CROHNCROHN’s DISEASE’s DISEASEDefiniDefinitiontion Granulomatous inflammatory disease, non specific, Granulomatous inflammatory disease, non specific,

producing necrosis and scaring producing necrosis and scaring oof segments of f segments of gastrointestinal tract, which is chronic and develops gastrointestinal tract, which is chronic and develops in recurring episodes in recurring episodes :: Acute phase (inflammation)Acute phase (inflammation) = = deep ulcers deep ulcers +/- perfora+/- perforations tions

with abscess formation and adhesions to adjacent structures with abscess formation and adhesions to adjacent structures Chronic phase (fibrotic) Chronic phase (fibrotic) = = stricture formationstricture formation..

EpidemiologEpidemiologyy High incidence in Scandinavia, High incidence in Scandinavia, N-V Europe N-V Europe and and N-E N-E of of

North North AmeriAmericaca Maximum incidence Maximum incidence 20-30 20-30yy;; More in Caucasians and Jewish population More in Caucasians and Jewish population More in women More in women

CROHNCROHN’s DISEASE’s DISEASE EtEthiology:hiology: Unknown, probably multifactorialUnknown, probably multifactorial;; Potential factors involved:Potential factors involved:

GeneticGenetic:: Both twins develop diseaseBoth twins develop disease;; Higher chance for an individual with familial clustering of Higher chance for an individual with familial clustering of

Crohn’sCrohn’s;; InfectiousInfectious::

SugeSugested by the presence of granuloma sted by the presence of granuloma There is evidence for: viruses, bacteria and mycobacteriaThere is evidence for: viruses, bacteria and mycobacteria CConcomitentoncomitent infections infections – E. coli, Clostridi – E. coli, Clostridiaa, Campylobacter., Campylobacter.

AlergiesAlergies:: AlergenAlergens in food and inhaled (fungus, molds) – anamnestic data, s in food and inhaled (fungus, molds) – anamnestic data,

alergic testing and more favorable results with specific alergic testing and more favorable results with specific hyposensitisationhyposensitisation

FoodFood:: Elimination of wElimination of weaeath flour and sugar = evident augmentationth flour and sugar = evident augmentation

CROHNCROHN’s DISEASE’s DISEASE

Immunological Immunological Association with: arthritis, eritema nodosum: Association with: arthritis, eritema nodosum:

complex Ag-Ab should be present complex Ag-Ab should be present Presence of Ab against different Ag structures Presence of Ab against different Ag structures

and increase concentration of IgAand increase concentration of IgA;; Inflammatory infiltration and epitheliod Inflammatory infiltration and epitheliod

granuloma formation = high level immune cell granuloma formation = high level immune cell mediated reaction against Ag structuresmediated reaction against Ag structures;;

Corticoids and immune suppresive medication are Corticoids and immune suppresive medication are highly effected in Crohn’s diseasehighly effected in Crohn’s disease; ;

Probable: immune changes at the level of the Probable: immune changes at the level of the mucosa with hyperactive immune response mucosa with hyperactive immune response against foreign Ag with cross reaction and against foreign Ag with cross reaction and nonspecific tisular injury (innocent nonspecific tisular injury (innocent bystander) bystander)

CROHNCROHN’s DISEASE’s DISEASE

CROHNCROHN’s DISEASE’s DISEASE Pathology:Pathology: distributiondistribution::

Terminal ileumTerminal ileum and and colon colon 90% 90% of casesof cases;;

Oro pharinx, Oro pharinx, esophagus, stomach esophagus, stomach and duodenum – very and duodenum – very rarerare;;

Number of lesionsNumber of lesions Numerous lesions with Numerous lesions with

normal segments in normal segments in between ESSENTIAL between ESSENTIAL of diagnosticof diagnostic

MacroscopMacroscopyy EdemEdemaa, eritem, eritemaa, ,

ulceraulcerationtions, s, pseudopolpseudopolyyppss, fibro, fibrosissis, , sclerosclerosissis

Acute phaseAcute phase:: bowel bowel edema,edema, enlarged, inflammed enlarged, inflammed

(redish), inert(redish), inert friabile;friabile; Limits: very clearly delimited Limits: very clearly delimited Diseased areaDiseased areass are separated are separated

by normal segments by normal segments ;;

MesenteryMesentery Edema, infiltrated Edema, infiltrated wit withh

lymph node hlymph node hypertrophy ypertrophy Sometimes more extensive Sometimes more extensive

then bowel lesionsthen bowel lesions

CROHNCROHN’s ’s DISEASEDISEASE

PrePresence of sence of ulcer ulcer and and ulcerations ulcerations – – can be can be very small or serpent very small or serpent like + transverse ulcers like + transverse ulcers producing the image of producing the image of islands (islands (cobblestone);cobblestone);

FiFissures and ulcers are ssures and ulcers are the origin of fistulas the origin of fistulas (entero-enteric, entero-(entero-enteric, entero-colic, entero-cutaneous, colic, entero-cutaneous, entero-vezical, entero-entero-vezical, entero-vaginal)vaginal)

