inflammatory bowel disease 4 th year ms 2009-2010 khaled jadallah, md assistant professor of...
TRANSCRIPT
Inflammatory Bowel Inflammatory Bowel DiseaseDisease44thth year MS year MS2009-20102009-2010
Khaled Jadallah MDKhaled Jadallah MD
Assistant Professor of MedicineAssistant Professor of Medicine
Gastroenterology Hepatology amp Gastroenterology Hepatology amp NutritionNutrition
Educational ObjectivesEducational Objectives Definitions and spectrum of inflammatory Definitions and spectrum of inflammatory
bowel disease (IBD)bowel disease (IBD) Epidemiology of IBDEpidemiology of IBD Etiopathogenesis of IBDEtiopathogenesis of IBD Clinical manifestations of ulcerative colitis Clinical manifestations of ulcerative colitis
(UC)(UC) Clinical manifestations of Crohnrsquos disease Clinical manifestations of Crohnrsquos disease
(CD)(CD) Distinguishing features between UC and Distinguishing features between UC and
CDCD Diagnostic approach to IBDDiagnostic approach to IBD Complications of IBDComplications of IBD IBD managementIBD management
IBD include a group of chronic relapsing disorders that cause inflammation or ulceration in the small andor large intestines IBD is classified as
Ulcerative colitis (UC)- causes ulceration and inflammation of the mucosa of the colon and rectum
Crohns disease (CD) - an inflammation that extends into the deeper layers of the intestinal wall and also may affect other parts or layers of the digestive tract including the mouth esophagus stomach and small intestine
Inflammatory Bowel Disease
Educational ObjectivesEducational Objectives Definitions and spectrum of inflammatory Definitions and spectrum of inflammatory
bowel disease (IBD)bowel disease (IBD) Epidemiology of IBDEpidemiology of IBD Etiopathogenesis of IBDEtiopathogenesis of IBD Clinical manifestations of ulcerative colitis Clinical manifestations of ulcerative colitis
(UC)(UC) Clinical manifestations of Crohnrsquos disease Clinical manifestations of Crohnrsquos disease
(CD)(CD) Distinguishing features between UC and CDDistinguishing features between UC and CD Diagnostic approach to IBDDiagnostic approach to IBD Complications of IBDComplications of IBD IBD managementIBD management
Epidemiology of IBDEpidemiology of IBD
Ulcerative Ulcerative colitiscolitis
Crohnrsquos Crohnrsquos diseasedisease
Incidence (US)Incidence (US) 11100 00011100 000 7100 0007100 000Age of onsetAge of onset 15-30 amp 60-15-30 amp 60-
808015-30 amp 60-15-30 amp 60-8080
Malefemale Malefemale ratioratio
1111 11-18111-181
SmokingSmoking May prevent May prevent diseasedisease
May cause May cause diseasedisease
Oral Oral contraceptivecontraceptive
No increased No increased riskrisk
Relative risk Relative risk 1919
AppendectomyAppendectomy Not Not protectiveprotective
ProtectiveProtective
Monozygotic Monozygotic twinstwins
8 8 concordanceconcordance
67 67 concordanceconcordance
High
Medium
Low
Educational ObjectivesEducational Objectives Definitions and spectrum of inflammatory Definitions and spectrum of inflammatory
bowel disease (IBD)bowel disease (IBD) Epidemiology of IBDEpidemiology of IBD Etiopathogenesis of IBDEtiopathogenesis of IBD Clinical manifestations of ulcerative colitis Clinical manifestations of ulcerative colitis
(UC)(UC) Clinical manifestations of Crohnrsquos disease Clinical manifestations of Crohnrsquos disease
(CD)(CD) Distinguishing features between UC and CDDistinguishing features between UC and CD Diagnostic approach to IBDDiagnostic approach to IBD Complications of IBDComplications of IBD IBD managementIBD management
NatureNature NurtureNurture
IBDIBD
GenesGenes EnvironmentEnvironment
Educational ObjectivesEducational Objectives Definitions and spectrum of inflammatory Definitions and spectrum of inflammatory
bowel disease (IBD)bowel disease (IBD) Epidemiology of IBDEpidemiology of IBD Etiopathogenesis of IBDEtiopathogenesis of IBD Clinical manifestations of ulcerative Clinical manifestations of ulcerative
colitis (UC)colitis (UC) Clinical manifestations of Crohnrsquos disease Clinical manifestations of Crohnrsquos disease
(CD)(CD) Distinguishing features between UC and CDDistinguishing features between UC and CD Diagnostic approach to IBDDiagnostic approach to IBD Complications of IBDComplications of IBD IBD managementIBD management
Ulcerative Ulcerative CColitis ndash clinical olitis ndash clinical presentationpresentation
Patients with Patients with proctitisproctitis usually pass fresh blood usually pass fresh blood or blood-stained mucus either mixed with stool or blood-stained mucus either mixed with stool or streaked onto the surface of normal or hard or streaked onto the surface of normal or hard stoolstool tenesmustenesmus is a feature is a feature
When the disease extends When the disease extends beyond the rectumbeyond the rectum blood is usually mixed with stool or grossly blood is usually mixed with stool or grossly bloody diarrhea may be notedbloody diarrhea may be noted
When the disease is When the disease is severesevere patients pass a patients pass a liquid stool containing blood pus fecal matterliquid stool containing blood pus fecal matter
Other symptoms in moderate to severe disease Other symptoms in moderate to severe disease include anorexia nausea vomitting fever include anorexia nausea vomitting fever abdominal pain abdominal pain weight lossweight loss
Ulcerative colitis ndash Ulcerative colitis ndash macroscopic featuresmacroscopic features
Mucosa isMucosa is
- erythematous has a granular surface that looks - erythematous has a granular surface that looks like a sand paperlike a sand paper
In more severe diseasesIn more severe diseases
- hemorrhagic edematous and ulcerated- hemorrhagic edematous and ulcerated
In fulminant diseaseIn fulminant disease a toxic colitis or a toxic a toxic colitis or a toxic megacolon may develop ( wall becomemegacolon may develop ( wall becomess very thin very thin and mucosa is severand mucosa is severeely ulcerated)ly ulcerated)
UCUCDisease Distribution at Disease Distribution at
PresentationPresentation
4637
17
UC ndash disease UC ndash disease severityseverity
MILDMILD MODERATMODERATEE
SEVERESEVERE
BOWEL BOWEL MOVEMENTSMOVEMENTS lt 4 per lt 4 per
dayday 4-6 per 4-6 per dayday
gt6 per gt6 per dayday
BLOOD IN BLOOD IN STOOLSTOOL smallsmall moderatemoderate SevereSevere
FEVERFEVER nonenone lt375lt375degdegC C gt 375gt 375degdegC C
TACHYCARDITACHYCARDIAA
nonenone lt90 mean lt90 mean pulsepulse
gt90 mean gt90 mean pulsepulse
UC ndash disease UC ndash disease severityseverity
MILDMILD MODERATMODERATEE
SEVERESEVERE
ANEMIAANEMIA mildmild gt75gt75 lt75lt75
ESRESR lt30mmlt30mm gt30mmgt30mm
ENDOSCOPIC ENDOSCOPIC APPEARANCEAPPEARANCE
Erythema Erythema decreased decreased vascular vascular pattern fine pattern fine granularitygranularity
Marked Marked erythema erythema coarse coarse granularity granularity contact contact bleeding no bleeding no ulcerationulceration
Spontaneous Spontaneous bleeding bleeding ulcerationulceration
Educational ObjectivesEducational Objectives Definitions and spectrum of inflammatory Definitions and spectrum of inflammatory
bowel disease (IBD)bowel disease (IBD) Epidemiology of IBDEpidemiology of IBD Etiopathogenesis of IBDEtiopathogenesis of IBD Clinical manifestations of ulcerative colitis Clinical manifestations of ulcerative colitis
(UC)(UC) Clinical manifestations of Crohnrsquos disease Clinical manifestations of Crohnrsquos disease
(CD)(CD) Distinguishing features between UC and Distinguishing features between UC and
CDCD Diagnostic approach to IBDDiagnostic approach to IBD Complications of IBDComplications of IBD IBD managementIBD management
CD Clinical FeaturesCD Clinical Features
Abdominal pain often postprandialAbdominal pain often postprandial Diarrhea usually wateryDiarrhea usually watery Rectal bleedingRectal bleeding Weight lossWeight loss Right lower quadrant painpalpable Right lower quadrant painpalpable
massmass FeverFever Growth retardation in childrenGrowth retardation in children Perirectal fistulaPerirectal fistula
Crohnrsquos disease ndash macroscopic Crohnrsquos disease ndash macroscopic featuresfeatures
Can affect any part of GI tract from the mouth to the Can affect any part of GI tract from the mouth to the anusanus
30-40 of patients have small bowel disease alone30-40 of patients have small bowel disease alone
40-55 of patients have both small and large 40-55 of patients have both small and large intestines diseaseintestines disease
15-25 of patients have colitis alone15-25 of patients have colitis alone
In 75 of patients with small intestinal disease the In 75 of patients with small intestinal disease the terminal ileum in involved in 90terminal ileum in involved in 90
Crohnrsquos DiseaseCrohnrsquos DiseaseAnatomic DistributionAnatomic Distribution
Small bowelSmall bowelalonealone(33)(33)
IleocolicIleocolic(45)(45)
Colon aloneColon alone(20)(20)
Frequency of involvementFrequency of involvement
MostMost LeastLeast
Crohnrsquos disease ndash macroscopic Crohnrsquos disease ndash macroscopic featuresfeatures
CD is a CD is a transmuraltransmural process process
CD is CD is segmentalsegmental with skip areas in with skip areas in the midst of diseased intestinethe midst of diseased intestine
In one third of patients with CD In one third of patients with CD perirectal fistulas fissures perirectal fistulas fissures abscesses anal stenosis are presentabscesses anal stenosis are present
Crohnrsquos disease ndash macroscopic Crohnrsquos disease ndash macroscopic featuresfeatures
Active CD is characterized by focal Active CD is characterized by focal inflammation and formation of fistula inflammation and formation of fistula tractstracts
The bowel wall thickens and becomes The bowel wall thickens and becomes narrowed and fibrotic leading to narrowed and fibrotic leading to chronic recurrent bowel obstructionchronic recurrent bowel obstruction
Crohnrsquos Disease Activity Index(CDAI)
Incorporates 8 variables 1 liquid or very soft stools day 2 Abdominal pain amp cramping 3 Extraintestinal manifestations 4 Complications 5 Abdominal mass 6 Use of anti diarrheal medications anti- 7 Hematocrit 8 Body weight
Crohnrsquos Disease Red Crohnrsquos Disease Red FlagsFlags
Onset after stopping smokingOnset after stopping smoking Bleeding onlyBleeding only DiverticulosisDiverticulosis AtherosclerosisAtherosclerosis ProlapseProlapse
Extraintestinal Manifestations of IBD
SkinErythema nodosumPyoderma gangrenosum
JointsPeripheral arthritisSacroileitisAnkylosing spondylitis
EyeUveitisEpiscleritisIritis
Hepatobiliary complicationsGallstonesPSC
Renal complicationsNephrolithiasisRecurrent UTIs
Educational ObjectivesEducational Objectives Definitions and spectrum of inflammatory Definitions and spectrum of inflammatory
bowel disease (IBD)bowel disease (IBD) Epidemiology of IBDEpidemiology of IBD Etiopathogenesis of IBDEtiopathogenesis of IBD Clinical manifestations of ulcerative colitis Clinical manifestations of ulcerative colitis
(UC)(UC) Clinical manifestations of Crohnrsquos disease (CD)Clinical manifestations of Crohnrsquos disease (CD) Distinguishing features between UC and Distinguishing features between UC and
CDCD Diagnostic approach to IBDDiagnostic approach to IBD Medical management of IBDMedical management of IBD Indications for and role of surgeryIndications for and role of surgery
Symptoms of IBDUC vs CDUC vs CD
FeatureFeature UCUC CDCD
FeverFever UncommonUncommon CommonCommon
Rectal Rectal bleedingbleeding
CommonCommon lt frac12 of lt frac12 of patientspatients
Abdominal Abdominal tendernesstenderness
May be May be presentpresent
CommonCommon
Abdominal Abdominal massmass
UncommonUncommon CommonCommon
Abdominal Abdominal painpain
UncommonUncommon Very commonVery common
Weight lossWeight loss UncommonUncommon CommonCommon
TenesmusTenesmus Very commonVery common UncommonUncommon
UC vs CDUC vs CDComplicationsResponse to ComplicationsResponse to
TreatmentTreatmentUCUC CDCD
FistulasFistulas NoNo YesYes
Small Small intestine intestine obstructionobstruction
NoNo FrequentlyFrequently
Colonic Colonic obstructionobstruction
RarelyRarely FrequentlyFrequently
Response to Response to antibioticantibiotic
NoNo YesYes
Recurrence Recurrence after after surgerysurgery
NoNo YesYes
UC vs CDUC vs CDDifferent endoscopic featuresDifferent endoscopic features
UCUC CDCD
Rectal Rectal sparingsparing
RarelyRarely FrequentlyFrequently
Continuous Continuous diseasedisease
YesYes OccasionallyOccasionally
bdquobdquoCCobblestonobblestoningrdquoingrdquo
NoNo YesYes
Granuloma Granuloma on biopsyon biopsy
NoNo OccasionallyOccasionally
Criteria for Indeterminate Criteria for Indeterminate ColitisColitis
No evidence of No evidence of small bowel small bowel involvement involvement fistula or fistula or perianal diseaseperianal disease
Absence of Absence of diagnostic diagnostic criteria for CD criteria for CD or UC by or UC by microscopymicroscopy
Differential Diagnosis of Differential Diagnosis of Chronic Diarrhea and Weight Chronic Diarrhea and Weight
LossLoss Colonic diseasesColonic diseases
IBDIBD NeoplasiaNeoplasia Ischemic bowelIschemic bowel
PancreaticPancreatic Chronic pancreatitisChronic pancreatitis CancerCancer Cystic fibrosisCystic fibrosis
EnteropathicEnteropathic Celiac diseaseCeliac disease Tropical sprueTropical sprue LymphomaLymphoma Mesenteric ischemiaMesenteric ischemia Whipplersquos diseaseWhipplersquos disease
HormonaldrugsHormonaldrugs VipomaVipoma ZESZES Medullary CA of Medullary CA of
thyroidthyroid NSAIDS useNSAIDS use
Educational ObjectivesEducational Objectives Definitions and spectrum of inflammatory Definitions and spectrum of inflammatory
bowel disease (IBD)bowel disease (IBD) Epidemiology of IBDEpidemiology of IBD Etiopathogenesis of IBDEtiopathogenesis of IBD Clinical manifestations of ulcerative colitis Clinical manifestations of ulcerative colitis
(UC)(UC) Clinical manifestations of Crohnrsquos disease Clinical manifestations of Crohnrsquos disease
(CD)(CD) Distinguishing features between UC and CDDistinguishing features between UC and CD Diagnostic approach to IBDDiagnostic approach to IBD Medical management of IBDMedical management of IBD Indications for and role of surgeryIndications for and role of surgery
Diagnostic Approach to Diagnostic Approach to Patients with Suspected Patients with Suspected
IBDIBD HistoryhelliphelliphistoryhelliphelliphistoryHistoryhelliphelliphistoryhelliphelliphistory Clinical examClinical exam Laboratory testsLaboratory tests Radiological imagingRadiological imaging EndoscopyEndoscopy Special serological testingSpecial serological testing Genetic testingGenetic testing
Diagnosis-LAB Blood test
CD Mild anemia mild leukocytosis elevated ESR elevated CRP positive ASCA
UC Anemia hypokalemia hypoalbuminemia elevated ESR elevated LFTs positive p-ANCA
Stool analysis Many WBCs and or RBCs No ova or parasites
What are the Serological What are the Serological Markers in IBDMarkers in IBD
pANCA (perinuclear staining pattern)pANCA (perinuclear staining pattern) Loss of perinuclear pattern after Loss of perinuclear pattern after
DNAaseDNAase Differentiate from the ldquoother pANCAsrdquoDifferentiate from the ldquoother pANCAsrdquo
Antibody against myeloperoxidaseAntibody against myeloperoxidase Antibody against cathepsin G elastase lysozyme Antibody against cathepsin G elastase lysozyme
and lactoferrinand lactoferrin ASCA (anti-ASCA (anti-Saccharomyces cerevisiaeSaccharomyces cerevisiae))
Both IgG and IgABoth IgG and IgA Recognize mannose in the cell wall Recognize mannose in the cell wall
mannan of mannan of Saccharomyces cerevisiaeSaccharomyces cerevisiae
Why Use Serological Why Use Serological Markers in Clinical Markers in Clinical
PracticePractice Differentiate IBD from functional bowel Differentiate IBD from functional bowel
disordersdisorders Accurately diagnose Crohnrsquos or UC in a patient Accurately diagnose Crohnrsquos or UC in a patient
withwith Severe colitisSevere colitis Indeterminate colitisIndeterminate colitis
Predict disease course or complications in IBDPredict disease course or complications in IBD CD phenotypeCD phenotype Severity of diseaseSeverity of disease Risk of pouchitisRisk of pouchitis
SummarySummary
pANCA and ASCA are specific for UC pANCA and ASCA are specific for UC and CD respectivelyand CD respectively
Neither pANCA nor ASCA are sensitive Neither pANCA nor ASCA are sensitive enough to exclude IBDenough to exclude IBD
In patients with IC available In patients with IC available serological markers do not accurately serological markers do not accurately predict the subsequent disease coursepredict the subsequent disease course
Antibody profiles can predict disease Antibody profiles can predict disease behavior in IBDbehavior in IBD
Diagnostic ApproachDiagnostic ApproachEndoscopyEndoscopy
Endoscopy useful forEndoscopy useful for Initial diagnosisInitial diagnosis Assessment of severityAssessment of severity Tissue diagnosisTissue diagnosis FU during treatmentFU during treatment Assessment of disease exacerbationAssessment of disease exacerbation Surveillance for risk of cancerSurveillance for risk of cancer Treatment of certain complications (eg Treatment of certain complications (eg
strictures)strictures)
Crohnrsquos DiseaseCrohnrsquos DiseaseEndoscopic FeaturesEndoscopic Features
Asymmetric patchy inflammationAsymmetric patchy inflammation Skip lesionsSkip lesions Rectal sparingRectal sparing Ulcerations-deepserpiginousUlcerations-deepserpiginous Cobblestoning-commonCobblestoning-common Pseudopolyps-rarePseudopolyps-rare BiopsyBiopsy
Erosions and normal mucosaErosions and normal mucosa Granulomas in 15 to 35 of specimensGranulomas in 15 to 35 of specimens
Ulcerative ColitisUlcerative ColitisEndoscopic FeaturesEndoscopic Features
Diffuse involvementDiffuse involvement Rectum always diseasedRectum always diseased Superficial ulcerationsSuperficial ulcerations FriabilitybleedingFriabilitybleeding Flatteningdisappearance of haustral Flatteningdisappearance of haustral
foldsfolds PseudopolypsPseudopolyps No cobblestoningNo cobblestoning Bx No granulomasBx No granulomas
Imaging for Crohn Imaging for Crohn DiseaseDisease
Traditional TechniquesTraditional Techniques Abdominal RadiographsAbdominal Radiographs
Barium UGI Barium UGI
Barium small bowel follow throughBarium small bowel follow through
Barium EnteroclysisBarium Enteroclysis
Barium EnemaBarium Enema
Imaging for Crohn Disease Imaging for Crohn Disease Newer TechniquesNewer Techniques
CTCT
CT EnteroclysisCT Enteroclysis
CT EnterographyCT Enterography
Magnetic ResonanceMagnetic Resonance
UltrasoundUltrasound
Nuclear MedicineNuclear Medicine
Imaging for Crohns DiseaseImaging for Crohns Disease SummarySummary
Useful Newer TechniquesUseful Newer Techniques evolvingevolving CT EnterographyCT Enterography
Comprehensive evaluation of all bowel amp solid organsComprehensive evaluation of all bowel amp solid organs
Magnetic ResonanceMagnetic Resonance
Useful for ano-rectal diseaseUseful for ano-rectal disease
Real-time MR has potential for detection of stricturesReal-time MR has potential for detection of strictures
Traditional imaging techniques still of value in Traditional imaging techniques still of value in selected cases selected cases
The Capsule (WCE)The Capsule (WCE)
WCEWCE
bull Diameter 11mm Length 26mmDiameter 11mm Length 26mmbull Optical dome Intestinal illumination Optical dome Intestinal illumination
by white light emitting diodes (LEDrsquos)by white light emitting diodes (LEDrsquos)bull LensLensbull Complementary metal-oxide silicone Complementary metal-oxide silicone
imager (color camera chip)imager (color camera chip)bull TransmitterTransmitterbull Two batteries (silver oxide)Two batteries (silver oxide)
GE Junction Duodenum
Jejunum Ileocecal Valve
Educational ObjectivesEducational Objectives Definitions and spectrum of inflammatory Definitions and spectrum of inflammatory
bowel disease (IBD)bowel disease (IBD) Epidemiology of IBDEpidemiology of IBD Etiopathogenesis of IBDEtiopathogenesis of IBD Clinical manifestations of ulcerative colitis Clinical manifestations of ulcerative colitis
(UC)(UC) Clinical manifestations of Crohnrsquos disease Clinical manifestations of Crohnrsquos disease
(CD)(CD) Distinguishing features between UC and CDDistinguishing features between UC and CD Diagnostic approach to IBDDiagnostic approach to IBD Complications of IBDComplications of IBD IBD managementIBD management
IBD-ComplicationsIBD-Complications GI BleedingGI Bleeding Toxic megacolonToxic megacolon PerforationPerforation Thromboembolic phenomenaThromboembolic phenomena FistulasfissuresFistulasfissures AbscessAbscess StricturesobstructionStricturesobstruction MalabsorptionmalnutritionMalabsorptionmalnutrition CancerCancer
Best Protection
Surveillance colonoscopySurveillance colonoscopy
Procto-colectomy (for UC)Procto-colectomy (for UC)
Descending Colon Descending Colon StrictureStricture
Colonic StricturesColonic Strictures
Consider nonsurgical management Consider nonsurgical management ifif Endoscopically accessibleEndoscopically accessible Multiple prior resectionsMultiple prior resections Shorter strictures (less than 5 cm)Shorter strictures (less than 5 cm) Steroid injection if significant Steroid injection if significant
inflammationinflammation
Fistula DefinitionA communication between two epithelial-lined organsLifetime risk of fistula in CD30
Perianal FistulaPerianal Fistula
Pretreatment 2 Weeks
10 Weeks 18 weeks
Educational ObjectivesEducational Objectives Definitions and spectrum of inflammatory Definitions and spectrum of inflammatory
bowel disease (IBD)bowel disease (IBD) Epidemiology of IBDEpidemiology of IBD Etiopathogenesis of IBDEtiopathogenesis of IBD Clinical manifestations of ulcerative colitis Clinical manifestations of ulcerative colitis
(UC)(UC) Clinical manifestations of Crohnrsquos disease Clinical manifestations of Crohnrsquos disease
(CD)(CD) Distinguishing features between UC and CDDistinguishing features between UC and CD Diagnostic approach to IBDDiagnostic approach to IBD Complications of IBDComplications of IBD IBD managementIBD management
Goals of Therapy for IBDGoals of Therapy for IBD
Inducing remissionInducing remission Maintaining remissionMaintaining remission Restoring and maintaining nutritionRestoring and maintaining nutrition Maintaining patientrsquos quality of lifeMaintaining patientrsquos quality of life Prevention of complicationsPrevention of complications Surgical intervention (selection of Surgical intervention (selection of
optimal time for surgery)optimal time for surgery)
Inductive TherapiesInductive Therapies
For UCFor UC AminosalicylatesAminosalicylates CorticosteroidsCorticosteroids CyclosporinCyclosporin
For CDFor CD AminosalicylatesAminosalicylates CorticosteroidsCorticosteroids AntibioticsAntibiotics Anti-TNFAnti-TNF
Maintenance TherapiesMaintenance Therapies
ImmunosupressorsImmunosupressors AzathioprineAzathioprine 6-MP6-MP MethotrexateMethotrexate
AminosalicylatesAminosalicylates Anti-TNFAnti-TNF
NOT NOT corticosteroidscorticosteroids
IBD ManagementIBD ManagementSummarySummary
There is no ldquoone size fits allrdquo to IBD therapyThere is no ldquoone size fits allrdquo to IBD therapy Therapy and decision making are tailored to the Therapy and decision making are tailored to the
individualindividual
Algorithms are based upon available evidenceAlgorithms are based upon available evidence Evidence is in constant fluxEvidence is in constant flux
Success of algorithms depends upon Success of algorithms depends upon optimization of each step of therapy and optimization of each step of therapy and considerable judgment about each outcomeconsiderable judgment about each outcome Skillful application of medical therapy makes all Skillful application of medical therapy makes all
the difference in outcomesthe difference in outcomes
Surgery for IBDSurgery for IBDGeneral ConceptsGeneral Concepts
Majority will need surgery 78 over Majority will need surgery 78 over twenty yearstwenty years
Surgery generally indicated for Surgery generally indicated for complicationscomplications of disease of disease
Surgery must be directed at area of Surgery must be directed at area of bowel responsible for complicationbowel responsible for complication
Indications for SurgeryIndications for Surgery Intestinal obstruction (most Intestinal obstruction (most
common)common) Intractabilitysteroid Intractabilitysteroid
dependencedependence Non-healing fistulaAbscessNon-healing fistulaAbscess Toxic megacolonFree Toxic megacolonFree
perforationperforation Uncontrollable GI bleedingUncontrollable GI bleeding Severe perianal diseaseSevere perianal disease CancerCancer Growth retardation Growth retardation
(children)(children) Severe uncontrollable Severe uncontrollable
extraintestinal extraintestinal manifestationsmanifestations
Management of IBDSummary
The goals of therapy are Relieve symptoms Prevent relapse Correct nutritional deficiencies Control inflammation Prevent complications especially colon cancer
Treatment depends on 1048707 Type of disease 1048707 Site of disease 1048707 Disease severity
Treatment may include drugs nutrition supplements surgery or a combination of these options
Educational ObjectivesEducational Objectives Definitions and spectrum of inflammatory Definitions and spectrum of inflammatory
bowel disease (IBD)bowel disease (IBD) Epidemiology of IBDEpidemiology of IBD Etiopathogenesis of IBDEtiopathogenesis of IBD Clinical manifestations of ulcerative colitis Clinical manifestations of ulcerative colitis
(UC)(UC) Clinical manifestations of Crohnrsquos disease Clinical manifestations of Crohnrsquos disease
(CD)(CD) Distinguishing features between UC and Distinguishing features between UC and
CDCD Diagnostic approach to IBDDiagnostic approach to IBD Complications of IBDComplications of IBD IBD managementIBD management
IBD include a group of chronic relapsing disorders that cause inflammation or ulceration in the small andor large intestines IBD is classified as
Ulcerative colitis (UC)- causes ulceration and inflammation of the mucosa of the colon and rectum
Crohns disease (CD) - an inflammation that extends into the deeper layers of the intestinal wall and also may affect other parts or layers of the digestive tract including the mouth esophagus stomach and small intestine
Inflammatory Bowel Disease
Educational ObjectivesEducational Objectives Definitions and spectrum of inflammatory Definitions and spectrum of inflammatory
bowel disease (IBD)bowel disease (IBD) Epidemiology of IBDEpidemiology of IBD Etiopathogenesis of IBDEtiopathogenesis of IBD Clinical manifestations of ulcerative colitis Clinical manifestations of ulcerative colitis
(UC)(UC) Clinical manifestations of Crohnrsquos disease Clinical manifestations of Crohnrsquos disease
(CD)(CD) Distinguishing features between UC and CDDistinguishing features between UC and CD Diagnostic approach to IBDDiagnostic approach to IBD Complications of IBDComplications of IBD IBD managementIBD management
Epidemiology of IBDEpidemiology of IBD
Ulcerative Ulcerative colitiscolitis
Crohnrsquos Crohnrsquos diseasedisease
Incidence (US)Incidence (US) 11100 00011100 000 7100 0007100 000Age of onsetAge of onset 15-30 amp 60-15-30 amp 60-
808015-30 amp 60-15-30 amp 60-8080
Malefemale Malefemale ratioratio
1111 11-18111-181
SmokingSmoking May prevent May prevent diseasedisease
May cause May cause diseasedisease
Oral Oral contraceptivecontraceptive
No increased No increased riskrisk
Relative risk Relative risk 1919
AppendectomyAppendectomy Not Not protectiveprotective
ProtectiveProtective
Monozygotic Monozygotic twinstwins
8 8 concordanceconcordance
67 67 concordanceconcordance
High
Medium
Low
Educational ObjectivesEducational Objectives Definitions and spectrum of inflammatory Definitions and spectrum of inflammatory
bowel disease (IBD)bowel disease (IBD) Epidemiology of IBDEpidemiology of IBD Etiopathogenesis of IBDEtiopathogenesis of IBD Clinical manifestations of ulcerative colitis Clinical manifestations of ulcerative colitis
(UC)(UC) Clinical manifestations of Crohnrsquos disease Clinical manifestations of Crohnrsquos disease
(CD)(CD) Distinguishing features between UC and CDDistinguishing features between UC and CD Diagnostic approach to IBDDiagnostic approach to IBD Complications of IBDComplications of IBD IBD managementIBD management
NatureNature NurtureNurture
IBDIBD
GenesGenes EnvironmentEnvironment
Educational ObjectivesEducational Objectives Definitions and spectrum of inflammatory Definitions and spectrum of inflammatory
bowel disease (IBD)bowel disease (IBD) Epidemiology of IBDEpidemiology of IBD Etiopathogenesis of IBDEtiopathogenesis of IBD Clinical manifestations of ulcerative Clinical manifestations of ulcerative
colitis (UC)colitis (UC) Clinical manifestations of Crohnrsquos disease Clinical manifestations of Crohnrsquos disease
(CD)(CD) Distinguishing features between UC and CDDistinguishing features between UC and CD Diagnostic approach to IBDDiagnostic approach to IBD Complications of IBDComplications of IBD IBD managementIBD management
Ulcerative Ulcerative CColitis ndash clinical olitis ndash clinical presentationpresentation
Patients with Patients with proctitisproctitis usually pass fresh blood usually pass fresh blood or blood-stained mucus either mixed with stool or blood-stained mucus either mixed with stool or streaked onto the surface of normal or hard or streaked onto the surface of normal or hard stoolstool tenesmustenesmus is a feature is a feature
When the disease extends When the disease extends beyond the rectumbeyond the rectum blood is usually mixed with stool or grossly blood is usually mixed with stool or grossly bloody diarrhea may be notedbloody diarrhea may be noted
When the disease is When the disease is severesevere patients pass a patients pass a liquid stool containing blood pus fecal matterliquid stool containing blood pus fecal matter
Other symptoms in moderate to severe disease Other symptoms in moderate to severe disease include anorexia nausea vomitting fever include anorexia nausea vomitting fever abdominal pain abdominal pain weight lossweight loss
Ulcerative colitis ndash Ulcerative colitis ndash macroscopic featuresmacroscopic features
Mucosa isMucosa is
- erythematous has a granular surface that looks - erythematous has a granular surface that looks like a sand paperlike a sand paper
In more severe diseasesIn more severe diseases
- hemorrhagic edematous and ulcerated- hemorrhagic edematous and ulcerated
In fulminant diseaseIn fulminant disease a toxic colitis or a toxic a toxic colitis or a toxic megacolon may develop ( wall becomemegacolon may develop ( wall becomess very thin very thin and mucosa is severand mucosa is severeely ulcerated)ly ulcerated)
UCUCDisease Distribution at Disease Distribution at
PresentationPresentation
4637
17
UC ndash disease UC ndash disease severityseverity
MILDMILD MODERATMODERATEE
SEVERESEVERE
BOWEL BOWEL MOVEMENTSMOVEMENTS lt 4 per lt 4 per
dayday 4-6 per 4-6 per dayday
gt6 per gt6 per dayday
BLOOD IN BLOOD IN STOOLSTOOL smallsmall moderatemoderate SevereSevere
FEVERFEVER nonenone lt375lt375degdegC C gt 375gt 375degdegC C
TACHYCARDITACHYCARDIAA
nonenone lt90 mean lt90 mean pulsepulse
gt90 mean gt90 mean pulsepulse
UC ndash disease UC ndash disease severityseverity
MILDMILD MODERATMODERATEE
SEVERESEVERE
ANEMIAANEMIA mildmild gt75gt75 lt75lt75
ESRESR lt30mmlt30mm gt30mmgt30mm
ENDOSCOPIC ENDOSCOPIC APPEARANCEAPPEARANCE
Erythema Erythema decreased decreased vascular vascular pattern fine pattern fine granularitygranularity
Marked Marked erythema erythema coarse coarse granularity granularity contact contact bleeding no bleeding no ulcerationulceration
Spontaneous Spontaneous bleeding bleeding ulcerationulceration
Educational ObjectivesEducational Objectives Definitions and spectrum of inflammatory Definitions and spectrum of inflammatory
bowel disease (IBD)bowel disease (IBD) Epidemiology of IBDEpidemiology of IBD Etiopathogenesis of IBDEtiopathogenesis of IBD Clinical manifestations of ulcerative colitis Clinical manifestations of ulcerative colitis
(UC)(UC) Clinical manifestations of Crohnrsquos disease Clinical manifestations of Crohnrsquos disease
(CD)(CD) Distinguishing features between UC and Distinguishing features between UC and
CDCD Diagnostic approach to IBDDiagnostic approach to IBD Complications of IBDComplications of IBD IBD managementIBD management
CD Clinical FeaturesCD Clinical Features
Abdominal pain often postprandialAbdominal pain often postprandial Diarrhea usually wateryDiarrhea usually watery Rectal bleedingRectal bleeding Weight lossWeight loss Right lower quadrant painpalpable Right lower quadrant painpalpable
massmass FeverFever Growth retardation in childrenGrowth retardation in children Perirectal fistulaPerirectal fistula
Crohnrsquos disease ndash macroscopic Crohnrsquos disease ndash macroscopic featuresfeatures
Can affect any part of GI tract from the mouth to the Can affect any part of GI tract from the mouth to the anusanus
30-40 of patients have small bowel disease alone30-40 of patients have small bowel disease alone
40-55 of patients have both small and large 40-55 of patients have both small and large intestines diseaseintestines disease
15-25 of patients have colitis alone15-25 of patients have colitis alone
In 75 of patients with small intestinal disease the In 75 of patients with small intestinal disease the terminal ileum in involved in 90terminal ileum in involved in 90
Crohnrsquos DiseaseCrohnrsquos DiseaseAnatomic DistributionAnatomic Distribution
Small bowelSmall bowelalonealone(33)(33)
IleocolicIleocolic(45)(45)
Colon aloneColon alone(20)(20)
Frequency of involvementFrequency of involvement
MostMost LeastLeast
Crohnrsquos disease ndash macroscopic Crohnrsquos disease ndash macroscopic featuresfeatures
CD is a CD is a transmuraltransmural process process
CD is CD is segmentalsegmental with skip areas in with skip areas in the midst of diseased intestinethe midst of diseased intestine
In one third of patients with CD In one third of patients with CD perirectal fistulas fissures perirectal fistulas fissures abscesses anal stenosis are presentabscesses anal stenosis are present
Crohnrsquos disease ndash macroscopic Crohnrsquos disease ndash macroscopic featuresfeatures
Active CD is characterized by focal Active CD is characterized by focal inflammation and formation of fistula inflammation and formation of fistula tractstracts
The bowel wall thickens and becomes The bowel wall thickens and becomes narrowed and fibrotic leading to narrowed and fibrotic leading to chronic recurrent bowel obstructionchronic recurrent bowel obstruction
Crohnrsquos Disease Activity Index(CDAI)
Incorporates 8 variables 1 liquid or very soft stools day 2 Abdominal pain amp cramping 3 Extraintestinal manifestations 4 Complications 5 Abdominal mass 6 Use of anti diarrheal medications anti- 7 Hematocrit 8 Body weight
Crohnrsquos Disease Red Crohnrsquos Disease Red FlagsFlags
Onset after stopping smokingOnset after stopping smoking Bleeding onlyBleeding only DiverticulosisDiverticulosis AtherosclerosisAtherosclerosis ProlapseProlapse
Extraintestinal Manifestations of IBD
SkinErythema nodosumPyoderma gangrenosum
JointsPeripheral arthritisSacroileitisAnkylosing spondylitis
EyeUveitisEpiscleritisIritis
Hepatobiliary complicationsGallstonesPSC
Renal complicationsNephrolithiasisRecurrent UTIs
Educational ObjectivesEducational Objectives Definitions and spectrum of inflammatory Definitions and spectrum of inflammatory
bowel disease (IBD)bowel disease (IBD) Epidemiology of IBDEpidemiology of IBD Etiopathogenesis of IBDEtiopathogenesis of IBD Clinical manifestations of ulcerative colitis Clinical manifestations of ulcerative colitis
(UC)(UC) Clinical manifestations of Crohnrsquos disease (CD)Clinical manifestations of Crohnrsquos disease (CD) Distinguishing features between UC and Distinguishing features between UC and
CDCD Diagnostic approach to IBDDiagnostic approach to IBD Medical management of IBDMedical management of IBD Indications for and role of surgeryIndications for and role of surgery
Symptoms of IBDUC vs CDUC vs CD
FeatureFeature UCUC CDCD
FeverFever UncommonUncommon CommonCommon
Rectal Rectal bleedingbleeding
CommonCommon lt frac12 of lt frac12 of patientspatients
Abdominal Abdominal tendernesstenderness
May be May be presentpresent
CommonCommon
Abdominal Abdominal massmass
UncommonUncommon CommonCommon
Abdominal Abdominal painpain
UncommonUncommon Very commonVery common
Weight lossWeight loss UncommonUncommon CommonCommon
TenesmusTenesmus Very commonVery common UncommonUncommon
UC vs CDUC vs CDComplicationsResponse to ComplicationsResponse to
TreatmentTreatmentUCUC CDCD
FistulasFistulas NoNo YesYes
Small Small intestine intestine obstructionobstruction
NoNo FrequentlyFrequently
Colonic Colonic obstructionobstruction
RarelyRarely FrequentlyFrequently
Response to Response to antibioticantibiotic
NoNo YesYes
Recurrence Recurrence after after surgerysurgery
NoNo YesYes
UC vs CDUC vs CDDifferent endoscopic featuresDifferent endoscopic features
UCUC CDCD
Rectal Rectal sparingsparing
RarelyRarely FrequentlyFrequently
Continuous Continuous diseasedisease
YesYes OccasionallyOccasionally
bdquobdquoCCobblestonobblestoningrdquoingrdquo
NoNo YesYes
Granuloma Granuloma on biopsyon biopsy
NoNo OccasionallyOccasionally
Criteria for Indeterminate Criteria for Indeterminate ColitisColitis
No evidence of No evidence of small bowel small bowel involvement involvement fistula or fistula or perianal diseaseperianal disease
Absence of Absence of diagnostic diagnostic criteria for CD criteria for CD or UC by or UC by microscopymicroscopy
Differential Diagnosis of Differential Diagnosis of Chronic Diarrhea and Weight Chronic Diarrhea and Weight
LossLoss Colonic diseasesColonic diseases
IBDIBD NeoplasiaNeoplasia Ischemic bowelIschemic bowel
PancreaticPancreatic Chronic pancreatitisChronic pancreatitis CancerCancer Cystic fibrosisCystic fibrosis
EnteropathicEnteropathic Celiac diseaseCeliac disease Tropical sprueTropical sprue LymphomaLymphoma Mesenteric ischemiaMesenteric ischemia Whipplersquos diseaseWhipplersquos disease
HormonaldrugsHormonaldrugs VipomaVipoma ZESZES Medullary CA of Medullary CA of
thyroidthyroid NSAIDS useNSAIDS use
Educational ObjectivesEducational Objectives Definitions and spectrum of inflammatory Definitions and spectrum of inflammatory
bowel disease (IBD)bowel disease (IBD) Epidemiology of IBDEpidemiology of IBD Etiopathogenesis of IBDEtiopathogenesis of IBD Clinical manifestations of ulcerative colitis Clinical manifestations of ulcerative colitis
(UC)(UC) Clinical manifestations of Crohnrsquos disease Clinical manifestations of Crohnrsquos disease
(CD)(CD) Distinguishing features between UC and CDDistinguishing features between UC and CD Diagnostic approach to IBDDiagnostic approach to IBD Medical management of IBDMedical management of IBD Indications for and role of surgeryIndications for and role of surgery
Diagnostic Approach to Diagnostic Approach to Patients with Suspected Patients with Suspected
IBDIBD HistoryhelliphelliphistoryhelliphelliphistoryHistoryhelliphelliphistoryhelliphelliphistory Clinical examClinical exam Laboratory testsLaboratory tests Radiological imagingRadiological imaging EndoscopyEndoscopy Special serological testingSpecial serological testing Genetic testingGenetic testing
Diagnosis-LAB Blood test
CD Mild anemia mild leukocytosis elevated ESR elevated CRP positive ASCA
UC Anemia hypokalemia hypoalbuminemia elevated ESR elevated LFTs positive p-ANCA
Stool analysis Many WBCs and or RBCs No ova or parasites
What are the Serological What are the Serological Markers in IBDMarkers in IBD
pANCA (perinuclear staining pattern)pANCA (perinuclear staining pattern) Loss of perinuclear pattern after Loss of perinuclear pattern after
DNAaseDNAase Differentiate from the ldquoother pANCAsrdquoDifferentiate from the ldquoother pANCAsrdquo
Antibody against myeloperoxidaseAntibody against myeloperoxidase Antibody against cathepsin G elastase lysozyme Antibody against cathepsin G elastase lysozyme
and lactoferrinand lactoferrin ASCA (anti-ASCA (anti-Saccharomyces cerevisiaeSaccharomyces cerevisiae))
Both IgG and IgABoth IgG and IgA Recognize mannose in the cell wall Recognize mannose in the cell wall
mannan of mannan of Saccharomyces cerevisiaeSaccharomyces cerevisiae
Why Use Serological Why Use Serological Markers in Clinical Markers in Clinical
PracticePractice Differentiate IBD from functional bowel Differentiate IBD from functional bowel
disordersdisorders Accurately diagnose Crohnrsquos or UC in a patient Accurately diagnose Crohnrsquos or UC in a patient
