Download - Management of Inflammatory Bowel Disease
![Page 1: Management of Inflammatory Bowel Disease](https://reader035.vdocuments.mx/reader035/viewer/2022062303/55506e28b4c905cc0f8b4a24/html5/thumbnails/1.jpg)
INFLAMMATORY BOWEL DISEASE
Dr. Nasir Khokhar MD FACP FACGProfessor of Medicine and
GastroenterologyShifa International Hosptal,
Islamabad, Pakistan
![Page 2: Management of Inflammatory Bowel Disease](https://reader035.vdocuments.mx/reader035/viewer/2022062303/55506e28b4c905cc0f8b4a24/html5/thumbnails/2.jpg)
![Page 3: Management of Inflammatory Bowel Disease](https://reader035.vdocuments.mx/reader035/viewer/2022062303/55506e28b4c905cc0f8b4a24/html5/thumbnails/3.jpg)
Crohns and Ulcerative colitis
![Page 4: Management of Inflammatory Bowel Disease](https://reader035.vdocuments.mx/reader035/viewer/2022062303/55506e28b4c905cc0f8b4a24/html5/thumbnails/4.jpg)
IBD
![Page 5: Management of Inflammatory Bowel Disease](https://reader035.vdocuments.mx/reader035/viewer/2022062303/55506e28b4c905cc0f8b4a24/html5/thumbnails/5.jpg)
CROHN’S DISEASE
![Page 6: Management of Inflammatory Bowel Disease](https://reader035.vdocuments.mx/reader035/viewer/2022062303/55506e28b4c905cc0f8b4a24/html5/thumbnails/6.jpg)
Anatomic Distribution
![Page 7: Management of Inflammatory Bowel Disease](https://reader035.vdocuments.mx/reader035/viewer/2022062303/55506e28b4c905cc0f8b4a24/html5/thumbnails/7.jpg)
Bimodal Distribution
![Page 8: Management of Inflammatory Bowel Disease](https://reader035.vdocuments.mx/reader035/viewer/2022062303/55506e28b4c905cc0f8b4a24/html5/thumbnails/8.jpg)
Prevalence of Crohn’s Disease
![Page 9: Management of Inflammatory Bowel Disease](https://reader035.vdocuments.mx/reader035/viewer/2022062303/55506e28b4c905cc0f8b4a24/html5/thumbnails/9.jpg)
Immune Dysregulation in Crohn’s Disease
![Page 10: Management of Inflammatory Bowel Disease](https://reader035.vdocuments.mx/reader035/viewer/2022062303/55506e28b4c905cc0f8b4a24/html5/thumbnails/10.jpg)
Potential Risk Factors
Diet
NSAIDS
Smoking
Infections
Oral Contraceptives
Psycho social factors
![Page 11: Management of Inflammatory Bowel Disease](https://reader035.vdocuments.mx/reader035/viewer/2022062303/55506e28b4c905cc0f8b4a24/html5/thumbnails/11.jpg)
Etiology
![Page 12: Management of Inflammatory Bowel Disease](https://reader035.vdocuments.mx/reader035/viewer/2022062303/55506e28b4c905cc0f8b4a24/html5/thumbnails/12.jpg)
Gut structure
![Page 13: Management of Inflammatory Bowel Disease](https://reader035.vdocuments.mx/reader035/viewer/2022062303/55506e28b4c905cc0f8b4a24/html5/thumbnails/13.jpg)
Intestinal defences
![Page 14: Management of Inflammatory Bowel Disease](https://reader035.vdocuments.mx/reader035/viewer/2022062303/55506e28b4c905cc0f8b4a24/html5/thumbnails/14.jpg)
Pathogenesis
![Page 15: Management of Inflammatory Bowel Disease](https://reader035.vdocuments.mx/reader035/viewer/2022062303/55506e28b4c905cc0f8b4a24/html5/thumbnails/15.jpg)
Pathogenesis