BOALA CROHNBOALA CROHN

pseudopolpseudopolyyppss

Fibrosis, sclerosis, structure formationFibrosis, sclerosis, structure formation Bowel wall very thick (up to 1cm) Bowel wall very thick (up to 1cm) Structures, short or long, unic or multipleStructures, short or long, unic or multiple;; Advanced stages: on long continuous stenosisAdvanced stages: on long continuous stenosis

CROHNCROHN’s DISEASE’s DISEASE

MMyycroscopcroscopy: y: cchharacteristic = aracteristic = granulomgranuloma with a with epitepithelioid giganto helioid giganto cellular cells cellular cells ::

Giant cells + Giant cells + LangerhansLangerhans cells cells + lim + limphphococyytetess ((++ plasm plasma cellsa cells, , eosinophils and PMN)eosinophils and PMN);;

Never caseous necrosis≠tuberculosisNever caseous necrosis≠tuberculosis;; Same inflammation in regional lymphnodesSame inflammation in regional lymphnodes

Inflammatory infiltration is found Inflammatory infiltration is found through all strata of the bowel wallthrough all strata of the bowel wall;;

CROHNCROHN’s DISEASE’s DISEASE SSyymptommptomss

InsidiosInsidios onset but mai also be sudden onset but mai also be sudden;; A. A. symptoms associtaed with bowel problemssymptoms associtaed with bowel problems

PAIN PAIN Dull pain, medium intensity in the RLQ Dull pain, medium intensity in the RLQ Colicky when associated with obstruction: may be Colicky when associated with obstruction: may be

projected in the upper abdomenprojected in the upper abdomen.. DIARHEADIARHEA

4-6/4-6/dayday – – watery or semisolidwatery or semisolid Proportional to extent of lesions and activity of diseaseProportional to extent of lesions and activity of disease;; Bleeding per rectum: distal lesionsBleeding per rectum: distal lesions..

NAUSEA, VOMITING, BORBORISMNAUSEA, VOMITING, BORBORISM.. B. general symptomsB. general symptoms

fefeverver 38 38 00C, +/- C, +/- chillschills Weight loss: diarhhea plus reduced surface for nutrient Weight loss: diarhhea plus reduced surface for nutrient

absorbtionabsorbtion

CROHNCROHN’s ’s DISEASEDISEASE

C. C. extraintestinal extraintestinal SkinSkin

„„metastatic”metastatic” ulcers ulcers – – submamar, subpubian, submamar, subpubian, abdomen;abdomen;

Parastomal ulcerationParastomal ulceration Anal and perianal Anal and perianal

ulcerationsulcerations:: eritemeritemaa nodos nodosumum;; Aftoid oral ulcerationsAftoid oral ulcerations Pyoderma Pyoderma

gangrenosum.gangrenosum. JointsJoints

Peripheral arthriitsPeripheral arthriits Spondilitis Spondilitis

ankilopoeticaankilopoetica ArtralgiaArtralgia..

Hepatobiliary Hepatobiliary Sones due to Sones due to

interruption of interruption of enterohepatic cycleenterohepatic cycle;;

Granulomatous hepatitisGranulomatous hepatitis;; Steatosis Steatosis ;; CholangitisCholangitis;; FFibroibrosissis..

UUrinarrinaryy StonesStones;; HyHydronefrodronefrosissis;; FFistulistulaa..

Ocular Ocular IriIridociclitis dociclitis ;; keratikeratitistis;; conjunctivitconjunctivitisis;; uveituveitisis

HHematologicematologicalal anemianemiaa;; trombocitotrombocitosissis;; limfocitolimfocitosissis – B12, – B12,

ferferumum, folic., folic. acid acid deficitdeficit

CROHNCROHN’s DISEASE’s DISEASE Clinical Clinical

examination examination general: general: malnurishes, malnurishes,

pale, cutaneous lesionspale, cutaneous lesions;; abdomenabdomen::

inspecinspectiontion nothingnothing Regional distension Regional distension

(stenosis)(stenosis);; P.O. scarsP.O. scars – – important important

postapendectomypostapendectomy ..

palpapalpationtion Pain in the RLQPain in the RLQ Guarding: perforative Guarding: perforative

complicationscomplications;; Palpable bowel loop in Palpable bowel loop in

RLQ, deep, badly RLQ, deep, badly delimited, painfuldelimited, painful..

percupercutiontion dulldull

ascultaascultationtion borborism, borborism, sometimesometime..

perinealperineal region region Perianal fistulaPerianal fistula;; ulcerulcerationsations;; fisfissuresure..

rectalrectal Often nothingOften nothing;; Sometimes diffuse Sometimes diffuse

inflammationinflammation.. FistulaFistula

entero-cutanentero-cutaneouseous visiblevisible;; entero-vezicaentero-vezicall

disuridisuriaa, polakiuri, polakiuriaa pneumofecaluripneumofecaluriaa..

recto-vaginal – recto-vaginal – symptoms symptoms and visible on direct and visible on direct examinationexamination..

