gastroenterology and hepatology - inflammatory bowel disease

8/22/2019 Gastroenterology and Hepatology - Inflammatory Bowel Disease

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INFLAMMATORY

BOWEL DISEASE

Steve Polyak, MD

Gastroenterology M3 Lecture Series


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Case

28 yo Caucasian female presents to clinic withabdominal pain and diarrhea for 6 months

Pain

S b/l lower quadrants

0 6 months ago

C dull to sharp

R seem to radiate to lower back

A/A improved with defecation

T dull feeling most of the time, intermittent sharp pains last until BM

E worsened with food

S persistent 2/10 and flares up to 9/10


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Case

Stooling characteristics

Loose brown runny

Small volume

Improved with fasting

Intermittent red blood

Urgency and tenesmus


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Case

Associated symptoms

No wt loss

No N/V

Knee pain, hip pain and low back pain on and offNo fever but has chills

No sick contacts, travel or camping

No PMH

Medications: NSAIDS prn for joint pain

SHx: does not drink, smoke or use drugs

FHx: Denies CRC and IBD


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Case

Vitals stable BMI 21

Exam (positive findings)Pale

Abd is nondistended,

normoactive BS, soft w/o

tympany, tender in b/l LQ, no

guarding

Rectal exam with no stool

Tests?

Blood

WBC 9.5, HCT 30.3, PLT 575

Chem 7, LFTs wnl

Stool studies

Fecal lactoferrin positive

Culture negC diff PCR neg

Giardia/Crypto antigen neg

O&P neg


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Differential

1

2

3

4

5

6

7

8

9

10


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Colonoscopy/Histology

Normal appearing Terminal Ileum Normal appearing histology of TI

Colonoscopy Inflamed mucosa to transverse colon


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Example of normal colon Transmural inflammation, crypt distortion


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Architectural distortion of the crypts

Crypt

Abscess


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Active vs Chronic Cryptitis

Crypt abscess formation

Erosions

Ulcers

Pseudomembranes(plaques of surface exudatewith fibrin, mucin,degeneratedepithelial/inflammatorycells

Crypt distortion/atrophy

Surface villiform change

Basal plasmacytosis

Basal lymphoid aggregates

Paneth cell metaplasia (intransverse and left colon)

Increased mononuclearinflammation in the laminapropria (least useful)

Histology


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Histology

CD

Transmural inflammation

Deep fissures

Cryptitis

Crypt abscess

Crypt arch distortion

Noncaseating granulomas

in 25-50%

UC

Inflammation confined to

mucosa

Cryptitis

Crypt abscess

Crypt arch distortion

Glandular drop out

Basal lymphoid aggregates


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Crohns Indeterminate Ulcerative

Disease Colitis Colitis

10-15 %

IBD Overview

IBD

1-2 million in USA

Loftus EV. Gastroenterology. 2004;126:1504-1517.


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Ulcerative Colitis Crohns Disease

*Per 100,000 population

Reprinted from Lashner BA. In: Stein SH and Rood RP, eds. Inflammatory Bowel Disease: A Guide forPatients and Their Families. Lippincott-Raven Publishers; 1999:23-29.

10

0

2

4

6

8

0 20 40 60 80

10

0

2

4

6

8

0 20 40 60 80

Age (yrs) Age (yrs)

Age Specific Incidence


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Genetic Environment

Immunology Microbial

Immune

Dysregulation

Epithelial

Dysfunction

Pathogenesis


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Clinical Features

Feature UC CD

Abdominal pain Less frequent Frequent

Bloody diarrhea Frequent Occasional

Abdominal mass Never Frequent

Intestinal obstruction Never Frequent

Perianal disease Infrequent Frequent

Fistula Never Common

Effect of smoking Protective Detrimental

Systemic symptoms/EIMs Less common Common


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Extraintestinal Manifestations

PeripheralArthritis

I 5-10% of IBD pts

II 3-4% of IBD pts

Type I pauciarticular yes

Type II polyarticular no

SI

AS

5-20% of IBD pts

1-25% of IBD pts

NO HLA B27 + in AS

ErythemaNodosum

10-20% of IBD pts YES

PyodermaGangrenosum

2% 5% NO IBD in up to 50% of PG pts

Uveitis 1-3% of IBD pts NO Painful, blindness risk

Scleritis

Episcleritis

5% of IBD pts

10% of IBD ptsYES

SclerosingCholangitis

4% 5-20% NOUC in up to 90% of PSC pts

Cholangiocarcinoma and CRC risk

Aphthae 5-20% of IBD pts YES

IBD Preference

CD UC

Disease Activity

Correlation Special Features


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Involvement

Crohns Disease

Image adapted from CDWG


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Involvement

Pro

Proctitis

28%

Left-sided

25%

Pancolitis

47%

Image adapted from CDWG

Ulcerative Colitis


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Diagnostic Tools

Endoscopy

EGD

Colonoscopy

Capsule endoscopy

Radiology

SBFT

Enterography


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Endoscopic Features

Feature UC CD

Mucosal involvementDiffuse continuous

superficial ulcerations

Focal asymmetric

aphthoid or linear

ulcerations

Strictures Rare (neoplasm) Common

Rectal involvement

Always present at

diagnosisSparing may represent

healing

Common


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Endoscopic features of UC


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Endoscopic features of CD

Discrete ulcers and aphthae in the terminal ileum


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Discrete aphthae in the colon Linear ulcerations in the colon


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Severe linear ulcers in the colon Severe disease with narrowing


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Types of CD


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Perianal Disease of CD


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Enterocutaneous Fistula of CD


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Medical Treatment

Aminosalicylates 5ASAAzulfidine

Pentasa

Asacol

Colazal

Apriso

Lialda

Rowasa & Canasa

Steroids

PrednisoneEntocort (Budesonide)

AntibioticsFlagyl

Cipro

Rifaxamin

Immunomodulators6MP

Azathioprine (Imuran)

Methotrexate

Cyclosporin

Myocphenolate (CellCept)

Thalidomide

FK506

Biologic Agents

Infliximab (Remicade)Adalimumab (Humira

Certolizumab (Cimzia)

Probiotics

Elemental diet


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Surgical Therapy

CD

Resection only for

complications

Recurrence 40-70%

Post op treatment reduces

recurrence at anastomosis

UC

Potentially curative

TAC with

Ileostomy

IPAA (J pouch)

10% failure rate

30% pouchitis

Some post op cases developinto Crohns


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Surveillance of CRC

in Chronic Colitis

Colon cancer risk directly related to duration and

extent of disease

Increase 1%/yr each year after 10 years

UC and Crohns colitis similar

Begin after 8-10 yrs of disease if disease is beyond

the splenic flexure

Left sided disease begin surveillance after 15 yrs

Surveillance Q1-2yrs

gastroenterology and hepatology - inflammatory bowel disease

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