![Page 16: Management of Inflammatory Bowel Disease](https://reader035.vdocuments.mx/reader035/viewer/2022062303/55506e28b4c905cc0f8b4a24/html5/thumbnails/16.jpg)
Tumor Necrosis Factor (TNF)
![Page 17: Management of Inflammatory Bowel Disease](https://reader035.vdocuments.mx/reader035/viewer/2022062303/55506e28b4c905cc0f8b4a24/html5/thumbnails/17.jpg)
TNF induced apoptosis
![Page 18: Management of Inflammatory Bowel Disease](https://reader035.vdocuments.mx/reader035/viewer/2022062303/55506e28b4c905cc0f8b4a24/html5/thumbnails/18.jpg)
TNF actions
![Page 19: Management of Inflammatory Bowel Disease](https://reader035.vdocuments.mx/reader035/viewer/2022062303/55506e28b4c905cc0f8b4a24/html5/thumbnails/19.jpg)
Patterns of Crohn’s Disease
![Page 20: Management of Inflammatory Bowel Disease](https://reader035.vdocuments.mx/reader035/viewer/2022062303/55506e28b4c905cc0f8b4a24/html5/thumbnails/20.jpg)
Chronic abdominal pain
![Page 21: Management of Inflammatory Bowel Disease](https://reader035.vdocuments.mx/reader035/viewer/2022062303/55506e28b4c905cc0f8b4a24/html5/thumbnails/21.jpg)
Imaging in Crohn’s Disease
![Page 22: Management of Inflammatory Bowel Disease](https://reader035.vdocuments.mx/reader035/viewer/2022062303/55506e28b4c905cc0f8b4a24/html5/thumbnails/22.jpg)
Aphthoid Ulceration
![Page 23: Management of Inflammatory Bowel Disease](https://reader035.vdocuments.mx/reader035/viewer/2022062303/55506e28b4c905cc0f8b4a24/html5/thumbnails/23.jpg)
Aphthoid Ulceration
![Page 24: Management of Inflammatory Bowel Disease](https://reader035.vdocuments.mx/reader035/viewer/2022062303/55506e28b4c905cc0f8b4a24/html5/thumbnails/24.jpg)
Endoscopic view
![Page 25: Management of Inflammatory Bowel Disease](https://reader035.vdocuments.mx/reader035/viewer/2022062303/55506e28b4c905cc0f8b4a24/html5/thumbnails/25.jpg)
Crohn’s Ileitis
![Page 26: Management of Inflammatory Bowel Disease](https://reader035.vdocuments.mx/reader035/viewer/2022062303/55506e28b4c905cc0f8b4a24/html5/thumbnails/26.jpg)
Chronic Subserositis
![Page 27: Management of Inflammatory Bowel Disease](https://reader035.vdocuments.mx/reader035/viewer/2022062303/55506e28b4c905cc0f8b4a24/html5/thumbnails/27.jpg)
Granuloma
![Page 28: Management of Inflammatory Bowel Disease](https://reader035.vdocuments.mx/reader035/viewer/2022062303/55506e28b4c905cc0f8b4a24/html5/thumbnails/28.jpg)
Post stenotic Dilatation
![Page 29: Management of Inflammatory Bowel Disease](https://reader035.vdocuments.mx/reader035/viewer/2022062303/55506e28b4c905cc0f8b4a24/html5/thumbnails/29.jpg)
Enteroenteric Fistula
![Page 30: Management of Inflammatory Bowel Disease](https://reader035.vdocuments.mx/reader035/viewer/2022062303/55506e28b4c905cc0f8b4a24/html5/thumbnails/30.jpg)
Enterocutaneous Fistula
![Page 31: Management of Inflammatory Bowel Disease](https://reader035.vdocuments.mx/reader035/viewer/2022062303/55506e28b4c905cc0f8b4a24/html5/thumbnails/31.jpg)
Perianal Fistula
![Page 32: Management of Inflammatory Bowel Disease](https://reader035.vdocuments.mx/reader035/viewer/2022062303/55506e28b4c905cc0f8b4a24/html5/thumbnails/32.jpg)