in the gallbladder: similar in the gallbladder: similar with acute cholecistitiswith acute cholecistitis

retroperitoneal – retroperitoneal – diffuse diffuse celulitis (very severe but celulitis (very severe but very rare)very rare)

CROHNCROHN’s DISEASE’s DISEASE

ParaclinicParaclinicalal LabLab

anemia – anemia – most oftem microcytic, hypochromc most oftem microcytic, hypochromc but macrocytic anemia can develop (B12 deficit) but macrocytic anemia can develop (B12 deficit)

leucocitoleucocitosissis In acute phaseIn acute phase iin complican complicationstions (ab (abssces, fistulces, fistulaa))

trombocitotrombocitosissis ESR increasedESR increased;; Electrolite embalance due to diarheaElectrolite embalance due to diarhea

RadiologRadiology - barium y - barium mealmeal

Alternation of normal and affected Alternation of normal and affected areasareas

Early stagesEarly stages nnonspecificonspecific;; irregular folds, thickened foldsirregular folds, thickened folds;;

Ulcers: deep in the wall aspect of Ulcers: deep in the wall aspect of rose thorn associating 3 aspectsrose thorn associating 3 aspects PseudopolypsPseudopolyps;; Small spiculiform lateral ulcerationsSmall spiculiform lateral ulcerations Large ulcers Large ulcers ;;IRREGULAR COBLESTONE IRREGULAR COBLESTONE

Advanced stages Advanced stages No more foldsNo more folds;; Rigid stenotic tube Rigid stenotic tube Stenosis + distended segments aboveStenosis + distended segments above;; FistulasFistulas..

particularparticular Terminal ileum – rigid cordTerminal ileum – rigid cord;; CecumCecum – – filling defect on the inner filling defect on the inner

border + retractionborder + retraction..

EndoscopEndoscopy GOLD y GOLD STANDARDSTANDARD Small lesions + biopsy + Small lesions + biopsy +

extent of lesions + monitorextent of lesions + monitor RRectoscopia:ectoscopia:

75% normal;75% normal; Coblestones aspectCoblestones aspect Ulcers or stenosisUlcers or stenosis friable mucosa that bleeds on friable mucosa that bleeds on

touchtouch.. CColonoscopolonoscopyy – – similar + similar +

ileum!!!ileum!!! GastroscopyGastroscopy

BiopsBiopsy y Deep + multipleDeep + multiple Even in normal areaEven in normal area..

OthersOthers:: Plain abdominal X-rayPlain abdominal X-ray

– – in onclusive diseasein onclusive disease;; Bone X-ray for Bone X-ray for

associated bone associated bone diseasedisease;;

FistulograFistulographyphy.. LaparLaparoscopyoscopy

CROHNCROHN’s DISEASE’s DISEASEDiagnosticDiagnostic: positive: positive Clinical scenarioClinical scenario

Young pt with diarhhea, abdominal pain I RLQ (often) Young pt with diarhhea, abdominal pain I RLQ (often) +/- mass on palpation +/- fissure or fistula perianal.+/- mass on palpation +/- fissure or fistula perianal...

RadilogyRadilogy segmentarsegmentaryy, discontinu, discontinuous lesions and asymetric lesionous lesions and asymetric lesion;; Deep transmural ulcersDeep transmural ulcers;; „„cobblestone”, „string sign”, pcobblestone”, „string sign”, presence of resence of

pseudopolipilor;pseudopolipilor; Stenosis and fistulaStenosis and fistula..

EEndoscopndoscopyy Skip lesionsSkip lesions;; Multiple ulcers associated with edematous mucosa +/- Multiple ulcers associated with edematous mucosa +/-

stenosis stenosis PathologyPathology

epitepithhelio-giganto-celularelio-giganto-celular granuloma granuloma;; llyymmphphoocytes and cytes and plasmplasma cells infiltration - suggestivea cells infiltration - suggestive

BOALA CROHNBOALA CROHNDiferentialDiferential 1. Ileal disease1. Ileal disease Acute ileitisAcute ileitis Acute apendicitis, apendiceal plastic Acute apendicitis, apendiceal plastic

peritonitisperitonitis.. tuberculosistuberculosis

More general signs and More general signs and PPD+;PPD+; BiopsyBiopsy..

Adnexal tumorsAdnexal tumors.. Ileal carcinoid tumors: carcinoid Ileal carcinoid tumors: carcinoid

syndromesyndrome Radiation enteritis Radiation enteritis

After RXT and diseapears after monthsAfter RXT and diseapears after months.. Cecal tumors – local aspects may be Cecal tumors – local aspects may be

misleadingmisleading

BOALA CROHNBOALA CROHNDiferential Diferential 2. 2. colonic colonic

diseasedisease Ulcerative colitisUlcerative colitis Colonic cahnges in laxative abuse Colonic cahnges in laxative abuse

Watery diarrhea in a person that uses laxatives Watery diarrhea in a person that uses laxatives Rx – loss of haustrations and signs of iritable Rx – loss of haustrations and signs of iritable

bowel syndromebowel syndrome.. Ischemic colitis Ischemic colitis DiverticuloDiverticulosissis CancerCancer PolipoPoliposissis IBSIBS

ComplicaComplications tions - local- local

AbAbscess formation scess formation FistulFistula a StenoStenosis sis

InflamatorInflamatory or scarsy or scars;; Incomplete obstructionIncomplete obstruction

GI Bleeding - mostly from GI Bleeding - mostly from colic origincolic origin

PerforaPerforation: free tion: free perforation with peritonitis perforation with peritonitis is very unusualis very unusual..

