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Inflammatory Bowel Disease
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Inflammatory Bowel Disease (IBD) Ulcerative colitis and Crohn's disease
• Chronic inflammatory diseases of the gastrointestinal tract
• No single finding is diagnostic for these diseases
• Epidemiological, clinical, laboratory, imaging and pathological characteristics
• Some patients have a clinical picture that falls between the two diseases
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Case
• 23 y old female with 6 weeks diarrhea• Liquid stools no blood• Bowel movement at night• Colicky abdominal pain• Fever to 38°C• Loss of appetite• Weight loss 6 kilograms
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Case
• Red painful nodules on the lower leg
• Painful knee and wrist joints
• Previous history of a perianal abcess
• Smokes 20 cigarettes a day for 5 years
• Brother with Crohn’s disease
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Questions
1. Does the patient have inflammatory bowel disease?
2. How do we diagnose it?
3. How do we treat the patient?
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Differential DiagnosisSmall Intestine
• Infections • Malabsorption• Lymphoma• Ulcerative jejenoileitis• Tuberculosis• NSAID enteropathy• Ischemic bowel
– etiology– epidemiological, – clinical, – laboratory, – imaging– pathology
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Differential DiagnosisColon
• Infection• Pseudomembranous
colitis• Radiation colitis• Ischemic colitis• Microscopic colitis
– etiology– epidemiological– clinical– laboratory– imaging– pathology
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Diagnosis – Building the Picture
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Epidemiology
Clinical
Laboratory
Imaging
Pathology
Response to treatment
IBD
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Epidemiology IBD
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Epidemiology
• 23 y old
• Female
• Jewish
• Smoker
• Brother with Crohn’s
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Cause(s) of IBD
• Genetic• Infection• Immunological
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Genetic Influence
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GEOGRAPHICAL PREVALENCE OF IBD
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Epidemiology
Clinical
IBD
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Symptoms
• Diarrhea ± mucus, blood• Abdominal pain• Fever• Loss of appetite• Weight loss• Tiredness and weakness
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Symptoms (continued)
• Joint pains, arthritis
• Mouth ulcers
• Skin rash – erythema nodosum
• Perianal abscesses and fistuli
• Eye inflammation
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Epidemiology
Clinical
Laboratory
IBD
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Laboratory
• Infection – stool microscopy and culture
• Malabsorption – stool fat (>6g/day)
• Inflammation – – Erythrocyte sedimentation rate, CRP– Anemia: iron deficiency, Vit B12 deficiency,
anemia of chronic disease,
• Nutrition – low albumin
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p-ANCA and ASCA in IBD
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Epidemiology
Clinical
Laboratory
Imaging
IBD
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IBD and Imaging
• Is there inflammation in the digestive tract?– If not – are there any other relevant processes
• What is the distribution of the inflammation?
• What are the characteristics of the inflammation?
• Take biopsies during imaging?
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Small Intestine and Colon • Duodenum (60 cm long)
– shortest and widest; • Jejunum (2.5 m long)
– most of digestion & absorption• Ileum (longest at 3.5 m)
– water and electrolyte absorption– ends at ileocecal valve
• Colon (1.5 m long)– water and electrolyte absorption
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Differences Between UC and Crohn’s Disease
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Characteristic Features of Ulcerative Colitis
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Crohn’s DiseaseAnatomic Distribution
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Crohn’s DiseaseConsequences of Transmural
Inflammation
• Inflammatory masses• Fistuli• Intestinal obstruction• Perforation
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Ulcerative Colitis-Imaging Modalities
Colon:
• Plain abdominal X-ray
• Colonoscopy
• Barium enema
• (CT)
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Ulcerative Colitis
Colon:• Plain
abdominal X-ray
• Colonoscopy• Barium enema• (CT)
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Normal Barium Enema
Colon:• Plain abdominal X-ray• Colonoscopy• Barium enema• (CT)
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Ulcerative Colitis
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BENIGN STRICTURE
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Ulcerative Colitis
Colon:• Plain abdominal X-
ray• Colonoscopy• Barium enema• (CT)
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Crohn’s Disease Imaging modalities
• Barium studies– Small bowel follow through and enteroclysis– Barium enema
• Endoscopy– Ileoscopy at colonoscopy– Upper GI endoscopy and enteroscopy
• CT• Ultrasound• Isotope scan• Capsule endoscopy
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X-ray Appearance of Crohn’s Disease
• Barium studies– Small bowel follow through
and enteroclysis– Barium enema
• Endoscopy– Ileoscopy at colonoscopy– Upper GI endoscopy and
enteroscopy• CT• Ultrasound• Isotope scan• Capsule endoscopy
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Mesenteric Involvement
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Jejenitis
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Gastro-duodenitis
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Crohn’s Colitis
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Early Crohn’s Disease-Terminal Ileum
• Barium studies– Small bowel follow through and
enteroclysis– Barium enema
• Endoscopy– Ileoscopy and colonoscopy– Upper GI endoscopy and
enteroscopy• CT• Ultrasound• Isotope scan• Capsule endoscopy
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Crohn’s Colitis
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Crohn’s Disease
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UC
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Crohn’s Disease - Enteroscopy• Barium studies
– Small bowel follow through and enteroclysis
– Barium enema• Endoscopy
– Ileoscopy at colonoscopy– Upper GI endoscopy and
enteroscopy• CT• Ultrasound• Isotope scan• Capsule endoscopy
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Crohn’s Disease
• Small bowel follow through and enteroclysis – barium
• Ileoscopy at colonoscopy• Upper GI endoscopy and
enteroscopy• CT• Ultrasound• Isotope scan• Capsule endoscopy
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Crohn’s Disease - CT
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Crohn’s Disease
• Small bowel follow through and enteroclysis – barium
• Ileoscopy at colonoscopy• Upper GI endoscopy and
enteroscopy• CT• Ultrasound• Isotope scan• Capsule endoscopy
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Video Capsule Endoscopy in IBD
• 17 patients with suspected CD not diagnosable by conventional methods
• Iron deficiency anemia (9), abdominal pain (8), diarrhea (7), weight loss (3)
• 12 (70.6%) patients diagnosed as Crohn’s
• Mean duration of symptoms 7.4 years
Fireman et al
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Epidemiology
Clinical
Laboratory
Imaging
Pathology
IBD
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Differences Between UC and Crohn’s Disease
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Ulcerative colitis and Crohn’s disease
UC• Mucosal disease
Crohn’s Disease• Transmural
inflammation
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Crohn’s Disease-Serosal View
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Removed Colon
UC Crohn’s
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Distinguishing Features of Crohn’s Disease
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Colorectal Cancer and IBD
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RISK OF COLORECTAL CANCER
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FACTORS MODIFYING RISK OF COLITIS-ASSOCIATED
CANCER
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COLONOSCOPIC SURVEILLANCE FOR
DYSPLASIA
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Extraintestinal Manifestations
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Erythema nodosumAphthous ulcer
Iritis
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Crohn’s Perianal Disease
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PERIPHERAL ARTHRITIS
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Osteopenia
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Skin LesionsErythema Nodosum Pyoderma Gangrenosum
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SCLEROSING CHOLANGITIS
Primary Sclerosing Cholangitis
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Sclerosing Cholangitis- MR Cholangiography (MRCP)
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IBD in Kibbutzim Crohn’s Disease UC
25.5/100,000 in 1987 to
65.1/100,000 in 1997
121/100,000 in 1987 to
167/100,000 in 1997