Mechanism of Perianal Fistula
![Page 33: Management of Inflammatory Bowel Disease](https://reader035.vdocuments.mx/reader035/viewer/2022062303/55506e28b4c905cc0f8b4a24/html5/thumbnails/33.jpg)
Carcinoma in Crohn’s Disease
![Page 34: Management of Inflammatory Bowel Disease](https://reader035.vdocuments.mx/reader035/viewer/2022062303/55506e28b4c905cc0f8b4a24/html5/thumbnails/34.jpg)
Acute Inflammatory Presentation
![Page 35: Management of Inflammatory Bowel Disease](https://reader035.vdocuments.mx/reader035/viewer/2022062303/55506e28b4c905cc0f8b4a24/html5/thumbnails/35.jpg)
Chronic Inflammatory Presentation
![Page 36: Management of Inflammatory Bowel Disease](https://reader035.vdocuments.mx/reader035/viewer/2022062303/55506e28b4c905cc0f8b4a24/html5/thumbnails/36.jpg)
Scarring and Narrowing
![Page 37: Management of Inflammatory Bowel Disease](https://reader035.vdocuments.mx/reader035/viewer/2022062303/55506e28b4c905cc0f8b4a24/html5/thumbnails/37.jpg)
Enteroenteric Fistula
![Page 38: Management of Inflammatory Bowel Disease](https://reader035.vdocuments.mx/reader035/viewer/2022062303/55506e28b4c905cc0f8b4a24/html5/thumbnails/38.jpg)
Enterovesical Fistula
![Page 39: Management of Inflammatory Bowel Disease](https://reader035.vdocuments.mx/reader035/viewer/2022062303/55506e28b4c905cc0f8b4a24/html5/thumbnails/39.jpg)
Localised Phlegmon
![Page 40: Management of Inflammatory Bowel Disease](https://reader035.vdocuments.mx/reader035/viewer/2022062303/55506e28b4c905cc0f8b4a24/html5/thumbnails/40.jpg)
Presentation
![Page 41: Management of Inflammatory Bowel Disease](https://reader035.vdocuments.mx/reader035/viewer/2022062303/55506e28b4c905cc0f8b4a24/html5/thumbnails/41.jpg)
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
![Page 42: Management of Inflammatory Bowel Disease](https://reader035.vdocuments.mx/reader035/viewer/2022062303/55506e28b4c905cc0f8b4a24/html5/thumbnails/42.jpg)
Laboratory Diagnosis
CBC
Albumin
ESR, CRP
Stool RE
P-ANCA: 10% crohns, 70% UC
ASCA (antibody to yeast S cerevisiae): 70% crohn, 10% UC
![Page 43: Management of Inflammatory Bowel Disease](https://reader035.vdocuments.mx/reader035/viewer/2022062303/55506e28b4c905cc0f8b4a24/html5/thumbnails/43.jpg)
Radiological Diagnosis
![Page 44: Management of Inflammatory Bowel Disease](https://reader035.vdocuments.mx/reader035/viewer/2022062303/55506e28b4c905cc0f8b4a24/html5/thumbnails/44.jpg)
Endoscopic Diagnosis
![Page 45: Management of Inflammatory Bowel Disease](https://reader035.vdocuments.mx/reader035/viewer/2022062303/55506e28b4c905cc0f8b4a24/html5/thumbnails/45.jpg)
Differential Diagnosis:Appendiceal Abscess
![Page 46: Management of Inflammatory Bowel Disease](https://reader035.vdocuments.mx/reader035/viewer/2022062303/55506e28b4c905cc0f8b4a24/html5/thumbnails/46.jpg)
Differential Diagnosis:Carcinoma
![Page 47: Management of Inflammatory Bowel Disease](https://reader035.vdocuments.mx/reader035/viewer/2022062303/55506e28b4c905cc0f8b4a24/html5/thumbnails/47.jpg)
Differential Diagnosis:Carcinoid