withwith Severe colitisSevere colitis Indeterminate colitisIndeterminate colitis
Predict disease course or complications in IBDPredict disease course or complications in IBD CD phenotypeCD phenotype Severity of diseaseSeverity of disease Risk of pouchitisRisk of pouchitis
SummarySummary
pANCA and ASCA are specific for UC pANCA and ASCA are specific for UC and CD respectivelyand CD respectively
Neither pANCA nor ASCA are sensitive Neither pANCA nor ASCA are sensitive enough to exclude IBDenough to exclude IBD
In patients with IC available In patients with IC available serological markers do not accurately serological markers do not accurately predict the subsequent disease coursepredict the subsequent disease course
Antibody profiles can predict disease Antibody profiles can predict disease behavior in IBDbehavior in IBD
Diagnostic ApproachDiagnostic ApproachEndoscopyEndoscopy
Endoscopy useful forEndoscopy useful for Initial diagnosisInitial diagnosis Assessment of severityAssessment of severity Tissue diagnosisTissue diagnosis FU during treatmentFU during treatment Assessment of disease exacerbationAssessment of disease exacerbation Surveillance for risk of cancerSurveillance for risk of cancer Treatment of certain complications (eg Treatment of certain complications (eg
strictures)strictures)
Crohnrsquos DiseaseCrohnrsquos DiseaseEndoscopic FeaturesEndoscopic Features
Asymmetric patchy inflammationAsymmetric patchy inflammation Skip lesionsSkip lesions Rectal sparingRectal sparing Ulcerations-deepserpiginousUlcerations-deepserpiginous Cobblestoning-commonCobblestoning-common Pseudopolyps-rarePseudopolyps-rare BiopsyBiopsy
Erosions and normal mucosaErosions and normal mucosa Granulomas in 15 to 35 of specimensGranulomas in 15 to 35 of specimens
Ulcerative ColitisUlcerative ColitisEndoscopic FeaturesEndoscopic Features
Diffuse involvementDiffuse involvement Rectum always diseasedRectum always diseased Superficial ulcerationsSuperficial ulcerations FriabilitybleedingFriabilitybleeding Flatteningdisappearance of haustral Flatteningdisappearance of haustral
foldsfolds PseudopolypsPseudopolyps No cobblestoningNo cobblestoning Bx No granulomasBx No granulomas
Imaging for Crohn Imaging for Crohn DiseaseDisease
Traditional TechniquesTraditional Techniques Abdominal RadiographsAbdominal Radiographs
Barium UGI Barium UGI
Barium small bowel follow throughBarium small bowel follow through
Barium EnteroclysisBarium Enteroclysis
Barium EnemaBarium Enema
Imaging for Crohn Disease Imaging for Crohn Disease Newer TechniquesNewer Techniques
CTCT
CT EnteroclysisCT Enteroclysis
CT EnterographyCT Enterography
Magnetic ResonanceMagnetic Resonance
UltrasoundUltrasound
Nuclear MedicineNuclear Medicine
Imaging for Crohns DiseaseImaging for Crohns Disease SummarySummary
Useful Newer TechniquesUseful Newer Techniques evolvingevolving CT EnterographyCT Enterography
Comprehensive evaluation of all bowel amp solid organsComprehensive evaluation of all bowel amp solid organs
Magnetic ResonanceMagnetic Resonance
Useful for ano-rectal diseaseUseful for ano-rectal disease
Real-time MR has potential for detection of stricturesReal-time MR has potential for detection of strictures
Traditional imaging techniques still of value in Traditional imaging techniques still of value in selected cases selected cases
The Capsule (WCE)The Capsule (WCE)
WCEWCE
bull Diameter 11mm Length 26mmDiameter 11mm Length 26mmbull Optical dome Intestinal illumination Optical dome Intestinal illumination
by white light emitting diodes (LEDrsquos)by white light emitting diodes (LEDrsquos)bull LensLensbull Complementary metal-oxide silicone Complementary metal-oxide silicone
imager (color camera chip)imager (color camera chip)bull TransmitterTransmitterbull Two batteries (silver oxide)Two batteries (silver oxide)
GE Junction Duodenum
Jejunum Ileocecal Valve
Educational ObjectivesEducational Objectives Definitions and spectrum of inflammatory Definitions and spectrum of inflammatory
bowel disease (IBD)bowel disease (IBD) Epidemiology of IBDEpidemiology of IBD Etiopathogenesis of IBDEtiopathogenesis of IBD Clinical manifestations of ulcerative colitis Clinical manifestations of ulcerative colitis
(UC)(UC) Clinical manifestations of Crohnrsquos disease Clinical manifestations of Crohnrsquos disease
(CD)(CD) Distinguishing features between UC and CDDistinguishing features between UC and CD Diagnostic approach to IBDDiagnostic approach to IBD Complications of IBDComplications of IBD IBD managementIBD management
IBD-ComplicationsIBD-Complications GI BleedingGI Bleeding Toxic megacolonToxic megacolon PerforationPerforation Thromboembolic phenomenaThromboembolic phenomena FistulasfissuresFistulasfissures AbscessAbscess StricturesobstructionStricturesobstruction MalabsorptionmalnutritionMalabsorptionmalnutrition CancerCancer
Best Protection
Surveillance colonoscopySurveillance colonoscopy
Procto-colectomy (for UC)Procto-colectomy (for UC)
Descending Colon Descending Colon StrictureStricture
Colonic StricturesColonic Strictures
Consider nonsurgical management Consider nonsurgical management ifif Endoscopically accessibleEndoscopically accessible Multiple prior resectionsMultiple prior resections Shorter strictures (less than 5 cm)Shorter strictures (less than 5 cm) Steroid injection if significant Steroid injection if significant
inflammationinflammation
Fistula DefinitionA communication between two epithelial-lined organsLifetime risk of fistula in CD30
Perianal FistulaPerianal Fistula
Pretreatment 2 Weeks
10 Weeks 18 weeks
Educational ObjectivesEducational Objectives Definitions and spectrum of inflammatory Definitions and spectrum of inflammatory
bowel disease (IBD)bowel disease (IBD) Epidemiology of IBDEpidemiology of IBD Etiopathogenesis of IBDEtiopathogenesis of IBD Clinical manifestations of ulcerative colitis Clinical manifestations of ulcerative colitis
(UC)(UC) Clinical manifestations of Crohnrsquos disease Clinical manifestations of Crohnrsquos disease
(CD)(CD) Distinguishing features between UC and CDDistinguishing features between UC and CD Diagnostic approach to IBDDiagnostic approach to IBD Complications of IBDComplications of IBD IBD managementIBD management
Goals of Therapy for IBDGoals of Therapy for IBD
Inducing remissionInducing remission Maintaining remissionMaintaining remission Restoring and maintaining nutritionRestoring and maintaining nutrition Maintaining patientrsquos quality of lifeMaintaining patientrsquos quality of life Prevention of complicationsPrevention of complications Surgical intervention (selection of Surgical intervention (selection of
optimal time for surgery)optimal time for surgery)
Inductive TherapiesInductive Therapies
For UCFor UC AminosalicylatesAminosalicylates CorticosteroidsCorticosteroids CyclosporinCyclosporin
For CDFor CD AminosalicylatesAminosalicylates CorticosteroidsCorticosteroids AntibioticsAntibiotics Anti-TNFAnti-TNF
Maintenance TherapiesMaintenance Therapies
ImmunosupressorsImmunosupressors AzathioprineAzathioprine 6-MP6-MP MethotrexateMethotrexate
AminosalicylatesAminosalicylates Anti-TNFAnti-TNF
NOT NOT corticosteroidscorticosteroids
IBD ManagementIBD ManagementSummarySummary
There is no ldquoone size fits allrdquo to IBD therapyThere is no ldquoone size fits allrdquo to IBD therapy Therapy and decision making are tailored to the Therapy and decision making are tailored to the
individualindividual
Algorithms are based upon available evidenceAlgorithms are based upon available evidence Evidence is in constant fluxEvidence is in constant flux
Success of algorithms depends upon Success of algorithms depends upon optimization of each step of therapy and optimization of each step of therapy and considerable judgment about each outcomeconsiderable judgment about each outcome Skillful application of medical therapy makes all Skillful application of medical therapy makes all
the difference in outcomesthe difference in outcomes
Surgery for IBDSurgery for IBDGeneral ConceptsGeneral Concepts
Majority will need surgery 78 over Majority will need surgery 78 over twenty yearstwenty years
Surgery generally indicated for Surgery generally indicated for complicationscomplications of disease of disease
Surgery must be directed at area of Surgery must be directed at area of bowel responsible for complicationbowel responsible for complication
Indications for SurgeryIndications for Surgery Intestinal obstruction (most Intestinal obstruction (most
common)common) Intractabilitysteroid Intractabilitysteroid
dependencedependence Non-healing fistulaAbscessNon-healing fistulaAbscess Toxic megacolonFree Toxic megacolonFree
perforationperforation Uncontrollable GI bleedingUncontrollable GI bleeding Severe perianal diseaseSevere perianal disease CancerCancer Growth retardation Growth retardation
(children)(children) Severe uncontrollable Severe uncontrollable
extraintestinal extraintestinal manifestationsmanifestations
Management of IBDSummary
The goals of therapy are Relieve symptoms Prevent relapse Correct nutritional deficiencies Control inflammation Prevent complications especially colon cancer
Treatment depends on 1048707 Type of disease 1048707 Site of disease 1048707 Disease severity
Treatment may include drugs nutrition supplements surgery or a combination of these options
IBD include a group of chronic relapsing disorders that cause inflammation or ulceration in the small andor large intestines IBD is classified as
Ulcerative colitis (UC)- causes ulceration and inflammation of the mucosa of the colon and rectum
Crohns disease (CD) - an inflammation that extends into the deeper layers of the intestinal wall and also may affect other parts or layers of the digestive tract including the mouth esophagus stomach and small intestine
Inflammatory Bowel Disease
Educational ObjectivesEducational Objectives Definitions and spectrum of inflammatory Definitions and spectrum of inflammatory
bowel disease (IBD)bowel disease (IBD) Epidemiology of IBDEpidemiology of IBD Etiopathogenesis of IBDEtiopathogenesis of IBD Clinical manifestations of ulcerative colitis Clinical manifestations of ulcerative colitis
(UC)(UC) Clinical manifestations of Crohnrsquos disease Clinical manifestations of Crohnrsquos disease
(CD)(CD) Distinguishing features between UC and CDDistinguishing features between UC and CD Diagnostic approach to IBDDiagnostic approach to IBD Complications of IBDComplications of IBD IBD managementIBD management
Epidemiology of IBDEpidemiology of IBD
Ulcerative Ulcerative colitiscolitis
Crohnrsquos Crohnrsquos diseasedisease
Incidence (US)Incidence (US) 11100 00011100 000 7100 0007100 000Age of onsetAge of onset 15-30 amp 60-15-30 amp 60-
808015-30 amp 60-15-30 amp 60-8080
Malefemale Malefemale ratioratio
1111 11-18111-181
SmokingSmoking May prevent May prevent diseasedisease
May cause May cause diseasedisease
Oral Oral contraceptivecontraceptive
No increased No increased riskrisk
Relative risk Relative risk 1919
AppendectomyAppendectomy Not Not protectiveprotective
ProtectiveProtective
Monozygotic Monozygotic twinstwins
8 8 concordanceconcordance
67 67 concordanceconcordance
High
Medium
Low
Educational ObjectivesEducational Objectives Definitions and spectrum of inflammatory Definitions and spectrum of inflammatory
bowel disease (IBD)bowel disease (IBD) Epidemiology of IBDEpidemiology of IBD Etiopathogenesis of IBDEtiopathogenesis of IBD Clinical manifestations of ulcerative colitis Clinical manifestations of ulcerative colitis
(UC)(UC) Clinical manifestations of Crohnrsquos disease Clinical manifestations of Crohnrsquos disease
(CD)(CD) Distinguishing features between UC and CDDistinguishing features between UC and CD Diagnostic approach to IBDDiagnostic approach to IBD Complications of IBDComplications of IBD IBD managementIBD management
NatureNature NurtureNurture
IBDIBD
GenesGenes EnvironmentEnvironment
Educational ObjectivesEducational Objectives Definitions and spectrum of inflammatory Definitions and spectrum of inflammatory
bowel disease (IBD)bowel disease (IBD) Epidemiology of IBDEpidemiology of IBD Etiopathogenesis of IBDEtiopathogenesis of IBD Clinical manifestations of ulcerative Clinical manifestations of ulcerative
colitis (UC)colitis (UC) Clinical manifestations of Crohnrsquos disease Clinical manifestations of Crohnrsquos disease
(CD)(CD) Distinguishing features between UC and CDDistinguishing features between UC and CD Diagnostic approach to IBDDiagnostic approach to IBD Complications of IBDComplications of IBD IBD managementIBD management
Ulcerative Ulcerative CColitis ndash clinical olitis ndash clinical presentationpresentation
Patients with Patients with proctitisproctitis usually pass fresh blood usually pass fresh blood or blood-stained mucus either mixed with stool or blood-stained mucus either mixed with stool or streaked onto the surface of normal or hard or streaked onto the surface of normal or hard stoolstool tenesmustenesmus is a feature is a feature
When the disease extends When the disease extends beyond the rectumbeyond the rectum blood is usually mixed with stool or grossly blood is usually mixed with stool or grossly bloody diarrhea may be notedbloody diarrhea may be noted
When the disease is When the disease is severesevere patients pass a patients pass a liquid stool containing blood pus fecal matterliquid stool containing blood pus fecal matter
Other symptoms in moderate to severe disease Other symptoms in moderate to severe disease include anorexia nausea vomitting fever include anorexia nausea vomitting fever abdominal pain abdominal pain weight lossweight loss
Ulcerative colitis ndash Ulcerative colitis ndash macroscopic featuresmacroscopic features
Mucosa isMucosa is
- erythematous has a granular surface that looks - erythematous has a granular surface that looks like a sand paperlike a sand paper
In more severe diseasesIn more severe diseases
- hemorrhagic edematous and ulcerated- hemorrhagic edematous and ulcerated
In fulminant diseaseIn fulminant disease a toxic colitis or a toxic a toxic colitis or a toxic megacolon may develop ( wall becomemegacolon may develop ( wall becomess very thin very thin and mucosa is severand mucosa is severeely ulcerated)ly ulcerated)
UCUCDisease Distribution at Disease Distribution at
PresentationPresentation
4637
17
UC ndash disease UC ndash disease severityseverity
MILDMILD MODERATMODERATEE
SEVERESEVERE
BOWEL BOWEL MOVEMENTSMOVEMENTS lt 4 per lt 4 per
dayday 4-6 per 4-6 per dayday
gt6 per gt6 per dayday
BLOOD IN BLOOD IN STOOLSTOOL smallsmall moderatemoderate SevereSevere
FEVERFEVER nonenone lt375lt375degdegC C gt 375gt 375degdegC C
TACHYCARDITACHYCARDIAA
nonenone lt90 mean lt90 mean pulsepulse
gt90 mean gt90 mean pulsepulse
UC ndash disease UC ndash disease severityseverity
MILDMILD MODERATMODERATEE
SEVERESEVERE
ANEMIAANEMIA mildmild gt75gt75 lt75lt75
ESRESR lt30mmlt30mm gt30mmgt30mm
ENDOSCOPIC ENDOSCOPIC APPEARANCEAPPEARANCE
Erythema Erythema decreased decreased vascular vascular pattern fine pattern fine granularitygranularity
Marked Marked erythema erythema coarse coarse granularity granularity contact contact bleeding no bleeding no ulcerationulceration
Spontaneous Spontaneous bleeding bleeding ulcerationulceration
Educational ObjectivesEducational Objectives Definitions and spectrum of inflammatory Definitions and spectrum of inflammatory
bowel disease (IBD)bowel disease (IBD) Epidemiology of IBDEpidemiology of IBD Etiopathogenesis of IBDEtiopathogenesis of IBD Clinical manifestations of ulcerative colitis Clinical manifestations of ulcerative colitis
(UC)(UC) Clinical manifestations of Crohnrsquos disease Clinical manifestations of Crohnrsquos disease
(CD)(CD) Distinguishing features between UC and Distinguishing features between UC and
CDCD Diagnostic approach to IBDDiagnostic approach to IBD Complications of IBDComplications of IBD IBD managementIBD management
CD Clinical FeaturesCD Clinical Features
Abdominal pain often postprandialAbdominal pain often postprandial Diarrhea usually wateryDiarrhea usually watery Rectal bleedingRectal bleeding Weight lossWeight loss Right lower quadrant painpalpable Right lower quadrant painpalpable
massmass FeverFever Growth retardation in childrenGrowth retardation in children Perirectal fistulaPerirectal fistula
Crohnrsquos disease ndash macroscopic Crohnrsquos disease ndash macroscopic featuresfeatures
Can affect any part of GI tract from the mouth to the Can affect any part of GI tract from the mouth to the anusanus
30-40 of patients have small bowel disease alone30-40 of patients have small bowel disease alone
40-55 of patients have both small and large 40-55 of patients have both small and large intestines diseaseintestines disease
15-25 of patients have colitis alone15-25 of patients have colitis alone
In 75 of patients with small intestinal disease the In 75 of patients with small intestinal disease the terminal ileum in involved in 90terminal ileum in involved in 90
Crohnrsquos DiseaseCrohnrsquos DiseaseAnatomic DistributionAnatomic Distribution
Small bowelSmall bowelalonealone(33)(33)
IleocolicIleocolic(45)(45)
Colon aloneColon alone(20)(20)
Frequency of involvementFrequency of involvement
MostMost LeastLeast
Crohnrsquos disease ndash macroscopic Crohnrsquos disease ndash macroscopic featuresfeatures
CD is a CD is a transmuraltransmural process process
CD is CD is segmentalsegmental with skip areas in with skip areas in the midst of diseased intestinethe midst of diseased intestine
In one third of patients with CD In one third of patients with CD perirectal fistulas fissures perirectal fistulas fissures abscesses anal stenosis are presentabscesses anal stenosis are present
Crohnrsquos disease ndash macroscopic Crohnrsquos disease ndash macroscopic featuresfeatures
Active CD is characterized by focal Active CD is characterized by focal inflammation and formation of fistula inflammation and formation of fistula tractstracts
The bowel wall thickens and becomes The bowel wall thickens and becomes narrowed and fibrotic leading to narrowed and fibrotic leading to chronic recurrent bowel obstructionchronic recurrent bowel obstruction
Crohnrsquos Disease Activity Index(CDAI)
Incorporates 8 variables 1 liquid or very soft stools day 2 Abdominal pain amp cramping 3 Extraintestinal manifestations 4 Complications 5 Abdominal mass 6 Use of anti diarrheal medications anti- 7 Hematocrit 8 Body weight
Crohnrsquos Disease Red Crohnrsquos Disease Red FlagsFlags
Onset after stopping smokingOnset after stopping smoking Bleeding onlyBleeding only DiverticulosisDiverticulosis AtherosclerosisAtherosclerosis ProlapseProlapse
Extraintestinal Manifestations of IBD
SkinErythema nodosumPyoderma gangrenosum
JointsPeripheral arthritisSacroileitisAnkylosing spondylitis
EyeUveitisEpiscleritisIritis
Hepatobiliary complicationsGallstonesPSC
Renal complicationsNephrolithiasisRecurrent UTIs
Educational ObjectivesEducational Objectives Definitions and spectrum of inflammatory Definitions and spectrum of inflammatory
bowel disease (IBD)bowel disease (IBD) Epidemiology of IBDEpidemiology of IBD Etiopathogenesis of IBDEtiopathogenesis of IBD Clinical manifestations of ulcerative colitis Clinical manifestations of ulcerative colitis
(UC)(UC) Clinical manifestations of Crohnrsquos disease (CD)Clinical manifestations of Crohnrsquos disease (CD) Distinguishing features between UC and Distinguishing features between UC and
CDCD Diagnostic approach to IBDDiagnostic approach to IBD Medical management of IBDMedical management of IBD Indications for and role of surgeryIndications for and role of surgery
Symptoms of IBDUC vs CDUC vs CD
FeatureFeature UCUC CDCD
FeverFever UncommonUncommon CommonCommon
Rectal Rectal bleedingbleeding
CommonCommon lt frac12 of lt frac12 of patientspatients
Abdominal Abdominal tendernesstenderness
May be May be presentpresent
CommonCommon
Abdominal Abdominal massmass
UncommonUncommon CommonCommon
Abdominal Abdominal painpain
UncommonUncommon Very commonVery common
Weight lossWeight loss UncommonUncommon CommonCommon
TenesmusTenesmus Very commonVery common UncommonUncommon
UC vs CDUC vs CDComplicationsResponse to ComplicationsResponse to
TreatmentTreatmentUCUC CDCD
FistulasFistulas NoNo YesYes
Small Small intestine intestine obstructionobstruction
NoNo FrequentlyFrequently
Colonic Colonic obstructionobstruction
RarelyRarely FrequentlyFrequently
Response to Response to antibioticantibiotic
NoNo YesYes
Recurrence Recurrence after after surgerysurgery
NoNo YesYes
UC vs CDUC vs CDDifferent endoscopic featuresDifferent endoscopic features
UCUC CDCD
Rectal Rectal sparingsparing
RarelyRarely FrequentlyFrequently
Continuous Continuous diseasedisease
YesYes OccasionallyOccasionally
bdquobdquoCCobblestonobblestoningrdquoingrdquo
NoNo YesYes
Granuloma Granuloma on biopsyon biopsy
NoNo OccasionallyOccasionally
Criteria for Indeterminate Criteria for Indeterminate ColitisColitis
No evidence of No evidence of small bowel small bowel involvement involvement fistula or fistula or perianal diseaseperianal disease
Absence of Absence of diagnostic diagnostic criteria for CD criteria for CD or UC by or UC by microscopymicroscopy
Differential Diagnosis of Differential Diagnosis of Chronic Diarrhea and Weight Chronic Diarrhea and Weight
LossLoss Colonic diseasesColonic diseases
IBDIBD NeoplasiaNeoplasia Ischemic bowelIschemic bowel
PancreaticPancreatic Chronic pancreatitisChronic pancreatitis CancerCancer Cystic fibrosisCystic fibrosis
EnteropathicEnteropathic Celiac diseaseCeliac disease Tropical sprueTropical sprue LymphomaLymphoma Mesenteric ischemiaMesenteric ischemia Whipplersquos diseaseWhipplersquos disease
HormonaldrugsHormonaldrugs VipomaVipoma ZESZES Medullary CA of Medullary CA of
thyroidthyroid NSAIDS useNSAIDS use
Educational ObjectivesEducational Objectives Definitions and spectrum of inflammatory Definitions and spectrum of inflammatory
bowel disease (IBD)bowel disease (IBD) Epidemiology of IBDEpidemiology of IBD Etiopathogenesis of IBDEtiopathogenesis of IBD Clinical manifestations of ulcerative colitis Clinical manifestations of ulcerative colitis
(UC)(UC) Clinical manifestations of Crohnrsquos disease Clinical manifestations of Crohnrsquos disease
(CD)(CD) Distinguishing features between UC and CDDistinguishing features between UC and CD Diagnostic approach to IBDDiagnostic approach to IBD Medical management of IBDMedical management of IBD Indications for and role of surgeryIndications for and role of surgery
Diagnostic Approach to Diagnostic Approach to Patients with Suspected Patients with Suspected
IBDIBD HistoryhelliphelliphistoryhelliphelliphistoryHistoryhelliphelliphistoryhelliphelliphistory Clinical examClinical exam Laboratory testsLaboratory tests Radiological imagingRadiological imaging EndoscopyEndoscopy Special serological testingSpecial serological testing Genetic testingGenetic testing
Diagnosis-LAB Blood test
CD Mild anemia mild leukocytosis elevated ESR elevated CRP positive ASCA
UC Anemia hypokalemia hypoalbuminemia elevated ESR elevated LFTs positive p-ANCA
Stool analysis Many WBCs and or RBCs No ova or parasites
What are the Serological What are the Serological Markers in IBDMarkers in IBD
pANCA (perinuclear staining pattern)pANCA (perinuclear staining pattern) Loss of perinuclear pattern after Loss of perinuclear pattern after
DNAaseDNAase Differentiate from the ldquoother pANCAsrdquoDifferentiate from the ldquoother pANCAsrdquo
Antibody against myeloperoxidaseAntibody against myeloperoxidase Antibody against cathepsin G elastase lysozyme Antibody against cathepsin G elastase lysozyme
and lactoferrinand lactoferrin ASCA (anti-ASCA (anti-Saccharomyces cerevisiaeSaccharomyces cerevisiae))
Both IgG and IgABoth IgG and IgA Recognize mannose in the cell wall Recognize mannose in the cell wall
mannan of mannan of Saccharomyces cerevisiaeSaccharomyces cerevisiae
Why Use Serological Why Use Serological Markers in Clinical Markers in Clinical
PracticePractice Differentiate IBD from functional bowel Differentiate IBD from functional bowel
disordersdisorders Accurately diagnose Crohnrsquos or UC in a patient Accurately diagnose Crohnrsquos or UC in a patient
withwith Severe colitisSevere colitis Indeterminate colitisIndeterminate colitis
Predict disease course or complications in IBDPredict disease course or complications in IBD CD phenotypeCD phenotype Severity of diseaseSeverity of disease Risk of pouchitisRisk of pouchitis
SummarySummary
pANCA and ASCA are specific for UC pANCA and ASCA are specific for UC and CD respectivelyand CD respectively
Neither pANCA nor ASCA are sensitive Neither pANCA nor ASCA are sensitive enough to exclude IBDenough to exclude IBD
In patients with IC available In patients with IC available serological markers do not accurately serological markers do not accurately predict the subsequent disease coursepredict the subsequent disease course
Antibody profiles can predict disease Antibody profiles can predict disease behavior in IBDbehavior in IBD
Diagnostic ApproachDiagnostic ApproachEndoscopyEndoscopy
Endoscopy useful forEndoscopy useful for Initial diagnosisInitial diagnosis Assessment of severityAssessment of severity Tissue diagnosisTissue diagnosis FU during treatmentFU during treatment Assessment of disease exacerbationAssessment of disease exacerbation Surveillance for risk of cancerSurveillance for risk of cancer Treatment of certain complications (eg Treatment of certain complications (eg
strictures)strictures)
Crohnrsquos DiseaseCrohnrsquos DiseaseEndoscopic FeaturesEndoscopic Features
Asymmetric patchy inflammationAsymmetric patchy inflammation Skip lesionsSkip lesions Rectal sparingRectal sparing Ulcerations-deepserpiginousUlcerations-deepserpiginous Cobblestoning-commonCobblestoning-common Pseudopolyps-rarePseudopolyps-rare BiopsyBiopsy
Erosions and normal mucosaErosions and normal mucosa Granulomas in 15 to 35 of specimensGranulomas in 15 to 35 of specimens
Ulcerative ColitisUlcerative ColitisEndoscopic FeaturesEndoscopic Features
Diffuse involvementDiffuse involvement Rectum always diseasedRectum always diseased Superficial ulcerationsSuperficial ulcerations FriabilitybleedingFriabilitybleeding Flatteningdisappearance of haustral Flatteningdisappearance of haustral
foldsfolds PseudopolypsPseudopolyps No cobblestoningNo cobblestoning Bx No granulomasBx No granulomas
Imaging for Crohn Imaging for Crohn DiseaseDisease
Traditional TechniquesTraditional Techniques Abdominal RadiographsAbdominal Radiographs
Barium UGI Barium UGI
Barium small bowel follow throughBarium small bowel follow through
Barium EnteroclysisBarium Enteroclysis
Barium EnemaBarium Enema
Imaging for Crohn Disease Imaging for Crohn Disease Newer TechniquesNewer Techniques
CTCT
CT EnteroclysisCT Enteroclysis
CT EnterographyCT Enterography
Magnetic ResonanceMagnetic Resonance
UltrasoundUltrasound
Nuclear MedicineNuclear Medicine
Imaging for Crohns DiseaseImaging for Crohns Disease SummarySummary
Useful Newer TechniquesUseful Newer Techniques evolvingevolving CT EnterographyCT Enterography
Comprehensive evaluation of all bowel amp solid organsComprehensive evaluation of all bowel amp solid organs
Magnetic ResonanceMagnetic Resonance
Useful for ano-rectal diseaseUseful for ano-rectal disease
Real-time MR has potential for detection of stricturesReal-time MR has potential for detection of strictures
Traditional imaging techniques still of value in Traditional imaging techniques still of value in selected cases selected cases
The Capsule (WCE)The Capsule (WCE)
WCEWCE
bull Diameter 11mm Length 26mmDiameter 11mm Length 26mmbull Optical dome Intestinal illumination Optical dome Intestinal illumination
by white light emitting diodes (LEDrsquos)by white light emitting diodes (LEDrsquos)bull LensLensbull Complementary metal-oxide silicone Complementary metal-oxide silicone
imager (color camera chip)imager (color camera chip)bull TransmitterTransmitterbull Two batteries (silver oxide)Two batteries (silver oxide)
GE Junction Duodenum
Jejunum Ileocecal Valve
Educational ObjectivesEducational Objectives Definitions and spectrum of inflammatory Definitions and spectrum of inflammatory
bowel disease (IBD)bowel disease (IBD) Epidemiology of IBDEpidemiology of IBD Etiopathogenesis of IBDEtiopathogenesis of IBD Clinical manifestations of ulcerative colitis Clinical manifestations of ulcerative colitis
(UC)(UC) Clinical manifestations of Crohnrsquos disease Clinical manifestations of Crohnrsquos disease
(CD)(CD) Distinguishing features between UC and CDDistinguishing features between UC and CD Diagnostic approach to IBDDiagnostic approach to IBD Complications of IBDComplications of IBD IBD managementIBD management
IBD-ComplicationsIBD-Complications GI BleedingGI Bleeding Toxic megacolonToxic megacolon PerforationPerforation Thromboembolic phenomenaThromboembolic phenomena FistulasfissuresFistulasfissures AbscessAbscess StricturesobstructionStricturesobstruction MalabsorptionmalnutritionMalabsorptionmalnutrition CancerCancer
Best Protection
Surveillance colonoscopySurveillance colonoscopy
Procto-colectomy (for UC)Procto-colectomy (for UC)
Descending Colon Descending Colon StrictureStricture
Colonic StricturesColonic Strictures
Consider nonsurgical management Consider nonsurgical management ifif Endoscopically accessibleEndoscopically accessible Multiple prior resectionsMultiple prior resections Shorter strictures (less than 5 cm)Shorter strictures (less than 5 cm) Steroid injection if significant Steroid injection if significant
inflammationinflammation
Fistula DefinitionA communication between two epithelial-lined organsLifetime risk of fistula in CD30
Perianal FistulaPerianal Fistula
Pretreatment 2 Weeks
10 Weeks 18 weeks
Educational ObjectivesEducational Objectives Definitions and spectrum of inflammatory Definitions and spectrum of inflammatory
bowel disease (IBD)bowel disease (IBD) Epidemiology of IBDEpidemiology of IBD Etiopathogenesis of IBDEtiopathogenesis of IBD Clinical manifestations of ulcerative colitis Clinical manifestations of ulcerative colitis
(UC)(UC) Clinical manifestations of Crohnrsquos disease Clinical manifestations of Crohnrsquos disease
(CD)(CD) Distinguishing features between UC and CDDistinguishing features between UC and CD Diagnostic approach to IBDDiagnostic approach to IBD Complications of IBDComplications of IBD IBD managementIBD management
Goals of Therapy for IBDGoals of Therapy for IBD
Inducing remissionInducing remission Maintaining remissionMaintaining remission Restoring and maintaining nutritionRestoring and maintaining nutrition Maintaining patientrsquos quality of lifeMaintaining patientrsquos quality of life Prevention of complicationsPrevention of complications Surgical intervention (selection of Surgical intervention (selection of
optimal time for surgery)optimal time for surgery)
Inductive TherapiesInductive Therapies
For UCFor UC AminosalicylatesAminosalicylates CorticosteroidsCorticosteroids CyclosporinCyclosporin
For CDFor CD AminosalicylatesAminosalicylates CorticosteroidsCorticosteroids AntibioticsAntibiotics Anti-TNFAnti-TNF
Maintenance TherapiesMaintenance Therapies
ImmunosupressorsImmunosupressors AzathioprineAzathioprine 6-MP6-MP MethotrexateMethotrexate
AminosalicylatesAminosalicylates Anti-TNFAnti-TNF
NOT NOT corticosteroidscorticosteroids
IBD ManagementIBD ManagementSummarySummary
There is no ldquoone size fits allrdquo to IBD therapyThere is no ldquoone size fits allrdquo to IBD therapy Therapy and decision making are tailored to the Therapy and decision making are tailored to the
individualindividual
Algorithms are based upon available evidenceAlgorithms are based upon available evidence Evidence is in constant fluxEvidence is in constant flux
Success of algorithms depends upon Success of algorithms depends upon optimization of each step of therapy and optimization of each step of therapy and considerable judgment about each outcomeconsiderable judgment about each outcome Skillful application of medical therapy makes all Skillful application of medical therapy makes all
the difference in outcomesthe difference in outcomes
Surgery for IBDSurgery for IBDGeneral ConceptsGeneral Concepts
Majority will need surgery 78 over Majority will need surgery 78 over twenty yearstwenty years
Surgery generally indicated for Surgery generally indicated for complicationscomplications of disease of disease
Surgery must be directed at area of Surgery must be directed at area of bowel responsible for complicationbowel responsible for complication
Indications for SurgeryIndications for Surgery Intestinal obstruction (most Intestinal obstruction (most
common)common) Intractabilitysteroid Intractabilitysteroid
dependencedependence Non-healing fistulaAbscessNon-healing fistulaAbscess Toxic megacolonFree Toxic megacolonFree
perforationperforation Uncontrollable GI bleedingUncontrollable GI bleeding Severe perianal diseaseSevere perianal disease CancerCancer Growth retardation Growth retardation
(children)(children) Severe uncontrollable Severe uncontrollable
extraintestinal extraintestinal manifestationsmanifestations
Management of IBDSummary
The goals of therapy are Relieve symptoms Prevent relapse Correct nutritional deficiencies Control inflammation Prevent complications especially colon cancer
Treatment depends on 1048707 Type of disease 1048707 Site of disease 1048707 Disease severity
Treatment may include drugs nutrition supplements surgery or a combination of these options
Educational ObjectivesEducational Objectives Definitions and spectrum of inflammatory Definitions and spectrum of inflammatory
bowel disease (IBD)bowel disease (IBD) Epidemiology of IBDEpidemiology of IBD Etiopathogenesis of IBDEtiopathogenesis of IBD Clinical manifestations of ulcerative colitis Clinical manifestations of ulcerative colitis
(UC)(UC) Clinical manifestations of Crohnrsquos disease Clinical manifestations of Crohnrsquos disease
(CD)(CD) Distinguishing features between UC and CDDistinguishing features between UC and CD Diagnostic approach to IBDDiagnostic approach to IBD Complications of IBDComplications of IBD IBD managementIBD management
Epidemiology of IBDEpidemiology of IBD
Ulcerative Ulcerative colitiscolitis
Crohnrsquos Crohnrsquos diseasedisease
Incidence (US)Incidence (US) 11100 00011100 000 7100 0007100 000Age of onsetAge of onset 15-30 amp 60-15-30 amp 60-
808015-30 amp 60-15-30 amp 60-8080
Malefemale Malefemale ratioratio
1111 11-18111-181
SmokingSmoking May prevent May prevent diseasedisease
May cause May cause diseasedisease
Oral Oral contraceptivecontraceptive
No increased No increased riskrisk
Relative risk Relative risk 1919
AppendectomyAppendectomy Not Not protectiveprotective
ProtectiveProtective
Monozygotic Monozygotic twinstwins
8 8 concordanceconcordance
67 67 concordanceconcordance
High
Medium
Low
Educational ObjectivesEducational Objectives Definitions and spectrum of inflammatory Definitions and spectrum of inflammatory
bowel disease (IBD)bowel disease (IBD) Epidemiology of IBDEpidemiology of IBD Etiopathogenesis of IBDEtiopathogenesis of IBD Clinical manifestations of ulcerative colitis Clinical manifestations of ulcerative colitis
(UC)(UC) Clinical manifestations of Crohnrsquos disease Clinical manifestations of Crohnrsquos disease
(CD)(CD) Distinguishing features between UC and CDDistinguishing features between UC and CD Diagnostic approach to IBDDiagnostic approach to IBD Complications of IBDComplications of IBD IBD managementIBD management
NatureNature NurtureNurture
IBDIBD
GenesGenes EnvironmentEnvironment
Educational ObjectivesEducational Objectives Definitions and spectrum of inflammatory Definitions and spectrum of inflammatory
bowel disease (IBD)bowel disease (IBD) Epidemiology of IBDEpidemiology of IBD Etiopathogenesis of IBDEtiopathogenesis of IBD Clinical manifestations of ulcerative Clinical manifestations of ulcerative
colitis (UC)colitis (UC) Clinical manifestations of Crohnrsquos disease Clinical manifestations of Crohnrsquos disease
(CD)(CD) Distinguishing features between UC and CDDistinguishing features between UC and CD Diagnostic approach to IBDDiagnostic approach to IBD Complications of IBDComplications of IBD IBD managementIBD management
Ulcerative Ulcerative CColitis ndash clinical olitis ndash clinical presentationpresentation
Patients with Patients with proctitisproctitis usually pass fresh blood usually pass fresh blood or blood-stained mucus either mixed with stool or blood-stained mucus either mixed with stool or streaked onto the surface of normal or hard or streaked onto the surface of normal or hard stoolstool tenesmustenesmus is a feature is a feature
When the disease extends When the disease extends beyond the rectumbeyond the rectum blood is usually mixed with stool or grossly blood is usually mixed with stool or grossly bloody diarrhea may be notedbloody diarrhea may be noted
When the disease is When the disease is severesevere patients pass a patients pass a liquid stool containing blood pus fecal matterliquid stool containing blood pus fecal matter
Other symptoms in moderate to severe disease Other symptoms in moderate to severe disease include anorexia nausea vomitting fever include anorexia nausea vomitting fever abdominal pain abdominal pain weight lossweight loss
Ulcerative colitis ndash Ulcerative colitis ndash macroscopic featuresmacroscopic features
Mucosa isMucosa is
- erythematous has a granular surface that looks - erythematous has a granular surface that looks like a sand paperlike a sand paper
In more severe diseasesIn more severe diseases
- hemorrhagic edematous and ulcerated- hemorrhagic edematous and ulcerated
In fulminant diseaseIn fulminant disease a toxic colitis or a toxic a toxic colitis or a toxic megacolon may develop ( wall becomemegacolon may develop ( wall becomess very thin very thin and mucosa is severand mucosa is severeely ulcerated)ly ulcerated)
UCUCDisease Distribution at Disease Distribution at
PresentationPresentation
4637
17
UC ndash disease UC ndash disease severityseverity
MILDMILD MODERATMODERATEE
SEVERESEVERE
BOWEL BOWEL MOVEMENTSMOVEMENTS lt 4 per lt 4 per
dayday 4-6 per 4-6 per dayday
gt6 per gt6 per dayday
BLOOD IN BLOOD IN STOOLSTOOL smallsmall moderatemoderate SevereSevere
FEVERFEVER nonenone lt375lt375degdegC C gt 375gt 375degdegC C
TACHYCARDITACHYCARDIAA
nonenone lt90 mean lt90 mean pulsepulse
gt90 mean gt90 mean pulsepulse
UC ndash disease UC ndash disease severityseverity
MILDMILD MODERATMODERATEE
SEVERESEVERE
ANEMIAANEMIA mildmild gt75gt75 lt75lt75
ESRESR lt30mmlt30mm gt30mmgt30mm
ENDOSCOPIC ENDOSCOPIC APPEARANCEAPPEARANCE
Erythema Erythema decreased decreased vascular vascular pattern fine pattern fine granularitygranularity
Marked Marked erythema erythema coarse coarse granularity granularity contact contact bleeding no bleeding no ulcerationulceration
Spontaneous Spontaneous bleeding bleeding ulcerationulceration
Educational ObjectivesEducational Objectives Definitions and spectrum of inflammatory Definitions and spectrum of inflammatory
bowel disease (IBD)bowel disease (IBD) Epidemiology of IBDEpidemiology of IBD Etiopathogenesis of IBDEtiopathogenesis of IBD Clinical manifestations of ulcerative colitis Clinical manifestations of ulcerative colitis
(UC)(UC) Clinical manifestations of Crohnrsquos disease Clinical manifestations of Crohnrsquos disease
(CD)(CD) Distinguishing features between UC and Distinguishing features between UC and
CDCD Diagnostic approach to IBDDiagnostic approach to IBD Complications of IBDComplications of IBD IBD managementIBD management
CD Clinical FeaturesCD Clinical Features
Abdominal pain often postprandialAbdominal pain often postprandial Diarrhea usually wateryDiarrhea usually watery Rectal bleedingRectal bleeding Weight lossWeight loss Right lower quadrant painpalpable Right lower quadrant painpalpable
massmass FeverFever Growth retardation in childrenGrowth retardation in children Perirectal fistulaPerirectal fistula
Crohnrsquos disease ndash macroscopic Crohnrsquos disease ndash macroscopic featuresfeatures
Can affect any part of GI tract from the mouth to the Can affect any part of GI tract from the mouth to the anusanus
30-40 of patients have small bowel disease alone30-40 of patients have small bowel disease alone
40-55 of patients have both small and large 40-55 of patients have both small and large intestines diseaseintestines disease
15-25 of patients have colitis alone15-25 of patients have colitis alone
In 75 of patients with small intestinal disease the In 75 of patients with small intestinal disease the terminal ileum in involved in 90terminal ileum in involved in 90
Crohnrsquos DiseaseCrohnrsquos DiseaseAnatomic DistributionAnatomic Distribution
