pyoderma gangrenosum
Unrelated to Inflammatory Bowel Disease
• Autoimmune hepatitis
• Primary sclerosing cholangitis and
cholangiocarcinoma (ulcerative colitis)
• Amyliodosis and oxalale calculi
• Sacroilitis/ankylosing spondylitis
• Metabolic bone disease

•QUESTIONS?

7



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