Toxic megacolon – rare but Toxic megacolon – rare but very serious diseasevery serious disease Toxic statusToxic status + fe + feverver + + major major

abdominal painabdominal pain + + bloody and bloody and mucus diarrhea + abdominal mucus diarrhea + abdominal distensiondistension

RX massive distension and RX massive distension and destructuringdestructuring

Complications - generalComplications - general

EExtraintestinalxtraintestinal may be considered part of the may be considered part of the disease or complications if severe disease or complications if severe CutanCutaneous, joints, liver, small vessels (thromboembolic eous, joints, liver, small vessels (thromboembolic

disease, Takayashu diseasedisease, Takayashu disease RenalRenal

Urinary lithiasis Urinary lithiasis Obstructions due to mechanical compression of urethersObstructions due to mechanical compression of urethers;;

NeuropsyhicNeuropsyhic:: Sciesures or tetany due to hypoC and hypoMg Sciesures or tetany due to hypoC and hypoMg AnorexiaAnorexia PsihosisPsihosis..

Malabrobtion with consequences on growthMalabrobtion with consequences on growth.. Amiloidosis (visceral and renal) – after 10 years of Amiloidosis (visceral and renal) – after 10 years of

evolutionevolution EEndocrine:ndocrine:

amenoreea, infertilitamenoreea, infertilityy, , late puberty late puberty Small bowel or colonic cancer – after many years Small bowel or colonic cancer – after many years

TREATMENT TREATMENT Medical Medical GeneralGeneral

Bed restBed rest PsihoterapPsihoterapyy;; DietaryDietary

hhyypercaloric, percaloric, hperproteic, vitaminehperproteic, vitaminess (folic, A, D, K, C, B12) (folic, A, D, K, C, B12) andand mineral mineralss (Ca++, (Ca++, Mg++, K+, Fe++, Zn+Mg++, K+, Fe++, Zn++);+);

EXCLUDEEXCLUDE:: Food with many Food with many

fibers )mostly in pt with fibers )mostly in pt with stenosisstenosis;;

Milk – intolerance Milk – intolerance ;; Lipids in case of Lipids in case of

malabsorbtion of lipidsmalabsorbtion of lipids.. MAJOR situations- TPN MAJOR situations- TPN

Symptomatic Symptomatic Pain therapyPain therapy Treat diarrheaTreat diarrhea::

ccodeinodeine phosphat e phosphat Treat Treat dep on cause:dep on cause:

No spices No spices ;; No milk - intoleranceNo milk - intolerance;; Bile salts: interruption Bile salts: interruption

of the liver-enteric of the liver-enteric cyclecycle;;

Atb - infectionAtb - infection

Treat electrolytic Treat electrolytic imbalanceimbalance..

Traet anemia Traet anemia :: Fe, Fe, B12, folic acidB12, folic acid

TREATMENT - pathogenicTREATMENT - pathogenic ANTIINFLAMMATORY ANTIINFLAMMATORY

5ASA 5ASA SalazopirinSalazopirinee:: better in colonic disease better in colonic disease

ANTIBIOTICS ANTIBIOTICS Metronidazol.;Metronidazol.; Chinolone Chinolone

CORTICOIDS - may induce remission CORTICOIDS - may induce remission IMMUNE SUPRESSIONIMMUNE SUPRESSION

Azatioprina (Imuran) – Azatioprina (Imuran) – prevention of prevention of recurrencerecurrence;;

6 mercaptopurin6 mercaptopurinee CCyyclosporinclosporinee MetMethhotrexatotrexat

BIOLOGICAL BIOLOGICAL Infliximab (Remicade)Infliximab (Remicade)

TREATMENTTREATMENT

SURGICALSURGICAL IndicaIndicationstions

Acute complicationsAcute complications locallocal complications complications – steno – stenosissis, fistul, fistulaa;; Unclear diagnosticUnclear diagnostic..

Limited resection of involved bowelLimited resection of involved bowel Enterostomy – end later resectionEnterostomy – end later resection

TREATMENTTREATMENT A. Crohn ileocolicA. Crohn ileocolic IndicaIndicationstions::

fistula;fistula; obstrucobstructiontion;;;;

Percutaneous drainage and resections Percutaneous drainage and resections

TREATMENTTREATMENT B. B. Colonic Crohn Colonic Crohn IndicaIndicationtion

samesame;; megacolon toxic.megacolon toxic.