Small bowelSmall bowelalonealone(33)(33)
IleocolicIleocolic(45)(45)
Colon aloneColon alone(20)(20)
Frequency of involvementFrequency of involvement
MostMost LeastLeast
Crohnrsquos disease ndash macroscopic Crohnrsquos disease ndash macroscopic featuresfeatures
CD is a CD is a transmuraltransmural process process
CD is CD is segmentalsegmental with skip areas in with skip areas in the midst of diseased intestinethe midst of diseased intestine
In one third of patients with CD In one third of patients with CD perirectal fistulas fissures perirectal fistulas fissures abscesses anal stenosis are presentabscesses anal stenosis are present
Crohnrsquos disease ndash macroscopic Crohnrsquos disease ndash macroscopic featuresfeatures
Active CD is characterized by focal Active CD is characterized by focal inflammation and formation of fistula inflammation and formation of fistula tractstracts
The bowel wall thickens and becomes The bowel wall thickens and becomes narrowed and fibrotic leading to narrowed and fibrotic leading to chronic recurrent bowel obstructionchronic recurrent bowel obstruction
Crohnrsquos Disease Activity Index(CDAI)
Incorporates 8 variables 1 liquid or very soft stools day 2 Abdominal pain amp cramping 3 Extraintestinal manifestations 4 Complications 5 Abdominal mass 6 Use of anti diarrheal medications anti- 7 Hematocrit 8 Body weight
Crohnrsquos Disease Red Crohnrsquos Disease Red FlagsFlags
Onset after stopping smokingOnset after stopping smoking Bleeding onlyBleeding only DiverticulosisDiverticulosis AtherosclerosisAtherosclerosis ProlapseProlapse
Extraintestinal Manifestations of IBD
SkinErythema nodosumPyoderma gangrenosum
JointsPeripheral arthritisSacroileitisAnkylosing spondylitis
EyeUveitisEpiscleritisIritis
Hepatobiliary complicationsGallstonesPSC
Renal complicationsNephrolithiasisRecurrent UTIs
Educational ObjectivesEducational Objectives Definitions and spectrum of inflammatory Definitions and spectrum of inflammatory
bowel disease (IBD)bowel disease (IBD) Epidemiology of IBDEpidemiology of IBD Etiopathogenesis of IBDEtiopathogenesis of IBD Clinical manifestations of ulcerative colitis Clinical manifestations of ulcerative colitis
(UC)(UC) Clinical manifestations of Crohnrsquos disease (CD)Clinical manifestations of Crohnrsquos disease (CD) Distinguishing features between UC and Distinguishing features between UC and
CDCD Diagnostic approach to IBDDiagnostic approach to IBD Medical management of IBDMedical management of IBD Indications for and role of surgeryIndications for and role of surgery
Symptoms of IBDUC vs CDUC vs CD
FeatureFeature UCUC CDCD
FeverFever UncommonUncommon CommonCommon
Rectal Rectal bleedingbleeding
CommonCommon lt frac12 of lt frac12 of patientspatients
Abdominal Abdominal tendernesstenderness
May be May be presentpresent
CommonCommon
Abdominal Abdominal massmass
UncommonUncommon CommonCommon
Abdominal Abdominal painpain
UncommonUncommon Very commonVery common
Weight lossWeight loss UncommonUncommon CommonCommon
TenesmusTenesmus Very commonVery common UncommonUncommon
UC vs CDUC vs CDComplicationsResponse to ComplicationsResponse to
TreatmentTreatmentUCUC CDCD
FistulasFistulas NoNo YesYes
Small Small intestine intestine obstructionobstruction
NoNo FrequentlyFrequently
Colonic Colonic obstructionobstruction
RarelyRarely FrequentlyFrequently
Response to Response to antibioticantibiotic
NoNo YesYes
Recurrence Recurrence after after surgerysurgery
NoNo YesYes
UC vs CDUC vs CDDifferent endoscopic featuresDifferent endoscopic features
UCUC CDCD
Rectal Rectal sparingsparing
RarelyRarely FrequentlyFrequently
Continuous Continuous diseasedisease
YesYes OccasionallyOccasionally
bdquobdquoCCobblestonobblestoningrdquoingrdquo
NoNo YesYes
Granuloma Granuloma on biopsyon biopsy
NoNo OccasionallyOccasionally
Criteria for Indeterminate Criteria for Indeterminate ColitisColitis
No evidence of No evidence of small bowel small bowel involvement involvement fistula or fistula or perianal diseaseperianal disease
Absence of Absence of diagnostic diagnostic criteria for CD criteria for CD or UC by or UC by microscopymicroscopy
Differential Diagnosis of Differential Diagnosis of Chronic Diarrhea and Weight Chronic Diarrhea and Weight
LossLoss Colonic diseasesColonic diseases
IBDIBD NeoplasiaNeoplasia Ischemic bowelIschemic bowel
PancreaticPancreatic Chronic pancreatitisChronic pancreatitis CancerCancer Cystic fibrosisCystic fibrosis
EnteropathicEnteropathic Celiac diseaseCeliac disease Tropical sprueTropical sprue LymphomaLymphoma Mesenteric ischemiaMesenteric ischemia Whipplersquos diseaseWhipplersquos disease
HormonaldrugsHormonaldrugs VipomaVipoma ZESZES Medullary CA of Medullary CA of
thyroidthyroid NSAIDS useNSAIDS use
Educational ObjectivesEducational Objectives Definitions and spectrum of inflammatory Definitions and spectrum of inflammatory
bowel disease (IBD)bowel disease (IBD) Epidemiology of IBDEpidemiology of IBD Etiopathogenesis of IBDEtiopathogenesis of IBD Clinical manifestations of ulcerative colitis Clinical manifestations of ulcerative colitis
(UC)(UC) Clinical manifestations of Crohnrsquos disease Clinical manifestations of Crohnrsquos disease
(CD)(CD) Distinguishing features between UC and CDDistinguishing features between UC and CD Diagnostic approach to IBDDiagnostic approach to IBD Medical management of IBDMedical management of IBD Indications for and role of surgeryIndications for and role of surgery
Diagnostic Approach to Diagnostic Approach to Patients with Suspected Patients with Suspected
IBDIBD HistoryhelliphelliphistoryhelliphelliphistoryHistoryhelliphelliphistoryhelliphelliphistory Clinical examClinical exam Laboratory testsLaboratory tests Radiological imagingRadiological imaging EndoscopyEndoscopy Special serological testingSpecial serological testing Genetic testingGenetic testing
Diagnosis-LAB Blood test
CD Mild anemia mild leukocytosis elevated ESR elevated CRP positive ASCA
UC Anemia hypokalemia hypoalbuminemia elevated ESR elevated LFTs positive p-ANCA
Stool analysis Many WBCs and or RBCs No ova or parasites
What are the Serological What are the Serological Markers in IBDMarkers in IBD
pANCA (perinuclear staining pattern)pANCA (perinuclear staining pattern) Loss of perinuclear pattern after Loss of perinuclear pattern after
DNAaseDNAase Differentiate from the ldquoother pANCAsrdquoDifferentiate from the ldquoother pANCAsrdquo
Antibody against myeloperoxidaseAntibody against myeloperoxidase Antibody against cathepsin G elastase lysozyme Antibody against cathepsin G elastase lysozyme
and lactoferrinand lactoferrin ASCA (anti-ASCA (anti-Saccharomyces cerevisiaeSaccharomyces cerevisiae))
Both IgG and IgABoth IgG and IgA Recognize mannose in the cell wall Recognize mannose in the cell wall
mannan of mannan of Saccharomyces cerevisiaeSaccharomyces cerevisiae
Why Use Serological Why Use Serological Markers in Clinical Markers in Clinical
PracticePractice Differentiate IBD from functional bowel Differentiate IBD from functional bowel
disordersdisorders Accurately diagnose Crohnrsquos or UC in a patient Accurately diagnose Crohnrsquos or UC in a patient
withwith Severe colitisSevere colitis Indeterminate colitisIndeterminate colitis
Predict disease course or complications in IBDPredict disease course or complications in IBD CD phenotypeCD phenotype Severity of diseaseSeverity of disease Risk of pouchitisRisk of pouchitis
SummarySummary
pANCA and ASCA are specific for UC pANCA and ASCA are specific for UC and CD respectivelyand CD respectively
Neither pANCA nor ASCA are sensitive Neither pANCA nor ASCA are sensitive enough to exclude IBDenough to exclude IBD
In patients with IC available In patients with IC available serological markers do not accurately serological markers do not accurately predict the subsequent disease coursepredict the subsequent disease course
Antibody profiles can predict disease Antibody profiles can predict disease behavior in IBDbehavior in IBD
Diagnostic ApproachDiagnostic ApproachEndoscopyEndoscopy
Endoscopy useful forEndoscopy useful for Initial diagnosisInitial diagnosis Assessment of severityAssessment of severity Tissue diagnosisTissue diagnosis FU during treatmentFU during treatment Assessment of disease exacerbationAssessment of disease exacerbation Surveillance for risk of cancerSurveillance for risk of cancer Treatment of certain complications (eg Treatment of certain complications (eg
strictures)strictures)
Crohnrsquos DiseaseCrohnrsquos DiseaseEndoscopic FeaturesEndoscopic Features
Asymmetric patchy inflammationAsymmetric patchy inflammation Skip lesionsSkip lesions Rectal sparingRectal sparing Ulcerations-deepserpiginousUlcerations-deepserpiginous Cobblestoning-commonCobblestoning-common Pseudopolyps-rarePseudopolyps-rare BiopsyBiopsy
Erosions and normal mucosaErosions and normal mucosa Granulomas in 15 to 35 of specimensGranulomas in 15 to 35 of specimens
Ulcerative ColitisUlcerative ColitisEndoscopic FeaturesEndoscopic Features
Diffuse involvementDiffuse involvement Rectum always diseasedRectum always diseased Superficial ulcerationsSuperficial ulcerations FriabilitybleedingFriabilitybleeding Flatteningdisappearance of haustral Flatteningdisappearance of haustral
foldsfolds PseudopolypsPseudopolyps No cobblestoningNo cobblestoning Bx No granulomasBx No granulomas
Imaging for Crohn Imaging for Crohn DiseaseDisease
Traditional TechniquesTraditional Techniques Abdominal RadiographsAbdominal Radiographs
Barium UGI Barium UGI
Barium small bowel follow throughBarium small bowel follow through
Barium EnteroclysisBarium Enteroclysis
Barium EnemaBarium Enema
Imaging for Crohn Disease Imaging for Crohn Disease Newer TechniquesNewer Techniques
CTCT
CT EnteroclysisCT Enteroclysis
CT EnterographyCT Enterography
Magnetic ResonanceMagnetic Resonance
UltrasoundUltrasound
Nuclear MedicineNuclear Medicine
Imaging for Crohns DiseaseImaging for Crohns Disease SummarySummary
Useful Newer TechniquesUseful Newer Techniques evolvingevolving CT EnterographyCT Enterography
Comprehensive evaluation of all bowel amp solid organsComprehensive evaluation of all bowel amp solid organs
Magnetic ResonanceMagnetic Resonance
Useful for ano-rectal diseaseUseful for ano-rectal disease
Real-time MR has potential for detection of stricturesReal-time MR has potential for detection of strictures
Traditional imaging techniques still of value in Traditional imaging techniques still of value in selected cases selected cases
The Capsule (WCE)The Capsule (WCE)
WCEWCE
bull Diameter 11mm Length 26mmDiameter 11mm Length 26mmbull Optical dome Intestinal illumination Optical dome Intestinal illumination
by white light emitting diodes (LEDrsquos)by white light emitting diodes (LEDrsquos)bull LensLensbull Complementary metal-oxide silicone Complementary metal-oxide silicone
imager (color camera chip)imager (color camera chip)bull TransmitterTransmitterbull Two batteries (silver oxide)Two batteries (silver oxide)
GE Junction Duodenum
Jejunum Ileocecal Valve
Educational ObjectivesEducational Objectives Definitions and spectrum of inflammatory Definitions and spectrum of inflammatory
bowel disease (IBD)bowel disease (IBD) Epidemiology of IBDEpidemiology of IBD Etiopathogenesis of IBDEtiopathogenesis of IBD Clinical manifestations of ulcerative colitis Clinical manifestations of ulcerative colitis
(UC)(UC) Clinical manifestations of Crohnrsquos disease Clinical manifestations of Crohnrsquos disease
(CD)(CD) Distinguishing features between UC and CDDistinguishing features between UC and CD Diagnostic approach to IBDDiagnostic approach to IBD Complications of IBDComplications of IBD IBD managementIBD management
IBD-ComplicationsIBD-Complications GI BleedingGI Bleeding Toxic megacolonToxic megacolon PerforationPerforation Thromboembolic phenomenaThromboembolic phenomena FistulasfissuresFistulasfissures AbscessAbscess StricturesobstructionStricturesobstruction MalabsorptionmalnutritionMalabsorptionmalnutrition CancerCancer
Best Protection
Surveillance colonoscopySurveillance colonoscopy
Procto-colectomy (for UC)Procto-colectomy (for UC)
Descending Colon Descending Colon StrictureStricture
Colonic StricturesColonic Strictures
Consider nonsurgical management Consider nonsurgical management ifif Endoscopically accessibleEndoscopically accessible Multiple prior resectionsMultiple prior resections Shorter strictures (less than 5 cm)Shorter strictures (less than 5 cm) Steroid injection if significant Steroid injection if significant
inflammationinflammation
Fistula DefinitionA communication between two epithelial-lined organsLifetime risk of fistula in CD30
Perianal FistulaPerianal Fistula
Pretreatment 2 Weeks
10 Weeks 18 weeks
Educational ObjectivesEducational Objectives Definitions and spectrum of inflammatory Definitions and spectrum of inflammatory
bowel disease (IBD)bowel disease (IBD) Epidemiology of IBDEpidemiology of IBD Etiopathogenesis of IBDEtiopathogenesis of IBD Clinical manifestations of ulcerative colitis Clinical manifestations of ulcerative colitis
(UC)(UC) Clinical manifestations of Crohnrsquos disease Clinical manifestations of Crohnrsquos disease
(CD)(CD) Distinguishing features between UC and CDDistinguishing features between UC and CD Diagnostic approach to IBDDiagnostic approach to IBD Complications of IBDComplications of IBD IBD managementIBD management
Goals of Therapy for IBDGoals of Therapy for IBD
Inducing remissionInducing remission Maintaining remissionMaintaining remission Restoring and maintaining nutritionRestoring and maintaining nutrition Maintaining patientrsquos quality of lifeMaintaining patientrsquos quality of life Prevention of complicationsPrevention of complications Surgical intervention (selection of Surgical intervention (selection of
optimal time for surgery)optimal time for surgery)
Inductive TherapiesInductive Therapies
For UCFor UC AminosalicylatesAminosalicylates CorticosteroidsCorticosteroids CyclosporinCyclosporin
For CDFor CD AminosalicylatesAminosalicylates CorticosteroidsCorticosteroids AntibioticsAntibiotics Anti-TNFAnti-TNF
Maintenance TherapiesMaintenance Therapies
ImmunosupressorsImmunosupressors AzathioprineAzathioprine 6-MP6-MP MethotrexateMethotrexate
AminosalicylatesAminosalicylates Anti-TNFAnti-TNF
NOT NOT corticosteroidscorticosteroids
IBD ManagementIBD ManagementSummarySummary
There is no ldquoone size fits allrdquo to IBD therapyThere is no ldquoone size fits allrdquo to IBD therapy Therapy and decision making are tailored to the Therapy and decision making are tailored to the
individualindividual
Algorithms are based upon available evidenceAlgorithms are based upon available evidence Evidence is in constant fluxEvidence is in constant flux
Success of algorithms depends upon Success of algorithms depends upon optimization of each step of therapy and optimization of each step of therapy and considerable judgment about each outcomeconsiderable judgment about each outcome Skillful application of medical therapy makes all Skillful application of medical therapy makes all
the difference in outcomesthe difference in outcomes
Surgery for IBDSurgery for IBDGeneral ConceptsGeneral Concepts
Majority will need surgery 78 over Majority will need surgery 78 over twenty yearstwenty years
Surgery generally indicated for Surgery generally indicated for complicationscomplications of disease of disease
Surgery must be directed at area of Surgery must be directed at area of bowel responsible for complicationbowel responsible for complication
Indications for SurgeryIndications for Surgery Intestinal obstruction (most Intestinal obstruction (most
common)common) Intractabilitysteroid Intractabilitysteroid
dependencedependence Non-healing fistulaAbscessNon-healing fistulaAbscess Toxic megacolonFree Toxic megacolonFree
perforationperforation Uncontrollable GI bleedingUncontrollable GI bleeding Severe perianal diseaseSevere perianal disease CancerCancer Growth retardation Growth retardation
(children)(children) Severe uncontrollable Severe uncontrollable
extraintestinal extraintestinal manifestationsmanifestations
Management of IBDSummary
The goals of therapy are Relieve symptoms Prevent relapse Correct nutritional deficiencies Control inflammation Prevent complications especially colon cancer
Treatment depends on 1048707 Type of disease 1048707 Site of disease 1048707 Disease severity
Treatment may include drugs nutrition supplements surgery or a combination of these options
Epidemiology of IBDEpidemiology of IBD
Ulcerative Ulcerative colitiscolitis
Crohnrsquos Crohnrsquos diseasedisease
Incidence (US)Incidence (US) 11100 00011100 000 7100 0007100 000Age of onsetAge of onset 15-30 amp 60-15-30 amp 60-
808015-30 amp 60-15-30 amp 60-8080
Malefemale Malefemale ratioratio
1111 11-18111-181
SmokingSmoking May prevent May prevent diseasedisease
May cause May cause diseasedisease
Oral Oral contraceptivecontraceptive
No increased No increased riskrisk
Relative risk Relative risk 1919
AppendectomyAppendectomy Not Not protectiveprotective
ProtectiveProtective
Monozygotic Monozygotic twinstwins
8 8 concordanceconcordance
67 67 concordanceconcordance
High
Medium
Low
Educational ObjectivesEducational Objectives Definitions and spectrum of inflammatory Definitions and spectrum of inflammatory
bowel disease (IBD)bowel disease (IBD) Epidemiology of IBDEpidemiology of IBD Etiopathogenesis of IBDEtiopathogenesis of IBD Clinical manifestations of ulcerative colitis Clinical manifestations of ulcerative colitis
(UC)(UC) Clinical manifestations of Crohnrsquos disease Clinical manifestations of Crohnrsquos disease
(CD)(CD) Distinguishing features between UC and CDDistinguishing features between UC and CD Diagnostic approach to IBDDiagnostic approach to IBD Complications of IBDComplications of IBD IBD managementIBD management
NatureNature NurtureNurture
IBDIBD
GenesGenes EnvironmentEnvironment
Educational ObjectivesEducational Objectives Definitions and spectrum of inflammatory Definitions and spectrum of inflammatory
bowel disease (IBD)bowel disease (IBD) Epidemiology of IBDEpidemiology of IBD Etiopathogenesis of IBDEtiopathogenesis of IBD Clinical manifestations of ulcerative Clinical manifestations of ulcerative
colitis (UC)colitis (UC) Clinical manifestations of Crohnrsquos disease Clinical manifestations of Crohnrsquos disease
(CD)(CD) Distinguishing features between UC and CDDistinguishing features between UC and CD Diagnostic approach to IBDDiagnostic approach to IBD Complications of IBDComplications of IBD IBD managementIBD management
Ulcerative Ulcerative CColitis ndash clinical olitis ndash clinical presentationpresentation
Patients with Patients with proctitisproctitis usually pass fresh blood usually pass fresh blood or blood-stained mucus either mixed with stool or blood-stained mucus either mixed with stool or streaked onto the surface of normal or hard or streaked onto the surface of normal or hard stoolstool tenesmustenesmus is a feature is a feature
When the disease extends When the disease extends beyond the rectumbeyond the rectum blood is usually mixed with stool or grossly blood is usually mixed with stool or grossly bloody diarrhea may be notedbloody diarrhea may be noted
When the disease is When the disease is severesevere patients pass a patients pass a liquid stool containing blood pus fecal matterliquid stool containing blood pus fecal matter
Other symptoms in moderate to severe disease Other symptoms in moderate to severe disease include anorexia nausea vomitting fever include anorexia nausea vomitting fever abdominal pain abdominal pain weight lossweight loss
Ulcerative colitis ndash Ulcerative colitis ndash macroscopic featuresmacroscopic features
Mucosa isMucosa is
- erythematous has a granular surface that looks - erythematous has a granular surface that looks like a sand paperlike a sand paper
In more severe diseasesIn more severe diseases
- hemorrhagic edematous and ulcerated- hemorrhagic edematous and ulcerated
In fulminant diseaseIn fulminant disease a toxic colitis or a toxic a toxic colitis or a toxic megacolon may develop ( wall becomemegacolon may develop ( wall becomess very thin very thin and mucosa is severand mucosa is severeely ulcerated)ly ulcerated)
UCUCDisease Distribution at Disease Distribution at
PresentationPresentation
4637
17
UC ndash disease UC ndash disease severityseverity
MILDMILD MODERATMODERATEE
SEVERESEVERE
BOWEL BOWEL MOVEMENTSMOVEMENTS lt 4 per lt 4 per
dayday 4-6 per 4-6 per dayday
gt6 per gt6 per dayday
BLOOD IN BLOOD IN STOOLSTOOL smallsmall moderatemoderate SevereSevere
FEVERFEVER nonenone lt375lt375degdegC C gt 375gt 375degdegC C
TACHYCARDITACHYCARDIAA
nonenone lt90 mean lt90 mean pulsepulse
gt90 mean gt90 mean pulsepulse
UC ndash disease UC ndash disease severityseverity
MILDMILD MODERATMODERATEE
SEVERESEVERE
ANEMIAANEMIA mildmild gt75gt75 lt75lt75
ESRESR lt30mmlt30mm gt30mmgt30mm
ENDOSCOPIC ENDOSCOPIC APPEARANCEAPPEARANCE
Erythema Erythema decreased decreased vascular vascular pattern fine pattern fine granularitygranularity
Marked Marked erythema erythema coarse coarse granularity granularity contact contact bleeding no bleeding no ulcerationulceration
Spontaneous Spontaneous bleeding bleeding ulcerationulceration
Educational ObjectivesEducational Objectives Definitions and spectrum of inflammatory Definitions and spectrum of inflammatory
bowel disease (IBD)bowel disease (IBD) Epidemiology of IBDEpidemiology of IBD Etiopathogenesis of IBDEtiopathogenesis of IBD Clinical manifestations of ulcerative colitis Clinical manifestations of ulcerative colitis
(UC)(UC) Clinical manifestations of Crohnrsquos disease Clinical manifestations of Crohnrsquos disease
(CD)(CD) Distinguishing features between UC and Distinguishing features between UC and
CDCD Diagnostic approach to IBDDiagnostic approach to IBD Complications of IBDComplications of IBD IBD managementIBD management
CD Clinical FeaturesCD Clinical Features
Abdominal pain often postprandialAbdominal pain often postprandial Diarrhea usually wateryDiarrhea usually watery Rectal bleedingRectal bleeding Weight lossWeight loss Right lower quadrant painpalpable Right lower quadrant painpalpable
massmass FeverFever Growth retardation in childrenGrowth retardation in children Perirectal fistulaPerirectal fistula
Crohnrsquos disease ndash macroscopic Crohnrsquos disease ndash macroscopic featuresfeatures
Can affect any part of GI tract from the mouth to the Can affect any part of GI tract from the mouth to the anusanus
30-40 of patients have small bowel disease alone30-40 of patients have small bowel disease alone
40-55 of patients have both small and large 40-55 of patients have both small and large intestines diseaseintestines disease
15-25 of patients have colitis alone15-25 of patients have colitis alone
In 75 of patients with small intestinal disease the In 75 of patients with small intestinal disease the terminal ileum in involved in 90terminal ileum in involved in 90
Crohnrsquos DiseaseCrohnrsquos DiseaseAnatomic DistributionAnatomic Distribution
Small bowelSmall bowelalonealone(33)(33)
IleocolicIleocolic(45)(45)
Colon aloneColon alone(20)(20)
Frequency of involvementFrequency of involvement
MostMost LeastLeast
Crohnrsquos disease ndash macroscopic Crohnrsquos disease ndash macroscopic featuresfeatures
CD is a CD is a transmuraltransmural process process
CD is CD is segmentalsegmental with skip areas in with skip areas in the midst of diseased intestinethe midst of diseased intestine
In one third of patients with CD In one third of patients with CD perirectal fistulas fissures perirectal fistulas fissures abscesses anal stenosis are presentabscesses anal stenosis are present
Crohnrsquos disease ndash macroscopic Crohnrsquos disease ndash macroscopic featuresfeatures
Active CD is characterized by focal Active CD is characterized by focal inflammation and formation of fistula inflammation and formation of fistula tractstracts
The bowel wall thickens and becomes The bowel wall thickens and becomes narrowed and fibrotic leading to narrowed and fibrotic leading to chronic recurrent bowel obstructionchronic recurrent bowel obstruction
Crohnrsquos Disease Activity Index(CDAI)
Incorporates 8 variables 1 liquid or very soft stools day 2 Abdominal pain amp cramping 3 Extraintestinal manifestations 4 Complications 5 Abdominal mass 6 Use of anti diarrheal medications anti- 7 Hematocrit 8 Body weight
Crohnrsquos Disease Red Crohnrsquos Disease Red FlagsFlags
Onset after stopping smokingOnset after stopping smoking Bleeding onlyBleeding only DiverticulosisDiverticulosis AtherosclerosisAtherosclerosis ProlapseProlapse
Extraintestinal Manifestations of IBD
SkinErythema nodosumPyoderma gangrenosum
JointsPeripheral arthritisSacroileitisAnkylosing spondylitis
EyeUveitisEpiscleritisIritis
Hepatobiliary complicationsGallstonesPSC
Renal complicationsNephrolithiasisRecurrent UTIs
Educational ObjectivesEducational Objectives Definitions and spectrum of inflammatory Definitions and spectrum of inflammatory
bowel disease (IBD)bowel disease (IBD) Epidemiology of IBDEpidemiology of IBD Etiopathogenesis of IBDEtiopathogenesis of IBD Clinical manifestations of ulcerative colitis Clinical manifestations of ulcerative colitis
(UC)(UC) Clinical manifestations of Crohnrsquos disease (CD)Clinical manifestations of Crohnrsquos disease (CD) Distinguishing features between UC and Distinguishing features between UC and
CDCD Diagnostic approach to IBDDiagnostic approach to IBD Medical management of IBDMedical management of IBD Indications for and role of surgeryIndications for and role of surgery
Symptoms of IBDUC vs CDUC vs CD
FeatureFeature UCUC CDCD
FeverFever UncommonUncommon CommonCommon
Rectal Rectal bleedingbleeding
CommonCommon lt frac12 of lt frac12 of patientspatients
Abdominal Abdominal tendernesstenderness
May be May be presentpresent
CommonCommon
Abdominal Abdominal massmass
UncommonUncommon CommonCommon
Abdominal Abdominal painpain
UncommonUncommon Very commonVery common
Weight lossWeight loss UncommonUncommon CommonCommon
TenesmusTenesmus Very commonVery common UncommonUncommon
UC vs CDUC vs CDComplicationsResponse to ComplicationsResponse to
TreatmentTreatmentUCUC CDCD
FistulasFistulas NoNo YesYes
Small Small intestine intestine obstructionobstruction
NoNo FrequentlyFrequently
Colonic Colonic obstructionobstruction
RarelyRarely FrequentlyFrequently
Response to Response to antibioticantibiotic
NoNo YesYes
Recurrence Recurrence after after surgerysurgery
NoNo YesYes
UC vs CDUC vs CDDifferent endoscopic featuresDifferent endoscopic features
UCUC CDCD
Rectal Rectal sparingsparing
RarelyRarely FrequentlyFrequently
Continuous Continuous diseasedisease
YesYes OccasionallyOccasionally
bdquobdquoCCobblestonobblestoningrdquoingrdquo
NoNo YesYes
Granuloma Granuloma on biopsyon biopsy
NoNo OccasionallyOccasionally
Criteria for Indeterminate Criteria for Indeterminate ColitisColitis
No evidence of No evidence of small bowel small bowel involvement involvement fistula or fistula or perianal diseaseperianal disease
Absence of Absence of diagnostic diagnostic criteria for CD criteria for CD or UC by or UC by microscopymicroscopy
Differential Diagnosis of Differential Diagnosis of Chronic Diarrhea and Weight Chronic Diarrhea and Weight
LossLoss Colonic diseasesColonic diseases
IBDIBD NeoplasiaNeoplasia Ischemic bowelIschemic bowel
PancreaticPancreatic Chronic pancreatitisChronic pancreatitis CancerCancer Cystic fibrosisCystic fibrosis
EnteropathicEnteropathic Celiac diseaseCeliac disease Tropical sprueTropical sprue LymphomaLymphoma Mesenteric ischemiaMesenteric ischemia Whipplersquos diseaseWhipplersquos disease
HormonaldrugsHormonaldrugs VipomaVipoma ZESZES Medullary CA of Medullary CA of
thyroidthyroid NSAIDS useNSAIDS use
Educational ObjectivesEducational Objectives Definitions and spectrum of inflammatory Definitions and spectrum of inflammatory
bowel disease (IBD)bowel disease (IBD) Epidemiology of IBDEpidemiology of IBD Etiopathogenesis of IBDEtiopathogenesis of IBD Clinical manifestations of ulcerative colitis Clinical manifestations of ulcerative colitis
(UC)(UC) Clinical manifestations of Crohnrsquos disease Clinical manifestations of Crohnrsquos disease
(CD)(CD) Distinguishing features between UC and CDDistinguishing features between UC and CD Diagnostic approach to IBDDiagnostic approach to IBD Medical management of IBDMedical management of IBD Indications for and role of surgeryIndications for and role of surgery
Diagnostic Approach to Diagnostic Approach to Patients with Suspected Patients with Suspected
IBDIBD HistoryhelliphelliphistoryhelliphelliphistoryHistoryhelliphelliphistoryhelliphelliphistory Clinical examClinical exam Laboratory testsLaboratory tests Radiological imagingRadiological imaging EndoscopyEndoscopy Special serological testingSpecial serological testing Genetic testingGenetic testing
Diagnosis-LAB Blood test
CD Mild anemia mild leukocytosis elevated ESR elevated CRP positive ASCA
UC Anemia hypokalemia hypoalbuminemia elevated ESR elevated LFTs positive p-ANCA
Stool analysis Many WBCs and or RBCs No ova or parasites
What are the Serological What are the Serological Markers in IBDMarkers in IBD
pANCA (perinuclear staining pattern)pANCA (perinuclear staining pattern) Loss of perinuclear pattern after Loss of perinuclear pattern after
DNAaseDNAase Differentiate from the ldquoother pANCAsrdquoDifferentiate from the ldquoother pANCAsrdquo
Antibody against myeloperoxidaseAntibody against myeloperoxidase Antibody against cathepsin G elastase lysozyme Antibody against cathepsin G elastase lysozyme
and lactoferrinand lactoferrin ASCA (anti-ASCA (anti-Saccharomyces cerevisiaeSaccharomyces cerevisiae))
Both IgG and IgABoth IgG and IgA Recognize mannose in the cell wall Recognize mannose in the cell wall
mannan of mannan of Saccharomyces cerevisiaeSaccharomyces cerevisiae
Why Use Serological Why Use Serological Markers in Clinical Markers in Clinical
PracticePractice Differentiate IBD from functional bowel Differentiate IBD from functional bowel
disordersdisorders Accurately diagnose Crohnrsquos or UC in a patient Accurately diagnose Crohnrsquos or UC in a patient
withwith Severe colitisSevere colitis Indeterminate colitisIndeterminate colitis
Predict disease course or complications in IBDPredict disease course or complications in IBD CD phenotypeCD phenotype Severity of diseaseSeverity of disease Risk of pouchitisRisk of pouchitis
SummarySummary
pANCA and ASCA are specific for UC pANCA and ASCA are specific for UC and CD respectivelyand CD respectively
Neither pANCA nor ASCA are sensitive Neither pANCA nor ASCA are sensitive enough to exclude IBDenough to exclude IBD
In patients with IC available In patients with IC available serological markers do not accurately serological markers do not accurately predict the subsequent disease coursepredict the subsequent disease course
Antibody profiles can predict disease Antibody profiles can predict disease behavior in IBDbehavior in IBD
Diagnostic ApproachDiagnostic ApproachEndoscopyEndoscopy
Endoscopy useful forEndoscopy useful for Initial diagnosisInitial diagnosis Assessment of severityAssessment of severity Tissue diagnosisTissue diagnosis FU during treatmentFU during treatment Assessment of disease exacerbationAssessment of disease exacerbation Surveillance for risk of cancerSurveillance for risk of cancer Treatment of certain complications (eg Treatment of certain complications (eg
strictures)strictures)
Crohnrsquos DiseaseCrohnrsquos DiseaseEndoscopic FeaturesEndoscopic Features
Asymmetric patchy inflammationAsymmetric patchy inflammation Skip lesionsSkip lesions Rectal sparingRectal sparing Ulcerations-deepserpiginousUlcerations-deepserpiginous Cobblestoning-commonCobblestoning-common Pseudopolyps-rarePseudopolyps-rare BiopsyBiopsy
Erosions and normal mucosaErosions and normal mucosa Granulomas in 15 to 35 of specimensGranulomas in 15 to 35 of specimens
Ulcerative ColitisUlcerative ColitisEndoscopic FeaturesEndoscopic Features
Diffuse involvementDiffuse involvement Rectum always diseasedRectum always diseased Superficial ulcerationsSuperficial ulcerations FriabilitybleedingFriabilitybleeding Flatteningdisappearance of haustral Flatteningdisappearance of haustral
foldsfolds PseudopolypsPseudopolyps No cobblestoningNo cobblestoning Bx No granulomasBx No granulomas
Imaging for Crohn Imaging for Crohn DiseaseDisease
Traditional TechniquesTraditional Techniques Abdominal RadiographsAbdominal Radiographs
Barium UGI Barium UGI
Barium small bowel follow throughBarium small bowel follow through
Barium EnteroclysisBarium Enteroclysis
Barium EnemaBarium Enema
Imaging for Crohn Disease Imaging for Crohn Disease Newer TechniquesNewer Techniques
CTCT
CT EnteroclysisCT Enteroclysis
CT EnterographyCT Enterography
Magnetic ResonanceMagnetic Resonance
UltrasoundUltrasound
Nuclear MedicineNuclear Medicine
Imaging for Crohns DiseaseImaging for Crohns Disease SummarySummary
Useful Newer TechniquesUseful Newer Techniques evolvingevolving CT EnterographyCT Enterography
Comprehensive evaluation of all bowel amp solid organsComprehensive evaluation of all bowel amp solid organs
Magnetic ResonanceMagnetic Resonance
Useful for ano-rectal diseaseUseful for ano-rectal disease
Real-time MR has potential for detection of stricturesReal-time MR has potential for detection of strictures
Traditional imaging techniques still of value in Traditional imaging techniques still of value in selected cases selected cases
The Capsule (WCE)The Capsule (WCE)
WCEWCE
bull Diameter 11mm Length 26mmDiameter 11mm Length 26mmbull Optical dome Intestinal illumination Optical dome Intestinal illumination
by white light emitting diodes (LEDrsquos)by white light emitting diodes (LEDrsquos)bull LensLensbull Complementary metal-oxide silicone Complementary metal-oxide silicone
imager (color camera chip)imager (color camera chip)bull TransmitterTransmitterbull Two batteries (silver oxide)Two batteries (silver oxide)
GE Junction Duodenum
Jejunum Ileocecal Valve
Educational ObjectivesEducational Objectives Definitions and spectrum of inflammatory Definitions and spectrum of inflammatory
bowel disease (IBD)bowel disease (IBD) Epidemiology of IBDEpidemiology of IBD Etiopathogenesis of IBDEtiopathogenesis of IBD Clinical manifestations of ulcerative colitis Clinical manifestations of ulcerative colitis
(UC)(UC) Clinical manifestations of Crohnrsquos disease Clinical manifestations of Crohnrsquos disease
(CD)(CD) Distinguishing features between UC and CDDistinguishing features between UC and CD Diagnostic approach to IBDDiagnostic approach to IBD Complications of IBDComplications of IBD IBD managementIBD management
IBD-ComplicationsIBD-Complications GI BleedingGI Bleeding Toxic megacolonToxic megacolon PerforationPerforation Thromboembolic phenomenaThromboembolic phenomena FistulasfissuresFistulasfissures AbscessAbscess StricturesobstructionStricturesobstruction MalabsorptionmalnutritionMalabsorptionmalnutrition CancerCancer
Best Protection
Surveillance colonoscopySurveillance colonoscopy
Procto-colectomy (for UC)Procto-colectomy (for UC)
Descending Colon Descending Colon StrictureStricture
Colonic StricturesColonic Strictures
Consider nonsurgical management Consider nonsurgical management ifif Endoscopically accessibleEndoscopically accessible Multiple prior resectionsMultiple prior resections Shorter strictures (less than 5 cm)Shorter strictures (less than 5 cm) Steroid injection if significant Steroid injection if significant
inflammationinflammation
Fistula DefinitionA communication between two epithelial-lined organsLifetime risk of fistula in CD30
Perianal FistulaPerianal Fistula
Pretreatment 2 Weeks
10 Weeks 18 weeks
Educational ObjectivesEducational Objectives Definitions and spectrum of inflammatory Definitions and spectrum of inflammatory
bowel disease (IBD)bowel disease (IBD) Epidemiology of IBDEpidemiology of IBD Etiopathogenesis of IBDEtiopathogenesis of IBD Clinical manifestations of ulcerative colitis Clinical manifestations of ulcerative colitis
(UC)(UC) Clinical manifestations of Crohnrsquos disease Clinical manifestations of Crohnrsquos disease
(CD)(CD) Distinguishing features between UC and CDDistinguishing features between UC and CD Diagnostic approach to IBDDiagnostic approach to IBD Complications of IBDComplications of IBD IBD managementIBD management
Goals of Therapy for IBDGoals of Therapy for IBD
Inducing remissionInducing remission Maintaining remissionMaintaining remission Restoring and maintaining nutritionRestoring and maintaining nutrition Maintaining patientrsquos quality of lifeMaintaining patientrsquos quality of life Prevention of complicationsPrevention of complications Surgical intervention (selection of Surgical intervention (selection of
optimal time for surgery)optimal time for surgery)
Inductive TherapiesInductive Therapies
For UCFor UC AminosalicylatesAminosalicylates CorticosteroidsCorticosteroids CyclosporinCyclosporin
For CDFor CD AminosalicylatesAminosalicylates CorticosteroidsCorticosteroids AntibioticsAntibiotics Anti-TNFAnti-TNF
Maintenance TherapiesMaintenance Therapies
ImmunosupressorsImmunosupressors AzathioprineAzathioprine 6-MP6-MP MethotrexateMethotrexate
AminosalicylatesAminosalicylates Anti-TNFAnti-TNF
NOT NOT corticosteroidscorticosteroids
IBD ManagementIBD ManagementSummarySummary
There is no ldquoone size fits allrdquo to IBD therapyThere is no ldquoone size fits allrdquo to IBD therapy Therapy and decision making are tailored to the Therapy and decision making are tailored to the
individualindividual
Algorithms are based upon available evidenceAlgorithms are based upon available evidence Evidence is in constant fluxEvidence is in constant flux
Success of algorithms depends upon Success of algorithms depends upon optimization of each step of therapy and optimization of each step of therapy and considerable judgment about each outcomeconsiderable judgment about each outcome Skillful application of medical therapy makes all Skillful application of medical therapy makes all
the difference in outcomesthe difference in outcomes
Surgery for IBDSurgery for IBDGeneral ConceptsGeneral Concepts
Majority will need surgery 78 over Majority will need surgery 78 over twenty yearstwenty years
Surgery generally indicated for Surgery generally indicated for complicationscomplications of disease of disease
Surgery must be directed at area of Surgery must be directed at area of bowel responsible for complicationbowel responsible for complication
Indications for SurgeryIndications for Surgery Intestinal obstruction (most Intestinal obstruction (most
common)common) Intractabilitysteroid Intractabilitysteroid
dependencedependence Non-healing fistulaAbscessNon-healing fistulaAbscess Toxic megacolonFree Toxic megacolonFree
perforationperforation Uncontrollable GI bleedingUncontrollable GI bleeding Severe perianal diseaseSevere perianal disease CancerCancer Growth retardation Growth retardation
(children)(children) Severe uncontrollable Severe uncontrollable
extraintestinal extraintestinal manifestationsmanifestations
Management of IBDSummary
The goals of therapy are Relieve symptoms Prevent relapse Correct nutritional deficiencies Control inflammation Prevent complications especially colon cancer
Treatment depends on 1048707 Type of disease 1048707 Site of disease 1048707 Disease severity
Treatment may include drugs nutrition supplements surgery or a combination of these options
High
Medium
Low
Educational ObjectivesEducational Objectives Definitions and spectrum of inflammatory Definitions and spectrum of inflammatory
bowel disease (IBD)bowel disease (IBD) Epidemiology of IBDEpidemiology of IBD Etiopathogenesis of IBDEtiopathogenesis of IBD Clinical manifestations of ulcerative colitis Clinical manifestations of ulcerative colitis
(UC)(UC) Clinical manifestations of Crohnrsquos disease Clinical manifestations of Crohnrsquos disease
(CD)(CD) Distinguishing features between UC and CDDistinguishing features between UC and CD Diagnostic approach to IBDDiagnostic approach to IBD Complications of IBDComplications of IBD IBD managementIBD management
NatureNature NurtureNurture
IBDIBD
GenesGenes EnvironmentEnvironment
Educational ObjectivesEducational Objectives Definitions and spectrum of inflammatory Definitions and spectrum of inflammatory
bowel disease (IBD)bowel disease (IBD) Epidemiology of IBDEpidemiology of IBD Etiopathogenesis of IBDEtiopathogenesis of IBD Clinical manifestations of ulcerative Clinical manifestations of ulcerative
colitis (UC)colitis (UC) Clinical manifestations of Crohnrsquos disease Clinical manifestations of Crohnrsquos disease