![Page 48: Management of Inflammatory Bowel Disease](https://reader035.vdocuments.mx/reader035/viewer/2022062303/55506e28b4c905cc0f8b4a24/html5/thumbnails/48.jpg)
Differential Diagnosis:Lymphoma
![Page 49: Management of Inflammatory Bowel Disease](https://reader035.vdocuments.mx/reader035/viewer/2022062303/55506e28b4c905cc0f8b4a24/html5/thumbnails/49.jpg)
Differential Diagnosis:Tuberculosis
![Page 50: Management of Inflammatory Bowel Disease](https://reader035.vdocuments.mx/reader035/viewer/2022062303/55506e28b4c905cc0f8b4a24/html5/thumbnails/50.jpg)
COMPLICATIONS
ABSCESS
INTESTINAL OBSTRUCTION
FISTULAS
PERIANAL DISEASE
CARCINOMA
HEMORRHAGE
MALABSORPTION
![Page 51: Management of Inflammatory Bowel Disease](https://reader035.vdocuments.mx/reader035/viewer/2022062303/55506e28b4c905cc0f8b4a24/html5/thumbnails/51.jpg)
TREATMENT:Aminosalicylic acid
![Page 52: Management of Inflammatory Bowel Disease](https://reader035.vdocuments.mx/reader035/viewer/2022062303/55506e28b4c905cc0f8b4a24/html5/thumbnails/52.jpg)
![Page 53: Management of Inflammatory Bowel Disease](https://reader035.vdocuments.mx/reader035/viewer/2022062303/55506e28b4c905cc0f8b4a24/html5/thumbnails/53.jpg)
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
![Page 54: Management of Inflammatory Bowel Disease](https://reader035.vdocuments.mx/reader035/viewer/2022062303/55506e28b4c905cc0f8b4a24/html5/thumbnails/54.jpg)
![Page 55: Management of Inflammatory Bowel Disease](https://reader035.vdocuments.mx/reader035/viewer/2022062303/55506e28b4c905cc0f8b4a24/html5/thumbnails/55.jpg)
TREATMENT:Immunosuppressents
![Page 56: Management of Inflammatory Bowel Disease](https://reader035.vdocuments.mx/reader035/viewer/2022062303/55506e28b4c905cc0f8b4a24/html5/thumbnails/56.jpg)
TREATMENT:Immunosuppressents
![Page 57: Management of Inflammatory Bowel Disease](https://reader035.vdocuments.mx/reader035/viewer/2022062303/55506e28b4c905cc0f8b4a24/html5/thumbnails/57.jpg)
TREATMENT:Immunosuppressents
![Page 58: Management of Inflammatory Bowel Disease](https://reader035.vdocuments.mx/reader035/viewer/2022062303/55506e28b4c905cc0f8b4a24/html5/thumbnails/58.jpg)
TREATMENT:Immunosuppressents
![Page 59: Management of Inflammatory Bowel Disease](https://reader035.vdocuments.mx/reader035/viewer/2022062303/55506e28b4c905cc0f8b4a24/html5/thumbnails/59.jpg)
![Page 60: Management of Inflammatory Bowel Disease](https://reader035.vdocuments.mx/reader035/viewer/2022062303/55506e28b4c905cc0f8b4a24/html5/thumbnails/60.jpg)
Biologicals
![Page 61: Management of Inflammatory Bowel Disease](https://reader035.vdocuments.mx/reader035/viewer/2022062303/55506e28b4c905cc0f8b4a24/html5/thumbnails/61.jpg)
Mechanism of action
![Page 62: Management of Inflammatory Bowel Disease](https://reader035.vdocuments.mx/reader035/viewer/2022062303/55506e28b4c905cc0f8b4a24/html5/thumbnails/62.jpg)
TNF binding
![Page 63: Management of Inflammatory Bowel Disease](https://reader035.vdocuments.mx/reader035/viewer/2022062303/55506e28b4c905cc0f8b4a24/html5/thumbnails/63.jpg)
Summary of medical treatment of Crohn’s