3 operaţii:3 operaţii: proctocolectomproctocolectomyy ((abdomino-perinealabdomino-perineal) with permanent ) with permanent

ileostomyileostomy;; Total colectomy and ileostomy but rectum in placeTotal colectomy and ileostomy but rectum in place;; Total colectomy plus ileorectal anastomosisTotal colectomy plus ileorectal anastomosis..

TREATMENTTREATMENT Anal and perianalAnal and perianal TTreatment of the abscess and fistula + reatment of the abscess and fistula +

treatment of Crohnstreatment of Crohns.. If refractory disease n the rectum - If refractory disease n the rectum -

proctectomyproctectomy

TREATMENTTREATMENT ObstructionObstruction

ileon:ileon: Ileon resectionIleon resection;; Ileo-cecal resectionIleo-cecal resection By passBy pass..

colon:colon: by-pass;by-pass; IleostomIleostomy or colostomyy or colostomy..

TREATMENTTREATMENT StenoStenosissis

rezecrezectionstions Stricture-plasty Stricture-plasty

Long term complicationLong term complication CancerCancer

High risk for pt with long term Crohns, High risk for pt with long term Crohns, strictures and scleroiss cholangitis strictures and scleroiss cholangitis

Colonoscopic monitoring – 2-3 yColonoscopic monitoring – 2-3 y Displastic lesions: colectomyDisplastic lesions: colectomy

ULCERATIVE COLITISULCERATIVE COLITIS

Ethiology Ethiology unknownunknown MMore frequent ore frequent U USSA, A,

EnglandEngland,, northern northern countriescountries;;

Onset 18-30yOnset 18-30y Under 18 very severeUnder 18 very severe;; Over 50 very unusualOver 50 very unusual..

More often in male ptMore often in male pt

UCUC Genetic factors Genetic factors

Family clusteringFamily clustering;; Possible implication of a defect in IgA productionPossible implication of a defect in IgA production

InfectionInfection Numerous germs isolated but not clearNumerous germs isolated but not clear;; Atb not very goodAtb not very good;; Probably secondary and cause of recurrence Probably secondary and cause of recurrence ..

EnzimaticEnzimatic Increased synthesis of lizozim – destroys the Increased synthesis of lizozim – destroys the

protective mucusprotective mucus;; Not clear if primary or secundary Not clear if primary or secundary ..

PsiPsihhosomaticosomatic PPaattients areients are more psichological more psichologicallyly vulnerable to vulnerable to

conflictconflict;; Emotional problems involved in onset and Emotional problems involved in onset and

maintenance of new episodesmaintenance of new episodes

UCUC

PathologyPathology MacroscopyMacroscopy serosaserosa

AcuteAcute Reddish and glittering;Reddish and glittering;

chronicchronic Pale or pale with red spots.Pale or pale with red spots.

Intestinal wallIntestinal wall Initially:Initially:

Distended, thin;Distended, thin; AdvancedAdvanced

Shortening of the length;Shortening of the length; Narrow lumen;Narrow lumen; No haustrations;No haustrations; Thick wall (due to the muscle Thick wall (due to the muscle

layer);layer); Fulminant diseaseFulminant disease

Very dilated bowel.Very dilated bowel. SevereSevere

Friable, paper-like.Friable, paper-like. mesocolonmesocolon

initiallyinitially normal.normal.

advancedadvanced retracted;retracted; Large lymph nodes. Large lymph nodes. Sometimes psudopolypsSometimes psudopolyps

mucosa:mucosa: Acute:Acute:

redred Small erosions – ulcers Small erosions – ulcers

(superficial. Not deep);(superficial. Not deep); brittle;brittle; Continuous lesionsContinuous lesions Wieschelmann Wieschelmann

pseudiopolypspseudiopolyps subacute:subacute:

Patches of renewed Patches of renewed musosa near the lesionsmusosa near the lesions

Intense renewal – Intense renewal – mucosal bridges and mucosal bridges and vegetationsvegetations

chronicchronic Wide spread lesions Wide spread lesions

with incomplete healing with incomplete healing of the mucosa;of the mucosa;

Thin mucosa;Thin mucosa;

UCUC Particular aspects – affects only the mucosa of the Particular aspects – affects only the mucosa of the

rectum and the colonrectum and the colon First rectum then colonFirst rectum then colon The lower the segment the more aggressive the disease;The lower the segment the more aggressive the disease; The lesions are continuous;The lesions are continuous;

UCUC MicroscopyMicroscopy::

Dilation of vessels folllowed by haemmorhage;Dilation of vessels folllowed by haemmorhage; limfocites and plasmocites;limfocites and plasmocites; Deep glands are full of neutrophils – abcess of Deep glands are full of neutrophils – abcess of

the crypts – ulcerations and pseudopolips.the crypts – ulcerations and pseudopolips. histology:histology:

Granulocyte infiltration is specificGranulocyte infiltration is specific If inflammation spreads to all layers – toxic If inflammation spreads to all layers – toxic

megacolon.megacolon.