(CD)(CD) Distinguishing features between UC and CDDistinguishing features between UC and CD Diagnostic approach to IBDDiagnostic approach to IBD Complications of IBDComplications of IBD IBD managementIBD management
Ulcerative Ulcerative CColitis ndash clinical olitis ndash clinical presentationpresentation
Patients with Patients with proctitisproctitis usually pass fresh blood usually pass fresh blood or blood-stained mucus either mixed with stool or blood-stained mucus either mixed with stool or streaked onto the surface of normal or hard or streaked onto the surface of normal or hard stoolstool tenesmustenesmus is a feature is a feature
When the disease extends When the disease extends beyond the rectumbeyond the rectum blood is usually mixed with stool or grossly blood is usually mixed with stool or grossly bloody diarrhea may be notedbloody diarrhea may be noted
When the disease is When the disease is severesevere patients pass a patients pass a liquid stool containing blood pus fecal matterliquid stool containing blood pus fecal matter
Other symptoms in moderate to severe disease Other symptoms in moderate to severe disease include anorexia nausea vomitting fever include anorexia nausea vomitting fever abdominal pain abdominal pain weight lossweight loss
Ulcerative colitis ndash Ulcerative colitis ndash macroscopic featuresmacroscopic features
Mucosa isMucosa is
- erythematous has a granular surface that looks - erythematous has a granular surface that looks like a sand paperlike a sand paper
In more severe diseasesIn more severe diseases
- hemorrhagic edematous and ulcerated- hemorrhagic edematous and ulcerated
In fulminant diseaseIn fulminant disease a toxic colitis or a toxic a toxic colitis or a toxic megacolon may develop ( wall becomemegacolon may develop ( wall becomess very thin very thin and mucosa is severand mucosa is severeely ulcerated)ly ulcerated)
UCUCDisease Distribution at Disease Distribution at
PresentationPresentation
4637
17
UC ndash disease UC ndash disease severityseverity
MILDMILD MODERATMODERATEE
SEVERESEVERE
BOWEL BOWEL MOVEMENTSMOVEMENTS lt 4 per lt 4 per
dayday 4-6 per 4-6 per dayday
gt6 per gt6 per dayday
BLOOD IN BLOOD IN STOOLSTOOL smallsmall moderatemoderate SevereSevere
FEVERFEVER nonenone lt375lt375degdegC C gt 375gt 375degdegC C
TACHYCARDITACHYCARDIAA
nonenone lt90 mean lt90 mean pulsepulse
gt90 mean gt90 mean pulsepulse
UC ndash disease UC ndash disease severityseverity
MILDMILD MODERATMODERATEE
SEVERESEVERE
ANEMIAANEMIA mildmild gt75gt75 lt75lt75
ESRESR lt30mmlt30mm gt30mmgt30mm
ENDOSCOPIC ENDOSCOPIC APPEARANCEAPPEARANCE
Erythema Erythema decreased decreased vascular vascular pattern fine pattern fine granularitygranularity
Marked Marked erythema erythema coarse coarse granularity granularity contact contact bleeding no bleeding no ulcerationulceration
Spontaneous Spontaneous bleeding bleeding ulcerationulceration
Educational ObjectivesEducational Objectives Definitions and spectrum of inflammatory Definitions and spectrum of inflammatory
bowel disease (IBD)bowel disease (IBD) Epidemiology of IBDEpidemiology of IBD Etiopathogenesis of IBDEtiopathogenesis of IBD Clinical manifestations of ulcerative colitis Clinical manifestations of ulcerative colitis
(UC)(UC) Clinical manifestations of Crohnrsquos disease Clinical manifestations of Crohnrsquos disease
(CD)(CD) Distinguishing features between UC and Distinguishing features between UC and
CDCD Diagnostic approach to IBDDiagnostic approach to IBD Complications of IBDComplications of IBD IBD managementIBD management
CD Clinical FeaturesCD Clinical Features
Abdominal pain often postprandialAbdominal pain often postprandial Diarrhea usually wateryDiarrhea usually watery Rectal bleedingRectal bleeding Weight lossWeight loss Right lower quadrant painpalpable Right lower quadrant painpalpable
massmass FeverFever Growth retardation in childrenGrowth retardation in children Perirectal fistulaPerirectal fistula
Crohnrsquos disease ndash macroscopic Crohnrsquos disease ndash macroscopic featuresfeatures
Can affect any part of GI tract from the mouth to the Can affect any part of GI tract from the mouth to the anusanus
30-40 of patients have small bowel disease alone30-40 of patients have small bowel disease alone
40-55 of patients have both small and large 40-55 of patients have both small and large intestines diseaseintestines disease
15-25 of patients have colitis alone15-25 of patients have colitis alone
In 75 of patients with small intestinal disease the In 75 of patients with small intestinal disease the terminal ileum in involved in 90terminal ileum in involved in 90
Crohnrsquos DiseaseCrohnrsquos DiseaseAnatomic DistributionAnatomic Distribution
Small bowelSmall bowelalonealone(33)(33)
IleocolicIleocolic(45)(45)
Colon aloneColon alone(20)(20)
Frequency of involvementFrequency of involvement
MostMost LeastLeast
Crohnrsquos disease ndash macroscopic Crohnrsquos disease ndash macroscopic featuresfeatures
CD is a CD is a transmuraltransmural process process
CD is CD is segmentalsegmental with skip areas in with skip areas in the midst of diseased intestinethe midst of diseased intestine
In one third of patients with CD In one third of patients with CD perirectal fistulas fissures perirectal fistulas fissures abscesses anal stenosis are presentabscesses anal stenosis are present
Crohnrsquos disease ndash macroscopic Crohnrsquos disease ndash macroscopic featuresfeatures
Active CD is characterized by focal Active CD is characterized by focal inflammation and formation of fistula inflammation and formation of fistula tractstracts
The bowel wall thickens and becomes The bowel wall thickens and becomes narrowed and fibrotic leading to narrowed and fibrotic leading to chronic recurrent bowel obstructionchronic recurrent bowel obstruction
Crohnrsquos Disease Activity Index(CDAI)
Incorporates 8 variables 1 liquid or very soft stools day 2 Abdominal pain amp cramping 3 Extraintestinal manifestations 4 Complications 5 Abdominal mass 6 Use of anti diarrheal medications anti- 7 Hematocrit 8 Body weight
Crohnrsquos Disease Red Crohnrsquos Disease Red FlagsFlags
Onset after stopping smokingOnset after stopping smoking Bleeding onlyBleeding only DiverticulosisDiverticulosis AtherosclerosisAtherosclerosis ProlapseProlapse
Extraintestinal Manifestations of IBD
SkinErythema nodosumPyoderma gangrenosum
JointsPeripheral arthritisSacroileitisAnkylosing spondylitis
EyeUveitisEpiscleritisIritis
Hepatobiliary complicationsGallstonesPSC
Renal complicationsNephrolithiasisRecurrent UTIs
Educational ObjectivesEducational Objectives Definitions and spectrum of inflammatory Definitions and spectrum of inflammatory
bowel disease (IBD)bowel disease (IBD) Epidemiology of IBDEpidemiology of IBD Etiopathogenesis of IBDEtiopathogenesis of IBD Clinical manifestations of ulcerative colitis Clinical manifestations of ulcerative colitis
(UC)(UC) Clinical manifestations of Crohnrsquos disease (CD)Clinical manifestations of Crohnrsquos disease (CD) Distinguishing features between UC and Distinguishing features between UC and
CDCD Diagnostic approach to IBDDiagnostic approach to IBD Medical management of IBDMedical management of IBD Indications for and role of surgeryIndications for and role of surgery
Symptoms of IBDUC vs CDUC vs CD
FeatureFeature UCUC CDCD
FeverFever UncommonUncommon CommonCommon
Rectal Rectal bleedingbleeding
CommonCommon lt frac12 of lt frac12 of patientspatients
Abdominal Abdominal tendernesstenderness
May be May be presentpresent
CommonCommon
Abdominal Abdominal massmass
UncommonUncommon CommonCommon
Abdominal Abdominal painpain
UncommonUncommon Very commonVery common
Weight lossWeight loss UncommonUncommon CommonCommon
TenesmusTenesmus Very commonVery common UncommonUncommon
UC vs CDUC vs CDComplicationsResponse to ComplicationsResponse to
TreatmentTreatmentUCUC CDCD
FistulasFistulas NoNo YesYes
Small Small intestine intestine obstructionobstruction
NoNo FrequentlyFrequently
Colonic Colonic obstructionobstruction
RarelyRarely FrequentlyFrequently
Response to Response to antibioticantibiotic
NoNo YesYes
Recurrence Recurrence after after surgerysurgery
NoNo YesYes
UC vs CDUC vs CDDifferent endoscopic featuresDifferent endoscopic features
UCUC CDCD
Rectal Rectal sparingsparing
RarelyRarely FrequentlyFrequently
Continuous Continuous diseasedisease
YesYes OccasionallyOccasionally
bdquobdquoCCobblestonobblestoningrdquoingrdquo
NoNo YesYes
Granuloma Granuloma on biopsyon biopsy
NoNo OccasionallyOccasionally
Criteria for Indeterminate Criteria for Indeterminate ColitisColitis
No evidence of No evidence of small bowel small bowel involvement involvement fistula or fistula or perianal diseaseperianal disease
Absence of Absence of diagnostic diagnostic criteria for CD criteria for CD or UC by or UC by microscopymicroscopy
Differential Diagnosis of Differential Diagnosis of Chronic Diarrhea and Weight Chronic Diarrhea and Weight
LossLoss Colonic diseasesColonic diseases
IBDIBD NeoplasiaNeoplasia Ischemic bowelIschemic bowel
PancreaticPancreatic Chronic pancreatitisChronic pancreatitis CancerCancer Cystic fibrosisCystic fibrosis
EnteropathicEnteropathic Celiac diseaseCeliac disease Tropical sprueTropical sprue LymphomaLymphoma Mesenteric ischemiaMesenteric ischemia Whipplersquos diseaseWhipplersquos disease
HormonaldrugsHormonaldrugs VipomaVipoma ZESZES Medullary CA of Medullary CA of
thyroidthyroid NSAIDS useNSAIDS use
Educational ObjectivesEducational Objectives Definitions and spectrum of inflammatory Definitions and spectrum of inflammatory
bowel disease (IBD)bowel disease (IBD) Epidemiology of IBDEpidemiology of IBD Etiopathogenesis of IBDEtiopathogenesis of IBD Clinical manifestations of ulcerative colitis Clinical manifestations of ulcerative colitis
(UC)(UC) Clinical manifestations of Crohnrsquos disease Clinical manifestations of Crohnrsquos disease
(CD)(CD) Distinguishing features between UC and CDDistinguishing features between UC and CD Diagnostic approach to IBDDiagnostic approach to IBD Medical management of IBDMedical management of IBD Indications for and role of surgeryIndications for and role of surgery
Diagnostic Approach to Diagnostic Approach to Patients with Suspected Patients with Suspected
IBDIBD HistoryhelliphelliphistoryhelliphelliphistoryHistoryhelliphelliphistoryhelliphelliphistory Clinical examClinical exam Laboratory testsLaboratory tests Radiological imagingRadiological imaging EndoscopyEndoscopy Special serological testingSpecial serological testing Genetic testingGenetic testing
Diagnosis-LAB Blood test
CD Mild anemia mild leukocytosis elevated ESR elevated CRP positive ASCA
UC Anemia hypokalemia hypoalbuminemia elevated ESR elevated LFTs positive p-ANCA
Stool analysis Many WBCs and or RBCs No ova or parasites
What are the Serological What are the Serological Markers in IBDMarkers in IBD
pANCA (perinuclear staining pattern)pANCA (perinuclear staining pattern) Loss of perinuclear pattern after Loss of perinuclear pattern after
DNAaseDNAase Differentiate from the ldquoother pANCAsrdquoDifferentiate from the ldquoother pANCAsrdquo
Antibody against myeloperoxidaseAntibody against myeloperoxidase Antibody against cathepsin G elastase lysozyme Antibody against cathepsin G elastase lysozyme
and lactoferrinand lactoferrin ASCA (anti-ASCA (anti-Saccharomyces cerevisiaeSaccharomyces cerevisiae))
Both IgG and IgABoth IgG and IgA Recognize mannose in the cell wall Recognize mannose in the cell wall
mannan of mannan of Saccharomyces cerevisiaeSaccharomyces cerevisiae
Why Use Serological Why Use Serological Markers in Clinical Markers in Clinical
PracticePractice Differentiate IBD from functional bowel Differentiate IBD from functional bowel
disordersdisorders Accurately diagnose Crohnrsquos or UC in a patient Accurately diagnose Crohnrsquos or UC in a patient
withwith Severe colitisSevere colitis Indeterminate colitisIndeterminate colitis
Predict disease course or complications in IBDPredict disease course or complications in IBD CD phenotypeCD phenotype Severity of diseaseSeverity of disease Risk of pouchitisRisk of pouchitis
SummarySummary
pANCA and ASCA are specific for UC pANCA and ASCA are specific for UC and CD respectivelyand CD respectively
Neither pANCA nor ASCA are sensitive Neither pANCA nor ASCA are sensitive enough to exclude IBDenough to exclude IBD
In patients with IC available In patients with IC available serological markers do not accurately serological markers do not accurately predict the subsequent disease coursepredict the subsequent disease course
Antibody profiles can predict disease Antibody profiles can predict disease behavior in IBDbehavior in IBD
Diagnostic ApproachDiagnostic ApproachEndoscopyEndoscopy
Endoscopy useful forEndoscopy useful for Initial diagnosisInitial diagnosis Assessment of severityAssessment of severity Tissue diagnosisTissue diagnosis FU during treatmentFU during treatment Assessment of disease exacerbationAssessment of disease exacerbation Surveillance for risk of cancerSurveillance for risk of cancer Treatment of certain complications (eg Treatment of certain complications (eg
strictures)strictures)
Crohnrsquos DiseaseCrohnrsquos DiseaseEndoscopic FeaturesEndoscopic Features
Asymmetric patchy inflammationAsymmetric patchy inflammation Skip lesionsSkip lesions Rectal sparingRectal sparing Ulcerations-deepserpiginousUlcerations-deepserpiginous Cobblestoning-commonCobblestoning-common Pseudopolyps-rarePseudopolyps-rare BiopsyBiopsy
Erosions and normal mucosaErosions and normal mucosa Granulomas in 15 to 35 of specimensGranulomas in 15 to 35 of specimens
Ulcerative ColitisUlcerative ColitisEndoscopic FeaturesEndoscopic Features
Diffuse involvementDiffuse involvement Rectum always diseasedRectum always diseased Superficial ulcerationsSuperficial ulcerations FriabilitybleedingFriabilitybleeding Flatteningdisappearance of haustral Flatteningdisappearance of haustral
foldsfolds PseudopolypsPseudopolyps No cobblestoningNo cobblestoning Bx No granulomasBx No granulomas
Imaging for Crohn Imaging for Crohn DiseaseDisease
Traditional TechniquesTraditional Techniques Abdominal RadiographsAbdominal Radiographs
Barium UGI Barium UGI
Barium small bowel follow throughBarium small bowel follow through
Barium EnteroclysisBarium Enteroclysis
Barium EnemaBarium Enema
Imaging for Crohn Disease Imaging for Crohn Disease Newer TechniquesNewer Techniques
CTCT
CT EnteroclysisCT Enteroclysis
CT EnterographyCT Enterography
Magnetic ResonanceMagnetic Resonance
UltrasoundUltrasound
Nuclear MedicineNuclear Medicine
Imaging for Crohns DiseaseImaging for Crohns Disease SummarySummary
Useful Newer TechniquesUseful Newer Techniques evolvingevolving CT EnterographyCT Enterography
Comprehensive evaluation of all bowel amp solid organsComprehensive evaluation of all bowel amp solid organs
Magnetic ResonanceMagnetic Resonance
Useful for ano-rectal diseaseUseful for ano-rectal disease
Real-time MR has potential for detection of stricturesReal-time MR has potential for detection of strictures
Traditional imaging techniques still of value in Traditional imaging techniques still of value in selected cases selected cases
The Capsule (WCE)The Capsule (WCE)
WCEWCE
bull Diameter 11mm Length 26mmDiameter 11mm Length 26mmbull Optical dome Intestinal illumination Optical dome Intestinal illumination
by white light emitting diodes (LEDrsquos)by white light emitting diodes (LEDrsquos)bull LensLensbull Complementary metal-oxide silicone Complementary metal-oxide silicone
imager (color camera chip)imager (color camera chip)bull TransmitterTransmitterbull Two batteries (silver oxide)Two batteries (silver oxide)
GE Junction Duodenum
Jejunum Ileocecal Valve
Educational ObjectivesEducational Objectives Definitions and spectrum of inflammatory Definitions and spectrum of inflammatory
bowel disease (IBD)bowel disease (IBD) Epidemiology of IBDEpidemiology of IBD Etiopathogenesis of IBDEtiopathogenesis of IBD Clinical manifestations of ulcerative colitis Clinical manifestations of ulcerative colitis
(UC)(UC) Clinical manifestations of Crohnrsquos disease Clinical manifestations of Crohnrsquos disease
(CD)(CD) Distinguishing features between UC and CDDistinguishing features between UC and CD Diagnostic approach to IBDDiagnostic approach to IBD Complications of IBDComplications of IBD IBD managementIBD management
IBD-ComplicationsIBD-Complications GI BleedingGI Bleeding Toxic megacolonToxic megacolon PerforationPerforation Thromboembolic phenomenaThromboembolic phenomena FistulasfissuresFistulasfissures AbscessAbscess StricturesobstructionStricturesobstruction MalabsorptionmalnutritionMalabsorptionmalnutrition CancerCancer
Best Protection
Surveillance colonoscopySurveillance colonoscopy
Procto-colectomy (for UC)Procto-colectomy (for UC)
Descending Colon Descending Colon StrictureStricture
Colonic StricturesColonic Strictures
Consider nonsurgical management Consider nonsurgical management ifif Endoscopically accessibleEndoscopically accessible Multiple prior resectionsMultiple prior resections Shorter strictures (less than 5 cm)Shorter strictures (less than 5 cm) Steroid injection if significant Steroid injection if significant
inflammationinflammation
Fistula DefinitionA communication between two epithelial-lined organsLifetime risk of fistula in CD30
Perianal FistulaPerianal Fistula
Pretreatment 2 Weeks
10 Weeks 18 weeks
Educational ObjectivesEducational Objectives Definitions and spectrum of inflammatory Definitions and spectrum of inflammatory
bowel disease (IBD)bowel disease (IBD) Epidemiology of IBDEpidemiology of IBD Etiopathogenesis of IBDEtiopathogenesis of IBD Clinical manifestations of ulcerative colitis Clinical manifestations of ulcerative colitis
(UC)(UC) Clinical manifestations of Crohnrsquos disease Clinical manifestations of Crohnrsquos disease
(CD)(CD) Distinguishing features between UC and CDDistinguishing features between UC and CD Diagnostic approach to IBDDiagnostic approach to IBD Complications of IBDComplications of IBD IBD managementIBD management
Goals of Therapy for IBDGoals of Therapy for IBD
Inducing remissionInducing remission Maintaining remissionMaintaining remission Restoring and maintaining nutritionRestoring and maintaining nutrition Maintaining patientrsquos quality of lifeMaintaining patientrsquos quality of life Prevention of complicationsPrevention of complications Surgical intervention (selection of Surgical intervention (selection of
optimal time for surgery)optimal time for surgery)
Inductive TherapiesInductive Therapies
For UCFor UC AminosalicylatesAminosalicylates CorticosteroidsCorticosteroids CyclosporinCyclosporin
For CDFor CD AminosalicylatesAminosalicylates CorticosteroidsCorticosteroids AntibioticsAntibiotics Anti-TNFAnti-TNF
Maintenance TherapiesMaintenance Therapies
ImmunosupressorsImmunosupressors AzathioprineAzathioprine 6-MP6-MP MethotrexateMethotrexate
AminosalicylatesAminosalicylates Anti-TNFAnti-TNF
NOT NOT corticosteroidscorticosteroids
IBD ManagementIBD ManagementSummarySummary
There is no ldquoone size fits allrdquo to IBD therapyThere is no ldquoone size fits allrdquo to IBD therapy Therapy and decision making are tailored to the Therapy and decision making are tailored to the
individualindividual
Algorithms are based upon available evidenceAlgorithms are based upon available evidence Evidence is in constant fluxEvidence is in constant flux
Success of algorithms depends upon Success of algorithms depends upon optimization of each step of therapy and optimization of each step of therapy and considerable judgment about each outcomeconsiderable judgment about each outcome Skillful application of medical therapy makes all Skillful application of medical therapy makes all
the difference in outcomesthe difference in outcomes
Surgery for IBDSurgery for IBDGeneral ConceptsGeneral Concepts
Majority will need surgery 78 over Majority will need surgery 78 over twenty yearstwenty years
Surgery generally indicated for Surgery generally indicated for complicationscomplications of disease of disease
Surgery must be directed at area of Surgery must be directed at area of bowel responsible for complicationbowel responsible for complication
Indications for SurgeryIndications for Surgery Intestinal obstruction (most Intestinal obstruction (most
common)common) Intractabilitysteroid Intractabilitysteroid
dependencedependence Non-healing fistulaAbscessNon-healing fistulaAbscess Toxic megacolonFree Toxic megacolonFree
perforationperforation Uncontrollable GI bleedingUncontrollable GI bleeding Severe perianal diseaseSevere perianal disease CancerCancer Growth retardation Growth retardation
(children)(children) Severe uncontrollable Severe uncontrollable
extraintestinal extraintestinal manifestationsmanifestations
Management of IBDSummary
The goals of therapy are Relieve symptoms Prevent relapse Correct nutritional deficiencies Control inflammation Prevent complications especially colon cancer
Treatment depends on 1048707 Type of disease 1048707 Site of disease 1048707 Disease severity
Treatment may include drugs nutrition supplements surgery or a combination of these options
Educational ObjectivesEducational Objectives Definitions and spectrum of inflammatory Definitions and spectrum of inflammatory
bowel disease (IBD)bowel disease (IBD) Epidemiology of IBDEpidemiology of IBD Etiopathogenesis of IBDEtiopathogenesis of IBD Clinical manifestations of ulcerative colitis Clinical manifestations of ulcerative colitis
(UC)(UC) Clinical manifestations of Crohnrsquos disease Clinical manifestations of Crohnrsquos disease
(CD)(CD) Distinguishing features between UC and CDDistinguishing features between UC and CD Diagnostic approach to IBDDiagnostic approach to IBD Complications of IBDComplications of IBD IBD managementIBD management
NatureNature NurtureNurture
IBDIBD
GenesGenes EnvironmentEnvironment
Educational ObjectivesEducational Objectives Definitions and spectrum of inflammatory Definitions and spectrum of inflammatory
bowel disease (IBD)bowel disease (IBD) Epidemiology of IBDEpidemiology of IBD Etiopathogenesis of IBDEtiopathogenesis of IBD Clinical manifestations of ulcerative Clinical manifestations of ulcerative
colitis (UC)colitis (UC) Clinical manifestations of Crohnrsquos disease Clinical manifestations of Crohnrsquos disease
(CD)(CD) Distinguishing features between UC and CDDistinguishing features between UC and CD Diagnostic approach to IBDDiagnostic approach to IBD Complications of IBDComplications of IBD IBD managementIBD management
Ulcerative Ulcerative CColitis ndash clinical olitis ndash clinical presentationpresentation
Patients with Patients with proctitisproctitis usually pass fresh blood usually pass fresh blood or blood-stained mucus either mixed with stool or blood-stained mucus either mixed with stool or streaked onto the surface of normal or hard or streaked onto the surface of normal or hard stoolstool tenesmustenesmus is a feature is a feature
When the disease extends When the disease extends beyond the rectumbeyond the rectum blood is usually mixed with stool or grossly blood is usually mixed with stool or grossly bloody diarrhea may be notedbloody diarrhea may be noted
When the disease is When the disease is severesevere patients pass a patients pass a liquid stool containing blood pus fecal matterliquid stool containing blood pus fecal matter
Other symptoms in moderate to severe disease Other symptoms in moderate to severe disease include anorexia nausea vomitting fever include anorexia nausea vomitting fever abdominal pain abdominal pain weight lossweight loss
Ulcerative colitis ndash Ulcerative colitis ndash macroscopic featuresmacroscopic features
Mucosa isMucosa is
- erythematous has a granular surface that looks - erythematous has a granular surface that looks like a sand paperlike a sand paper
In more severe diseasesIn more severe diseases
- hemorrhagic edematous and ulcerated- hemorrhagic edematous and ulcerated
In fulminant diseaseIn fulminant disease a toxic colitis or a toxic a toxic colitis or a toxic megacolon may develop ( wall becomemegacolon may develop ( wall becomess very thin very thin and mucosa is severand mucosa is severeely ulcerated)ly ulcerated)
UCUCDisease Distribution at Disease Distribution at
PresentationPresentation
4637
17
UC ndash disease UC ndash disease severityseverity
MILDMILD MODERATMODERATEE
SEVERESEVERE
BOWEL BOWEL MOVEMENTSMOVEMENTS lt 4 per lt 4 per
dayday 4-6 per 4-6 per dayday
gt6 per gt6 per dayday
BLOOD IN BLOOD IN STOOLSTOOL smallsmall moderatemoderate SevereSevere
FEVERFEVER nonenone lt375lt375degdegC C gt 375gt 375degdegC C
TACHYCARDITACHYCARDIAA
nonenone lt90 mean lt90 mean pulsepulse
gt90 mean gt90 mean pulsepulse
UC ndash disease UC ndash disease severityseverity
MILDMILD MODERATMODERATEE
SEVERESEVERE
ANEMIAANEMIA mildmild gt75gt75 lt75lt75
ESRESR lt30mmlt30mm gt30mmgt30mm
ENDOSCOPIC ENDOSCOPIC APPEARANCEAPPEARANCE
Erythema Erythema decreased decreased vascular vascular pattern fine pattern fine granularitygranularity
Marked Marked erythema erythema coarse coarse granularity granularity contact contact bleeding no bleeding no ulcerationulceration
Spontaneous Spontaneous bleeding bleeding ulcerationulceration
Educational ObjectivesEducational Objectives Definitions and spectrum of inflammatory Definitions and spectrum of inflammatory
bowel disease (IBD)bowel disease (IBD) Epidemiology of IBDEpidemiology of IBD Etiopathogenesis of IBDEtiopathogenesis of IBD Clinical manifestations of ulcerative colitis Clinical manifestations of ulcerative colitis
(UC)(UC) Clinical manifestations of Crohnrsquos disease Clinical manifestations of Crohnrsquos disease
(CD)(CD) Distinguishing features between UC and Distinguishing features between UC and
CDCD Diagnostic approach to IBDDiagnostic approach to IBD Complications of IBDComplications of IBD IBD managementIBD management
CD Clinical FeaturesCD Clinical Features
Abdominal pain often postprandialAbdominal pain often postprandial Diarrhea usually wateryDiarrhea usually watery Rectal bleedingRectal bleeding Weight lossWeight loss Right lower quadrant painpalpable Right lower quadrant painpalpable
massmass FeverFever Growth retardation in childrenGrowth retardation in children Perirectal fistulaPerirectal fistula
Crohnrsquos disease ndash macroscopic Crohnrsquos disease ndash macroscopic featuresfeatures
Can affect any part of GI tract from the mouth to the Can affect any part of GI tract from the mouth to the anusanus
30-40 of patients have small bowel disease alone30-40 of patients have small bowel disease alone
40-55 of patients have both small and large 40-55 of patients have both small and large intestines diseaseintestines disease
15-25 of patients have colitis alone15-25 of patients have colitis alone
In 75 of patients with small intestinal disease the In 75 of patients with small intestinal disease the terminal ileum in involved in 90terminal ileum in involved in 90
Crohnrsquos DiseaseCrohnrsquos DiseaseAnatomic DistributionAnatomic Distribution
Small bowelSmall bowelalonealone(33)(33)
IleocolicIleocolic(45)(45)
Colon aloneColon alone(20)(20)
Frequency of involvementFrequency of involvement
MostMost LeastLeast
Crohnrsquos disease ndash macroscopic Crohnrsquos disease ndash macroscopic featuresfeatures
CD is a CD is a transmuraltransmural process process
CD is CD is segmentalsegmental with skip areas in with skip areas in the midst of diseased intestinethe midst of diseased intestine
In one third of patients with CD In one third of patients with CD perirectal fistulas fissures perirectal fistulas fissures abscesses anal stenosis are presentabscesses anal stenosis are present
Crohnrsquos disease ndash macroscopic Crohnrsquos disease ndash macroscopic featuresfeatures
Active CD is characterized by focal Active CD is characterized by focal inflammation and formation of fistula inflammation and formation of fistula tractstracts
The bowel wall thickens and becomes The bowel wall thickens and becomes narrowed and fibrotic leading to narrowed and fibrotic leading to chronic recurrent bowel obstructionchronic recurrent bowel obstruction
Crohnrsquos Disease Activity Index(CDAI)
Incorporates 8 variables 1 liquid or very soft stools day 2 Abdominal pain amp cramping 3 Extraintestinal manifestations 4 Complications 5 Abdominal mass 6 Use of anti diarrheal medications anti- 7 Hematocrit 8 Body weight
Crohnrsquos Disease Red Crohnrsquos Disease Red FlagsFlags
Onset after stopping smokingOnset after stopping smoking Bleeding onlyBleeding only DiverticulosisDiverticulosis AtherosclerosisAtherosclerosis ProlapseProlapse
Extraintestinal Manifestations of IBD
SkinErythema nodosumPyoderma gangrenosum
JointsPeripheral arthritisSacroileitisAnkylosing spondylitis
EyeUveitisEpiscleritisIritis
Hepatobiliary complicationsGallstonesPSC
Renal complicationsNephrolithiasisRecurrent UTIs
Educational ObjectivesEducational Objectives Definitions and spectrum of inflammatory Definitions and spectrum of inflammatory
bowel disease (IBD)bowel disease (IBD) Epidemiology of IBDEpidemiology of IBD Etiopathogenesis of IBDEtiopathogenesis of IBD Clinical manifestations of ulcerative colitis Clinical manifestations of ulcerative colitis
(UC)(UC) Clinical manifestations of Crohnrsquos disease (CD)Clinical manifestations of Crohnrsquos disease (CD) Distinguishing features between UC and Distinguishing features between UC and
CDCD Diagnostic approach to IBDDiagnostic approach to IBD Medical management of IBDMedical management of IBD Indications for and role of surgeryIndications for and role of surgery
Symptoms of IBDUC vs CDUC vs CD
FeatureFeature UCUC CDCD
FeverFever UncommonUncommon CommonCommon
Rectal Rectal bleedingbleeding
CommonCommon lt frac12 of lt frac12 of patientspatients
Abdominal Abdominal tendernesstenderness
May be May be presentpresent
CommonCommon
Abdominal Abdominal massmass
UncommonUncommon CommonCommon
Abdominal Abdominal painpain
UncommonUncommon Very commonVery common
Weight lossWeight loss UncommonUncommon CommonCommon
TenesmusTenesmus Very commonVery common UncommonUncommon
UC vs CDUC vs CDComplicationsResponse to ComplicationsResponse to
TreatmentTreatmentUCUC CDCD
FistulasFistulas NoNo YesYes
Small Small intestine intestine obstructionobstruction
NoNo FrequentlyFrequently
Colonic Colonic obstructionobstruction
RarelyRarely FrequentlyFrequently
Response to Response to antibioticantibiotic
NoNo YesYes
Recurrence Recurrence after after surgerysurgery
NoNo YesYes
UC vs CDUC vs CDDifferent endoscopic featuresDifferent endoscopic features
UCUC CDCD
Rectal Rectal sparingsparing
RarelyRarely FrequentlyFrequently
Continuous Continuous diseasedisease
YesYes OccasionallyOccasionally
bdquobdquoCCobblestonobblestoningrdquoingrdquo
NoNo YesYes
Granuloma Granuloma on biopsyon biopsy
NoNo OccasionallyOccasionally
Criteria for Indeterminate Criteria for Indeterminate ColitisColitis
No evidence of No evidence of small bowel small bowel involvement involvement fistula or fistula or perianal diseaseperianal disease
Absence of Absence of diagnostic diagnostic criteria for CD criteria for CD or UC by or UC by microscopymicroscopy
Differential Diagnosis of Differential Diagnosis of Chronic Diarrhea and Weight Chronic Diarrhea and Weight
LossLoss Colonic diseasesColonic diseases
IBDIBD NeoplasiaNeoplasia Ischemic bowelIschemic bowel
PancreaticPancreatic Chronic pancreatitisChronic pancreatitis CancerCancer Cystic fibrosisCystic fibrosis
EnteropathicEnteropathic Celiac diseaseCeliac disease Tropical sprueTropical sprue LymphomaLymphoma Mesenteric ischemiaMesenteric ischemia Whipplersquos diseaseWhipplersquos disease
HormonaldrugsHormonaldrugs VipomaVipoma ZESZES Medullary CA of Medullary CA of
thyroidthyroid NSAIDS useNSAIDS use
Educational ObjectivesEducational Objectives Definitions and spectrum of inflammatory Definitions and spectrum of inflammatory
bowel disease (IBD)bowel disease (IBD) Epidemiology of IBDEpidemiology of IBD Etiopathogenesis of IBDEtiopathogenesis of IBD Clinical manifestations of ulcerative colitis Clinical manifestations of ulcerative colitis
(UC)(UC) Clinical manifestations of Crohnrsquos disease Clinical manifestations of Crohnrsquos disease
(CD)(CD) Distinguishing features between UC and CDDistinguishing features between UC and CD Diagnostic approach to IBDDiagnostic approach to IBD Medical management of IBDMedical management of IBD Indications for and role of surgeryIndications for and role of surgery
Diagnostic Approach to Diagnostic Approach to Patients with Suspected Patients with Suspected
IBDIBD HistoryhelliphelliphistoryhelliphelliphistoryHistoryhelliphelliphistoryhelliphelliphistory Clinical examClinical exam Laboratory testsLaboratory tests Radiological imagingRadiological imaging EndoscopyEndoscopy Special serological testingSpecial serological testing Genetic testingGenetic testing
Diagnosis-LAB Blood test
CD Mild anemia mild leukocytosis elevated ESR elevated CRP positive ASCA
UC Anemia hypokalemia hypoalbuminemia elevated ESR elevated LFTs positive p-ANCA
Stool analysis Many WBCs and or RBCs No ova or parasites
What are the Serological What are the Serological Markers in IBDMarkers in IBD
pANCA (perinuclear staining pattern)pANCA (perinuclear staining pattern) Loss of perinuclear pattern after Loss of perinuclear pattern after
DNAaseDNAase Differentiate from the ldquoother pANCAsrdquoDifferentiate from the ldquoother pANCAsrdquo
Antibody against myeloperoxidaseAntibody against myeloperoxidase Antibody against cathepsin G elastase lysozyme Antibody against cathepsin G elastase lysozyme
and lactoferrinand lactoferrin ASCA (anti-ASCA (anti-Saccharomyces cerevisiaeSaccharomyces cerevisiae))
Both IgG and IgABoth IgG and IgA Recognize mannose in the cell wall Recognize mannose in the cell wall
mannan of mannan of Saccharomyces cerevisiaeSaccharomyces cerevisiae
Why Use Serological Why Use Serological Markers in Clinical Markers in Clinical
PracticePractice Differentiate IBD from functional bowel Differentiate IBD from functional bowel
disordersdisorders Accurately diagnose Crohnrsquos or UC in a patient Accurately diagnose Crohnrsquos or UC in a patient
withwith Severe colitisSevere colitis Indeterminate colitisIndeterminate colitis
Predict disease course or complications in IBDPredict disease course or complications in IBD CD phenotypeCD phenotype Severity of diseaseSeverity of disease Risk of pouchitisRisk of pouchitis
SummarySummary
pANCA and ASCA are specific for UC pANCA and ASCA are specific for UC and CD respectivelyand CD respectively
Neither pANCA nor ASCA are sensitive Neither pANCA nor ASCA are sensitive enough to exclude IBDenough to exclude IBD
In patients with IC available In patients with IC available serological markers do not accurately serological markers do not accurately predict the subsequent disease coursepredict the subsequent disease course
Antibody profiles can predict disease Antibody profiles can predict disease behavior in IBDbehavior in IBD
Diagnostic ApproachDiagnostic ApproachEndoscopyEndoscopy
Endoscopy useful forEndoscopy useful for Initial diagnosisInitial diagnosis Assessment of severityAssessment of severity Tissue diagnosisTissue diagnosis FU during treatmentFU during treatment Assessment of disease exacerbationAssessment of disease exacerbation Surveillance for risk of cancerSurveillance for risk of cancer Treatment of certain complications (eg Treatment of certain complications (eg
strictures)strictures)
Crohnrsquos DiseaseCrohnrsquos DiseaseEndoscopic FeaturesEndoscopic Features
Asymmetric patchy inflammationAsymmetric patchy inflammation Skip lesionsSkip lesions Rectal sparingRectal sparing Ulcerations-deepserpiginousUlcerations-deepserpiginous Cobblestoning-commonCobblestoning-common Pseudopolyps-rarePseudopolyps-rare BiopsyBiopsy
Erosions and normal mucosaErosions and normal mucosa Granulomas in 15 to 35 of specimensGranulomas in 15 to 35 of specimens
Ulcerative ColitisUlcerative ColitisEndoscopic FeaturesEndoscopic Features
Diffuse involvementDiffuse involvement Rectum always diseasedRectum always diseased Superficial ulcerationsSuperficial ulcerations FriabilitybleedingFriabilitybleeding Flatteningdisappearance of haustral Flatteningdisappearance of haustral
foldsfolds PseudopolypsPseudopolyps No cobblestoningNo cobblestoning Bx No granulomasBx No granulomas
Imaging for Crohn Imaging for Crohn DiseaseDisease
Traditional TechniquesTraditional Techniques Abdominal RadiographsAbdominal Radiographs
Barium UGI Barium UGI
Barium small bowel follow throughBarium small bowel follow through
Barium EnteroclysisBarium Enteroclysis
Barium EnemaBarium Enema
Imaging for Crohn Disease Imaging for Crohn Disease Newer TechniquesNewer Techniques
CTCT
CT EnteroclysisCT Enteroclysis
CT EnterographyCT Enterography
Magnetic ResonanceMagnetic Resonance
UltrasoundUltrasound
Nuclear MedicineNuclear Medicine
Imaging for Crohns DiseaseImaging for Crohns Disease SummarySummary
Useful Newer TechniquesUseful Newer Techniques evolvingevolving CT EnterographyCT Enterography
Comprehensive evaluation of all bowel amp solid organsComprehensive evaluation of all bowel amp solid organs
Magnetic ResonanceMagnetic Resonance
Useful for ano-rectal diseaseUseful for ano-rectal disease
Real-time MR has potential for detection of stricturesReal-time MR has potential for detection of strictures
Traditional imaging techniques still of value in Traditional imaging techniques still of value in selected cases selected cases
The Capsule (WCE)The Capsule (WCE)
WCEWCE
bull Diameter 11mm Length 26mmDiameter 11mm Length 26mmbull Optical dome Intestinal illumination Optical dome Intestinal illumination
by white light emitting diodes (LEDrsquos)by white light emitting diodes (LEDrsquos)bull LensLensbull Complementary metal-oxide silicone Complementary metal-oxide silicone
imager (color camera chip)imager (color camera chip)bull TransmitterTransmitterbull Two batteries (silver oxide)Two batteries (silver oxide)
GE Junction Duodenum
Jejunum Ileocecal Valve
Educational ObjectivesEducational Objectives Definitions and spectrum of inflammatory Definitions and spectrum of inflammatory
bowel disease (IBD)bowel disease (IBD) Epidemiology of IBDEpidemiology of IBD Etiopathogenesis of IBDEtiopathogenesis of IBD Clinical manifestations of ulcerative colitis Clinical manifestations of ulcerative colitis
(UC)(UC) Clinical manifestations of Crohnrsquos disease Clinical manifestations of Crohnrsquos disease
(CD)(CD) Distinguishing features between UC and CDDistinguishing features between UC and CD Diagnostic approach to IBDDiagnostic approach to IBD Complications of IBDComplications of IBD IBD managementIBD management
IBD-ComplicationsIBD-Complications GI BleedingGI Bleeding Toxic megacolonToxic megacolon PerforationPerforation Thromboembolic phenomenaThromboembolic phenomena FistulasfissuresFistulasfissures AbscessAbscess StricturesobstructionStricturesobstruction MalabsorptionmalnutritionMalabsorptionmalnutrition CancerCancer
Best Protection
Surveillance colonoscopySurveillance colonoscopy
Procto-colectomy (for UC)Procto-colectomy (for UC)
Descending Colon Descending Colon StrictureStricture
Colonic StricturesColonic Strictures
Consider nonsurgical management Consider nonsurgical management ifif Endoscopically accessibleEndoscopically accessible Multiple prior resectionsMultiple prior resections Shorter strictures (less than 5 cm)Shorter strictures (less than 5 cm) Steroid injection if significant Steroid injection if significant
inflammationinflammation
Fistula DefinitionA communication between two epithelial-lined organsLifetime risk of fistula in CD30
Perianal FistulaPerianal Fistula
Pretreatment 2 Weeks
10 Weeks 18 weeks
Educational ObjectivesEducational Objectives Definitions and spectrum of inflammatory Definitions and spectrum of inflammatory
bowel disease (IBD)bowel disease (IBD) Epidemiology of IBDEpidemiology of IBD Etiopathogenesis of IBDEtiopathogenesis of IBD Clinical manifestations of ulcerative colitis Clinical manifestations of ulcerative colitis
(UC)(UC) Clinical manifestations of Crohnrsquos disease Clinical manifestations of Crohnrsquos disease
(CD)(CD) Distinguishing features between UC and CDDistinguishing features between UC and CD Diagnostic approach to IBDDiagnostic approach to IBD Complications of IBDComplications of IBD IBD managementIBD management
Goals of Therapy for IBDGoals of Therapy for IBD
Inducing remissionInducing remission Maintaining remissionMaintaining remission Restoring and maintaining nutritionRestoring and maintaining nutrition Maintaining patientrsquos quality of lifeMaintaining patientrsquos quality of life Prevention of complicationsPrevention of complications Surgical intervention (selection of Surgical intervention (selection of
