management of inflammatory bowel disease

INFLAMMATORY BOWEL DISEASE

Dr. Nasir Khokhar MD FACP FACGProfessor of Medicine and

GastroenterologyShifa International Hosptal,

Islamabad, Pakistan

Crohns and Ulcerative colitis

IBD

CROHN’S DISEASE

Anatomic Distribution

Bimodal Distribution

Prevalence of Crohn’s Disease

Immune Dysregulation in Crohn’s Disease

Potential Risk Factors

Diet

NSAIDS

Smoking

Infections

Oral Contraceptives

Psycho social factors

Etiology

Gut structure

Intestinal defences

Pathogenesis

Pathogenesis

Tumor Necrosis Factor (TNF)

TNF induced apoptosis

TNF actions

Patterns of Crohn’s Disease

Chronic abdominal pain

Imaging in Crohn’s Disease

Aphthoid Ulceration

Aphthoid Ulceration

Endoscopic view

Crohn’s Ileitis

Chronic Subserositis

Granuloma

Post stenotic Dilatation

Enteroenteric Fistula

Enterocutaneous Fistula

Perianal Fistula

Mechanism of Perianal Fistula

Carcinoma in Crohn’s Disease

Acute Inflammatory Presentation

Chronic Inflammatory Presentation

Scarring and Narrowing

Enteroenteric Fistula

Enterovesical Fistula

Localised Phlegmon

Presentation

Clinical Presentations

CHRONIC INFLAMMATORY DISEASE: fever, malaise, weight loss, abdominal pain, RLQ mass

INTESTINAL OBSTRUCTION: Post prandial bloating, cramping, borborygmy

FISTULIZATION: Internal, external

ABSCESS: Fever, chills, tender mass

PERIANAL DISEASE: Fissure, abscess, fistula

EXTRAINTESTINAL: Oral, skin, joints, eye, gall stones, nephrolithiasis, liver

Laboratory Diagnosis

CBC

Albumin

ESR, CRP

Stool RE

P-ANCA: 10% crohns, 70% UC

ASCA (antibody to yeast S cerevisiae): 70% crohn, 10% UC

Radiological Diagnosis

Endoscopic Diagnosis

Differential Diagnosis:Appendiceal Abscess

Differential Diagnosis:Carcinoma

Differential Diagnosis:Carcinoid

Differential Diagnosis:Lymphoma

Differential Diagnosis:Tuberculosis

COMPLICATIONS

ABSCESS

INTESTINAL OBSTRUCTION

FISTULAS

PERIANAL DISEASE

CARCINOMA

HEMORRHAGE

MALABSORPTION

TREATMENT:Aminosalicylic acid

TREATMENT: Corticosteroids

Dramatically suppress clinical symptoms

Do not alter underlying disease process

Prednisone 40-60 mg/day, taper slowly

Side effects: Osteoporosis, others

Ileal release preparation: Budesonide 9mg/day, 50-70% remission in mild to mod

Persistent symptoms need ASA, AZA,MTX

TREATMENT:Immunosuppressents

TREATMENT:Immunosuppressents

TREATMENT:Immunosuppressents

TREATMENT:Immunosuppressents

Biologicals

Mechanism of action

TNF binding

Summary of medical treatment of Crohn’s

disease

Aminosalisylic acid: ASA

Corticosteroids: Pred, Budesonide

Immunosuppressents: AZA, MTX, Cyc

Antibiotics: Metronidazole, Ciproflox

TNF antibody: Infliximab

SURGICAL TREATMENT

ENDOSCOPIC TREATMENTBalloon Dilatation

MANAGEMENT

Life long illness, exacerbations, remissions

Psych social support: patient education

No specific therapy exists: supportive care; diarrhea, steatorrhea, pain

Nutritional support: enteral, parenteral; Fiber, iron, B12, low fat, MCT supplements well balanced diets

PROGNOSIS

Prolonged illness

Proper medical and surgical care help cope with disease

Anticipate complications and manage

Avoid side effects of drugs

Few die of direct effects of disease

ULCERATIVE COLITIS

Ulcerative Colitis: Forms

Ulcerative Colitis:Gross Appearance

Endoscopic Appearance

Microscopic Features

Crypt Abscess

Radiological Features

Pakistani scenario

Endoscopic extent: KPK

Hameed et al. JCPSP 2001;11:551-4.

Severity of disease: KPK

Khan et al. J Med Sci 2010;18:67-70

Shifa Experience

85 patients with 8 years follow up

Diarrhea with blood 100%

Raised ESR 80%

Mild disease 55%

Left sided colitis in 60%

Medical Treatment response nearly 100%

Khokhar N. Rawal Med J 2005;30:12-15

THANKS