UCUC Clinic Clinic digestive symptomsdigestive symptoms

diarrhea:diarrhea: First in 30-50% cases;First in 30-50% cases; Main symptom 4/5;Main symptom 4/5; Feces in a sero-hematic liquid full of pussFeces in a sero-hematic liquid full of puss 2-3 up to 15-20 stools/day;2-3 up to 15-20 stools/day; Sometimes just blood per anumSometimes just blood per anum

Abd pain:Abd pain: Colicky – left sideColicky – left side characteristic:characteristic:

tenesmus;tenesmus; No more pain after a stool is passed.No more pain after a stool is passed.

GeneralGeneral FeverFever –septic; –septic; Weight lossWeight loss;; Vomiting;Vomiting; Tachycardia - Tachycardia - depending on amount of lost fluids depending on amount of lost fluids..

UCUC Clinical examClinical exam abdomen:abdomen:

inspection:inspection: reduction of reduction of

subcutaneous tissue;subcutaneous tissue;bloating - especially bloating - especially suprasuprauumbilicalmbilical - - installation may installation may highlight acute toxic highlight acute toxic dilatation of the colondilatation of the colon..

percution:percution: timpanism increased in timpanism increased in

the case of toxic the case of toxic dilatation of the colon;dilatation of the colon;

painful;painful; auscultation:auscultation:

multiple air-liquid multiple air-liquid noises uncomplicated noises uncomplicated ulcerative colitis ulcerative colitis

tranquility in tranquility in ulcerative colitis ulcerative colitis complicated by complicated by megacolon.megacolon.

Rectal examRectal exam sphincter tone:sphincter tone:

increased due to increased due to pain;pain;

decreased in severe decreased in severe forms;forms;

rectal wall:rectal wall:rigid;rigid;granular mucosa;granular mucosa;stricture areas;stricture areas;

Mucosa: endoscopyMucosa: endoscopyinflammatory inflammatory

exudate in the rectal exudate in the rectal mucosa, or the presence of mucosa, or the presence of blood, mucus, pus;blood, mucus, pus;

highlights other highlights other injuries:injuries:cancer, hemorrhoids, cancer, hemorrhoids, abscesses, fistulas, etc..abscesses, fistulas, etc..

UCUC

stool:stool: in severe forms, in severe forms,

extensive:extensive:stools are unformed, with stools are unformed, with feces floating in a serous feces floating in a serous fluid, blood mixed with fluid, blood mixed with mucus and pus;mucus and pus;

bulky stools with much bulky stools with much blood.blood.in mild formsin mild forms

stool can be formed with stool can be formed with blood and mucus;blood and mucus;in forms limited to the in forms limited to the rectum:rectum:stools, wrapped in blood stools, wrapped in blood and mucus;and mucus;

emissions of blood and emissions of blood and mucus without stool.mucus without stool.

general:general: apathy or apathy or

restlessness, restlessness, anxiety;anxiety;palor;palor;

dehydration, dehydration, malnutrition;malnutrition;

detection detection of of systemic systemic events:events:

eye;eye;articulation;articulation;skin.skin.

UCUC

LaboratoryLaboratory:: leukocytosis - active phases;leukocytosis - active phases; anemia;anemia; hypoalbuminemia;hypoalbuminemia; electrolytes:electrolytes:

significant changes only in severe significant changes only in severe forms;forms; lowering of Na +, K +, Cl-, Mg + lowering of Na +, K +, Cl-, Mg + +;+;

UCUC Radiology Radiology

Simple x-ray or Simple x-ray or radioscopyradioscopy

Always first Always first (perforation, (perforation, incontinence)incontinence)

Active phaseActive phase:: No No

haustrations;haustrations; Thick wall;Thick wall; Cobblestone Cobblestone

aspect – aspect – psudopolyps;psudopolyps;

Distended Distended lumen;lumen;

UCUCLate, advanced stages Late, advanced stages

mucosal relief is mucosal relief is deleted;deleted;

haustations disappear haustations disappear completely;completely;

size is reduced;size is reduced; linear shape;linear shape; distensibility is distensibility is

greatly reduced;greatly reduced; angles rounded;angles rounded; sometimes stenosis;sometimes stenosis; rigid tube rigid tube

(microcolia).(microcolia).

UCUC Endoscopy Endoscopy Inititial stagesInititial stages::

Red mucosa with vessels Red mucosa with vessels visiblevisible;;

FriabFriable mucosale mucosa;; Bleeding is spontaneous and Bleeding is spontaneous and

difusedifuse;; Grainy aspectGrainy aspect;; Blood, mucus and pus in the Blood, mucus and pus in the

lumenlumen;; Florid stagesFlorid stages::

UlceraUlcerations that may tions that may converge with one-anotherconverge with one-another;;

Crypt abscessesCrypt abscesses;; FFalse membranealse membraness..