optimal time for surgery)optimal time for surgery)
Inductive TherapiesInductive Therapies
For UCFor UC AminosalicylatesAminosalicylates CorticosteroidsCorticosteroids CyclosporinCyclosporin
For CDFor CD AminosalicylatesAminosalicylates CorticosteroidsCorticosteroids AntibioticsAntibiotics Anti-TNFAnti-TNF
Maintenance TherapiesMaintenance Therapies
ImmunosupressorsImmunosupressors AzathioprineAzathioprine 6-MP6-MP MethotrexateMethotrexate
AminosalicylatesAminosalicylates Anti-TNFAnti-TNF
NOT NOT corticosteroidscorticosteroids
IBD ManagementIBD ManagementSummarySummary
There is no ldquoone size fits allrdquo to IBD therapyThere is no ldquoone size fits allrdquo to IBD therapy Therapy and decision making are tailored to the Therapy and decision making are tailored to the
individualindividual
Algorithms are based upon available evidenceAlgorithms are based upon available evidence Evidence is in constant fluxEvidence is in constant flux
Success of algorithms depends upon Success of algorithms depends upon optimization of each step of therapy and optimization of each step of therapy and considerable judgment about each outcomeconsiderable judgment about each outcome Skillful application of medical therapy makes all Skillful application of medical therapy makes all
the difference in outcomesthe difference in outcomes
Surgery for IBDSurgery for IBDGeneral ConceptsGeneral Concepts
Majority will need surgery 78 over Majority will need surgery 78 over twenty yearstwenty years
Surgery generally indicated for Surgery generally indicated for complicationscomplications of disease of disease
Surgery must be directed at area of Surgery must be directed at area of bowel responsible for complicationbowel responsible for complication
Indications for SurgeryIndications for Surgery Intestinal obstruction (most Intestinal obstruction (most
common)common) Intractabilitysteroid Intractabilitysteroid
dependencedependence Non-healing fistulaAbscessNon-healing fistulaAbscess Toxic megacolonFree Toxic megacolonFree
perforationperforation Uncontrollable GI bleedingUncontrollable GI bleeding Severe perianal diseaseSevere perianal disease CancerCancer Growth retardation Growth retardation
(children)(children) Severe uncontrollable Severe uncontrollable
extraintestinal extraintestinal manifestationsmanifestations
Management of IBDSummary
The goals of therapy are Relieve symptoms Prevent relapse Correct nutritional deficiencies Control inflammation Prevent complications especially colon cancer
Treatment depends on 1048707 Type of disease 1048707 Site of disease 1048707 Disease severity
Treatment may include drugs nutrition supplements surgery or a combination of these options
NatureNature NurtureNurture
IBDIBD
GenesGenes EnvironmentEnvironment
Educational ObjectivesEducational Objectives Definitions and spectrum of inflammatory Definitions and spectrum of inflammatory
bowel disease (IBD)bowel disease (IBD) Epidemiology of IBDEpidemiology of IBD Etiopathogenesis of IBDEtiopathogenesis of IBD Clinical manifestations of ulcerative Clinical manifestations of ulcerative
colitis (UC)colitis (UC) Clinical manifestations of Crohnrsquos disease Clinical manifestations of Crohnrsquos disease
(CD)(CD) Distinguishing features between UC and CDDistinguishing features between UC and CD Diagnostic approach to IBDDiagnostic approach to IBD Complications of IBDComplications of IBD IBD managementIBD management
Ulcerative Ulcerative CColitis ndash clinical olitis ndash clinical presentationpresentation
Patients with Patients with proctitisproctitis usually pass fresh blood usually pass fresh blood or blood-stained mucus either mixed with stool or blood-stained mucus either mixed with stool or streaked onto the surface of normal or hard or streaked onto the surface of normal or hard stoolstool tenesmustenesmus is a feature is a feature
When the disease extends When the disease extends beyond the rectumbeyond the rectum blood is usually mixed with stool or grossly blood is usually mixed with stool or grossly bloody diarrhea may be notedbloody diarrhea may be noted
When the disease is When the disease is severesevere patients pass a patients pass a liquid stool containing blood pus fecal matterliquid stool containing blood pus fecal matter
Other symptoms in moderate to severe disease Other symptoms in moderate to severe disease include anorexia nausea vomitting fever include anorexia nausea vomitting fever abdominal pain abdominal pain weight lossweight loss
Ulcerative colitis ndash Ulcerative colitis ndash macroscopic featuresmacroscopic features
Mucosa isMucosa is
- erythematous has a granular surface that looks - erythematous has a granular surface that looks like a sand paperlike a sand paper
In more severe diseasesIn more severe diseases
- hemorrhagic edematous and ulcerated- hemorrhagic edematous and ulcerated
In fulminant diseaseIn fulminant disease a toxic colitis or a toxic a toxic colitis or a toxic megacolon may develop ( wall becomemegacolon may develop ( wall becomess very thin very thin and mucosa is severand mucosa is severeely ulcerated)ly ulcerated)
UCUCDisease Distribution at Disease Distribution at
PresentationPresentation
4637
17
UC ndash disease UC ndash disease severityseverity
MILDMILD MODERATMODERATEE
SEVERESEVERE
BOWEL BOWEL MOVEMENTSMOVEMENTS lt 4 per lt 4 per
dayday 4-6 per 4-6 per dayday
gt6 per gt6 per dayday
BLOOD IN BLOOD IN STOOLSTOOL smallsmall moderatemoderate SevereSevere
FEVERFEVER nonenone lt375lt375degdegC C gt 375gt 375degdegC C
TACHYCARDITACHYCARDIAA
nonenone lt90 mean lt90 mean pulsepulse
gt90 mean gt90 mean pulsepulse
UC ndash disease UC ndash disease severityseverity
MILDMILD MODERATMODERATEE
SEVERESEVERE
ANEMIAANEMIA mildmild gt75gt75 lt75lt75
ESRESR lt30mmlt30mm gt30mmgt30mm
ENDOSCOPIC ENDOSCOPIC APPEARANCEAPPEARANCE
Erythema Erythema decreased decreased vascular vascular pattern fine pattern fine granularitygranularity
Marked Marked erythema erythema coarse coarse granularity granularity contact contact bleeding no bleeding no ulcerationulceration
Spontaneous Spontaneous bleeding bleeding ulcerationulceration
Educational ObjectivesEducational Objectives Definitions and spectrum of inflammatory Definitions and spectrum of inflammatory
bowel disease (IBD)bowel disease (IBD) Epidemiology of IBDEpidemiology of IBD Etiopathogenesis of IBDEtiopathogenesis of IBD Clinical manifestations of ulcerative colitis Clinical manifestations of ulcerative colitis
(UC)(UC) Clinical manifestations of Crohnrsquos disease Clinical manifestations of Crohnrsquos disease
(CD)(CD) Distinguishing features between UC and Distinguishing features between UC and
CDCD Diagnostic approach to IBDDiagnostic approach to IBD Complications of IBDComplications of IBD IBD managementIBD management
CD Clinical FeaturesCD Clinical Features
Abdominal pain often postprandialAbdominal pain often postprandial Diarrhea usually wateryDiarrhea usually watery Rectal bleedingRectal bleeding Weight lossWeight loss Right lower quadrant painpalpable Right lower quadrant painpalpable
massmass FeverFever Growth retardation in childrenGrowth retardation in children Perirectal fistulaPerirectal fistula
Crohnrsquos disease ndash macroscopic Crohnrsquos disease ndash macroscopic featuresfeatures
Can affect any part of GI tract from the mouth to the Can affect any part of GI tract from the mouth to the anusanus
30-40 of patients have small bowel disease alone30-40 of patients have small bowel disease alone
40-55 of patients have both small and large 40-55 of patients have both small and large intestines diseaseintestines disease
15-25 of patients have colitis alone15-25 of patients have colitis alone
In 75 of patients with small intestinal disease the In 75 of patients with small intestinal disease the terminal ileum in involved in 90terminal ileum in involved in 90
Crohnrsquos DiseaseCrohnrsquos DiseaseAnatomic DistributionAnatomic Distribution
Small bowelSmall bowelalonealone(33)(33)
IleocolicIleocolic(45)(45)
Colon aloneColon alone(20)(20)
Frequency of involvementFrequency of involvement
MostMost LeastLeast
Crohnrsquos disease ndash macroscopic Crohnrsquos disease ndash macroscopic featuresfeatures
CD is a CD is a transmuraltransmural process process
CD is CD is segmentalsegmental with skip areas in with skip areas in the midst of diseased intestinethe midst of diseased intestine
In one third of patients with CD In one third of patients with CD perirectal fistulas fissures perirectal fistulas fissures abscesses anal stenosis are presentabscesses anal stenosis are present
Crohnrsquos disease ndash macroscopic Crohnrsquos disease ndash macroscopic featuresfeatures
Active CD is characterized by focal Active CD is characterized by focal inflammation and formation of fistula inflammation and formation of fistula tractstracts
The bowel wall thickens and becomes The bowel wall thickens and becomes narrowed and fibrotic leading to narrowed and fibrotic leading to chronic recurrent bowel obstructionchronic recurrent bowel obstruction
Crohnrsquos Disease Activity Index(CDAI)
Incorporates 8 variables 1 liquid or very soft stools day 2 Abdominal pain amp cramping 3 Extraintestinal manifestations 4 Complications 5 Abdominal mass 6 Use of anti diarrheal medications anti- 7 Hematocrit 8 Body weight
Crohnrsquos Disease Red Crohnrsquos Disease Red FlagsFlags
Onset after stopping smokingOnset after stopping smoking Bleeding onlyBleeding only DiverticulosisDiverticulosis AtherosclerosisAtherosclerosis ProlapseProlapse
Extraintestinal Manifestations of IBD
SkinErythema nodosumPyoderma gangrenosum
JointsPeripheral arthritisSacroileitisAnkylosing spondylitis
EyeUveitisEpiscleritisIritis
Hepatobiliary complicationsGallstonesPSC
Renal complicationsNephrolithiasisRecurrent UTIs
Educational ObjectivesEducational Objectives Definitions and spectrum of inflammatory Definitions and spectrum of inflammatory
bowel disease (IBD)bowel disease (IBD) Epidemiology of IBDEpidemiology of IBD Etiopathogenesis of IBDEtiopathogenesis of IBD Clinical manifestations of ulcerative colitis Clinical manifestations of ulcerative colitis
(UC)(UC) Clinical manifestations of Crohnrsquos disease (CD)Clinical manifestations of Crohnrsquos disease (CD) Distinguishing features between UC and Distinguishing features between UC and
CDCD Diagnostic approach to IBDDiagnostic approach to IBD Medical management of IBDMedical management of IBD Indications for and role of surgeryIndications for and role of surgery
Symptoms of IBDUC vs CDUC vs CD
FeatureFeature UCUC CDCD
FeverFever UncommonUncommon CommonCommon
Rectal Rectal bleedingbleeding
CommonCommon lt frac12 of lt frac12 of patientspatients
Abdominal Abdominal tendernesstenderness
May be May be presentpresent
CommonCommon
Abdominal Abdominal massmass
UncommonUncommon CommonCommon
Abdominal Abdominal painpain
UncommonUncommon Very commonVery common
Weight lossWeight loss UncommonUncommon CommonCommon
TenesmusTenesmus Very commonVery common UncommonUncommon
UC vs CDUC vs CDComplicationsResponse to ComplicationsResponse to
TreatmentTreatmentUCUC CDCD
FistulasFistulas NoNo YesYes
Small Small intestine intestine obstructionobstruction
NoNo FrequentlyFrequently
Colonic Colonic obstructionobstruction
RarelyRarely FrequentlyFrequently
Response to Response to antibioticantibiotic
NoNo YesYes
Recurrence Recurrence after after surgerysurgery
NoNo YesYes
UC vs CDUC vs CDDifferent endoscopic featuresDifferent endoscopic features
UCUC CDCD
Rectal Rectal sparingsparing
RarelyRarely FrequentlyFrequently
Continuous Continuous diseasedisease
YesYes OccasionallyOccasionally
bdquobdquoCCobblestonobblestoningrdquoingrdquo
NoNo YesYes
Granuloma Granuloma on biopsyon biopsy
NoNo OccasionallyOccasionally
Criteria for Indeterminate Criteria for Indeterminate ColitisColitis
No evidence of No evidence of small bowel small bowel involvement involvement fistula or fistula or perianal diseaseperianal disease
Absence of Absence of diagnostic diagnostic criteria for CD criteria for CD or UC by or UC by microscopymicroscopy
Differential Diagnosis of Differential Diagnosis of Chronic Diarrhea and Weight Chronic Diarrhea and Weight
LossLoss Colonic diseasesColonic diseases
IBDIBD NeoplasiaNeoplasia Ischemic bowelIschemic bowel
PancreaticPancreatic Chronic pancreatitisChronic pancreatitis CancerCancer Cystic fibrosisCystic fibrosis
EnteropathicEnteropathic Celiac diseaseCeliac disease Tropical sprueTropical sprue LymphomaLymphoma Mesenteric ischemiaMesenteric ischemia Whipplersquos diseaseWhipplersquos disease
HormonaldrugsHormonaldrugs VipomaVipoma ZESZES Medullary CA of Medullary CA of
thyroidthyroid NSAIDS useNSAIDS use
Educational ObjectivesEducational Objectives Definitions and spectrum of inflammatory Definitions and spectrum of inflammatory
bowel disease (IBD)bowel disease (IBD) Epidemiology of IBDEpidemiology of IBD Etiopathogenesis of IBDEtiopathogenesis of IBD Clinical manifestations of ulcerative colitis Clinical manifestations of ulcerative colitis
(UC)(UC) Clinical manifestations of Crohnrsquos disease Clinical manifestations of Crohnrsquos disease
(CD)(CD) Distinguishing features between UC and CDDistinguishing features between UC and CD Diagnostic approach to IBDDiagnostic approach to IBD Medical management of IBDMedical management of IBD Indications for and role of surgeryIndications for and role of surgery
Diagnostic Approach to Diagnostic Approach to Patients with Suspected Patients with Suspected
IBDIBD HistoryhelliphelliphistoryhelliphelliphistoryHistoryhelliphelliphistoryhelliphelliphistory Clinical examClinical exam Laboratory testsLaboratory tests Radiological imagingRadiological imaging EndoscopyEndoscopy Special serological testingSpecial serological testing Genetic testingGenetic testing
Diagnosis-LAB Blood test
CD Mild anemia mild leukocytosis elevated ESR elevated CRP positive ASCA
UC Anemia hypokalemia hypoalbuminemia elevated ESR elevated LFTs positive p-ANCA
Stool analysis Many WBCs and or RBCs No ova or parasites
What are the Serological What are the Serological Markers in IBDMarkers in IBD
pANCA (perinuclear staining pattern)pANCA (perinuclear staining pattern) Loss of perinuclear pattern after Loss of perinuclear pattern after
DNAaseDNAase Differentiate from the ldquoother pANCAsrdquoDifferentiate from the ldquoother pANCAsrdquo
Antibody against myeloperoxidaseAntibody against myeloperoxidase Antibody against cathepsin G elastase lysozyme Antibody against cathepsin G elastase lysozyme
and lactoferrinand lactoferrin ASCA (anti-ASCA (anti-Saccharomyces cerevisiaeSaccharomyces cerevisiae))
Both IgG and IgABoth IgG and IgA Recognize mannose in the cell wall Recognize mannose in the cell wall
mannan of mannan of Saccharomyces cerevisiaeSaccharomyces cerevisiae
Why Use Serological Why Use Serological Markers in Clinical Markers in Clinical
PracticePractice Differentiate IBD from functional bowel Differentiate IBD from functional bowel
disordersdisorders Accurately diagnose Crohnrsquos or UC in a patient Accurately diagnose Crohnrsquos or UC in a patient
withwith Severe colitisSevere colitis Indeterminate colitisIndeterminate colitis
Predict disease course or complications in IBDPredict disease course or complications in IBD CD phenotypeCD phenotype Severity of diseaseSeverity of disease Risk of pouchitisRisk of pouchitis
SummarySummary
pANCA and ASCA are specific for UC pANCA and ASCA are specific for UC and CD respectivelyand CD respectively
Neither pANCA nor ASCA are sensitive Neither pANCA nor ASCA are sensitive enough to exclude IBDenough to exclude IBD
In patients with IC available In patients with IC available serological markers do not accurately serological markers do not accurately predict the subsequent disease coursepredict the subsequent disease course
Antibody profiles can predict disease Antibody profiles can predict disease behavior in IBDbehavior in IBD
Diagnostic ApproachDiagnostic ApproachEndoscopyEndoscopy
Endoscopy useful forEndoscopy useful for Initial diagnosisInitial diagnosis Assessment of severityAssessment of severity Tissue diagnosisTissue diagnosis FU during treatmentFU during treatment Assessment of disease exacerbationAssessment of disease exacerbation Surveillance for risk of cancerSurveillance for risk of cancer Treatment of certain complications (eg Treatment of certain complications (eg
strictures)strictures)
Crohnrsquos DiseaseCrohnrsquos DiseaseEndoscopic FeaturesEndoscopic Features
Asymmetric patchy inflammationAsymmetric patchy inflammation Skip lesionsSkip lesions Rectal sparingRectal sparing Ulcerations-deepserpiginousUlcerations-deepserpiginous Cobblestoning-commonCobblestoning-common Pseudopolyps-rarePseudopolyps-rare BiopsyBiopsy
Erosions and normal mucosaErosions and normal mucosa Granulomas in 15 to 35 of specimensGranulomas in 15 to 35 of specimens
Ulcerative ColitisUlcerative ColitisEndoscopic FeaturesEndoscopic Features
Diffuse involvementDiffuse involvement Rectum always diseasedRectum always diseased Superficial ulcerationsSuperficial ulcerations FriabilitybleedingFriabilitybleeding Flatteningdisappearance of haustral Flatteningdisappearance of haustral
foldsfolds PseudopolypsPseudopolyps No cobblestoningNo cobblestoning Bx No granulomasBx No granulomas
Imaging for Crohn Imaging for Crohn DiseaseDisease
Traditional TechniquesTraditional Techniques Abdominal RadiographsAbdominal Radiographs
Barium UGI Barium UGI
Barium small bowel follow throughBarium small bowel follow through
Barium EnteroclysisBarium Enteroclysis
Barium EnemaBarium Enema
Imaging for Crohn Disease Imaging for Crohn Disease Newer TechniquesNewer Techniques
CTCT
CT EnteroclysisCT Enteroclysis
CT EnterographyCT Enterography
Magnetic ResonanceMagnetic Resonance
UltrasoundUltrasound
Nuclear MedicineNuclear Medicine
Imaging for Crohns DiseaseImaging for Crohns Disease SummarySummary
Useful Newer TechniquesUseful Newer Techniques evolvingevolving CT EnterographyCT Enterography
Comprehensive evaluation of all bowel amp solid organsComprehensive evaluation of all bowel amp solid organs
Magnetic ResonanceMagnetic Resonance
Useful for ano-rectal diseaseUseful for ano-rectal disease
Real-time MR has potential for detection of stricturesReal-time MR has potential for detection of strictures
Traditional imaging techniques still of value in Traditional imaging techniques still of value in selected cases selected cases
The Capsule (WCE)The Capsule (WCE)
WCEWCE
bull Diameter 11mm Length 26mmDiameter 11mm Length 26mmbull Optical dome Intestinal illumination Optical dome Intestinal illumination
by white light emitting diodes (LEDrsquos)by white light emitting diodes (LEDrsquos)bull LensLensbull Complementary metal-oxide silicone Complementary metal-oxide silicone
imager (color camera chip)imager (color camera chip)bull TransmitterTransmitterbull Two batteries (silver oxide)Two batteries (silver oxide)
GE Junction Duodenum
Jejunum Ileocecal Valve
Educational ObjectivesEducational Objectives Definitions and spectrum of inflammatory Definitions and spectrum of inflammatory
bowel disease (IBD)bowel disease (IBD) Epidemiology of IBDEpidemiology of IBD Etiopathogenesis of IBDEtiopathogenesis of IBD Clinical manifestations of ulcerative colitis Clinical manifestations of ulcerative colitis
(UC)(UC) Clinical manifestations of Crohnrsquos disease Clinical manifestations of Crohnrsquos disease
(CD)(CD) Distinguishing features between UC and CDDistinguishing features between UC and CD Diagnostic approach to IBDDiagnostic approach to IBD Complications of IBDComplications of IBD IBD managementIBD management
IBD-ComplicationsIBD-Complications GI BleedingGI Bleeding Toxic megacolonToxic megacolon PerforationPerforation Thromboembolic phenomenaThromboembolic phenomena FistulasfissuresFistulasfissures AbscessAbscess StricturesobstructionStricturesobstruction MalabsorptionmalnutritionMalabsorptionmalnutrition CancerCancer
Best Protection
Surveillance colonoscopySurveillance colonoscopy
Procto-colectomy (for UC)Procto-colectomy (for UC)
Descending Colon Descending Colon StrictureStricture
Colonic StricturesColonic Strictures
Consider nonsurgical management Consider nonsurgical management ifif Endoscopically accessibleEndoscopically accessible Multiple prior resectionsMultiple prior resections Shorter strictures (less than 5 cm)Shorter strictures (less than 5 cm) Steroid injection if significant Steroid injection if significant
inflammationinflammation
Fistula DefinitionA communication between two epithelial-lined organsLifetime risk of fistula in CD30
Perianal FistulaPerianal Fistula
Pretreatment 2 Weeks
10 Weeks 18 weeks
Educational ObjectivesEducational Objectives Definitions and spectrum of inflammatory Definitions and spectrum of inflammatory
bowel disease (IBD)bowel disease (IBD) Epidemiology of IBDEpidemiology of IBD Etiopathogenesis of IBDEtiopathogenesis of IBD Clinical manifestations of ulcerative colitis Clinical manifestations of ulcerative colitis
(UC)(UC) Clinical manifestations of Crohnrsquos disease Clinical manifestations of Crohnrsquos disease
(CD)(CD) Distinguishing features between UC and CDDistinguishing features between UC and CD Diagnostic approach to IBDDiagnostic approach to IBD Complications of IBDComplications of IBD IBD managementIBD management
Goals of Therapy for IBDGoals of Therapy for IBD
Inducing remissionInducing remission Maintaining remissionMaintaining remission Restoring and maintaining nutritionRestoring and maintaining nutrition Maintaining patientrsquos quality of lifeMaintaining patientrsquos quality of life Prevention of complicationsPrevention of complications Surgical intervention (selection of Surgical intervention (selection of
optimal time for surgery)optimal time for surgery)
Inductive TherapiesInductive Therapies
For UCFor UC AminosalicylatesAminosalicylates CorticosteroidsCorticosteroids CyclosporinCyclosporin
For CDFor CD AminosalicylatesAminosalicylates CorticosteroidsCorticosteroids AntibioticsAntibiotics Anti-TNFAnti-TNF
Maintenance TherapiesMaintenance Therapies
ImmunosupressorsImmunosupressors AzathioprineAzathioprine 6-MP6-MP MethotrexateMethotrexate
AminosalicylatesAminosalicylates Anti-TNFAnti-TNF
NOT NOT corticosteroidscorticosteroids
IBD ManagementIBD ManagementSummarySummary
There is no ldquoone size fits allrdquo to IBD therapyThere is no ldquoone size fits allrdquo to IBD therapy Therapy and decision making are tailored to the Therapy and decision making are tailored to the
individualindividual
Algorithms are based upon available evidenceAlgorithms are based upon available evidence Evidence is in constant fluxEvidence is in constant flux
Success of algorithms depends upon Success of algorithms depends upon optimization of each step of therapy and optimization of each step of therapy and considerable judgment about each outcomeconsiderable judgment about each outcome Skillful application of medical therapy makes all Skillful application of medical therapy makes all
the difference in outcomesthe difference in outcomes
Surgery for IBDSurgery for IBDGeneral ConceptsGeneral Concepts
Majority will need surgery 78 over Majority will need surgery 78 over twenty yearstwenty years
Surgery generally indicated for Surgery generally indicated for complicationscomplications of disease of disease
Surgery must be directed at area of Surgery must be directed at area of bowel responsible for complicationbowel responsible for complication
Indications for SurgeryIndications for Surgery Intestinal obstruction (most Intestinal obstruction (most
common)common) Intractabilitysteroid Intractabilitysteroid
dependencedependence Non-healing fistulaAbscessNon-healing fistulaAbscess Toxic megacolonFree Toxic megacolonFree
perforationperforation Uncontrollable GI bleedingUncontrollable GI bleeding Severe perianal diseaseSevere perianal disease CancerCancer Growth retardation Growth retardation
(children)(children) Severe uncontrollable Severe uncontrollable
extraintestinal extraintestinal manifestationsmanifestations
Management of IBDSummary
The goals of therapy are Relieve symptoms Prevent relapse Correct nutritional deficiencies Control inflammation Prevent complications especially colon cancer
Treatment depends on 1048707 Type of disease 1048707 Site of disease 1048707 Disease severity
Treatment may include drugs nutrition supplements surgery or a combination of these options
Educational ObjectivesEducational Objectives Definitions and spectrum of inflammatory Definitions and spectrum of inflammatory
bowel disease (IBD)bowel disease (IBD) Epidemiology of IBDEpidemiology of IBD Etiopathogenesis of IBDEtiopathogenesis of IBD Clinical manifestations of ulcerative Clinical manifestations of ulcerative
colitis (UC)colitis (UC) Clinical manifestations of Crohnrsquos disease Clinical manifestations of Crohnrsquos disease
(CD)(CD) Distinguishing features between UC and CDDistinguishing features between UC and CD Diagnostic approach to IBDDiagnostic approach to IBD Complications of IBDComplications of IBD IBD managementIBD management
Ulcerative Ulcerative CColitis ndash clinical olitis ndash clinical presentationpresentation
Patients with Patients with proctitisproctitis usually pass fresh blood usually pass fresh blood or blood-stained mucus either mixed with stool or blood-stained mucus either mixed with stool or streaked onto the surface of normal or hard or streaked onto the surface of normal or hard stoolstool tenesmustenesmus is a feature is a feature
When the disease extends When the disease extends beyond the rectumbeyond the rectum blood is usually mixed with stool or grossly blood is usually mixed with stool or grossly bloody diarrhea may be notedbloody diarrhea may be noted
When the disease is When the disease is severesevere patients pass a patients pass a liquid stool containing blood pus fecal matterliquid stool containing blood pus fecal matter
Other symptoms in moderate to severe disease Other symptoms in moderate to severe disease include anorexia nausea vomitting fever include anorexia nausea vomitting fever abdominal pain abdominal pain weight lossweight loss
Ulcerative colitis ndash Ulcerative colitis ndash macroscopic featuresmacroscopic features
Mucosa isMucosa is
- erythematous has a granular surface that looks - erythematous has a granular surface that looks like a sand paperlike a sand paper
In more severe diseasesIn more severe diseases
- hemorrhagic edematous and ulcerated- hemorrhagic edematous and ulcerated
In fulminant diseaseIn fulminant disease a toxic colitis or a toxic a toxic colitis or a toxic megacolon may develop ( wall becomemegacolon may develop ( wall becomess very thin very thin and mucosa is severand mucosa is severeely ulcerated)ly ulcerated)
UCUCDisease Distribution at Disease Distribution at
PresentationPresentation
4637
17
UC ndash disease UC ndash disease severityseverity
MILDMILD MODERATMODERATEE
SEVERESEVERE
BOWEL BOWEL MOVEMENTSMOVEMENTS lt 4 per lt 4 per
dayday 4-6 per 4-6 per dayday
gt6 per gt6 per dayday
BLOOD IN BLOOD IN STOOLSTOOL smallsmall moderatemoderate SevereSevere
FEVERFEVER nonenone lt375lt375degdegC C gt 375gt 375degdegC C
TACHYCARDITACHYCARDIAA
nonenone lt90 mean lt90 mean pulsepulse
gt90 mean gt90 mean pulsepulse
UC ndash disease UC ndash disease severityseverity
MILDMILD MODERATMODERATEE
SEVERESEVERE
ANEMIAANEMIA mildmild gt75gt75 lt75lt75
ESRESR lt30mmlt30mm gt30mmgt30mm
ENDOSCOPIC ENDOSCOPIC APPEARANCEAPPEARANCE
Erythema Erythema decreased decreased vascular vascular pattern fine pattern fine granularitygranularity
Marked Marked erythema erythema coarse coarse granularity granularity contact contact bleeding no bleeding no ulcerationulceration
Spontaneous Spontaneous bleeding bleeding ulcerationulceration
Educational ObjectivesEducational Objectives Definitions and spectrum of inflammatory Definitions and spectrum of inflammatory
bowel disease (IBD)bowel disease (IBD) Epidemiology of IBDEpidemiology of IBD Etiopathogenesis of IBDEtiopathogenesis of IBD Clinical manifestations of ulcerative colitis Clinical manifestations of ulcerative colitis
(UC)(UC) Clinical manifestations of Crohnrsquos disease Clinical manifestations of Crohnrsquos disease
(CD)(CD) Distinguishing features between UC and Distinguishing features between UC and
CDCD Diagnostic approach to IBDDiagnostic approach to IBD Complications of IBDComplications of IBD IBD managementIBD management
CD Clinical FeaturesCD Clinical Features
Abdominal pain often postprandialAbdominal pain often postprandial Diarrhea usually wateryDiarrhea usually watery Rectal bleedingRectal bleeding Weight lossWeight loss Right lower quadrant painpalpable Right lower quadrant painpalpable
massmass FeverFever Growth retardation in childrenGrowth retardation in children Perirectal fistulaPerirectal fistula
Crohnrsquos disease ndash macroscopic Crohnrsquos disease ndash macroscopic featuresfeatures
Can affect any part of GI tract from the mouth to the Can affect any part of GI tract from the mouth to the anusanus
30-40 of patients have small bowel disease alone30-40 of patients have small bowel disease alone
40-55 of patients have both small and large 40-55 of patients have both small and large intestines diseaseintestines disease
15-25 of patients have colitis alone15-25 of patients have colitis alone
In 75 of patients with small intestinal disease the In 75 of patients with small intestinal disease the terminal ileum in involved in 90terminal ileum in involved in 90
Crohnrsquos DiseaseCrohnrsquos DiseaseAnatomic DistributionAnatomic Distribution
Small bowelSmall bowelalonealone(33)(33)
IleocolicIleocolic(45)(45)
Colon aloneColon alone(20)(20)
Frequency of involvementFrequency of involvement
MostMost LeastLeast
Crohnrsquos disease ndash macroscopic Crohnrsquos disease ndash macroscopic featuresfeatures
CD is a CD is a transmuraltransmural process process
CD is CD is segmentalsegmental with skip areas in with skip areas in the midst of diseased intestinethe midst of diseased intestine
In one third of patients with CD In one third of patients with CD perirectal fistulas fissures perirectal fistulas fissures abscesses anal stenosis are presentabscesses anal stenosis are present
Crohnrsquos disease ndash macroscopic Crohnrsquos disease ndash macroscopic featuresfeatures
Active CD is characterized by focal Active CD is characterized by focal inflammation and formation of fistula inflammation and formation of fistula tractstracts
The bowel wall thickens and becomes The bowel wall thickens and becomes narrowed and fibrotic leading to narrowed and fibrotic leading to chronic recurrent bowel obstructionchronic recurrent bowel obstruction
Crohnrsquos Disease Activity Index(CDAI)
Incorporates 8 variables 1 liquid or very soft stools day 2 Abdominal pain amp cramping 3 Extraintestinal manifestations 4 Complications 5 Abdominal mass 6 Use of anti diarrheal medications anti- 7 Hematocrit 8 Body weight
Crohnrsquos Disease Red Crohnrsquos Disease Red FlagsFlags
Onset after stopping smokingOnset after stopping smoking Bleeding onlyBleeding only DiverticulosisDiverticulosis AtherosclerosisAtherosclerosis ProlapseProlapse
Extraintestinal Manifestations of IBD
SkinErythema nodosumPyoderma gangrenosum
JointsPeripheral arthritisSacroileitisAnkylosing spondylitis
EyeUveitisEpiscleritisIritis
Hepatobiliary complicationsGallstonesPSC
Renal complicationsNephrolithiasisRecurrent UTIs
Educational ObjectivesEducational Objectives Definitions and spectrum of inflammatory Definitions and spectrum of inflammatory
bowel disease (IBD)bowel disease (IBD) Epidemiology of IBDEpidemiology of IBD Etiopathogenesis of IBDEtiopathogenesis of IBD Clinical manifestations of ulcerative colitis Clinical manifestations of ulcerative colitis
(UC)(UC) Clinical manifestations of Crohnrsquos disease (CD)Clinical manifestations of Crohnrsquos disease (CD) Distinguishing features between UC and Distinguishing features between UC and
CDCD Diagnostic approach to IBDDiagnostic approach to IBD Medical management of IBDMedical management of IBD Indications for and role of surgeryIndications for and role of surgery
Symptoms of IBDUC vs CDUC vs CD
FeatureFeature UCUC CDCD
FeverFever UncommonUncommon CommonCommon
Rectal Rectal bleedingbleeding
CommonCommon lt frac12 of lt frac12 of patientspatients
Abdominal Abdominal tendernesstenderness
May be May be presentpresent
CommonCommon
Abdominal Abdominal massmass
UncommonUncommon CommonCommon
Abdominal Abdominal painpain
UncommonUncommon Very commonVery common
Weight lossWeight loss UncommonUncommon CommonCommon
TenesmusTenesmus Very commonVery common UncommonUncommon
UC vs CDUC vs CDComplicationsResponse to ComplicationsResponse to
TreatmentTreatmentUCUC CDCD
FistulasFistulas NoNo YesYes
Small Small intestine intestine obstructionobstruction
NoNo FrequentlyFrequently
Colonic Colonic obstructionobstruction
RarelyRarely FrequentlyFrequently
Response to Response to antibioticantibiotic
NoNo YesYes
Recurrence Recurrence after after surgerysurgery
NoNo YesYes
UC vs CDUC vs CDDifferent endoscopic featuresDifferent endoscopic features
UCUC CDCD
Rectal Rectal sparingsparing
RarelyRarely FrequentlyFrequently
Continuous Continuous diseasedisease
YesYes OccasionallyOccasionally
bdquobdquoCCobblestonobblestoningrdquoingrdquo
NoNo YesYes
Granuloma Granuloma on biopsyon biopsy
NoNo OccasionallyOccasionally
Criteria for Indeterminate Criteria for Indeterminate ColitisColitis
No evidence of No evidence of small bowel small bowel involvement involvement fistula or fistula or perianal diseaseperianal disease
Absence of Absence of diagnostic diagnostic criteria for CD criteria for CD or UC by or UC by microscopymicroscopy
Differential Diagnosis of Differential Diagnosis of Chronic Diarrhea and Weight Chronic Diarrhea and Weight
LossLoss Colonic diseasesColonic diseases
IBDIBD NeoplasiaNeoplasia Ischemic bowelIschemic bowel
PancreaticPancreatic Chronic pancreatitisChronic pancreatitis CancerCancer Cystic fibrosisCystic fibrosis
EnteropathicEnteropathic Celiac diseaseCeliac disease Tropical sprueTropical sprue LymphomaLymphoma Mesenteric ischemiaMesenteric ischemia Whipplersquos diseaseWhipplersquos disease
HormonaldrugsHormonaldrugs VipomaVipoma ZESZES Medullary CA of Medullary CA of
thyroidthyroid NSAIDS useNSAIDS use
Educational ObjectivesEducational Objectives Definitions and spectrum of inflammatory Definitions and spectrum of inflammatory
bowel disease (IBD)bowel disease (IBD) Epidemiology of IBDEpidemiology of IBD Etiopathogenesis of IBDEtiopathogenesis of IBD Clinical manifestations of ulcerative colitis Clinical manifestations of ulcerative colitis
(UC)(UC) Clinical manifestations of Crohnrsquos disease Clinical manifestations of Crohnrsquos disease
(CD)(CD) Distinguishing features between UC and CDDistinguishing features between UC and CD Diagnostic approach to IBDDiagnostic approach to IBD Medical management of IBDMedical management of IBD Indications for and role of surgeryIndications for and role of surgery
Diagnostic Approach to Diagnostic Approach to Patients with Suspected Patients with Suspected
IBDIBD HistoryhelliphelliphistoryhelliphelliphistoryHistoryhelliphelliphistoryhelliphelliphistory Clinical examClinical exam Laboratory testsLaboratory tests Radiological imagingRadiological imaging EndoscopyEndoscopy Special serological testingSpecial serological testing Genetic testingGenetic testing
Diagnosis-LAB Blood test
CD Mild anemia mild leukocytosis elevated ESR elevated CRP positive ASCA
UC Anemia hypokalemia hypoalbuminemia elevated ESR elevated LFTs positive p-ANCA
Stool analysis Many WBCs and or RBCs No ova or parasites
What are the Serological What are the Serological Markers in IBDMarkers in IBD
pANCA (perinuclear staining pattern)pANCA (perinuclear staining pattern) Loss of perinuclear pattern after Loss of perinuclear pattern after
DNAaseDNAase Differentiate from the ldquoother pANCAsrdquoDifferentiate from the ldquoother pANCAsrdquo
Antibody against myeloperoxidaseAntibody against myeloperoxidase Antibody against cathepsin G elastase lysozyme Antibody against cathepsin G elastase lysozyme
and lactoferrinand lactoferrin ASCA (anti-ASCA (anti-Saccharomyces cerevisiaeSaccharomyces cerevisiae))
Both IgG and IgABoth IgG and IgA Recognize mannose in the cell wall Recognize mannose in the cell wall
mannan of mannan of Saccharomyces cerevisiaeSaccharomyces cerevisiae
Why Use Serological Why Use Serological Markers in Clinical Markers in Clinical
PracticePractice Differentiate IBD from functional bowel Differentiate IBD from functional bowel
disordersdisorders Accurately diagnose Crohnrsquos or UC in a patient Accurately diagnose Crohnrsquos or UC in a patient
withwith Severe colitisSevere colitis Indeterminate colitisIndeterminate colitis
Predict disease course or complications in IBDPredict disease course or complications in IBD CD phenotypeCD phenotype Severity of diseaseSeverity of disease Risk of pouchitisRisk of pouchitis
SummarySummary
pANCA and ASCA are specific for UC pANCA and ASCA are specific for UC and CD respectivelyand CD respectively
Neither pANCA nor ASCA are sensitive Neither pANCA nor ASCA are sensitive enough to exclude IBDenough to exclude IBD
In patients with IC available In patients with IC available serological markers do not accurately serological markers do not accurately predict the subsequent disease coursepredict the subsequent disease course
Antibody profiles can predict disease Antibody profiles can predict disease behavior in IBDbehavior in IBD
Diagnostic ApproachDiagnostic ApproachEndoscopyEndoscopy
Endoscopy useful forEndoscopy useful for Initial diagnosisInitial diagnosis Assessment of severityAssessment of severity Tissue diagnosisTissue diagnosis FU during treatmentFU during treatment Assessment of disease exacerbationAssessment of disease exacerbation Surveillance for risk of cancerSurveillance for risk of cancer Treatment of certain complications (eg Treatment of certain complications (eg
strictures)strictures)
Crohnrsquos DiseaseCrohnrsquos DiseaseEndoscopic FeaturesEndoscopic Features
Asymmetric patchy inflammationAsymmetric patchy inflammation Skip lesionsSkip lesions Rectal sparingRectal sparing Ulcerations-deepserpiginousUlcerations-deepserpiginous Cobblestoning-commonCobblestoning-common Pseudopolyps-rarePseudopolyps-rare BiopsyBiopsy
Erosions and normal mucosaErosions and normal mucosa Granulomas in 15 to 35 of specimensGranulomas in 15 to 35 of specimens
Ulcerative ColitisUlcerative ColitisEndoscopic FeaturesEndoscopic Features
Diffuse involvementDiffuse involvement Rectum always diseasedRectum always diseased Superficial ulcerationsSuperficial ulcerations FriabilitybleedingFriabilitybleeding Flatteningdisappearance of haustral Flatteningdisappearance of haustral
foldsfolds PseudopolypsPseudopolyps No cobblestoningNo cobblestoning Bx No granulomasBx No granulomas
Imaging for Crohn Imaging for Crohn DiseaseDisease
Traditional TechniquesTraditional Techniques Abdominal RadiographsAbdominal Radiographs
Barium UGI Barium UGI
Barium small bowel follow throughBarium small bowel follow through
Barium EnteroclysisBarium Enteroclysis
Barium EnemaBarium Enema
Imaging for Crohn Disease Imaging for Crohn Disease Newer TechniquesNewer Techniques
CTCT
CT EnteroclysisCT Enteroclysis
CT EnterographyCT Enterography
Magnetic ResonanceMagnetic Resonance
UltrasoundUltrasound
Nuclear MedicineNuclear Medicine
Imaging for Crohns DiseaseImaging for Crohns Disease SummarySummary
Useful Newer TechniquesUseful Newer Techniques evolvingevolving CT EnterographyCT Enterography
Comprehensive evaluation of all bowel amp solid organsComprehensive evaluation of all bowel amp solid organs
Magnetic ResonanceMagnetic Resonance
Useful for ano-rectal diseaseUseful for ano-rectal disease
Real-time MR has potential for detection of stricturesReal-time MR has potential for detection of strictures
Traditional imaging techniques still of value in Traditional imaging techniques still of value in selected cases selected cases
The Capsule (WCE)The Capsule (WCE)
WCEWCE
bull Diameter 11mm Length 26mmDiameter 11mm Length 26mmbull Optical dome Intestinal illumination Optical dome Intestinal illumination
by white light emitting diodes (LEDrsquos)by white light emitting diodes (LEDrsquos)bull LensLensbull Complementary metal-oxide silicone Complementary metal-oxide silicone
imager (color camera chip)imager (color camera chip)bull TransmitterTransmitterbull Two batteries (silver oxide)Two batteries (silver oxide)
GE Junction Duodenum
Jejunum Ileocecal Valve
Educational ObjectivesEducational Objectives Definitions and spectrum of inflammatory Definitions and spectrum of inflammatory