disease
Aminosalisylic acid: ASA
Corticosteroids: Pred, Budesonide
Immunosuppressents: AZA, MTX, Cyc
Antibiotics: Metronidazole, Ciproflox
TNF antibody: Infliximab
![Page 64: Management of Inflammatory Bowel Disease](https://reader035.vdocuments.mx/reader035/viewer/2022062303/55506e28b4c905cc0f8b4a24/html5/thumbnails/64.jpg)
SURGICAL TREATMENT
![Page 65: Management of Inflammatory Bowel Disease](https://reader035.vdocuments.mx/reader035/viewer/2022062303/55506e28b4c905cc0f8b4a24/html5/thumbnails/65.jpg)
ENDOSCOPIC TREATMENTBalloon Dilatation
![Page 66: Management of Inflammatory Bowel Disease](https://reader035.vdocuments.mx/reader035/viewer/2022062303/55506e28b4c905cc0f8b4a24/html5/thumbnails/66.jpg)
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
![Page 67: Management of Inflammatory Bowel Disease](https://reader035.vdocuments.mx/reader035/viewer/2022062303/55506e28b4c905cc0f8b4a24/html5/thumbnails/67.jpg)
![Page 68: Management of Inflammatory Bowel Disease](https://reader035.vdocuments.mx/reader035/viewer/2022062303/55506e28b4c905cc0f8b4a24/html5/thumbnails/68.jpg)
![Page 69: Management of Inflammatory Bowel Disease](https://reader035.vdocuments.mx/reader035/viewer/2022062303/55506e28b4c905cc0f8b4a24/html5/thumbnails/69.jpg)
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
![Page 70: Management of Inflammatory Bowel Disease](https://reader035.vdocuments.mx/reader035/viewer/2022062303/55506e28b4c905cc0f8b4a24/html5/thumbnails/70.jpg)
ULCERATIVE COLITIS
![Page 71: Management of Inflammatory Bowel Disease](https://reader035.vdocuments.mx/reader035/viewer/2022062303/55506e28b4c905cc0f8b4a24/html5/thumbnails/71.jpg)
Ulcerative Colitis: Forms
![Page 72: Management of Inflammatory Bowel Disease](https://reader035.vdocuments.mx/reader035/viewer/2022062303/55506e28b4c905cc0f8b4a24/html5/thumbnails/72.jpg)
Ulcerative Colitis:Gross Appearance
![Page 73: Management of Inflammatory Bowel Disease](https://reader035.vdocuments.mx/reader035/viewer/2022062303/55506e28b4c905cc0f8b4a24/html5/thumbnails/73.jpg)
Endoscopic Appearance
![Page 74: Management of Inflammatory Bowel Disease](https://reader035.vdocuments.mx/reader035/viewer/2022062303/55506e28b4c905cc0f8b4a24/html5/thumbnails/74.jpg)
Microscopic Features
![Page 75: Management of Inflammatory Bowel Disease](https://reader035.vdocuments.mx/reader035/viewer/2022062303/55506e28b4c905cc0f8b4a24/html5/thumbnails/75.jpg)
Crypt Abscess
![Page 76: Management of Inflammatory Bowel Disease](https://reader035.vdocuments.mx/reader035/viewer/2022062303/55506e28b4c905cc0f8b4a24/html5/thumbnails/76.jpg)
Radiological Features
![Page 77: Management of Inflammatory Bowel Disease](https://reader035.vdocuments.mx/reader035/viewer/2022062303/55506e28b4c905cc0f8b4a24/html5/thumbnails/77.jpg)
Pakistani scenario
![Page 78: Management of Inflammatory Bowel Disease](https://reader035.vdocuments.mx/reader035/viewer/2022062303/55506e28b4c905cc0f8b4a24/html5/thumbnails/78.jpg)
Endoscopic extent: KPK
Hameed et al. JCPSP 2001;11:551-4.