Late stagesLate stages:: Atrophy of the mucosaAtrophy of the mucosa;; Lack of haustrationsLack of haustrations;; Pseudopolyps;Pseudopolyps;

biopsbiopsyy:: Exfoliative cytologyExfoliative cytology

UCUC CT, CT, MRIMRI

UCUC

LocalLocal complications complications May appear in May appear in

acute UCacute UC PerforaPerforationtion Acute dilationAcute dilation Massive bleeding Massive bleeding

((more than more than 3000 ml 3000 ml iin 24 n 24 hourshours

Perianal lessionsPerianal lessions Due to chronic Due to chronic

diseasedisease SStenotenosis of the sis of the

rectum and colonrectum and colon PseudopolipoPseudopoliposissis CancerCancer

UC general complicationsUC general complications articulararticular

most frequentlymost frequently;; 5 categories5 categories::

Rheumatoid arthritisRheumatoid arthritis;; SpondilitisSpondilitis;; Erythema nodosumErythema nodosum;; Joint painJoint pain;; Acute toxic arteritisAcute toxic arteritis

Spondilitis is the only Spondilitis is the only one that can persist one that can persist after surgery and after surgery and medical treatmentmedical treatment..

ophtalmologicophtalmologic conjunctivitconjunctivitisis;; uveituveitisis;;

iritiritisis;; episcleritepiscleritisis;; keratitkeratitisis;; retinitretinitisis..

cutancutaneous and eous and mucousmucous:: cutancutaneouseous

Erythema nodosumErythema nodosum;; pyoderma pyoderma

gangrenosum;gangrenosum; Urticaria, acnea, Urticaria, acnea,

dermatitisdermatitis..

mucomucousus – stomatit – stomatitisis;; liverliver – – chronic liver chronic liver

disease and cirrhosis;disease and cirrhosis; Kidney Kidney -- stones, stones,

hidronefrosishidronefrosis

UCUC

DiDiferentialferential CrohnCrohn’s disease’s disease ColorectalColorectal cancer cancer DiDiseneteriaseneteria IschemicIschemic colitis colitis Polyposis Polyposis Bacilarry colitisBacilarry colitis Irritable bowel syndromeIrritable bowel syndrome DiverticuloDiverticulosissis PilesPiles

UCUC

TrTreatmenteatment ObObjectivesjectives::

Reduce the time that the patient spends in Reduce the time that the patient spends in acute stages of the diseaseacute stages of the disease..

Prevent relapses and complicationsPrevent relapses and complications;; A. A. Treatment of the acute stageTreatment of the acute stage

1. 1. bed restbed rest 2. 2. food intakefood intake

3-5 days of a colon sparing diet3-5 days of a colon sparing diet Small, frequent mealsSmall, frequent meals;; No milkNo milk

3. psihot3. psihotherapy herapy 4. 4. correct nutritional and hydroelectrolitical correct nutritional and hydroelectrolitical

imbalancesimbalances..

5. 5. antiinflammatories antiinflammatories and antibioticsand antibiotics a) salazopirina) salazopirin b) 5-aminosalicilic b) 5-aminosalicilic

acid acid c) c) corticoids and corticoids and

ACTHACTH d) antibioticd) antibioticss

feverfever;; sepsissepsis..

e) e) immunosuppressivimmunosuppressive treatmente treatment

6-mercaptopurin;6-mercaptopurin; 6-tioguanin;6-tioguanin; AzatioprinAzatioprin MetrotrexatMetrotrexatee Ciclosporin Ciclosporin

UCUC

BB. . PrevenPrevent relapset relapse 1. Salazopirin1. Salazopirin

1,5-2 g/1,5-2 g/dayday 6-9 6-9 monthsmonths;; 2-2,5 g/2-2,5 g/dayday 10 10 daysdays//monthmonth..

2. 2. dietdiet.. 3. 3. avoid psychological stress, avoid psychological stress,

respiratory or digestive tract infectionsrespiratory or digestive tract infections;; 4. 4. follow upfollow up..

C. C. SurgerySurgery 1.1. total total

proctoproctocolectomcolectomy y and permanent and permanent ileostomyileostomy

2.2. total colectomy, total colectomy, treatment of the rectal treatment of the rectal stump and stump and reestablishment of the reestablishment of the continuity of the continuity of the digestive tract 6-12 digestive tract 6-12 months latermonths later

Risc of a disease Risc of a disease progression or progression or relapserelapse

Cancer riskCancer risk.. 3. 3. total colectomy total colectomy

with ileorectal with ileorectal anastomosis in the anastomosis in the same proceduresame procedure;;

Diverticular diseaseDiverticular disease DefiniDefinitiontion

Herniation of the colic Herniation of the colic mucosa through defects of mucosa through defects of the muscle layersthe muscle layers

FreFrequencyquency Incresed with agingIncresed with aging:: SexSex: ♂:♀ = 2:1;: ♂:♀ = 2:1; IncidenceIncidence::

MaximMaximal in Western al in Western EuropeEurope

MMiniminimalal în Africa în Africa andand Asia. Asia. More frequent in urban More frequent in urban

patients and in patients patients and in patients with stressfull jobswith stressfull jobs..