bowel disease (IBD)bowel disease (IBD) Epidemiology of IBDEpidemiology of IBD Etiopathogenesis of IBDEtiopathogenesis of IBD Clinical manifestations of ulcerative colitis Clinical manifestations of ulcerative colitis
(UC)(UC) Clinical manifestations of Crohnrsquos disease Clinical manifestations of Crohnrsquos disease
(CD)(CD) Distinguishing features between UC and CDDistinguishing features between UC and CD Diagnostic approach to IBDDiagnostic approach to IBD Complications of IBDComplications of IBD IBD managementIBD management
IBD-ComplicationsIBD-Complications GI BleedingGI Bleeding Toxic megacolonToxic megacolon PerforationPerforation Thromboembolic phenomenaThromboembolic phenomena FistulasfissuresFistulasfissures AbscessAbscess StricturesobstructionStricturesobstruction MalabsorptionmalnutritionMalabsorptionmalnutrition CancerCancer
Best Protection
Surveillance colonoscopySurveillance colonoscopy
Procto-colectomy (for UC)Procto-colectomy (for UC)
Descending Colon Descending Colon StrictureStricture
Colonic StricturesColonic Strictures
Consider nonsurgical management Consider nonsurgical management ifif Endoscopically accessibleEndoscopically accessible Multiple prior resectionsMultiple prior resections Shorter strictures (less than 5 cm)Shorter strictures (less than 5 cm) Steroid injection if significant Steroid injection if significant
inflammationinflammation
Fistula DefinitionA communication between two epithelial-lined organsLifetime risk of fistula in CD30
Perianal FistulaPerianal Fistula
Pretreatment 2 Weeks
10 Weeks 18 weeks
Educational ObjectivesEducational Objectives Definitions and spectrum of inflammatory Definitions and spectrum of inflammatory
bowel disease (IBD)bowel disease (IBD) Epidemiology of IBDEpidemiology of IBD Etiopathogenesis of IBDEtiopathogenesis of IBD Clinical manifestations of ulcerative colitis Clinical manifestations of ulcerative colitis
(UC)(UC) Clinical manifestations of Crohnrsquos disease Clinical manifestations of Crohnrsquos disease
(CD)(CD) Distinguishing features between UC and CDDistinguishing features between UC and CD Diagnostic approach to IBDDiagnostic approach to IBD Complications of IBDComplications of IBD IBD managementIBD management
Goals of Therapy for IBDGoals of Therapy for IBD
Inducing remissionInducing remission Maintaining remissionMaintaining remission Restoring and maintaining nutritionRestoring and maintaining nutrition Maintaining patientrsquos quality of lifeMaintaining patientrsquos quality of life Prevention of complicationsPrevention of complications Surgical intervention (selection of Surgical intervention (selection of
optimal time for surgery)optimal time for surgery)
Inductive TherapiesInductive Therapies
For UCFor UC AminosalicylatesAminosalicylates CorticosteroidsCorticosteroids CyclosporinCyclosporin
For CDFor CD AminosalicylatesAminosalicylates CorticosteroidsCorticosteroids AntibioticsAntibiotics Anti-TNFAnti-TNF
Maintenance TherapiesMaintenance Therapies
ImmunosupressorsImmunosupressors AzathioprineAzathioprine 6-MP6-MP MethotrexateMethotrexate
AminosalicylatesAminosalicylates Anti-TNFAnti-TNF
NOT NOT corticosteroidscorticosteroids
IBD ManagementIBD ManagementSummarySummary
There is no ldquoone size fits allrdquo to IBD therapyThere is no ldquoone size fits allrdquo to IBD therapy Therapy and decision making are tailored to the Therapy and decision making are tailored to the
individualindividual
Algorithms are based upon available evidenceAlgorithms are based upon available evidence Evidence is in constant fluxEvidence is in constant flux
Success of algorithms depends upon Success of algorithms depends upon optimization of each step of therapy and optimization of each step of therapy and considerable judgment about each outcomeconsiderable judgment about each outcome Skillful application of medical therapy makes all Skillful application of medical therapy makes all
the difference in outcomesthe difference in outcomes
Surgery for IBDSurgery for IBDGeneral ConceptsGeneral Concepts
Majority will need surgery 78 over Majority will need surgery 78 over twenty yearstwenty years
Surgery generally indicated for Surgery generally indicated for complicationscomplications of disease of disease
Surgery must be directed at area of Surgery must be directed at area of bowel responsible for complicationbowel responsible for complication
Indications for SurgeryIndications for Surgery Intestinal obstruction (most Intestinal obstruction (most
common)common) Intractabilitysteroid Intractabilitysteroid
dependencedependence Non-healing fistulaAbscessNon-healing fistulaAbscess Toxic megacolonFree Toxic megacolonFree
perforationperforation Uncontrollable GI bleedingUncontrollable GI bleeding Severe perianal diseaseSevere perianal disease CancerCancer Growth retardation Growth retardation
(children)(children) Severe uncontrollable Severe uncontrollable
extraintestinal extraintestinal manifestationsmanifestations
Management of IBDSummary
The goals of therapy are Relieve symptoms Prevent relapse Correct nutritional deficiencies Control inflammation Prevent complications especially colon cancer
Treatment depends on 1048707 Type of disease 1048707 Site of disease 1048707 Disease severity
Treatment may include drugs nutrition supplements surgery or a combination of these options
Ulcerative Ulcerative CColitis ndash clinical olitis ndash clinical presentationpresentation
Patients with Patients with proctitisproctitis usually pass fresh blood usually pass fresh blood or blood-stained mucus either mixed with stool or blood-stained mucus either mixed with stool or streaked onto the surface of normal or hard or streaked onto the surface of normal or hard stoolstool tenesmustenesmus is a feature is a feature
When the disease extends When the disease extends beyond the rectumbeyond the rectum blood is usually mixed with stool or grossly blood is usually mixed with stool or grossly bloody diarrhea may be notedbloody diarrhea may be noted
When the disease is When the disease is severesevere patients pass a patients pass a liquid stool containing blood pus fecal matterliquid stool containing blood pus fecal matter
Other symptoms in moderate to severe disease Other symptoms in moderate to severe disease include anorexia nausea vomitting fever include anorexia nausea vomitting fever abdominal pain abdominal pain weight lossweight loss
Ulcerative colitis ndash Ulcerative colitis ndash macroscopic featuresmacroscopic features
Mucosa isMucosa is
- erythematous has a granular surface that looks - erythematous has a granular surface that looks like a sand paperlike a sand paper
In more severe diseasesIn more severe diseases
- hemorrhagic edematous and ulcerated- hemorrhagic edematous and ulcerated
In fulminant diseaseIn fulminant disease a toxic colitis or a toxic a toxic colitis or a toxic megacolon may develop ( wall becomemegacolon may develop ( wall becomess very thin very thin and mucosa is severand mucosa is severeely ulcerated)ly ulcerated)
UCUCDisease Distribution at Disease Distribution at
PresentationPresentation
4637
17
UC ndash disease UC ndash disease severityseverity
MILDMILD MODERATMODERATEE
SEVERESEVERE
BOWEL BOWEL MOVEMENTSMOVEMENTS lt 4 per lt 4 per
dayday 4-6 per 4-6 per dayday
gt6 per gt6 per dayday
BLOOD IN BLOOD IN STOOLSTOOL smallsmall moderatemoderate SevereSevere
FEVERFEVER nonenone lt375lt375degdegC C gt 375gt 375degdegC C
TACHYCARDITACHYCARDIAA
nonenone lt90 mean lt90 mean pulsepulse
gt90 mean gt90 mean pulsepulse
UC ndash disease UC ndash disease severityseverity
MILDMILD MODERATMODERATEE
SEVERESEVERE
ANEMIAANEMIA mildmild gt75gt75 lt75lt75
ESRESR lt30mmlt30mm gt30mmgt30mm
ENDOSCOPIC ENDOSCOPIC APPEARANCEAPPEARANCE
Erythema Erythema decreased decreased vascular vascular pattern fine pattern fine granularitygranularity
Marked Marked erythema erythema coarse coarse granularity granularity contact contact bleeding no bleeding no ulcerationulceration
Spontaneous Spontaneous bleeding bleeding ulcerationulceration
Educational ObjectivesEducational Objectives Definitions and spectrum of inflammatory Definitions and spectrum of inflammatory
bowel disease (IBD)bowel disease (IBD) Epidemiology of IBDEpidemiology of IBD Etiopathogenesis of IBDEtiopathogenesis of IBD Clinical manifestations of ulcerative colitis Clinical manifestations of ulcerative colitis
(UC)(UC) Clinical manifestations of Crohnrsquos disease Clinical manifestations of Crohnrsquos disease
(CD)(CD) Distinguishing features between UC and Distinguishing features between UC and
CDCD Diagnostic approach to IBDDiagnostic approach to IBD Complications of IBDComplications of IBD IBD managementIBD management
CD Clinical FeaturesCD Clinical Features
Abdominal pain often postprandialAbdominal pain often postprandial Diarrhea usually wateryDiarrhea usually watery Rectal bleedingRectal bleeding Weight lossWeight loss Right lower quadrant painpalpable Right lower quadrant painpalpable
massmass FeverFever Growth retardation in childrenGrowth retardation in children Perirectal fistulaPerirectal fistula
Crohnrsquos disease ndash macroscopic Crohnrsquos disease ndash macroscopic featuresfeatures
Can affect any part of GI tract from the mouth to the Can affect any part of GI tract from the mouth to the anusanus
30-40 of patients have small bowel disease alone30-40 of patients have small bowel disease alone
40-55 of patients have both small and large 40-55 of patients have both small and large intestines diseaseintestines disease
15-25 of patients have colitis alone15-25 of patients have colitis alone
In 75 of patients with small intestinal disease the In 75 of patients with small intestinal disease the terminal ileum in involved in 90terminal ileum in involved in 90
Crohnrsquos DiseaseCrohnrsquos DiseaseAnatomic DistributionAnatomic Distribution
Small bowelSmall bowelalonealone(33)(33)
IleocolicIleocolic(45)(45)
Colon aloneColon alone(20)(20)
Frequency of involvementFrequency of involvement
MostMost LeastLeast
Crohnrsquos disease ndash macroscopic Crohnrsquos disease ndash macroscopic featuresfeatures
CD is a CD is a transmuraltransmural process process
CD is CD is segmentalsegmental with skip areas in with skip areas in the midst of diseased intestinethe midst of diseased intestine
In one third of patients with CD In one third of patients with CD perirectal fistulas fissures perirectal fistulas fissures abscesses anal stenosis are presentabscesses anal stenosis are present
Crohnrsquos disease ndash macroscopic Crohnrsquos disease ndash macroscopic featuresfeatures
Active CD is characterized by focal Active CD is characterized by focal inflammation and formation of fistula inflammation and formation of fistula tractstracts
The bowel wall thickens and becomes The bowel wall thickens and becomes narrowed and fibrotic leading to narrowed and fibrotic leading to chronic recurrent bowel obstructionchronic recurrent bowel obstruction
Crohnrsquos Disease Activity Index(CDAI)
Incorporates 8 variables 1 liquid or very soft stools day 2 Abdominal pain amp cramping 3 Extraintestinal manifestations 4 Complications 5 Abdominal mass 6 Use of anti diarrheal medications anti- 7 Hematocrit 8 Body weight
Crohnrsquos Disease Red Crohnrsquos Disease Red FlagsFlags
Onset after stopping smokingOnset after stopping smoking Bleeding onlyBleeding only DiverticulosisDiverticulosis AtherosclerosisAtherosclerosis ProlapseProlapse
Extraintestinal Manifestations of IBD
SkinErythema nodosumPyoderma gangrenosum
JointsPeripheral arthritisSacroileitisAnkylosing spondylitis
EyeUveitisEpiscleritisIritis
Hepatobiliary complicationsGallstonesPSC
Renal complicationsNephrolithiasisRecurrent UTIs
Educational ObjectivesEducational Objectives Definitions and spectrum of inflammatory Definitions and spectrum of inflammatory
bowel disease (IBD)bowel disease (IBD) Epidemiology of IBDEpidemiology of IBD Etiopathogenesis of IBDEtiopathogenesis of IBD Clinical manifestations of ulcerative colitis Clinical manifestations of ulcerative colitis
(UC)(UC) Clinical manifestations of Crohnrsquos disease (CD)Clinical manifestations of Crohnrsquos disease (CD) Distinguishing features between UC and Distinguishing features between UC and
CDCD Diagnostic approach to IBDDiagnostic approach to IBD Medical management of IBDMedical management of IBD Indications for and role of surgeryIndications for and role of surgery
Symptoms of IBDUC vs CDUC vs CD
FeatureFeature UCUC CDCD
FeverFever UncommonUncommon CommonCommon
Rectal Rectal bleedingbleeding
CommonCommon lt frac12 of lt frac12 of patientspatients
Abdominal Abdominal tendernesstenderness
May be May be presentpresent
CommonCommon
Abdominal Abdominal massmass
UncommonUncommon CommonCommon
Abdominal Abdominal painpain
UncommonUncommon Very commonVery common
Weight lossWeight loss UncommonUncommon CommonCommon
TenesmusTenesmus Very commonVery common UncommonUncommon
UC vs CDUC vs CDComplicationsResponse to ComplicationsResponse to
TreatmentTreatmentUCUC CDCD
FistulasFistulas NoNo YesYes
Small Small intestine intestine obstructionobstruction
NoNo FrequentlyFrequently
Colonic Colonic obstructionobstruction
RarelyRarely FrequentlyFrequently
Response to Response to antibioticantibiotic
NoNo YesYes
Recurrence Recurrence after after surgerysurgery
NoNo YesYes
UC vs CDUC vs CDDifferent endoscopic featuresDifferent endoscopic features
UCUC CDCD
Rectal Rectal sparingsparing
RarelyRarely FrequentlyFrequently
Continuous Continuous diseasedisease
YesYes OccasionallyOccasionally
bdquobdquoCCobblestonobblestoningrdquoingrdquo
NoNo YesYes
Granuloma Granuloma on biopsyon biopsy
NoNo OccasionallyOccasionally
Criteria for Indeterminate Criteria for Indeterminate ColitisColitis
No evidence of No evidence of small bowel small bowel involvement involvement fistula or fistula or perianal diseaseperianal disease
Absence of Absence of diagnostic diagnostic criteria for CD criteria for CD or UC by or UC by microscopymicroscopy
Differential Diagnosis of Differential Diagnosis of Chronic Diarrhea and Weight Chronic Diarrhea and Weight
LossLoss Colonic diseasesColonic diseases
IBDIBD NeoplasiaNeoplasia Ischemic bowelIschemic bowel
PancreaticPancreatic Chronic pancreatitisChronic pancreatitis CancerCancer Cystic fibrosisCystic fibrosis
EnteropathicEnteropathic Celiac diseaseCeliac disease Tropical sprueTropical sprue LymphomaLymphoma Mesenteric ischemiaMesenteric ischemia Whipplersquos diseaseWhipplersquos disease
HormonaldrugsHormonaldrugs VipomaVipoma ZESZES Medullary CA of Medullary CA of
thyroidthyroid NSAIDS useNSAIDS use
Educational ObjectivesEducational Objectives Definitions and spectrum of inflammatory Definitions and spectrum of inflammatory
bowel disease (IBD)bowel disease (IBD) Epidemiology of IBDEpidemiology of IBD Etiopathogenesis of IBDEtiopathogenesis of IBD Clinical manifestations of ulcerative colitis Clinical manifestations of ulcerative colitis
(UC)(UC) Clinical manifestations of Crohnrsquos disease Clinical manifestations of Crohnrsquos disease
(CD)(CD) Distinguishing features between UC and CDDistinguishing features between UC and CD Diagnostic approach to IBDDiagnostic approach to IBD Medical management of IBDMedical management of IBD Indications for and role of surgeryIndications for and role of surgery
Diagnostic Approach to Diagnostic Approach to Patients with Suspected Patients with Suspected
IBDIBD HistoryhelliphelliphistoryhelliphelliphistoryHistoryhelliphelliphistoryhelliphelliphistory Clinical examClinical exam Laboratory testsLaboratory tests Radiological imagingRadiological imaging EndoscopyEndoscopy Special serological testingSpecial serological testing Genetic testingGenetic testing
Diagnosis-LAB Blood test
CD Mild anemia mild leukocytosis elevated ESR elevated CRP positive ASCA
UC Anemia hypokalemia hypoalbuminemia elevated ESR elevated LFTs positive p-ANCA
Stool analysis Many WBCs and or RBCs No ova or parasites
What are the Serological What are the Serological Markers in IBDMarkers in IBD
pANCA (perinuclear staining pattern)pANCA (perinuclear staining pattern) Loss of perinuclear pattern after Loss of perinuclear pattern after
DNAaseDNAase Differentiate from the ldquoother pANCAsrdquoDifferentiate from the ldquoother pANCAsrdquo
Antibody against myeloperoxidaseAntibody against myeloperoxidase Antibody against cathepsin G elastase lysozyme Antibody against cathepsin G elastase lysozyme
and lactoferrinand lactoferrin ASCA (anti-ASCA (anti-Saccharomyces cerevisiaeSaccharomyces cerevisiae))
Both IgG and IgABoth IgG and IgA Recognize mannose in the cell wall Recognize mannose in the cell wall
mannan of mannan of Saccharomyces cerevisiaeSaccharomyces cerevisiae
Why Use Serological Why Use Serological Markers in Clinical Markers in Clinical
PracticePractice Differentiate IBD from functional bowel Differentiate IBD from functional bowel
disordersdisorders Accurately diagnose Crohnrsquos or UC in a patient Accurately diagnose Crohnrsquos or UC in a patient
withwith Severe colitisSevere colitis Indeterminate colitisIndeterminate colitis
Predict disease course or complications in IBDPredict disease course or complications in IBD CD phenotypeCD phenotype Severity of diseaseSeverity of disease Risk of pouchitisRisk of pouchitis
SummarySummary
pANCA and ASCA are specific for UC pANCA and ASCA are specific for UC and CD respectivelyand CD respectively
Neither pANCA nor ASCA are sensitive Neither pANCA nor ASCA are sensitive enough to exclude IBDenough to exclude IBD
In patients with IC available In patients with IC available serological markers do not accurately serological markers do not accurately predict the subsequent disease coursepredict the subsequent disease course
Antibody profiles can predict disease Antibody profiles can predict disease behavior in IBDbehavior in IBD
Diagnostic ApproachDiagnostic ApproachEndoscopyEndoscopy
Endoscopy useful forEndoscopy useful for Initial diagnosisInitial diagnosis Assessment of severityAssessment of severity Tissue diagnosisTissue diagnosis FU during treatmentFU during treatment Assessment of disease exacerbationAssessment of disease exacerbation Surveillance for risk of cancerSurveillance for risk of cancer Treatment of certain complications (eg Treatment of certain complications (eg
strictures)strictures)
Crohnrsquos DiseaseCrohnrsquos DiseaseEndoscopic FeaturesEndoscopic Features
Asymmetric patchy inflammationAsymmetric patchy inflammation Skip lesionsSkip lesions Rectal sparingRectal sparing Ulcerations-deepserpiginousUlcerations-deepserpiginous Cobblestoning-commonCobblestoning-common Pseudopolyps-rarePseudopolyps-rare BiopsyBiopsy
Erosions and normal mucosaErosions and normal mucosa Granulomas in 15 to 35 of specimensGranulomas in 15 to 35 of specimens
Ulcerative ColitisUlcerative ColitisEndoscopic FeaturesEndoscopic Features
Diffuse involvementDiffuse involvement Rectum always diseasedRectum always diseased Superficial ulcerationsSuperficial ulcerations FriabilitybleedingFriabilitybleeding Flatteningdisappearance of haustral Flatteningdisappearance of haustral
foldsfolds PseudopolypsPseudopolyps No cobblestoningNo cobblestoning Bx No granulomasBx No granulomas
Imaging for Crohn Imaging for Crohn DiseaseDisease
Traditional TechniquesTraditional Techniques Abdominal RadiographsAbdominal Radiographs
Barium UGI Barium UGI
Barium small bowel follow throughBarium small bowel follow through
Barium EnteroclysisBarium Enteroclysis
Barium EnemaBarium Enema
Imaging for Crohn Disease Imaging for Crohn Disease Newer TechniquesNewer Techniques
CTCT
CT EnteroclysisCT Enteroclysis
CT EnterographyCT Enterography
Magnetic ResonanceMagnetic Resonance
UltrasoundUltrasound
Nuclear MedicineNuclear Medicine
Imaging for Crohns DiseaseImaging for Crohns Disease SummarySummary
Useful Newer TechniquesUseful Newer Techniques evolvingevolving CT EnterographyCT Enterography
Comprehensive evaluation of all bowel amp solid organsComprehensive evaluation of all bowel amp solid organs
Magnetic ResonanceMagnetic Resonance
Useful for ano-rectal diseaseUseful for ano-rectal disease
Real-time MR has potential for detection of stricturesReal-time MR has potential for detection of strictures
Traditional imaging techniques still of value in Traditional imaging techniques still of value in selected cases selected cases
The Capsule (WCE)The Capsule (WCE)
WCEWCE
bull Diameter 11mm Length 26mmDiameter 11mm Length 26mmbull Optical dome Intestinal illumination Optical dome Intestinal illumination
by white light emitting diodes (LEDrsquos)by white light emitting diodes (LEDrsquos)bull LensLensbull Complementary metal-oxide silicone Complementary metal-oxide silicone
imager (color camera chip)imager (color camera chip)bull TransmitterTransmitterbull Two batteries (silver oxide)Two batteries (silver oxide)
GE Junction Duodenum
Jejunum Ileocecal Valve
Educational ObjectivesEducational Objectives Definitions and spectrum of inflammatory Definitions and spectrum of inflammatory
bowel disease (IBD)bowel disease (IBD) Epidemiology of IBDEpidemiology of IBD Etiopathogenesis of IBDEtiopathogenesis of IBD Clinical manifestations of ulcerative colitis Clinical manifestations of ulcerative colitis
(UC)(UC) Clinical manifestations of Crohnrsquos disease Clinical manifestations of Crohnrsquos disease
(CD)(CD) Distinguishing features between UC and CDDistinguishing features between UC and CD Diagnostic approach to IBDDiagnostic approach to IBD Complications of IBDComplications of IBD IBD managementIBD management
IBD-ComplicationsIBD-Complications GI BleedingGI Bleeding Toxic megacolonToxic megacolon PerforationPerforation Thromboembolic phenomenaThromboembolic phenomena FistulasfissuresFistulasfissures AbscessAbscess StricturesobstructionStricturesobstruction MalabsorptionmalnutritionMalabsorptionmalnutrition CancerCancer
Best Protection
Surveillance colonoscopySurveillance colonoscopy
Procto-colectomy (for UC)Procto-colectomy (for UC)
Descending Colon Descending Colon StrictureStricture
Colonic StricturesColonic Strictures
Consider nonsurgical management Consider nonsurgical management ifif Endoscopically accessibleEndoscopically accessible Multiple prior resectionsMultiple prior resections Shorter strictures (less than 5 cm)Shorter strictures (less than 5 cm) Steroid injection if significant Steroid injection if significant
inflammationinflammation
Fistula DefinitionA communication between two epithelial-lined organsLifetime risk of fistula in CD30
Perianal FistulaPerianal Fistula
Pretreatment 2 Weeks
10 Weeks 18 weeks
Educational ObjectivesEducational Objectives Definitions and spectrum of inflammatory Definitions and spectrum of inflammatory
bowel disease (IBD)bowel disease (IBD) Epidemiology of IBDEpidemiology of IBD Etiopathogenesis of IBDEtiopathogenesis of IBD Clinical manifestations of ulcerative colitis Clinical manifestations of ulcerative colitis
(UC)(UC) Clinical manifestations of Crohnrsquos disease Clinical manifestations of Crohnrsquos disease
(CD)(CD) Distinguishing features between UC and CDDistinguishing features between UC and CD Diagnostic approach to IBDDiagnostic approach to IBD Complications of IBDComplications of IBD IBD managementIBD management
Goals of Therapy for IBDGoals of Therapy for IBD
Inducing remissionInducing remission Maintaining remissionMaintaining remission Restoring and maintaining nutritionRestoring and maintaining nutrition Maintaining patientrsquos quality of lifeMaintaining patientrsquos quality of life Prevention of complicationsPrevention of complications Surgical intervention (selection of Surgical intervention (selection of
optimal time for surgery)optimal time for surgery)
Inductive TherapiesInductive Therapies
For UCFor UC AminosalicylatesAminosalicylates CorticosteroidsCorticosteroids CyclosporinCyclosporin
For CDFor CD AminosalicylatesAminosalicylates CorticosteroidsCorticosteroids AntibioticsAntibiotics Anti-TNFAnti-TNF
Maintenance TherapiesMaintenance Therapies
ImmunosupressorsImmunosupressors AzathioprineAzathioprine 6-MP6-MP MethotrexateMethotrexate
AminosalicylatesAminosalicylates Anti-TNFAnti-TNF
NOT NOT corticosteroidscorticosteroids
IBD ManagementIBD ManagementSummarySummary
There is no ldquoone size fits allrdquo to IBD therapyThere is no ldquoone size fits allrdquo to IBD therapy Therapy and decision making are tailored to the Therapy and decision making are tailored to the
individualindividual
Algorithms are based upon available evidenceAlgorithms are based upon available evidence Evidence is in constant fluxEvidence is in constant flux
Success of algorithms depends upon Success of algorithms depends upon optimization of each step of therapy and optimization of each step of therapy and considerable judgment about each outcomeconsiderable judgment about each outcome Skillful application of medical therapy makes all Skillful application of medical therapy makes all
the difference in outcomesthe difference in outcomes
Surgery for IBDSurgery for IBDGeneral ConceptsGeneral Concepts
Majority will need surgery 78 over Majority will need surgery 78 over twenty yearstwenty years
Surgery generally indicated for Surgery generally indicated for complicationscomplications of disease of disease
Surgery must be directed at area of Surgery must be directed at area of bowel responsible for complicationbowel responsible for complication
Indications for SurgeryIndications for Surgery Intestinal obstruction (most Intestinal obstruction (most
common)common) Intractabilitysteroid Intractabilitysteroid
dependencedependence Non-healing fistulaAbscessNon-healing fistulaAbscess Toxic megacolonFree Toxic megacolonFree
perforationperforation Uncontrollable GI bleedingUncontrollable GI bleeding Severe perianal diseaseSevere perianal disease CancerCancer Growth retardation Growth retardation
(children)(children) Severe uncontrollable Severe uncontrollable
extraintestinal extraintestinal manifestationsmanifestations
Management of IBDSummary
The goals of therapy are Relieve symptoms Prevent relapse Correct nutritional deficiencies Control inflammation Prevent complications especially colon cancer
Treatment depends on 1048707 Type of disease 1048707 Site of disease 1048707 Disease severity
Treatment may include drugs nutrition supplements surgery or a combination of these options
Ulcerative colitis ndash Ulcerative colitis ndash macroscopic featuresmacroscopic features
Mucosa isMucosa is
- erythematous has a granular surface that looks - erythematous has a granular surface that looks like a sand paperlike a sand paper
In more severe diseasesIn more severe diseases
- hemorrhagic edematous and ulcerated- hemorrhagic edematous and ulcerated
In fulminant diseaseIn fulminant disease a toxic colitis or a toxic a toxic colitis or a toxic megacolon may develop ( wall becomemegacolon may develop ( wall becomess very thin very thin and mucosa is severand mucosa is severeely ulcerated)ly ulcerated)
UCUCDisease Distribution at Disease Distribution at
PresentationPresentation
4637
17
UC ndash disease UC ndash disease severityseverity
MILDMILD MODERATMODERATEE
SEVERESEVERE
BOWEL BOWEL MOVEMENTSMOVEMENTS lt 4 per lt 4 per
dayday 4-6 per 4-6 per dayday
gt6 per gt6 per dayday
BLOOD IN BLOOD IN STOOLSTOOL smallsmall moderatemoderate SevereSevere
FEVERFEVER nonenone lt375lt375degdegC C gt 375gt 375degdegC C
TACHYCARDITACHYCARDIAA
nonenone lt90 mean lt90 mean pulsepulse
gt90 mean gt90 mean pulsepulse
UC ndash disease UC ndash disease severityseverity
MILDMILD MODERATMODERATEE
SEVERESEVERE
ANEMIAANEMIA mildmild gt75gt75 lt75lt75
ESRESR lt30mmlt30mm gt30mmgt30mm
ENDOSCOPIC ENDOSCOPIC APPEARANCEAPPEARANCE
Erythema Erythema decreased decreased vascular vascular pattern fine pattern fine granularitygranularity
Marked Marked erythema erythema coarse coarse granularity granularity contact contact bleeding no bleeding no ulcerationulceration
Spontaneous Spontaneous bleeding bleeding ulcerationulceration
Educational ObjectivesEducational Objectives Definitions and spectrum of inflammatory Definitions and spectrum of inflammatory
bowel disease (IBD)bowel disease (IBD) Epidemiology of IBDEpidemiology of IBD Etiopathogenesis of IBDEtiopathogenesis of IBD Clinical manifestations of ulcerative colitis Clinical manifestations of ulcerative colitis
(UC)(UC) Clinical manifestations of Crohnrsquos disease Clinical manifestations of Crohnrsquos disease
(CD)(CD) Distinguishing features between UC and Distinguishing features between UC and
CDCD Diagnostic approach to IBDDiagnostic approach to IBD Complications of IBDComplications of IBD IBD managementIBD management
CD Clinical FeaturesCD Clinical Features
Abdominal pain often postprandialAbdominal pain often postprandial Diarrhea usually wateryDiarrhea usually watery Rectal bleedingRectal bleeding Weight lossWeight loss Right lower quadrant painpalpable Right lower quadrant painpalpable
massmass FeverFever Growth retardation in childrenGrowth retardation in children Perirectal fistulaPerirectal fistula
Crohnrsquos disease ndash macroscopic Crohnrsquos disease ndash macroscopic featuresfeatures
Can affect any part of GI tract from the mouth to the Can affect any part of GI tract from the mouth to the anusanus
30-40 of patients have small bowel disease alone30-40 of patients have small bowel disease alone
40-55 of patients have both small and large 40-55 of patients have both small and large intestines diseaseintestines disease
15-25 of patients have colitis alone15-25 of patients have colitis alone
In 75 of patients with small intestinal disease the In 75 of patients with small intestinal disease the terminal ileum in involved in 90terminal ileum in involved in 90
Crohnrsquos DiseaseCrohnrsquos DiseaseAnatomic DistributionAnatomic Distribution
Small bowelSmall bowelalonealone(33)(33)
IleocolicIleocolic(45)(45)
Colon aloneColon alone(20)(20)
Frequency of involvementFrequency of involvement
MostMost LeastLeast
Crohnrsquos disease ndash macroscopic Crohnrsquos disease ndash macroscopic featuresfeatures
CD is a CD is a transmuraltransmural process process
CD is CD is segmentalsegmental with skip areas in with skip areas in the midst of diseased intestinethe midst of diseased intestine
In one third of patients with CD In one third of patients with CD perirectal fistulas fissures perirectal fistulas fissures abscesses anal stenosis are presentabscesses anal stenosis are present
Crohnrsquos disease ndash macroscopic Crohnrsquos disease ndash macroscopic featuresfeatures
Active CD is characterized by focal Active CD is characterized by focal inflammation and formation of fistula inflammation and formation of fistula tractstracts
The bowel wall thickens and becomes The bowel wall thickens and becomes narrowed and fibrotic leading to narrowed and fibrotic leading to chronic recurrent bowel obstructionchronic recurrent bowel obstruction
Crohnrsquos Disease Activity Index(CDAI)
Incorporates 8 variables 1 liquid or very soft stools day 2 Abdominal pain amp cramping 3 Extraintestinal manifestations 4 Complications 5 Abdominal mass 6 Use of anti diarrheal medications anti- 7 Hematocrit 8 Body weight
Crohnrsquos Disease Red Crohnrsquos Disease Red FlagsFlags
Onset after stopping smokingOnset after stopping smoking Bleeding onlyBleeding only DiverticulosisDiverticulosis AtherosclerosisAtherosclerosis ProlapseProlapse
Extraintestinal Manifestations of IBD
SkinErythema nodosumPyoderma gangrenosum
JointsPeripheral arthritisSacroileitisAnkylosing spondylitis
EyeUveitisEpiscleritisIritis
Hepatobiliary complicationsGallstonesPSC
Renal complicationsNephrolithiasisRecurrent UTIs
Educational ObjectivesEducational Objectives Definitions and spectrum of inflammatory Definitions and spectrum of inflammatory
bowel disease (IBD)bowel disease (IBD) Epidemiology of IBDEpidemiology of IBD Etiopathogenesis of IBDEtiopathogenesis of IBD Clinical manifestations of ulcerative colitis Clinical manifestations of ulcerative colitis
(UC)(UC) Clinical manifestations of Crohnrsquos disease (CD)Clinical manifestations of Crohnrsquos disease (CD) Distinguishing features between UC and Distinguishing features between UC and
CDCD Diagnostic approach to IBDDiagnostic approach to IBD Medical management of IBDMedical management of IBD Indications for and role of surgeryIndications for and role of surgery
Symptoms of IBDUC vs CDUC vs CD
FeatureFeature UCUC CDCD
FeverFever UncommonUncommon CommonCommon
Rectal Rectal bleedingbleeding
CommonCommon lt frac12 of lt frac12 of patientspatients
Abdominal Abdominal tendernesstenderness
May be May be presentpresent
CommonCommon
Abdominal Abdominal massmass
UncommonUncommon CommonCommon
Abdominal Abdominal painpain
UncommonUncommon Very commonVery common
Weight lossWeight loss UncommonUncommon CommonCommon
TenesmusTenesmus Very commonVery common UncommonUncommon
UC vs CDUC vs CDComplicationsResponse to ComplicationsResponse to
TreatmentTreatmentUCUC CDCD
FistulasFistulas NoNo YesYes
Small Small intestine intestine obstructionobstruction
NoNo FrequentlyFrequently
Colonic Colonic obstructionobstruction
RarelyRarely FrequentlyFrequently
Response to Response to antibioticantibiotic
NoNo YesYes
Recurrence Recurrence after after surgerysurgery
NoNo YesYes
UC vs CDUC vs CDDifferent endoscopic featuresDifferent endoscopic features
UCUC CDCD
Rectal Rectal sparingsparing
RarelyRarely FrequentlyFrequently
Continuous Continuous diseasedisease
YesYes OccasionallyOccasionally
bdquobdquoCCobblestonobblestoningrdquoingrdquo
NoNo YesYes
Granuloma Granuloma on biopsyon biopsy
NoNo OccasionallyOccasionally
Criteria for Indeterminate Criteria for Indeterminate ColitisColitis
No evidence of No evidence of small bowel small bowel involvement involvement fistula or fistula or perianal diseaseperianal disease
Absence of Absence of diagnostic diagnostic criteria for CD criteria for CD or UC by or UC by microscopymicroscopy
Differential Diagnosis of Differential Diagnosis of Chronic Diarrhea and Weight Chronic Diarrhea and Weight
LossLoss Colonic diseasesColonic diseases
IBDIBD NeoplasiaNeoplasia Ischemic bowelIschemic bowel
PancreaticPancreatic Chronic pancreatitisChronic pancreatitis CancerCancer Cystic fibrosisCystic fibrosis
EnteropathicEnteropathic Celiac diseaseCeliac disease Tropical sprueTropical sprue LymphomaLymphoma Mesenteric ischemiaMesenteric ischemia Whipplersquos diseaseWhipplersquos disease
HormonaldrugsHormonaldrugs VipomaVipoma ZESZES Medullary CA of Medullary CA of
thyroidthyroid NSAIDS useNSAIDS use
Educational ObjectivesEducational Objectives Definitions and spectrum of inflammatory Definitions and spectrum of inflammatory
bowel disease (IBD)bowel disease (IBD) Epidemiology of IBDEpidemiology of IBD Etiopathogenesis of IBDEtiopathogenesis of IBD Clinical manifestations of ulcerative colitis Clinical manifestations of ulcerative colitis
(UC)(UC) Clinical manifestations of Crohnrsquos disease Clinical manifestations of Crohnrsquos disease
(CD)(CD) Distinguishing features between UC and CDDistinguishing features between UC and CD Diagnostic approach to IBDDiagnostic approach to IBD Medical management of IBDMedical management of IBD Indications for and role of surgeryIndications for and role of surgery
Diagnostic Approach to Diagnostic Approach to Patients with Suspected Patients with Suspected
IBDIBD HistoryhelliphelliphistoryhelliphelliphistoryHistoryhelliphelliphistoryhelliphelliphistory Clinical examClinical exam Laboratory testsLaboratory tests Radiological imagingRadiological imaging EndoscopyEndoscopy Special serological testingSpecial serological testing Genetic testingGenetic testing
Diagnosis-LAB Blood test
CD Mild anemia mild leukocytosis elevated ESR elevated CRP positive ASCA
UC Anemia hypokalemia hypoalbuminemia elevated ESR elevated LFTs positive p-ANCA
Stool analysis Many WBCs and or RBCs No ova or parasites
What are the Serological What are the Serological Markers in IBDMarkers in IBD
pANCA (perinuclear staining pattern)pANCA (perinuclear staining pattern) Loss of perinuclear pattern after Loss of perinuclear pattern after
DNAaseDNAase Differentiate from the ldquoother pANCAsrdquoDifferentiate from the ldquoother pANCAsrdquo
Antibody against myeloperoxidaseAntibody against myeloperoxidase Antibody against cathepsin G elastase lysozyme Antibody against cathepsin G elastase lysozyme
and lactoferrinand lactoferrin ASCA (anti-ASCA (anti-Saccharomyces cerevisiaeSaccharomyces cerevisiae))
Both IgG and IgABoth IgG and IgA Recognize mannose in the cell wall Recognize mannose in the cell wall
mannan of mannan of Saccharomyces cerevisiaeSaccharomyces cerevisiae
Why Use Serological Why Use Serological Markers in Clinical Markers in Clinical
PracticePractice Differentiate IBD from functional bowel Differentiate IBD from functional bowel
disordersdisorders Accurately diagnose Crohnrsquos or UC in a patient Accurately diagnose Crohnrsquos or UC in a patient
withwith Severe colitisSevere colitis Indeterminate colitisIndeterminate colitis
Predict disease course or complications in IBDPredict disease course or complications in IBD CD phenotypeCD phenotype Severity of diseaseSeverity of disease Risk of pouchitisRisk of pouchitis
SummarySummary
pANCA and ASCA are specific for UC pANCA and ASCA are specific for UC and CD respectivelyand CD respectively
Neither pANCA nor ASCA are sensitive Neither pANCA nor ASCA are sensitive enough to exclude IBDenough to exclude IBD
In patients with IC available In patients with IC available serological markers do not accurately serological markers do not accurately predict the subsequent disease coursepredict the subsequent disease course
Antibody profiles can predict disease Antibody profiles can predict disease behavior in IBDbehavior in IBD
Diagnostic ApproachDiagnostic ApproachEndoscopyEndoscopy
Endoscopy useful forEndoscopy useful for Initial diagnosisInitial diagnosis Assessment of severityAssessment of severity Tissue diagnosisTissue diagnosis FU during treatmentFU during treatment Assessment of disease exacerbationAssessment of disease exacerbation Surveillance for risk of cancerSurveillance for risk of cancer Treatment of certain complications (eg Treatment of certain complications (eg
strictures)strictures)
Crohnrsquos DiseaseCrohnrsquos DiseaseEndoscopic FeaturesEndoscopic Features
Asymmetric patchy inflammationAsymmetric patchy inflammation Skip lesionsSkip lesions Rectal sparingRectal sparing Ulcerations-deepserpiginousUlcerations-deepserpiginous Cobblestoning-commonCobblestoning-common Pseudopolyps-rarePseudopolyps-rare BiopsyBiopsy
Erosions and normal mucosaErosions and normal mucosa Granulomas in 15 to 35 of specimensGranulomas in 15 to 35 of specimens
Ulcerative ColitisUlcerative ColitisEndoscopic FeaturesEndoscopic Features
Diffuse involvementDiffuse involvement Rectum always diseasedRectum always diseased Superficial ulcerationsSuperficial ulcerations FriabilitybleedingFriabilitybleeding Flatteningdisappearance of haustral Flatteningdisappearance of haustral
foldsfolds PseudopolypsPseudopolyps No cobblestoningNo cobblestoning Bx No granulomasBx No granulomas
Imaging for Crohn Imaging for Crohn DiseaseDisease
Traditional TechniquesTraditional Techniques Abdominal RadiographsAbdominal Radiographs
Barium UGI Barium UGI
Barium small bowel follow throughBarium small bowel follow through
Barium EnteroclysisBarium Enteroclysis
Barium EnemaBarium Enema
Imaging for Crohn Disease Imaging for Crohn Disease Newer TechniquesNewer Techniques
CTCT
CT EnteroclysisCT Enteroclysis
CT EnterographyCT Enterography
Magnetic ResonanceMagnetic Resonance
UltrasoundUltrasound
Nuclear MedicineNuclear Medicine
Imaging for Crohns DiseaseImaging for Crohns Disease SummarySummary
Useful Newer TechniquesUseful Newer Techniques evolvingevolving CT EnterographyCT Enterography
Comprehensive evaluation of all bowel amp solid organsComprehensive evaluation of all bowel amp solid organs
Magnetic ResonanceMagnetic Resonance
Useful for ano-rectal diseaseUseful for ano-rectal disease
Real-time MR has potential for detection of stricturesReal-time MR has potential for detection of strictures
Traditional imaging techniques still of value in Traditional imaging techniques still of value in selected cases selected cases
The Capsule (WCE)The Capsule (WCE)
WCEWCE
bull Diameter 11mm Length 26mmDiameter 11mm Length 26mmbull Optical dome Intestinal illumination Optical dome Intestinal illumination
by white light emitting diodes (LEDrsquos)by white light emitting diodes (LEDrsquos)bull LensLensbull Complementary metal-oxide silicone Complementary metal-oxide silicone
imager (color camera chip)imager (color camera chip)bull TransmitterTransmitterbull Two batteries (silver oxide)Two batteries (silver oxide)
GE Junction Duodenum
Jejunum Ileocecal Valve
Educational ObjectivesEducational Objectives Definitions and spectrum of inflammatory Definitions and spectrum of inflammatory