![Page 79: Management of Inflammatory Bowel Disease](https://reader035.vdocuments.mx/reader035/viewer/2022062303/55506e28b4c905cc0f8b4a24/html5/thumbnails/79.jpg)
Severity of disease: KPK
Khan et al. J Med Sci 2010;18:67-70
![Page 80: Management of Inflammatory Bowel Disease](https://reader035.vdocuments.mx/reader035/viewer/2022062303/55506e28b4c905cc0f8b4a24/html5/thumbnails/80.jpg)
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
![Page 81: Management of Inflammatory Bowel Disease](https://reader035.vdocuments.mx/reader035/viewer/2022062303/55506e28b4c905cc0f8b4a24/html5/thumbnails/81.jpg)
![Page 82: Management of Inflammatory Bowel Disease](https://reader035.vdocuments.mx/reader035/viewer/2022062303/55506e28b4c905cc0f8b4a24/html5/thumbnails/82.jpg)
![Page 83: Management of Inflammatory Bowel Disease](https://reader035.vdocuments.mx/reader035/viewer/2022062303/55506e28b4c905cc0f8b4a24/html5/thumbnails/83.jpg)
![Page 84: Management of Inflammatory Bowel Disease](https://reader035.vdocuments.mx/reader035/viewer/2022062303/55506e28b4c905cc0f8b4a24/html5/thumbnails/84.jpg)
![Page 85: Management of Inflammatory Bowel Disease](https://reader035.vdocuments.mx/reader035/viewer/2022062303/55506e28b4c905cc0f8b4a24/html5/thumbnails/85.jpg)
![Page 86: Management of Inflammatory Bowel Disease](https://reader035.vdocuments.mx/reader035/viewer/2022062303/55506e28b4c905cc0f8b4a24/html5/thumbnails/86.jpg)
![Page 87: Management of Inflammatory Bowel Disease](https://reader035.vdocuments.mx/reader035/viewer/2022062303/55506e28b4c905cc0f8b4a24/html5/thumbnails/87.jpg)
![Page 88: Management of Inflammatory Bowel Disease](https://reader035.vdocuments.mx/reader035/viewer/2022062303/55506e28b4c905cc0f8b4a24/html5/thumbnails/88.jpg)
![Page 89: Management of Inflammatory Bowel Disease](https://reader035.vdocuments.mx/reader035/viewer/2022062303/55506e28b4c905cc0f8b4a24/html5/thumbnails/89.jpg)
![Page 90: Management of Inflammatory Bowel Disease](https://reader035.vdocuments.mx/reader035/viewer/2022062303/55506e28b4c905cc0f8b4a24/html5/thumbnails/90.jpg)
![Page 91: Management of Inflammatory Bowel Disease](https://reader035.vdocuments.mx/reader035/viewer/2022062303/55506e28b4c905cc0f8b4a24/html5/thumbnails/91.jpg)
![Page 92: Management of Inflammatory Bowel Disease](https://reader035.vdocuments.mx/reader035/viewer/2022062303/55506e28b4c905cc0f8b4a24/html5/thumbnails/92.jpg)
![Page 93: Management of Inflammatory Bowel Disease](https://reader035.vdocuments.mx/reader035/viewer/2022062303/55506e28b4c905cc0f8b4a24/html5/thumbnails/93.jpg)
![Page 94: Management of Inflammatory Bowel Disease](https://reader035.vdocuments.mx/reader035/viewer/2022062303/55506e28b4c905cc0f8b4a24/html5/thumbnails/94.jpg)
![Page 95: Management of Inflammatory Bowel Disease](https://reader035.vdocuments.mx/reader035/viewer/2022062303/55506e28b4c905cc0f8b4a24/html5/thumbnails/95.jpg)
![Page 96: Management of Inflammatory Bowel Disease](https://reader035.vdocuments.mx/reader035/viewer/2022062303/55506e28b4c905cc0f8b4a24/html5/thumbnails/96.jpg)
![Page 97: Management of Inflammatory Bowel Disease](https://reader035.vdocuments.mx/reader035/viewer/2022062303/55506e28b4c905cc0f8b4a24/html5/thumbnails/97.jpg)
![Page 98: Management of Inflammatory Bowel Disease](https://reader035.vdocuments.mx/reader035/viewer/2022062303/55506e28b4c905cc0f8b4a24/html5/thumbnails/98.jpg)
![Page 99: Management of Inflammatory Bowel Disease](https://reader035.vdocuments.mx/reader035/viewer/2022062303/55506e28b4c905cc0f8b4a24/html5/thumbnails/99.jpg)
![Page 100: Management of Inflammatory Bowel Disease](https://reader035.vdocuments.mx/reader035/viewer/2022062303/55506e28b4c905cc0f8b4a24/html5/thumbnails/100.jpg)
![Page 101: Management of Inflammatory Bowel Disease](https://reader035.vdocuments.mx/reader035/viewer/2022062303/55506e28b4c905cc0f8b4a24/html5/thumbnails/101.jpg)
![Page 102: Management of Inflammatory Bowel Disease](https://reader035.vdocuments.mx/reader035/viewer/2022062303/55506e28b4c905cc0f8b4a24/html5/thumbnails/102.jpg)
![Page 103: Management of Inflammatory Bowel Disease](https://reader035.vdocuments.mx/reader035/viewer/2022062303/55506e28b4c905cc0f8b4a24/html5/thumbnails/103.jpg)
THANKS