Diverticular diseaseDiverticular disease AethiologyAethiology Precise cause is Precise cause is

unknownunknown.. Development of Development of

diverticulaediverticulae:: Muscle contractionMuscle contraction::

HipertroHipertrophy of the circular phy of the circular musculaturemusculature

Shortening of longitudinal Shortening of longitudinal fibersfibers;;

The result is pressure The result is pressure pockets that push the pockets that push the mucosa throus the muscle mucosa throus the muscle fibersfibers

Weak spots in the colonic Weak spots in the colonic wallwall

Diverticular diseaseDiverticular disease Weakening of the wall due to fatty inflammationWeakening of the wall due to fatty inflammation;; Low fiber intake - constipationLow fiber intake - constipation;; Psychological stress;Psychological stress;

In timeIn time:: Stasis of feces – fecaliths – ulcerations of the mucosa Stasis of feces – fecaliths – ulcerations of the mucosa

due to mechanical irritation – increase in septic due to mechanical irritation – increase in septic fenomenaefenomenae..

Closed cavity – increase in virulence of germs and Closed cavity – increase in virulence of germs and increase in mucus secretion – congestion – increase in mucus secretion – congestion – inflammation – thickening of the wallinflammation – thickening of the wall

PathologyPathology NuNumber – rarely uniquember – rarely unique:: TopographyTopography::

Entire colonEntire colon:: Most frequent on Most frequent on

descending and sigmoiddescending and sigmoid;; Rectum is not affectedRectum is not affected..

StructureStructure:: Body and sometimes also Body and sometimes also

a necka neck !False diverticulae!!False diverticulae!

CColon:olon: Shortened and thickened Shortened and thickened

teniaeteniae;; Arches of circular Arches of circular

musculature between musculature between diverticulae;diverticulae;

Normal nercous plexusesNormal nercous plexuses..

DiagnosDiagnosisis ClinicClinicalal:: AAsimptomaticsimptomatic Atypical digestive Atypical digestive

symptomssymptoms:: Symptoms usually Symptoms usually

due to complicationsdue to complications.. ParaclinicParaclinicalal:: Barium enema, Barium enema,

colonoscopycolonoscopy

ComplicationsComplications A. DiverticulitA. Diverticulitisis

30% 30% of patients with diverticular disease of patients with diverticular disease ;; One or more diverticulaeOne or more diverticulae Due to stasis of fecesDue to stasis of feces peridiverticulitisperidiverticulitis

simptomsimptomss:: Very painful – left iliac fosaVery painful – left iliac fosa;; Irregular bowel habits;Irregular bowel habits; Bloating;Bloating; Nausea;Nausea; Fever;Fever;

Clinical examClinical exam:: Tumor mass in left iliac fosaTumor mass in left iliac fosa painfulpainful;; Lower limit of tumor can be assessed on rectal Lower limit of tumor can be assessed on rectal

digital examdigital exam Above the tumor the descending colon is short and Above the tumor the descending colon is short and

rigidrigid

CT, CT, USUS

Diverticular diseaseDiverticular disease

B. HB. Haemmorhageaemmorhage Frequent due to vecinity of vessels Frequent due to vecinity of vessels ;; More frequent in the right colonMore frequent in the right colon;; clinicclinicalal::

Large haemmorhage;Large haemmorhage; Rarely melenaRarely melena;; Reocurring frequentlyReocurring frequently..

paraclinicparaclinicalal:: scintigrascintigraphyphy arteriograarteriographyphy:: pancolonoscoppancolonoscopyy laparotomylaparotomy..

C. C. Fistulae - dueFistulae - due to to an abscessan abscess::

exterioexteriorr:: colocolo--cutancutaneouseous

interiore:interiore: colo-enteric, colo-colo-enteric, colo-

coliccolic colo-uretcolo-uretheralheral colo-vecolo-vesicalsical colo-uterincolo-uterinee:: colo-vaginalcolo-vaginal

3 s3 syyndrondromsms:: General septicGeneral septic;; Pericolic abscessPericolic abscess;; PeritonitisPeritonitis

D. D. PerforationPerforation First a pericolic abscess and then First a pericolic abscess and then

peritonitisperitonitis E. E. ObstructionObstruction

MecMechanical - due to inflammationhanical - due to inflammation clinicclinicalal::

Suboclusive syndromSuboclusive syndrom Low obstruction + feverLow obstruction + fever:: Tumor mass in the left iliac fossaTumor mass in the left iliac fossa

Barium enemaBarium enema;; Colonoscopy + biopsyColonoscopy + biopsy..

MedicalMedical Profilaxis of complicationsProfilaxis of complications::

Avoid constipationAvoid constipation;; No spicesNo spices;; Mild antispasticsMild antispastics;;

diverticulitdiverticulitisis High fiber intake and laxativesHigh fiber intake and laxatives;; Antiinflammatory drugsAntiinflammatory drugs AntibioticsAntibiotics..

TREATMENTTREATMENT

SurgerySurgery Segmental Segmental

resection of resection of affected colon;affected colon;

In emergency – In emergency – 2 step 2 step procedureprocedure::

Hartmann Hartmann I I followed by followed by reestablishment reestablishment of continuityof continuity

Colostomy in Colostomy in emergency emergency followed by followed by resection with resection with anastomosis anastomosis after acute fase after acute fase passespasses..