bowel disease (IBD)bowel disease (IBD) Epidemiology of IBDEpidemiology of IBD Etiopathogenesis of IBDEtiopathogenesis of IBD Clinical manifestations of ulcerative colitis Clinical manifestations of ulcerative colitis
(UC)(UC) Clinical manifestations of Crohnrsquos disease Clinical manifestations of Crohnrsquos disease
(CD)(CD) Distinguishing features between UC and CDDistinguishing features between UC and CD Diagnostic approach to IBDDiagnostic approach to IBD Complications of IBDComplications of IBD IBD managementIBD management
IBD-ComplicationsIBD-Complications GI BleedingGI Bleeding Toxic megacolonToxic megacolon PerforationPerforation Thromboembolic phenomenaThromboembolic phenomena FistulasfissuresFistulasfissures AbscessAbscess StricturesobstructionStricturesobstruction MalabsorptionmalnutritionMalabsorptionmalnutrition CancerCancer
Best Protection
Surveillance colonoscopySurveillance colonoscopy
Procto-colectomy (for UC)Procto-colectomy (for UC)
Descending Colon Descending Colon StrictureStricture
Colonic StricturesColonic Strictures
Consider nonsurgical management Consider nonsurgical management ifif Endoscopically accessibleEndoscopically accessible Multiple prior resectionsMultiple prior resections Shorter strictures (less than 5 cm)Shorter strictures (less than 5 cm) Steroid injection if significant Steroid injection if significant
inflammationinflammation
Fistula DefinitionA communication between two epithelial-lined organsLifetime risk of fistula in CD30
Perianal FistulaPerianal Fistula
Pretreatment 2 Weeks
10 Weeks 18 weeks
Educational ObjectivesEducational Objectives Definitions and spectrum of inflammatory Definitions and spectrum of inflammatory
bowel disease (IBD)bowel disease (IBD) Epidemiology of IBDEpidemiology of IBD Etiopathogenesis of IBDEtiopathogenesis of IBD Clinical manifestations of ulcerative colitis Clinical manifestations of ulcerative colitis
(UC)(UC) Clinical manifestations of Crohnrsquos disease Clinical manifestations of Crohnrsquos disease
(CD)(CD) Distinguishing features between UC and CDDistinguishing features between UC and CD Diagnostic approach to IBDDiagnostic approach to IBD Complications of IBDComplications of IBD IBD managementIBD management
Goals of Therapy for IBDGoals of Therapy for IBD
Inducing remissionInducing remission Maintaining remissionMaintaining remission Restoring and maintaining nutritionRestoring and maintaining nutrition Maintaining patientrsquos quality of lifeMaintaining patientrsquos quality of life Prevention of complicationsPrevention of complications Surgical intervention (selection of Surgical intervention (selection of
optimal time for surgery)optimal time for surgery)
Inductive TherapiesInductive Therapies
For UCFor UC AminosalicylatesAminosalicylates CorticosteroidsCorticosteroids CyclosporinCyclosporin
For CDFor CD AminosalicylatesAminosalicylates CorticosteroidsCorticosteroids AntibioticsAntibiotics Anti-TNFAnti-TNF
Maintenance TherapiesMaintenance Therapies
ImmunosupressorsImmunosupressors AzathioprineAzathioprine 6-MP6-MP MethotrexateMethotrexate
AminosalicylatesAminosalicylates Anti-TNFAnti-TNF
NOT NOT corticosteroidscorticosteroids
IBD ManagementIBD ManagementSummarySummary
There is no ldquoone size fits allrdquo to IBD therapyThere is no ldquoone size fits allrdquo to IBD therapy Therapy and decision making are tailored to the Therapy and decision making are tailored to the
individualindividual
Algorithms are based upon available evidenceAlgorithms are based upon available evidence Evidence is in constant fluxEvidence is in constant flux
Success of algorithms depends upon Success of algorithms depends upon optimization of each step of therapy and optimization of each step of therapy and considerable judgment about each outcomeconsiderable judgment about each outcome Skillful application of medical therapy makes all Skillful application of medical therapy makes all
the difference in outcomesthe difference in outcomes
Surgery for IBDSurgery for IBDGeneral ConceptsGeneral Concepts
Majority will need surgery 78 over Majority will need surgery 78 over twenty yearstwenty years
Surgery generally indicated for Surgery generally indicated for complicationscomplications of disease of disease
Surgery must be directed at area of Surgery must be directed at area of bowel responsible for complicationbowel responsible for complication
Indications for SurgeryIndications for Surgery Intestinal obstruction (most Intestinal obstruction (most
common)common) Intractabilitysteroid Intractabilitysteroid
dependencedependence Non-healing fistulaAbscessNon-healing fistulaAbscess Toxic megacolonFree Toxic megacolonFree
perforationperforation Uncontrollable GI bleedingUncontrollable GI bleeding Severe perianal diseaseSevere perianal disease CancerCancer Growth retardation Growth retardation
(children)(children) Severe uncontrollable Severe uncontrollable
extraintestinal extraintestinal manifestationsmanifestations
Management of IBDSummary
The goals of therapy are Relieve symptoms Prevent relapse Correct nutritional deficiencies Control inflammation Prevent complications especially colon cancer
Treatment depends on 1048707 Type of disease 1048707 Site of disease 1048707 Disease severity
Treatment may include drugs nutrition supplements surgery or a combination of these options
UCUCDisease Distribution at Disease Distribution at
PresentationPresentation
4637
17
UC ndash disease UC ndash disease severityseverity
MILDMILD MODERATMODERATEE
SEVERESEVERE
BOWEL BOWEL MOVEMENTSMOVEMENTS lt 4 per lt 4 per
dayday 4-6 per 4-6 per dayday
gt6 per gt6 per dayday
BLOOD IN BLOOD IN STOOLSTOOL smallsmall moderatemoderate SevereSevere
FEVERFEVER nonenone lt375lt375degdegC C gt 375gt 375degdegC C
TACHYCARDITACHYCARDIAA
nonenone lt90 mean lt90 mean pulsepulse
gt90 mean gt90 mean pulsepulse
UC ndash disease UC ndash disease severityseverity
MILDMILD MODERATMODERATEE
SEVERESEVERE
ANEMIAANEMIA mildmild gt75gt75 lt75lt75
ESRESR lt30mmlt30mm gt30mmgt30mm
ENDOSCOPIC ENDOSCOPIC APPEARANCEAPPEARANCE
Erythema Erythema decreased decreased vascular vascular pattern fine pattern fine granularitygranularity
Marked Marked erythema erythema coarse coarse granularity granularity contact contact bleeding no bleeding no ulcerationulceration
Spontaneous Spontaneous bleeding bleeding ulcerationulceration
Educational ObjectivesEducational Objectives Definitions and spectrum of inflammatory Definitions and spectrum of inflammatory
bowel disease (IBD)bowel disease (IBD) Epidemiology of IBDEpidemiology of IBD Etiopathogenesis of IBDEtiopathogenesis of IBD Clinical manifestations of ulcerative colitis Clinical manifestations of ulcerative colitis
(UC)(UC) Clinical manifestations of Crohnrsquos disease Clinical manifestations of Crohnrsquos disease
(CD)(CD) Distinguishing features between UC and Distinguishing features between UC and
CDCD Diagnostic approach to IBDDiagnostic approach to IBD Complications of IBDComplications of IBD IBD managementIBD management
CD Clinical FeaturesCD Clinical Features
Abdominal pain often postprandialAbdominal pain often postprandial Diarrhea usually wateryDiarrhea usually watery Rectal bleedingRectal bleeding Weight lossWeight loss Right lower quadrant painpalpable Right lower quadrant painpalpable
massmass FeverFever Growth retardation in childrenGrowth retardation in children Perirectal fistulaPerirectal fistula
Crohnrsquos disease ndash macroscopic Crohnrsquos disease ndash macroscopic featuresfeatures
Can affect any part of GI tract from the mouth to the Can affect any part of GI tract from the mouth to the anusanus
30-40 of patients have small bowel disease alone30-40 of patients have small bowel disease alone
40-55 of patients have both small and large 40-55 of patients have both small and large intestines diseaseintestines disease
15-25 of patients have colitis alone15-25 of patients have colitis alone
In 75 of patients with small intestinal disease the In 75 of patients with small intestinal disease the terminal ileum in involved in 90terminal ileum in involved in 90
Crohnrsquos DiseaseCrohnrsquos DiseaseAnatomic DistributionAnatomic Distribution
Small bowelSmall bowelalonealone(33)(33)
IleocolicIleocolic(45)(45)
Colon aloneColon alone(20)(20)
Frequency of involvementFrequency of involvement
MostMost LeastLeast
Crohnrsquos disease ndash macroscopic Crohnrsquos disease ndash macroscopic featuresfeatures
CD is a CD is a transmuraltransmural process process
CD is CD is segmentalsegmental with skip areas in with skip areas in the midst of diseased intestinethe midst of diseased intestine
In one third of patients with CD In one third of patients with CD perirectal fistulas fissures perirectal fistulas fissures abscesses anal stenosis are presentabscesses anal stenosis are present
Crohnrsquos disease ndash macroscopic Crohnrsquos disease ndash macroscopic featuresfeatures
Active CD is characterized by focal Active CD is characterized by focal inflammation and formation of fistula inflammation and formation of fistula tractstracts
The bowel wall thickens and becomes The bowel wall thickens and becomes narrowed and fibrotic leading to narrowed and fibrotic leading to chronic recurrent bowel obstructionchronic recurrent bowel obstruction
Crohnrsquos Disease Activity Index(CDAI)
Incorporates 8 variables 1 liquid or very soft stools day 2 Abdominal pain amp cramping 3 Extraintestinal manifestations 4 Complications 5 Abdominal mass 6 Use of anti diarrheal medications anti- 7 Hematocrit 8 Body weight
Crohnrsquos Disease Red Crohnrsquos Disease Red FlagsFlags
Onset after stopping smokingOnset after stopping smoking Bleeding onlyBleeding only DiverticulosisDiverticulosis AtherosclerosisAtherosclerosis ProlapseProlapse
Extraintestinal Manifestations of IBD
SkinErythema nodosumPyoderma gangrenosum
JointsPeripheral arthritisSacroileitisAnkylosing spondylitis
EyeUveitisEpiscleritisIritis
Hepatobiliary complicationsGallstonesPSC
Renal complicationsNephrolithiasisRecurrent UTIs
Educational ObjectivesEducational Objectives Definitions and spectrum of inflammatory Definitions and spectrum of inflammatory
bowel disease (IBD)bowel disease (IBD) Epidemiology of IBDEpidemiology of IBD Etiopathogenesis of IBDEtiopathogenesis of IBD Clinical manifestations of ulcerative colitis Clinical manifestations of ulcerative colitis
(UC)(UC) Clinical manifestations of Crohnrsquos disease (CD)Clinical manifestations of Crohnrsquos disease (CD) Distinguishing features between UC and Distinguishing features between UC and
CDCD Diagnostic approach to IBDDiagnostic approach to IBD Medical management of IBDMedical management of IBD Indications for and role of surgeryIndications for and role of surgery
Symptoms of IBDUC vs CDUC vs CD
FeatureFeature UCUC CDCD
FeverFever UncommonUncommon CommonCommon
Rectal Rectal bleedingbleeding
CommonCommon lt frac12 of lt frac12 of patientspatients
Abdominal Abdominal tendernesstenderness
May be May be presentpresent
CommonCommon
Abdominal Abdominal massmass
UncommonUncommon CommonCommon
Abdominal Abdominal painpain
UncommonUncommon Very commonVery common
Weight lossWeight loss UncommonUncommon CommonCommon
TenesmusTenesmus Very commonVery common UncommonUncommon
UC vs CDUC vs CDComplicationsResponse to ComplicationsResponse to
TreatmentTreatmentUCUC CDCD
FistulasFistulas NoNo YesYes
Small Small intestine intestine obstructionobstruction
NoNo FrequentlyFrequently
Colonic Colonic obstructionobstruction
RarelyRarely FrequentlyFrequently
Response to Response to antibioticantibiotic
NoNo YesYes
Recurrence Recurrence after after surgerysurgery
NoNo YesYes
UC vs CDUC vs CDDifferent endoscopic featuresDifferent endoscopic features
UCUC CDCD
Rectal Rectal sparingsparing
RarelyRarely FrequentlyFrequently
Continuous Continuous diseasedisease
YesYes OccasionallyOccasionally
bdquobdquoCCobblestonobblestoningrdquoingrdquo
NoNo YesYes
Granuloma Granuloma on biopsyon biopsy
NoNo OccasionallyOccasionally
Criteria for Indeterminate Criteria for Indeterminate ColitisColitis
No evidence of No evidence of small bowel small bowel involvement involvement fistula or fistula or perianal diseaseperianal disease
Absence of Absence of diagnostic diagnostic criteria for CD criteria for CD or UC by or UC by microscopymicroscopy
Differential Diagnosis of Differential Diagnosis of Chronic Diarrhea and Weight Chronic Diarrhea and Weight
LossLoss Colonic diseasesColonic diseases
IBDIBD NeoplasiaNeoplasia Ischemic bowelIschemic bowel
PancreaticPancreatic Chronic pancreatitisChronic pancreatitis CancerCancer Cystic fibrosisCystic fibrosis
EnteropathicEnteropathic Celiac diseaseCeliac disease Tropical sprueTropical sprue LymphomaLymphoma Mesenteric ischemiaMesenteric ischemia Whipplersquos diseaseWhipplersquos disease
HormonaldrugsHormonaldrugs VipomaVipoma ZESZES Medullary CA of Medullary CA of
thyroidthyroid NSAIDS useNSAIDS use
Educational ObjectivesEducational Objectives Definitions and spectrum of inflammatory Definitions and spectrum of inflammatory
bowel disease (IBD)bowel disease (IBD) Epidemiology of IBDEpidemiology of IBD Etiopathogenesis of IBDEtiopathogenesis of IBD Clinical manifestations of ulcerative colitis Clinical manifestations of ulcerative colitis
(UC)(UC) Clinical manifestations of Crohnrsquos disease Clinical manifestations of Crohnrsquos disease
(CD)(CD) Distinguishing features between UC and CDDistinguishing features between UC and CD Diagnostic approach to IBDDiagnostic approach to IBD Medical management of IBDMedical management of IBD Indications for and role of surgeryIndications for and role of surgery
Diagnostic Approach to Diagnostic Approach to Patients with Suspected Patients with Suspected
IBDIBD HistoryhelliphelliphistoryhelliphelliphistoryHistoryhelliphelliphistoryhelliphelliphistory Clinical examClinical exam Laboratory testsLaboratory tests Radiological imagingRadiological imaging EndoscopyEndoscopy Special serological testingSpecial serological testing Genetic testingGenetic testing
Diagnosis-LAB Blood test
CD Mild anemia mild leukocytosis elevated ESR elevated CRP positive ASCA
UC Anemia hypokalemia hypoalbuminemia elevated ESR elevated LFTs positive p-ANCA
Stool analysis Many WBCs and or RBCs No ova or parasites
What are the Serological What are the Serological Markers in IBDMarkers in IBD
pANCA (perinuclear staining pattern)pANCA (perinuclear staining pattern) Loss of perinuclear pattern after Loss of perinuclear pattern after
DNAaseDNAase Differentiate from the ldquoother pANCAsrdquoDifferentiate from the ldquoother pANCAsrdquo
Antibody against myeloperoxidaseAntibody against myeloperoxidase Antibody against cathepsin G elastase lysozyme Antibody against cathepsin G elastase lysozyme
and lactoferrinand lactoferrin ASCA (anti-ASCA (anti-Saccharomyces cerevisiaeSaccharomyces cerevisiae))
Both IgG and IgABoth IgG and IgA Recognize mannose in the cell wall Recognize mannose in the cell wall
mannan of mannan of Saccharomyces cerevisiaeSaccharomyces cerevisiae
Why Use Serological Why Use Serological Markers in Clinical Markers in Clinical
PracticePractice Differentiate IBD from functional bowel Differentiate IBD from functional bowel
disordersdisorders Accurately diagnose Crohnrsquos or UC in a patient Accurately diagnose Crohnrsquos or UC in a patient
withwith Severe colitisSevere colitis Indeterminate colitisIndeterminate colitis
Predict disease course or complications in IBDPredict disease course or complications in IBD CD phenotypeCD phenotype Severity of diseaseSeverity of disease Risk of pouchitisRisk of pouchitis
SummarySummary
pANCA and ASCA are specific for UC pANCA and ASCA are specific for UC and CD respectivelyand CD respectively
Neither pANCA nor ASCA are sensitive Neither pANCA nor ASCA are sensitive enough to exclude IBDenough to exclude IBD
In patients with IC available In patients with IC available serological markers do not accurately serological markers do not accurately predict the subsequent disease coursepredict the subsequent disease course
Antibody profiles can predict disease Antibody profiles can predict disease behavior in IBDbehavior in IBD
Diagnostic ApproachDiagnostic ApproachEndoscopyEndoscopy
Endoscopy useful forEndoscopy useful for Initial diagnosisInitial diagnosis Assessment of severityAssessment of severity Tissue diagnosisTissue diagnosis FU during treatmentFU during treatment Assessment of disease exacerbationAssessment of disease exacerbation Surveillance for risk of cancerSurveillance for risk of cancer Treatment of certain complications (eg Treatment of certain complications (eg
strictures)strictures)
Crohnrsquos DiseaseCrohnrsquos DiseaseEndoscopic FeaturesEndoscopic Features
Asymmetric patchy inflammationAsymmetric patchy inflammation Skip lesionsSkip lesions Rectal sparingRectal sparing Ulcerations-deepserpiginousUlcerations-deepserpiginous Cobblestoning-commonCobblestoning-common Pseudopolyps-rarePseudopolyps-rare BiopsyBiopsy
Erosions and normal mucosaErosions and normal mucosa Granulomas in 15 to 35 of specimensGranulomas in 15 to 35 of specimens
Ulcerative ColitisUlcerative ColitisEndoscopic FeaturesEndoscopic Features
Diffuse involvementDiffuse involvement Rectum always diseasedRectum always diseased Superficial ulcerationsSuperficial ulcerations FriabilitybleedingFriabilitybleeding Flatteningdisappearance of haustral Flatteningdisappearance of haustral
foldsfolds PseudopolypsPseudopolyps No cobblestoningNo cobblestoning Bx No granulomasBx No granulomas
Imaging for Crohn Imaging for Crohn DiseaseDisease
Traditional TechniquesTraditional Techniques Abdominal RadiographsAbdominal Radiographs
Barium UGI Barium UGI
Barium small bowel follow throughBarium small bowel follow through
Barium EnteroclysisBarium Enteroclysis
Barium EnemaBarium Enema
Imaging for Crohn Disease Imaging for Crohn Disease Newer TechniquesNewer Techniques
CTCT
CT EnteroclysisCT Enteroclysis
CT EnterographyCT Enterography
Magnetic ResonanceMagnetic Resonance
UltrasoundUltrasound
Nuclear MedicineNuclear Medicine
Imaging for Crohns DiseaseImaging for Crohns Disease SummarySummary
Useful Newer TechniquesUseful Newer Techniques evolvingevolving CT EnterographyCT Enterography
Comprehensive evaluation of all bowel amp solid organsComprehensive evaluation of all bowel amp solid organs
Magnetic ResonanceMagnetic Resonance
Useful for ano-rectal diseaseUseful for ano-rectal disease
Real-time MR has potential for detection of stricturesReal-time MR has potential for detection of strictures
Traditional imaging techniques still of value in Traditional imaging techniques still of value in selected cases selected cases
The Capsule (WCE)The Capsule (WCE)
WCEWCE
bull Diameter 11mm Length 26mmDiameter 11mm Length 26mmbull Optical dome Intestinal illumination Optical dome Intestinal illumination
by white light emitting diodes (LEDrsquos)by white light emitting diodes (LEDrsquos)bull LensLensbull Complementary metal-oxide silicone Complementary metal-oxide silicone
imager (color camera chip)imager (color camera chip)bull TransmitterTransmitterbull Two batteries (silver oxide)Two batteries (silver oxide)
GE Junction Duodenum
Jejunum Ileocecal Valve
Educational ObjectivesEducational Objectives Definitions and spectrum of inflammatory Definitions and spectrum of inflammatory
bowel disease (IBD)bowel disease (IBD) Epidemiology of IBDEpidemiology of IBD Etiopathogenesis of IBDEtiopathogenesis of IBD Clinical manifestations of ulcerative colitis Clinical manifestations of ulcerative colitis
(UC)(UC) Clinical manifestations of Crohnrsquos disease Clinical manifestations of Crohnrsquos disease
(CD)(CD) Distinguishing features between UC and CDDistinguishing features between UC and CD Diagnostic approach to IBDDiagnostic approach to IBD Complications of IBDComplications of IBD IBD managementIBD management
IBD-ComplicationsIBD-Complications GI BleedingGI Bleeding Toxic megacolonToxic megacolon PerforationPerforation Thromboembolic phenomenaThromboembolic phenomena FistulasfissuresFistulasfissures AbscessAbscess StricturesobstructionStricturesobstruction MalabsorptionmalnutritionMalabsorptionmalnutrition CancerCancer
Best Protection
Surveillance colonoscopySurveillance colonoscopy
Procto-colectomy (for UC)Procto-colectomy (for UC)
Descending Colon Descending Colon StrictureStricture
Colonic StricturesColonic Strictures
Consider nonsurgical management Consider nonsurgical management ifif Endoscopically accessibleEndoscopically accessible Multiple prior resectionsMultiple prior resections Shorter strictures (less than 5 cm)Shorter strictures (less than 5 cm) Steroid injection if significant Steroid injection if significant
inflammationinflammation
Fistula DefinitionA communication between two epithelial-lined organsLifetime risk of fistula in CD30
Perianal FistulaPerianal Fistula
Pretreatment 2 Weeks
10 Weeks 18 weeks
Educational ObjectivesEducational Objectives Definitions and spectrum of inflammatory Definitions and spectrum of inflammatory
bowel disease (IBD)bowel disease (IBD) Epidemiology of IBDEpidemiology of IBD Etiopathogenesis of IBDEtiopathogenesis of IBD Clinical manifestations of ulcerative colitis Clinical manifestations of ulcerative colitis
(UC)(UC) Clinical manifestations of Crohnrsquos disease Clinical manifestations of Crohnrsquos disease
(CD)(CD) Distinguishing features between UC and CDDistinguishing features between UC and CD Diagnostic approach to IBDDiagnostic approach to IBD Complications of IBDComplications of IBD IBD managementIBD management
Goals of Therapy for IBDGoals of Therapy for IBD
Inducing remissionInducing remission Maintaining remissionMaintaining remission Restoring and maintaining nutritionRestoring and maintaining nutrition Maintaining patientrsquos quality of lifeMaintaining patientrsquos quality of life Prevention of complicationsPrevention of complications Surgical intervention (selection of Surgical intervention (selection of
optimal time for surgery)optimal time for surgery)
Inductive TherapiesInductive Therapies
For UCFor UC AminosalicylatesAminosalicylates CorticosteroidsCorticosteroids CyclosporinCyclosporin
For CDFor CD AminosalicylatesAminosalicylates CorticosteroidsCorticosteroids AntibioticsAntibiotics Anti-TNFAnti-TNF
Maintenance TherapiesMaintenance Therapies
ImmunosupressorsImmunosupressors AzathioprineAzathioprine 6-MP6-MP MethotrexateMethotrexate
AminosalicylatesAminosalicylates Anti-TNFAnti-TNF
NOT NOT corticosteroidscorticosteroids
IBD ManagementIBD ManagementSummarySummary
There is no ldquoone size fits allrdquo to IBD therapyThere is no ldquoone size fits allrdquo to IBD therapy Therapy and decision making are tailored to the Therapy and decision making are tailored to the
individualindividual
Algorithms are based upon available evidenceAlgorithms are based upon available evidence Evidence is in constant fluxEvidence is in constant flux
Success of algorithms depends upon Success of algorithms depends upon optimization of each step of therapy and optimization of each step of therapy and considerable judgment about each outcomeconsiderable judgment about each outcome Skillful application of medical therapy makes all Skillful application of medical therapy makes all
the difference in outcomesthe difference in outcomes
Surgery for IBDSurgery for IBDGeneral ConceptsGeneral Concepts
Majority will need surgery 78 over Majority will need surgery 78 over twenty yearstwenty years
Surgery generally indicated for Surgery generally indicated for complicationscomplications of disease of disease
Surgery must be directed at area of Surgery must be directed at area of bowel responsible for complicationbowel responsible for complication
Indications for SurgeryIndications for Surgery Intestinal obstruction (most Intestinal obstruction (most
common)common) Intractabilitysteroid Intractabilitysteroid
dependencedependence Non-healing fistulaAbscessNon-healing fistulaAbscess Toxic megacolonFree Toxic megacolonFree
perforationperforation Uncontrollable GI bleedingUncontrollable GI bleeding Severe perianal diseaseSevere perianal disease CancerCancer Growth retardation Growth retardation
(children)(children) Severe uncontrollable Severe uncontrollable
extraintestinal extraintestinal manifestationsmanifestations
Management of IBDSummary
The goals of therapy are Relieve symptoms Prevent relapse Correct nutritional deficiencies Control inflammation Prevent complications especially colon cancer
Treatment depends on 1048707 Type of disease 1048707 Site of disease 1048707 Disease severity
Treatment may include drugs nutrition supplements surgery or a combination of these options
UC ndash disease UC ndash disease severityseverity
MILDMILD MODERATMODERATEE
SEVERESEVERE
BOWEL BOWEL MOVEMENTSMOVEMENTS lt 4 per lt 4 per
dayday 4-6 per 4-6 per dayday
gt6 per gt6 per dayday
BLOOD IN BLOOD IN STOOLSTOOL smallsmall moderatemoderate SevereSevere
FEVERFEVER nonenone lt375lt375degdegC C gt 375gt 375degdegC C
TACHYCARDITACHYCARDIAA
nonenone lt90 mean lt90 mean pulsepulse
gt90 mean gt90 mean pulsepulse
UC ndash disease UC ndash disease severityseverity
MILDMILD MODERATMODERATEE
SEVERESEVERE
ANEMIAANEMIA mildmild gt75gt75 lt75lt75
ESRESR lt30mmlt30mm gt30mmgt30mm
ENDOSCOPIC ENDOSCOPIC APPEARANCEAPPEARANCE
Erythema Erythema decreased decreased vascular vascular pattern fine pattern fine granularitygranularity
Marked Marked erythema erythema coarse coarse granularity granularity contact contact bleeding no bleeding no ulcerationulceration
Spontaneous Spontaneous bleeding bleeding ulcerationulceration
Educational ObjectivesEducational Objectives Definitions and spectrum of inflammatory Definitions and spectrum of inflammatory
bowel disease (IBD)bowel disease (IBD) Epidemiology of IBDEpidemiology of IBD Etiopathogenesis of IBDEtiopathogenesis of IBD Clinical manifestations of ulcerative colitis Clinical manifestations of ulcerative colitis
(UC)(UC) Clinical manifestations of Crohnrsquos disease Clinical manifestations of Crohnrsquos disease
(CD)(CD) Distinguishing features between UC and Distinguishing features between UC and
CDCD Diagnostic approach to IBDDiagnostic approach to IBD Complications of IBDComplications of IBD IBD managementIBD management
CD Clinical FeaturesCD Clinical Features
Abdominal pain often postprandialAbdominal pain often postprandial Diarrhea usually wateryDiarrhea usually watery Rectal bleedingRectal bleeding Weight lossWeight loss Right lower quadrant painpalpable Right lower quadrant painpalpable
massmass FeverFever Growth retardation in childrenGrowth retardation in children Perirectal fistulaPerirectal fistula
Crohnrsquos disease ndash macroscopic Crohnrsquos disease ndash macroscopic featuresfeatures
Can affect any part of GI tract from the mouth to the Can affect any part of GI tract from the mouth to the anusanus
30-40 of patients have small bowel disease alone30-40 of patients have small bowel disease alone
40-55 of patients have both small and large 40-55 of patients have both small and large intestines diseaseintestines disease
15-25 of patients have colitis alone15-25 of patients have colitis alone
In 75 of patients with small intestinal disease the In 75 of patients with small intestinal disease the terminal ileum in involved in 90terminal ileum in involved in 90
Crohnrsquos DiseaseCrohnrsquos DiseaseAnatomic DistributionAnatomic Distribution
Small bowelSmall bowelalonealone(33)(33)
IleocolicIleocolic(45)(45)
Colon aloneColon alone(20)(20)
Frequency of involvementFrequency of involvement
MostMost LeastLeast
Crohnrsquos disease ndash macroscopic Crohnrsquos disease ndash macroscopic featuresfeatures
CD is a CD is a transmuraltransmural process process
CD is CD is segmentalsegmental with skip areas in with skip areas in the midst of diseased intestinethe midst of diseased intestine
In one third of patients with CD In one third of patients with CD perirectal fistulas fissures perirectal fistulas fissures abscesses anal stenosis are presentabscesses anal stenosis are present
Crohnrsquos disease ndash macroscopic Crohnrsquos disease ndash macroscopic featuresfeatures
Active CD is characterized by focal Active CD is characterized by focal inflammation and formation of fistula inflammation and formation of fistula tractstracts
The bowel wall thickens and becomes The bowel wall thickens and becomes narrowed and fibrotic leading to narrowed and fibrotic leading to chronic recurrent bowel obstructionchronic recurrent bowel obstruction
Crohnrsquos Disease Activity Index(CDAI)
Incorporates 8 variables 1 liquid or very soft stools day 2 Abdominal pain amp cramping 3 Extraintestinal manifestations 4 Complications 5 Abdominal mass 6 Use of anti diarrheal medications anti- 7 Hematocrit 8 Body weight
Crohnrsquos Disease Red Crohnrsquos Disease Red FlagsFlags
Onset after stopping smokingOnset after stopping smoking Bleeding onlyBleeding only DiverticulosisDiverticulosis AtherosclerosisAtherosclerosis ProlapseProlapse
Extraintestinal Manifestations of IBD
SkinErythema nodosumPyoderma gangrenosum
JointsPeripheral arthritisSacroileitisAnkylosing spondylitis
EyeUveitisEpiscleritisIritis
Hepatobiliary complicationsGallstonesPSC
Renal complicationsNephrolithiasisRecurrent UTIs
Educational ObjectivesEducational Objectives Definitions and spectrum of inflammatory Definitions and spectrum of inflammatory
bowel disease (IBD)bowel disease (IBD) Epidemiology of IBDEpidemiology of IBD Etiopathogenesis of IBDEtiopathogenesis of IBD Clinical manifestations of ulcerative colitis Clinical manifestations of ulcerative colitis
(UC)(UC) Clinical manifestations of Crohnrsquos disease (CD)Clinical manifestations of Crohnrsquos disease (CD) Distinguishing features between UC and Distinguishing features between UC and
CDCD Diagnostic approach to IBDDiagnostic approach to IBD Medical management of IBDMedical management of IBD Indications for and role of surgeryIndications for and role of surgery
Symptoms of IBDUC vs CDUC vs CD
FeatureFeature UCUC CDCD
FeverFever UncommonUncommon CommonCommon
Rectal Rectal bleedingbleeding
CommonCommon lt frac12 of lt frac12 of patientspatients
Abdominal Abdominal tendernesstenderness
May be May be presentpresent
CommonCommon
Abdominal Abdominal massmass
UncommonUncommon CommonCommon
Abdominal Abdominal painpain
UncommonUncommon Very commonVery common
Weight lossWeight loss UncommonUncommon CommonCommon
TenesmusTenesmus Very commonVery common UncommonUncommon
UC vs CDUC vs CDComplicationsResponse to ComplicationsResponse to
TreatmentTreatmentUCUC CDCD
FistulasFistulas NoNo YesYes
Small Small intestine intestine obstructionobstruction
NoNo FrequentlyFrequently
Colonic Colonic obstructionobstruction
RarelyRarely FrequentlyFrequently
Response to Response to antibioticantibiotic
NoNo YesYes
Recurrence Recurrence after after surgerysurgery
NoNo YesYes
UC vs CDUC vs CDDifferent endoscopic featuresDifferent endoscopic features
UCUC CDCD
Rectal Rectal sparingsparing
RarelyRarely FrequentlyFrequently
Continuous Continuous diseasedisease
YesYes OccasionallyOccasionally
bdquobdquoCCobblestonobblestoningrdquoingrdquo
NoNo YesYes
Granuloma Granuloma on biopsyon biopsy
NoNo OccasionallyOccasionally
Criteria for Indeterminate Criteria for Indeterminate ColitisColitis
No evidence of No evidence of small bowel small bowel involvement involvement fistula or fistula or perianal diseaseperianal disease
Absence of Absence of diagnostic diagnostic criteria for CD criteria for CD or UC by or UC by microscopymicroscopy
Differential Diagnosis of Differential Diagnosis of Chronic Diarrhea and Weight Chronic Diarrhea and Weight
LossLoss Colonic diseasesColonic diseases
IBDIBD NeoplasiaNeoplasia Ischemic bowelIschemic bowel
PancreaticPancreatic Chronic pancreatitisChronic pancreatitis CancerCancer Cystic fibrosisCystic fibrosis
EnteropathicEnteropathic Celiac diseaseCeliac disease Tropical sprueTropical sprue LymphomaLymphoma Mesenteric ischemiaMesenteric ischemia Whipplersquos diseaseWhipplersquos disease
HormonaldrugsHormonaldrugs VipomaVipoma ZESZES Medullary CA of Medullary CA of
thyroidthyroid NSAIDS useNSAIDS use
Educational ObjectivesEducational Objectives Definitions and spectrum of inflammatory Definitions and spectrum of inflammatory
bowel disease (IBD)bowel disease (IBD) Epidemiology of IBDEpidemiology of IBD Etiopathogenesis of IBDEtiopathogenesis of IBD Clinical manifestations of ulcerative colitis Clinical manifestations of ulcerative colitis
(UC)(UC) Clinical manifestations of Crohnrsquos disease Clinical manifestations of Crohnrsquos disease
(CD)(CD) Distinguishing features between UC and CDDistinguishing features between UC and CD Diagnostic approach to IBDDiagnostic approach to IBD Medical management of IBDMedical management of IBD Indications for and role of surgeryIndications for and role of surgery
Diagnostic Approach to Diagnostic Approach to Patients with Suspected Patients with Suspected
IBDIBD HistoryhelliphelliphistoryhelliphelliphistoryHistoryhelliphelliphistoryhelliphelliphistory Clinical examClinical exam Laboratory testsLaboratory tests Radiological imagingRadiological imaging EndoscopyEndoscopy Special serological testingSpecial serological testing Genetic testingGenetic testing
Diagnosis-LAB Blood test
CD Mild anemia mild leukocytosis elevated ESR elevated CRP positive ASCA
UC Anemia hypokalemia hypoalbuminemia elevated ESR elevated LFTs positive p-ANCA
Stool analysis Many WBCs and or RBCs No ova or parasites
What are the Serological What are the Serological Markers in IBDMarkers in IBD
pANCA (perinuclear staining pattern)pANCA (perinuclear staining pattern) Loss of perinuclear pattern after Loss of perinuclear pattern after
DNAaseDNAase Differentiate from the ldquoother pANCAsrdquoDifferentiate from the ldquoother pANCAsrdquo
Antibody against myeloperoxidaseAntibody against myeloperoxidase Antibody against cathepsin G elastase lysozyme Antibody against cathepsin G elastase lysozyme
and lactoferrinand lactoferrin ASCA (anti-ASCA (anti-Saccharomyces cerevisiaeSaccharomyces cerevisiae))
Both IgG and IgABoth IgG and IgA Recognize mannose in the cell wall Recognize mannose in the cell wall
mannan of mannan of Saccharomyces cerevisiaeSaccharomyces cerevisiae
Why Use Serological Why Use Serological Markers in Clinical Markers in Clinical
PracticePractice Differentiate IBD from functional bowel Differentiate IBD from functional bowel
disordersdisorders Accurately diagnose Crohnrsquos or UC in a patient Accurately diagnose Crohnrsquos or UC in a patient
withwith Severe colitisSevere colitis Indeterminate colitisIndeterminate colitis
Predict disease course or complications in IBDPredict disease course or complications in IBD CD phenotypeCD phenotype Severity of diseaseSeverity of disease Risk of pouchitisRisk of pouchitis
SummarySummary
pANCA and ASCA are specific for UC pANCA and ASCA are specific for UC and CD respectivelyand CD respectively
Neither pANCA nor ASCA are sensitive Neither pANCA nor ASCA are sensitive enough to exclude IBDenough to exclude IBD
In patients with IC available In patients with IC available serological markers do not accurately serological markers do not accurately predict the subsequent disease coursepredict the subsequent disease course
Antibody profiles can predict disease Antibody profiles can predict disease behavior in IBDbehavior in IBD
Diagnostic ApproachDiagnostic ApproachEndoscopyEndoscopy
Endoscopy useful forEndoscopy useful for Initial diagnosisInitial diagnosis Assessment of severityAssessment of severity Tissue diagnosisTissue diagnosis FU during treatmentFU during treatment Assessment of disease exacerbationAssessment of disease exacerbation Surveillance for risk of cancerSurveillance for risk of cancer Treatment of certain complications (eg Treatment of certain complications (eg
strictures)strictures)
Crohnrsquos DiseaseCrohnrsquos DiseaseEndoscopic FeaturesEndoscopic Features
Asymmetric patchy inflammationAsymmetric patchy inflammation Skip lesionsSkip lesions Rectal sparingRectal sparing Ulcerations-deepserpiginousUlcerations-deepserpiginous Cobblestoning-commonCobblestoning-common Pseudopolyps-rarePseudopolyps-rare BiopsyBiopsy
Erosions and normal mucosaErosions and normal mucosa Granulomas in 15 to 35 of specimensGranulomas in 15 to 35 of specimens
Ulcerative ColitisUlcerative ColitisEndoscopic FeaturesEndoscopic Features
Diffuse involvementDiffuse involvement Rectum always diseasedRectum always diseased Superficial ulcerationsSuperficial ulcerations FriabilitybleedingFriabilitybleeding Flatteningdisappearance of haustral Flatteningdisappearance of haustral
foldsfolds PseudopolypsPseudopolyps No cobblestoningNo cobblestoning Bx No granulomasBx No granulomas
Imaging for Crohn Imaging for Crohn DiseaseDisease
Traditional TechniquesTraditional Techniques Abdominal RadiographsAbdominal Radiographs
Barium UGI Barium UGI
Barium small bowel follow throughBarium small bowel follow through
Barium EnteroclysisBarium Enteroclysis
Barium EnemaBarium Enema
Imaging for Crohn Disease Imaging for Crohn Disease Newer TechniquesNewer Techniques
CTCT
CT EnteroclysisCT Enteroclysis
CT EnterographyCT Enterography
Magnetic ResonanceMagnetic Resonance
UltrasoundUltrasound
Nuclear MedicineNuclear Medicine
Imaging for Crohns DiseaseImaging for Crohns Disease SummarySummary
Useful Newer TechniquesUseful Newer Techniques evolvingevolving CT EnterographyCT Enterography
Comprehensive evaluation of all bowel amp solid organsComprehensive evaluation of all bowel amp solid organs
Magnetic ResonanceMagnetic Resonance
Useful for ano-rectal diseaseUseful for ano-rectal disease
Real-time MR has potential for detection of stricturesReal-time MR has potential for detection of strictures
Traditional imaging techniques still of value in Traditional imaging techniques still of value in selected cases selected cases
The Capsule (WCE)The Capsule (WCE)
WCEWCE
bull Diameter 11mm Length 26mmDiameter 11mm Length 26mmbull Optical dome Intestinal illumination Optical dome Intestinal illumination
by white light emitting diodes (LEDrsquos)by white light emitting diodes (LEDrsquos)bull LensLensbull Complementary metal-oxide silicone Complementary metal-oxide silicone
imager (color camera chip)imager (color camera chip)bull TransmitterTransmitterbull Two batteries (silver oxide)Two batteries (silver oxide)
GE Junction Duodenum
Jejunum Ileocecal Valve
Educational ObjectivesEducational Objectives Definitions and spectrum of inflammatory Definitions and spectrum of inflammatory
bowel disease (IBD)bowel disease (IBD) Epidemiology of IBDEpidemiology of IBD Etiopathogenesis of IBDEtiopathogenesis of IBD Clinical manifestations of ulcerative colitis Clinical manifestations of ulcerative colitis
(UC)(UC) Clinical manifestations of Crohnrsquos disease Clinical manifestations of Crohnrsquos disease
(CD)(CD) Distinguishing features between UC and CDDistinguishing features between UC and CD Diagnostic approach to IBDDiagnostic approach to IBD Complications of IBDComplications of IBD IBD managementIBD management
IBD-ComplicationsIBD-Complications GI BleedingGI Bleeding Toxic megacolonToxic megacolon PerforationPerforation Thromboembolic phenomenaThromboembolic phenomena FistulasfissuresFistulasfissures AbscessAbscess StricturesobstructionStricturesobstruction MalabsorptionmalnutritionMalabsorptionmalnutrition CancerCancer
Best Protection
Surveillance colonoscopySurveillance colonoscopy
Procto-colectomy (for UC)Procto-colectomy (for UC)
Descending Colon Descending Colon StrictureStricture
Colonic StricturesColonic Strictures
Consider nonsurgical management Consider nonsurgical management ifif Endoscopically accessibleEndoscopically accessible Multiple prior resectionsMultiple prior resections Shorter strictures (less than 5 cm)Shorter strictures (less than 5 cm) Steroid injection if significant Steroid injection if significant
inflammationinflammation
Fistula DefinitionA communication between two epithelial-lined organsLifetime risk of fistula in CD30
Perianal FistulaPerianal Fistula
Pretreatment 2 Weeks
10 Weeks 18 weeks
Educational ObjectivesEducational Objectives Definitions and spectrum of inflammatory Definitions and spectrum of inflammatory
bowel disease (IBD)bowel disease (IBD) Epidemiology of IBDEpidemiology of IBD Etiopathogenesis of IBDEtiopathogenesis of IBD Clinical manifestations of ulcerative colitis Clinical manifestations of ulcerative colitis
(UC)(UC) Clinical manifestations of Crohnrsquos disease Clinical manifestations of Crohnrsquos disease
(CD)(CD) Distinguishing features between UC and CDDistinguishing features between UC and CD Diagnostic approach to IBDDiagnostic approach to IBD Complications of IBDComplications of IBD IBD managementIBD management
Goals of Therapy for IBDGoals of Therapy for IBD
Inducing remissionInducing remission Maintaining remissionMaintaining remission Restoring and maintaining nutritionRestoring and maintaining nutrition Maintaining patientrsquos quality of lifeMaintaining patientrsquos quality of life Prevention of complicationsPrevention of complications Surgical intervention (selection of Surgical intervention (selection of
optimal time for surgery)optimal time for surgery)
Inductive TherapiesInductive Therapies
For UCFor UC AminosalicylatesAminosalicylates CorticosteroidsCorticosteroids CyclosporinCyclosporin
For CDFor CD AminosalicylatesAminosalicylates CorticosteroidsCorticosteroids AntibioticsAntibiotics Anti-TNFAnti-TNF
Maintenance TherapiesMaintenance Therapies
ImmunosupressorsImmunosupressors AzathioprineAzathioprine 6-MP6-MP MethotrexateMethotrexate
AminosalicylatesAminosalicylates Anti-TNFAnti-TNF
NOT NOT corticosteroidscorticosteroids
IBD ManagementIBD ManagementSummarySummary
There is no ldquoone size fits allrdquo to IBD therapyThere is no ldquoone size fits allrdquo to IBD therapy Therapy and decision making are tailored to the Therapy and decision making are tailored to the
individualindividual
Algorithms are based upon available evidenceAlgorithms are based upon available evidence Evidence is in constant fluxEvidence is in constant flux
Success of algorithms depends upon Success of algorithms depends upon optimization of each step of therapy and optimization of each step of therapy and considerable judgment about each outcomeconsiderable judgment about each outcome Skillful application of medical therapy makes all Skillful application of medical therapy makes all
the difference in outcomesthe difference in outcomes
Surgery for IBDSurgery for IBDGeneral ConceptsGeneral Concepts
Majority will need surgery 78 over Majority will need surgery 78 over twenty yearstwenty years
Surgery generally indicated for Surgery generally indicated for complicationscomplications of disease of disease
Surgery must be directed at area of Surgery must be directed at area of bowel responsible for complicationbowel responsible for complication
Indications for SurgeryIndications for Surgery Intestinal obstruction (most Intestinal obstruction (most
common)common) Intractabilitysteroid Intractabilitysteroid
dependencedependence Non-healing fistulaAbscessNon-healing fistulaAbscess Toxic megacolonFree Toxic megacolonFree
perforationperforation Uncontrollable GI bleedingUncontrollable GI bleeding Severe perianal diseaseSevere perianal disease CancerCancer Growth retardation Growth retardation
(children)(children) Severe uncontrollable Severe uncontrollable
extraintestinal extraintestinal manifestationsmanifestations
Management of IBDSummary
The goals of therapy are Relieve symptoms Prevent relapse Correct nutritional deficiencies Control inflammation Prevent complications especially colon cancer
Treatment depends on 1048707 Type of disease 1048707 Site of disease 1048707 Disease severity
Treatment may include drugs nutrition supplements surgery or a combination of these options
UC ndash disease UC ndash disease severityseverity
MILDMILD MODERATMODERATEE
SEVERESEVERE
ANEMIAANEMIA mildmild gt75gt75 lt75lt75
ESRESR lt30mmlt30mm gt30mmgt30mm
ENDOSCOPIC ENDOSCOPIC APPEARANCEAPPEARANCE
Erythema Erythema decreased decreased vascular vascular pattern fine pattern fine granularitygranularity
Marked Marked erythema erythema coarse coarse granularity granularity contact contact bleeding no bleeding no ulcerationulceration
Spontaneous Spontaneous bleeding bleeding ulcerationulceration
Educational ObjectivesEducational Objectives Definitions and spectrum of inflammatory Definitions and spectrum of inflammatory
bowel disease (IBD)bowel disease (IBD) Epidemiology of IBDEpidemiology of IBD Etiopathogenesis of IBDEtiopathogenesis of IBD Clinical manifestations of ulcerative colitis Clinical manifestations of ulcerative colitis
(UC)(UC) Clinical manifestations of Crohnrsquos disease Clinical manifestations of Crohnrsquos disease
(CD)(CD) Distinguishing features between UC and Distinguishing features between UC and
CDCD Diagnostic approach to IBDDiagnostic approach to IBD Complications of IBDComplications of IBD IBD managementIBD management
CD Clinical FeaturesCD Clinical Features
Abdominal pain often postprandialAbdominal pain often postprandial Diarrhea usually wateryDiarrhea usually watery Rectal bleedingRectal bleeding Weight lossWeight loss Right lower quadrant painpalpable Right lower quadrant painpalpable
massmass FeverFever Growth retardation in childrenGrowth retardation in children Perirectal fistulaPerirectal fistula
Crohnrsquos disease ndash macroscopic Crohnrsquos disease ndash macroscopic featuresfeatures
Can affect any part of GI tract from the mouth to the Can affect any part of GI tract from the mouth to the anusanus
30-40 of patients have small bowel disease alone30-40 of patients have small bowel disease alone
40-55 of patients have both small and large 40-55 of patients have both small and large intestines diseaseintestines disease
15-25 of patients have colitis alone15-25 of patients have colitis alone
In 75 of patients with small intestinal disease the In 75 of patients with small intestinal disease the terminal ileum in involved in 90terminal ileum in involved in 90
Crohnrsquos DiseaseCrohnrsquos DiseaseAnatomic DistributionAnatomic Distribution
Small bowelSmall bowelalonealone(33)(33)
IleocolicIleocolic(45)(45)
Colon aloneColon alone(20)(20)
Frequency of involvementFrequency of involvement
MostMost LeastLeast
Crohnrsquos disease ndash macroscopic Crohnrsquos disease ndash macroscopic featuresfeatures
CD is a CD is a transmuraltransmural process process
CD is CD is segmentalsegmental with skip areas in with skip areas in the midst of diseased intestinethe midst of diseased intestine
In one third of patients with CD In one third of patients with CD perirectal fistulas fissures perirectal fistulas fissures abscesses anal stenosis are presentabscesses anal stenosis are present
Crohnrsquos disease ndash macroscopic Crohnrsquos disease ndash macroscopic featuresfeatures
Active CD is characterized by focal Active CD is characterized by focal inflammation and formation of fistula inflammation and formation of fistula tractstracts
The bowel wall thickens and becomes The bowel wall thickens and becomes narrowed and fibrotic leading to narrowed and fibrotic leading to chronic recurrent bowel obstructionchronic recurrent bowel obstruction
Crohnrsquos Disease Activity Index(CDAI)
Incorporates 8 variables 1 liquid or very soft stools day 2 Abdominal pain amp cramping 3 Extraintestinal manifestations 4 Complications 5 Abdominal mass 6 Use of anti diarrheal medications anti- 7 Hematocrit 8 Body weight
Crohnrsquos Disease Red Crohnrsquos Disease Red FlagsFlags
Onset after stopping smokingOnset after stopping smoking Bleeding onlyBleeding only DiverticulosisDiverticulosis AtherosclerosisAtherosclerosis ProlapseProlapse
Extraintestinal Manifestations of IBD
SkinErythema nodosumPyoderma gangrenosum
JointsPeripheral arthritisSacroileitisAnkylosing spondylitis
EyeUveitisEpiscleritisIritis
Hepatobiliary complicationsGallstonesPSC
Renal complicationsNephrolithiasisRecurrent UTIs
Educational ObjectivesEducational Objectives Definitions and spectrum of inflammatory Definitions and spectrum of inflammatory
bowel disease (IBD)bowel disease (IBD) Epidemiology of IBDEpidemiology of IBD Etiopathogenesis of IBDEtiopathogenesis of IBD Clinical manifestations of ulcerative colitis Clinical manifestations of ulcerative colitis
(UC)(UC) Clinical manifestations of Crohnrsquos disease (CD)Clinical manifestations of Crohnrsquos disease (CD) Distinguishing features between UC and Distinguishing features between UC and
CDCD Diagnostic approach to IBDDiagnostic approach to IBD Medical management of IBDMedical management of IBD Indications for and role of surgeryIndications for and role of surgery
Symptoms of IBDUC vs CDUC vs CD
FeatureFeature UCUC CDCD
FeverFever UncommonUncommon CommonCommon
Rectal Rectal bleedingbleeding
CommonCommon lt frac12 of lt frac12 of patientspatients
Abdominal Abdominal tendernesstenderness
May be May be presentpresent
CommonCommon
Abdominal Abdominal massmass
UncommonUncommon CommonCommon
Abdominal Abdominal painpain
UncommonUncommon Very commonVery common
Weight lossWeight loss UncommonUncommon CommonCommon
TenesmusTenesmus Very commonVery common UncommonUncommon
UC vs CDUC vs CDComplicationsResponse to ComplicationsResponse to
TreatmentTreatmentUCUC CDCD
FistulasFistulas NoNo YesYes
Small Small intestine intestine obstructionobstruction
NoNo FrequentlyFrequently
Colonic Colonic obstructionobstruction
RarelyRarely FrequentlyFrequently
Response to Response to antibioticantibiotic
NoNo YesYes
Recurrence Recurrence after after surgerysurgery
NoNo YesYes
UC vs CDUC vs CDDifferent endoscopic featuresDifferent endoscopic features
UCUC CDCD
Rectal Rectal sparingsparing
RarelyRarely FrequentlyFrequently
Continuous Continuous diseasedisease
YesYes OccasionallyOccasionally
bdquobdquoCCobblestonobblestoningrdquoingrdquo
NoNo YesYes
Granuloma Granuloma on biopsyon biopsy
NoNo OccasionallyOccasionally
Criteria for Indeterminate Criteria for Indeterminate ColitisColitis
No evidence of No evidence of small bowel small bowel involvement involvement fistula or fistula or perianal diseaseperianal disease
Absence of Absence of diagnostic diagnostic criteria for CD criteria for CD or UC by or UC by microscopymicroscopy
Differential Diagnosis of Differential Diagnosis of Chronic Diarrhea and Weight Chronic Diarrhea and Weight
LossLoss Colonic diseasesColonic diseases
IBDIBD NeoplasiaNeoplasia Ischemic bowelIschemic bowel
PancreaticPancreatic Chronic pancreatitisChronic pancreatitis CancerCancer Cystic fibrosisCystic fibrosis
EnteropathicEnteropathic Celiac diseaseCeliac disease Tropical sprueTropical sprue LymphomaLymphoma Mesenteric ischemiaMesenteric ischemia Whipplersquos diseaseWhipplersquos disease
HormonaldrugsHormonaldrugs VipomaVipoma ZESZES Medullary CA of Medullary CA of
thyroidthyroid NSAIDS useNSAIDS use
Educational ObjectivesEducational Objectives Definitions and spectrum of inflammatory Definitions and spectrum of inflammatory
bowel disease (IBD)bowel disease (IBD) Epidemiology of IBDEpidemiology of IBD Etiopathogenesis of IBDEtiopathogenesis of IBD Clinical manifestations of ulcerative colitis Clinical manifestations of ulcerative colitis
(UC)(UC) Clinical manifestations of Crohnrsquos disease Clinical manifestations of Crohnrsquos disease
(CD)(CD) Distinguishing features between UC and CDDistinguishing features between UC and CD Diagnostic approach to IBDDiagnostic approach to IBD Medical management of IBDMedical management of IBD Indications for and role of surgeryIndications for and role of surgery
Diagnostic Approach to Diagnostic Approach to Patients with Suspected Patients with Suspected
IBDIBD HistoryhelliphelliphistoryhelliphelliphistoryHistoryhelliphelliphistoryhelliphelliphistory Clinical examClinical exam Laboratory testsLaboratory tests Radiological imagingRadiological imaging EndoscopyEndoscopy Special serological testingSpecial serological testing Genetic testingGenetic testing
Diagnosis-LAB Blood test
CD Mild anemia mild leukocytosis elevated ESR elevated CRP positive ASCA
UC Anemia hypokalemia hypoalbuminemia elevated ESR elevated LFTs positive p-ANCA
Stool analysis Many WBCs and or RBCs No ova or parasites
What are the Serological What are the Serological Markers in IBDMarkers in IBD
pANCA (perinuclear staining pattern)pANCA (perinuclear staining pattern) Loss of perinuclear pattern after Loss of perinuclear pattern after
DNAaseDNAase Differentiate from the ldquoother pANCAsrdquoDifferentiate from the ldquoother pANCAsrdquo
Antibody against myeloperoxidaseAntibody against myeloperoxidase Antibody against cathepsin G elastase lysozyme Antibody against cathepsin G elastase lysozyme
and lactoferrinand lactoferrin ASCA (anti-ASCA (anti-Saccharomyces cerevisiaeSaccharomyces cerevisiae))
Both IgG and IgABoth IgG and IgA Recognize mannose in the cell wall Recognize mannose in the cell wall
mannan of mannan of Saccharomyces cerevisiaeSaccharomyces cerevisiae
Why Use Serological Why Use Serological Markers in Clinical Markers in Clinical
PracticePractice Differentiate IBD from functional bowel Differentiate IBD from functional bowel
disordersdisorders Accurately diagnose Crohnrsquos or UC in a patient Accurately diagnose Crohnrsquos or UC in a patient
withwith Severe colitisSevere colitis Indeterminate colitisIndeterminate colitis
Predict disease course or complications in IBDPredict disease course or complications in IBD CD phenotypeCD phenotype Severity of diseaseSeverity of disease Risk of pouchitisRisk of pouchitis
SummarySummary
pANCA and ASCA are specific for UC pANCA and ASCA are specific for UC and CD respectivelyand CD respectively
Neither pANCA nor ASCA are sensitive Neither pANCA nor ASCA are sensitive enough to exclude IBDenough to exclude IBD
In patients with IC available In patients with IC available serological markers do not accurately serological markers do not accurately predict the subsequent disease coursepredict the subsequent disease course
Antibody profiles can predict disease Antibody profiles can predict disease behavior in IBDbehavior in IBD
Diagnostic ApproachDiagnostic ApproachEndoscopyEndoscopy
Endoscopy useful forEndoscopy useful for Initial diagnosisInitial diagnosis Assessment of severityAssessment of severity Tissue diagnosisTissue diagnosis FU during treatmentFU during treatment Assessment of disease exacerbationAssessment of disease exacerbation Surveillance for risk of cancerSurveillance for risk of cancer Treatment of certain complications (eg Treatment of certain complications (eg
strictures)strictures)
Crohnrsquos DiseaseCrohnrsquos DiseaseEndoscopic FeaturesEndoscopic Features
Asymmetric patchy inflammationAsymmetric patchy inflammation Skip lesionsSkip lesions Rectal sparingRectal sparing Ulcerations-deepserpiginousUlcerations-deepserpiginous Cobblestoning-commonCobblestoning-common Pseudopolyps-rarePseudopolyps-rare BiopsyBiopsy
Erosions and normal mucosaErosions and normal mucosa Granulomas in 15 to 35 of specimensGranulomas in 15 to 35 of specimens
Ulcerative ColitisUlcerative ColitisEndoscopic FeaturesEndoscopic Features
Diffuse involvementDiffuse involvement Rectum always diseasedRectum always diseased Superficial ulcerationsSuperficial ulcerations FriabilitybleedingFriabilitybleeding Flatteningdisappearance of haustral Flatteningdisappearance of haustral
foldsfolds PseudopolypsPseudopolyps No cobblestoningNo cobblestoning Bx No granulomasBx No granulomas
Imaging for Crohn Imaging for Crohn DiseaseDisease
Traditional TechniquesTraditional Techniques Abdominal RadiographsAbdominal Radiographs
Barium UGI Barium UGI
Barium small bowel follow throughBarium small bowel follow through
Barium EnteroclysisBarium Enteroclysis
Barium EnemaBarium Enema
Imaging for Crohn Disease Imaging for Crohn Disease Newer TechniquesNewer Techniques
CTCT
CT EnteroclysisCT Enteroclysis
CT EnterographyCT Enterography
Magnetic ResonanceMagnetic Resonance
UltrasoundUltrasound
Nuclear MedicineNuclear Medicine
Imaging for Crohns DiseaseImaging for Crohns Disease SummarySummary
Useful Newer TechniquesUseful Newer Techniques evolvingevolving CT EnterographyCT Enterography
Comprehensive evaluation of all bowel amp solid organsComprehensive evaluation of all bowel amp solid organs
Magnetic ResonanceMagnetic Resonance
Useful for ano-rectal diseaseUseful for ano-rectal disease
Real-time MR has potential for detection of stricturesReal-time MR has potential for detection of strictures
Traditional imaging techniques still of value in Traditional imaging techniques still of value in selected cases selected cases
The Capsule (WCE)The Capsule (WCE)
WCEWCE
bull Diameter 11mm Length 26mmDiameter 11mm Length 26mmbull Optical dome Intestinal illumination Optical dome Intestinal illumination
by white light emitting diodes (LEDrsquos)by white light emitting diodes (LEDrsquos)bull LensLensbull Complementary metal-oxide silicone Complementary metal-oxide silicone
imager (color camera chip)imager (color camera chip)bull TransmitterTransmitterbull Two batteries (silver oxide)Two batteries (silver oxide)
GE Junction Duodenum
Jejunum Ileocecal Valve
Educational ObjectivesEducational Objectives Definitions and spectrum of inflammatory Definitions and spectrum of inflammatory
bowel disease (IBD)bowel disease (IBD) Epidemiology of IBDEpidemiology of IBD Etiopathogenesis of IBDEtiopathogenesis of IBD Clinical manifestations of ulcerative colitis Clinical manifestations of ulcerative colitis
(UC)(UC) Clinical manifestations of Crohnrsquos disease Clinical manifestations of Crohnrsquos disease
(CD)(CD) Distinguishing features between UC and CDDistinguishing features between UC and CD Diagnostic approach to IBDDiagnostic approach to IBD Complications of IBDComplications of IBD IBD managementIBD management
IBD-ComplicationsIBD-Complications GI BleedingGI Bleeding Toxic megacolonToxic megacolon PerforationPerforation Thromboembolic phenomenaThromboembolic phenomena FistulasfissuresFistulasfissures AbscessAbscess StricturesobstructionStricturesobstruction MalabsorptionmalnutritionMalabsorptionmalnutrition CancerCancer
Best Protection
Surveillance colonoscopySurveillance colonoscopy
Procto-colectomy (for UC)Procto-colectomy (for UC)
Descending Colon Descending Colon StrictureStricture
Colonic StricturesColonic Strictures
Consider nonsurgical management Consider nonsurgical management ifif Endoscopically accessibleEndoscopically accessible Multiple prior resectionsMultiple prior resections Shorter strictures (less than 5 cm)Shorter strictures (less than 5 cm) Steroid injection if significant Steroid injection if significant
inflammationinflammation
Fistula DefinitionA communication between two epithelial-lined organsLifetime risk of fistula in CD30
Perianal FistulaPerianal Fistula
Pretreatment 2 Weeks
10 Weeks 18 weeks
Educational ObjectivesEducational Objectives Definitions and spectrum of inflammatory Definitions and spectrum of inflammatory
bowel disease (IBD)bowel disease (IBD) Epidemiology of IBDEpidemiology of IBD Etiopathogenesis of IBDEtiopathogenesis of IBD Clinical manifestations of ulcerative colitis Clinical manifestations of ulcerative colitis
(UC)(UC) Clinical manifestations of Crohnrsquos disease Clinical manifestations of Crohnrsquos disease
(CD)(CD) Distinguishing features between UC and CDDistinguishing features between UC and CD Diagnostic approach to IBDDiagnostic approach to IBD Complications of IBDComplications of IBD IBD managementIBD management
Goals of Therapy for IBDGoals of Therapy for IBD
Inducing remissionInducing remission Maintaining remissionMaintaining remission Restoring and maintaining nutritionRestoring and maintaining nutrition Maintaining patientrsquos quality of lifeMaintaining patientrsquos quality of life Prevention of complicationsPrevention of complications Surgical intervention (selection of Surgical intervention (selection of
optimal time for surgery)optimal time for surgery)
Inductive TherapiesInductive Therapies
For UCFor UC AminosalicylatesAminosalicylates CorticosteroidsCorticosteroids CyclosporinCyclosporin
For CDFor CD AminosalicylatesAminosalicylates CorticosteroidsCorticosteroids AntibioticsAntibiotics Anti-TNFAnti-TNF
Maintenance TherapiesMaintenance Therapies
ImmunosupressorsImmunosupressors AzathioprineAzathioprine 6-MP6-MP MethotrexateMethotrexate
AminosalicylatesAminosalicylates Anti-TNFAnti-TNF
NOT NOT corticosteroidscorticosteroids
IBD ManagementIBD ManagementSummarySummary
There is no ldquoone size fits allrdquo to IBD therapyThere is no ldquoone size fits allrdquo to IBD therapy Therapy and decision making are tailored to the Therapy and decision making are tailored to the
individualindividual
Algorithms are based upon available evidenceAlgorithms are based upon available evidence Evidence is in constant fluxEvidence is in constant flux
Success of algorithms depends upon Success of algorithms depends upon optimization of each step of therapy and optimization of each step of therapy and considerable judgment about each outcomeconsiderable judgment about each outcome Skillful application of medical therapy makes all Skillful application of medical therapy makes all
the difference in outcomesthe difference in outcomes
Surgery for IBDSurgery for IBDGeneral ConceptsGeneral Concepts
Majority will need surgery 78 over Majority will need surgery 78 over twenty yearstwenty years
Surgery generally indicated for Surgery generally indicated for complicationscomplications of disease of disease
Surgery must be directed at area of Surgery must be directed at area of bowel responsible for complicationbowel responsible for complication
Indications for SurgeryIndications for Surgery Intestinal obstruction (most Intestinal obstruction (most
common)common) Intractabilitysteroid Intractabilitysteroid
dependencedependence Non-healing fistulaAbscessNon-healing fistulaAbscess Toxic megacolonFree Toxic megacolonFree
perforationperforation Uncontrollable GI bleedingUncontrollable GI bleeding Severe perianal diseaseSevere perianal disease CancerCancer Growth retardation Growth retardation
(children)(children) Severe uncontrollable Severe uncontrollable
extraintestinal extraintestinal manifestationsmanifestations
Management of IBDSummary
The goals of therapy are Relieve symptoms Prevent relapse Correct nutritional deficiencies Control inflammation Prevent complications especially colon cancer
Treatment depends on 1048707 Type of disease 1048707 Site of disease 1048707 Disease severity
Treatment may include drugs nutrition supplements surgery or a combination of these options
Educational ObjectivesEducational Objectives Definitions and spectrum of inflammatory Definitions and spectrum of inflammatory
bowel disease (IBD)bowel disease (IBD) Epidemiology of IBDEpidemiology of IBD Etiopathogenesis of IBDEtiopathogenesis of IBD Clinical manifestations of ulcerative colitis Clinical manifestations of ulcerative colitis
(UC)(UC) Clinical manifestations of Crohnrsquos disease Clinical manifestations of Crohnrsquos disease
(CD)(CD) Distinguishing features between UC and Distinguishing features between UC and
CDCD Diagnostic approach to IBDDiagnostic approach to IBD Complications of IBDComplications of IBD IBD managementIBD management
CD Clinical FeaturesCD Clinical Features
Abdominal pain often postprandialAbdominal pain often postprandial Diarrhea usually wateryDiarrhea usually watery Rectal bleedingRectal bleeding Weight lossWeight loss Right lower quadrant painpalpable Right lower quadrant painpalpable
massmass FeverFever Growth retardation in childrenGrowth retardation in children Perirectal fistulaPerirectal fistula
Crohnrsquos disease ndash macroscopic Crohnrsquos disease ndash macroscopic featuresfeatures
Can affect any part of GI tract from the mouth to the Can affect any part of GI tract from the mouth to the anusanus
30-40 of patients have small bowel disease alone30-40 of patients have small bowel disease alone
40-55 of patients have both small and large 40-55 of patients have both small and large intestines diseaseintestines disease
15-25 of patients have colitis alone15-25 of patients have colitis alone
In 75 of patients with small intestinal disease the In 75 of patients with small intestinal disease the terminal ileum in involved in 90terminal ileum in involved in 90
Crohnrsquos DiseaseCrohnrsquos DiseaseAnatomic DistributionAnatomic Distribution
Small bowelSmall bowelalonealone(33)(33)
IleocolicIleocolic(45)(45)
Colon aloneColon alone(20)(20)
Frequency of involvementFrequency of involvement
MostMost LeastLeast
Crohnrsquos disease ndash macroscopic Crohnrsquos disease ndash macroscopic featuresfeatures
CD is a CD is a transmuraltransmural process process
CD is CD is segmentalsegmental with skip areas in with skip areas in the midst of diseased intestinethe midst of diseased intestine
In one third of patients with CD In one third of patients with CD perirectal fistulas fissures perirectal fistulas fissures abscesses anal stenosis are presentabscesses anal stenosis are present
Crohnrsquos disease ndash macroscopic Crohnrsquos disease ndash macroscopic featuresfeatures
Active CD is characterized by focal Active CD is characterized by focal inflammation and formation of fistula inflammation and formation of fistula tractstracts
The bowel wall thickens and becomes The bowel wall thickens and becomes narrowed and fibrotic leading to narrowed and fibrotic leading to chronic recurrent bowel obstructionchronic recurrent bowel obstruction
Crohnrsquos Disease Activity Index(CDAI)
Incorporates 8 variables 1 liquid or very soft stools day 2 Abdominal pain amp cramping 3 Extraintestinal manifestations 4 Complications 5 Abdominal mass 6 Use of anti diarrheal medications anti- 7 Hematocrit 8 Body weight
Crohnrsquos Disease Red Crohnrsquos Disease Red FlagsFlags
Onset after stopping smokingOnset after stopping smoking Bleeding onlyBleeding only DiverticulosisDiverticulosis AtherosclerosisAtherosclerosis ProlapseProlapse
Extraintestinal Manifestations of IBD
SkinErythema nodosumPyoderma gangrenosum
JointsPeripheral arthritisSacroileitisAnkylosing spondylitis
EyeUveitisEpiscleritisIritis
Hepatobiliary complicationsGallstonesPSC
Renal complicationsNephrolithiasisRecurrent UTIs
Educational ObjectivesEducational Objectives Definitions and spectrum of inflammatory Definitions and spectrum of inflammatory
bowel disease (IBD)bowel disease (IBD) Epidemiology of IBDEpidemiology of IBD Etiopathogenesis of IBDEtiopathogenesis of IBD Clinical manifestations of ulcerative colitis Clinical manifestations of ulcerative colitis
(UC)(UC) Clinical manifestations of Crohnrsquos disease (CD)Clinical manifestations of Crohnrsquos disease (CD) Distinguishing features between UC and Distinguishing features between UC and
CDCD Diagnostic approach to IBDDiagnostic approach to IBD Medical management of IBDMedical management of IBD Indications for and role of surgeryIndications for and role of surgery
Symptoms of IBDUC vs CDUC vs CD
FeatureFeature UCUC CDCD
FeverFever UncommonUncommon CommonCommon
Rectal Rectal bleedingbleeding
CommonCommon lt frac12 of lt frac12 of patientspatients
Abdominal Abdominal tendernesstenderness
May be May be presentpresent
CommonCommon
Abdominal Abdominal massmass
UncommonUncommon CommonCommon
Abdominal Abdominal painpain
UncommonUncommon Very commonVery common
Weight lossWeight loss UncommonUncommon CommonCommon
TenesmusTenesmus Very commonVery common UncommonUncommon
UC vs CDUC vs CDComplicationsResponse to ComplicationsResponse to
TreatmentTreatmentUCUC CDCD
FistulasFistulas NoNo YesYes
Small Small intestine intestine obstructionobstruction
NoNo FrequentlyFrequently
Colonic Colonic obstructionobstruction
RarelyRarely FrequentlyFrequently
Response to Response to antibioticantibiotic
NoNo YesYes
Recurrence Recurrence after after surgerysurgery
NoNo YesYes
UC vs CDUC vs CDDifferent endoscopic featuresDifferent endoscopic features
UCUC CDCD
Rectal Rectal sparingsparing
RarelyRarely FrequentlyFrequently
Continuous Continuous diseasedisease
YesYes OccasionallyOccasionally
bdquobdquoCCobblestonobblestoningrdquoingrdquo
NoNo YesYes
Granuloma Granuloma on biopsyon biopsy
NoNo OccasionallyOccasionally
Criteria for Indeterminate Criteria for Indeterminate ColitisColitis
No evidence of No evidence of small bowel small bowel involvement involvement fistula or fistula or perianal diseaseperianal disease
Absence of Absence of diagnostic diagnostic criteria for CD criteria for CD or UC by or UC by microscopymicroscopy
Differential Diagnosis of Differential Diagnosis of Chronic Diarrhea and Weight Chronic Diarrhea and Weight
LossLoss Colonic diseasesColonic diseases
IBDIBD NeoplasiaNeoplasia Ischemic bowelIschemic bowel
PancreaticPancreatic Chronic pancreatitisChronic pancreatitis CancerCancer Cystic fibrosisCystic fibrosis
EnteropathicEnteropathic Celiac diseaseCeliac disease Tropical sprueTropical sprue LymphomaLymphoma Mesenteric ischemiaMesenteric ischemia Whipplersquos diseaseWhipplersquos disease
HormonaldrugsHormonaldrugs VipomaVipoma ZESZES Medullary CA of Medullary CA of
thyroidthyroid NSAIDS useNSAIDS use
Educational ObjectivesEducational Objectives Definitions and spectrum of inflammatory Definitions and spectrum of inflammatory
bowel disease (IBD)bowel disease (IBD) Epidemiology of IBDEpidemiology of IBD Etiopathogenesis of IBDEtiopathogenesis of IBD Clinical manifestations of ulcerative colitis Clinical manifestations of ulcerative colitis
(UC)(UC) Clinical manifestations of Crohnrsquos disease Clinical manifestations of Crohnrsquos disease
(CD)(CD) Distinguishing features between UC and CDDistinguishing features between UC and CD Diagnostic approach to IBDDiagnostic approach to IBD Medical management of IBDMedical management of IBD Indications for and role of surgeryIndications for and role of surgery
Diagnostic Approach to Diagnostic Approach to Patients with Suspected Patients with Suspected
IBDIBD HistoryhelliphelliphistoryhelliphelliphistoryHistoryhelliphelliphistoryhelliphelliphistory Clinical examClinical exam Laboratory testsLaboratory tests Radiological imagingRadiological imaging EndoscopyEndoscopy Special serological testingSpecial serological testing Genetic testingGenetic testing
Diagnosis-LAB Blood test
CD Mild anemia mild leukocytosis elevated ESR elevated CRP positive ASCA
UC Anemia hypokalemia hypoalbuminemia elevated ESR elevated LFTs positive p-ANCA
Stool analysis Many WBCs and or RBCs No ova or parasites
What are the Serological What are the Serological Markers in IBDMarkers in IBD
pANCA (perinuclear staining pattern)pANCA (perinuclear staining pattern) Loss of perinuclear pattern after Loss of perinuclear pattern after
DNAaseDNAase Differentiate from the ldquoother pANCAsrdquoDifferentiate from the ldquoother pANCAsrdquo
Antibody against myeloperoxidaseAntibody against myeloperoxidase Antibody against cathepsin G elastase lysozyme Antibody against cathepsin G elastase lysozyme
and lactoferrinand lactoferrin ASCA (anti-ASCA (anti-Saccharomyces cerevisiaeSaccharomyces cerevisiae))
Both IgG and IgABoth IgG and IgA Recognize mannose in the cell wall Recognize mannose in the cell wall
mannan of mannan of Saccharomyces cerevisiaeSaccharomyces cerevisiae
Why Use Serological Why Use Serological Markers in Clinical Markers in Clinical
PracticePractice Differentiate IBD from functional bowel Differentiate IBD from functional bowel
disordersdisorders Accurately diagnose Crohnrsquos or UC in a patient Accurately diagnose Crohnrsquos or UC in a patient
withwith Severe colitisSevere colitis Indeterminate colitisIndeterminate colitis
Predict disease course or complications in IBDPredict disease course or complications in IBD CD phenotypeCD phenotype Severity of diseaseSeverity of disease Risk of pouchitisRisk of pouchitis
SummarySummary
pANCA and ASCA are specific for UC pANCA and ASCA are specific for UC and CD respectivelyand CD respectively
Neither pANCA nor ASCA are sensitive Neither pANCA nor ASCA are sensitive enough to exclude IBDenough to exclude IBD
In patients with IC available In patients with IC available serological markers do not accurately serological markers do not accurately predict the subsequent disease coursepredict the subsequent disease course
Antibody profiles can predict disease Antibody profiles can predict disease behavior in IBDbehavior in IBD
Diagnostic ApproachDiagnostic ApproachEndoscopyEndoscopy
Endoscopy useful forEndoscopy useful for Initial diagnosisInitial diagnosis Assessment of severityAssessment of severity Tissue diagnosisTissue diagnosis FU during treatmentFU during treatment Assessment of disease exacerbationAssessment of disease exacerbation Surveillance for risk of cancerSurveillance for risk of cancer Treatment of certain complications (eg Treatment of certain complications (eg
strictures)strictures)
Crohnrsquos DiseaseCrohnrsquos DiseaseEndoscopic FeaturesEndoscopic Features
Asymmetric patchy inflammationAsymmetric patchy inflammation Skip lesionsSkip lesions Rectal sparingRectal sparing Ulcerations-deepserpiginousUlcerations-deepserpiginous Cobblestoning-commonCobblestoning-common Pseudopolyps-rarePseudopolyps-rare BiopsyBiopsy
Erosions and normal mucosaErosions and normal mucosa Granulomas in 15 to 35 of specimensGranulomas in 15 to 35 of specimens
Ulcerative ColitisUlcerative ColitisEndoscopic FeaturesEndoscopic Features
Diffuse involvementDiffuse involvement Rectum always diseasedRectum always diseased Superficial ulcerationsSuperficial ulcerations FriabilitybleedingFriabilitybleeding Flatteningdisappearance of haustral Flatteningdisappearance of haustral
foldsfolds PseudopolypsPseudopolyps No cobblestoningNo cobblestoning Bx No granulomasBx No granulomas
Imaging for Crohn Imaging for Crohn DiseaseDisease
Traditional TechniquesTraditional Techniques Abdominal RadiographsAbdominal Radiographs
Barium UGI Barium UGI
Barium small bowel follow throughBarium small bowel follow through
Barium EnteroclysisBarium Enteroclysis
Barium EnemaBarium Enema
Imaging for Crohn Disease Imaging for Crohn Disease Newer TechniquesNewer Techniques
CTCT
CT EnteroclysisCT Enteroclysis
CT EnterographyCT Enterography
Magnetic ResonanceMagnetic Resonance
UltrasoundUltrasound
Nuclear MedicineNuclear Medicine
Imaging for Crohns DiseaseImaging for Crohns Disease SummarySummary
Useful Newer TechniquesUseful Newer Techniques evolvingevolving CT EnterographyCT Enterography
Comprehensive evaluation of all bowel amp solid organsComprehensive evaluation of all bowel amp solid organs
Magnetic ResonanceMagnetic Resonance
Useful for ano-rectal diseaseUseful for ano-rectal disease
Real-time MR has potential for detection of stricturesReal-time MR has potential for detection of strictures
Traditional imaging techniques still of value in Traditional imaging techniques still of value in selected cases selected cases
The Capsule (WCE)The Capsule (WCE)
WCEWCE
bull Diameter 11mm Length 26mmDiameter 11mm Length 26mmbull Optical dome Intestinal illumination Optical dome Intestinal illumination
by white light emitting diodes (LEDrsquos)by white light emitting diodes (LEDrsquos)bull LensLensbull Complementary metal-oxide silicone Complementary metal-oxide silicone
imager (color camera chip)imager (color camera chip)bull TransmitterTransmitterbull Two batteries (silver oxide)Two batteries (silver oxide)
GE Junction Duodenum
Jejunum Ileocecal Valve
Educational ObjectivesEducational Objectives Definitions and spectrum of inflammatory Definitions and spectrum of inflammatory
bowel disease (IBD)bowel disease (IBD) Epidemiology of IBDEpidemiology of IBD Etiopathogenesis of IBDEtiopathogenesis of IBD Clinical manifestations of ulcerative colitis Clinical manifestations of ulcerative colitis
(UC)(UC) Clinical manifestations of Crohnrsquos disease Clinical manifestations of Crohnrsquos disease
(CD)(CD) Distinguishing features between UC and CDDistinguishing features between UC and CD Diagnostic approach to IBDDiagnostic approach to IBD Complications of IBDComplications of IBD IBD managementIBD management
IBD-ComplicationsIBD-Complications GI BleedingGI Bleeding Toxic megacolonToxic megacolon PerforationPerforation Thromboembolic phenomenaThromboembolic phenomena FistulasfissuresFistulasfissures AbscessAbscess StricturesobstructionStricturesobstruction MalabsorptionmalnutritionMalabsorptionmalnutrition CancerCancer
Best Protection
Surveillance colonoscopySurveillance colonoscopy
Procto-colectomy (for UC)Procto-colectomy (for UC)
Descending Colon Descending Colon StrictureStricture
Colonic StricturesColonic Strictures
Consider nonsurgical management Consider nonsurgical management ifif Endoscopically accessibleEndoscopically accessible Multiple prior resectionsMultiple prior resections Shorter strictures (less than 5 cm)Shorter strictures (less than 5 cm) Steroid injection if significant Steroid injection if significant
inflammationinflammation
Fistula DefinitionA communication between two epithelial-lined organsLifetime risk of fistula in CD30
Perianal FistulaPerianal Fistula
Pretreatment 2 Weeks
10 Weeks 18 weeks
Educational ObjectivesEducational Objectives Definitions and spectrum of inflammatory Definitions and spectrum of inflammatory
bowel disease (IBD)bowel disease (IBD) Epidemiology of IBDEpidemiology of IBD Etiopathogenesis of IBDEtiopathogenesis of IBD Clinical manifestations of ulcerative colitis Clinical manifestations of ulcerative colitis
(UC)(UC) Clinical manifestations of Crohnrsquos disease Clinical manifestations of Crohnrsquos disease
(CD)(CD) Distinguishing features between UC and CDDistinguishing features between UC and CD Diagnostic approach to IBDDiagnostic approach to IBD Complications of IBDComplications of IBD IBD managementIBD management
Goals of Therapy for IBDGoals of Therapy for IBD
Inducing remissionInducing remission Maintaining remissionMaintaining remission Restoring and maintaining nutritionRestoring and maintaining nutrition Maintaining patientrsquos quality of lifeMaintaining patientrsquos quality of life Prevention of complicationsPrevention of complications Surgical intervention (selection of Surgical intervention (selection of
optimal time for surgery)optimal time for surgery)
Inductive TherapiesInductive Therapies
For UCFor UC AminosalicylatesAminosalicylates CorticosteroidsCorticosteroids CyclosporinCyclosporin
For CDFor CD AminosalicylatesAminosalicylates CorticosteroidsCorticosteroids AntibioticsAntibiotics Anti-TNFAnti-TNF
Maintenance TherapiesMaintenance Therapies
ImmunosupressorsImmunosupressors AzathioprineAzathioprine 6-MP6-MP MethotrexateMethotrexate
AminosalicylatesAminosalicylates Anti-TNFAnti-TNF
NOT NOT corticosteroidscorticosteroids
IBD ManagementIBD ManagementSummarySummary
There is no ldquoone size fits allrdquo to IBD therapyThere is no ldquoone size fits allrdquo to IBD therapy Therapy and decision making are tailored to the Therapy and decision making are tailored to the
individualindividual
Algorithms are based upon available evidenceAlgorithms are based upon available evidence Evidence is in constant fluxEvidence is in constant flux
Success of algorithms depends upon Success of algorithms depends upon optimization of each step of therapy and optimization of each step of therapy and considerable judgment about each outcomeconsiderable judgment about each outcome Skillful application of medical therapy makes all Skillful application of medical therapy makes all
the difference in outcomesthe difference in outcomes
Surgery for IBDSurgery for IBDGeneral ConceptsGeneral Concepts
Majority will need surgery 78 over Majority will need surgery 78 over twenty yearstwenty years
Surgery generally indicated for Surgery generally indicated for complicationscomplications of disease of disease
Surgery must be directed at area of Surgery must be directed at area of bowel responsible for complicationbowel responsible for complication
Indications for SurgeryIndications for Surgery Intestinal obstruction (most Intestinal obstruction (most
common)common) Intractabilitysteroid Intractabilitysteroid
dependencedependence Non-healing fistulaAbscessNon-healing fistulaAbscess Toxic megacolonFree Toxic megacolonFree
perforationperforation Uncontrollable GI bleedingUncontrollable GI bleeding Severe perianal diseaseSevere perianal disease CancerCancer Growth retardation Growth retardation
(children)(children) Severe uncontrollable Severe uncontrollable
extraintestinal extraintestinal manifestationsmanifestations
Management of IBDSummary
The goals of therapy are Relieve symptoms Prevent relapse Correct nutritional deficiencies Control inflammation Prevent complications especially colon cancer
Treatment depends on 1048707 Type of disease 1048707 Site of disease 1048707 Disease severity
Treatment may include drugs nutrition supplements surgery or a combination of these options
CD Clinical FeaturesCD Clinical Features
Abdominal pain often postprandialAbdominal pain often postprandial Diarrhea usually wateryDiarrhea usually watery Rectal bleedingRectal bleeding Weight lossWeight loss Right lower quadrant painpalpable Right lower quadrant painpalpable
massmass FeverFever Growth retardation in childrenGrowth retardation in children Perirectal fistulaPerirectal fistula
Crohnrsquos disease ndash macroscopic Crohnrsquos disease ndash macroscopic featuresfeatures
Can affect any part of GI tract from the mouth to the Can affect any part of GI tract from the mouth to the anusanus
30-40 of patients have small bowel disease alone30-40 of patients have small bowel disease alone
40-55 of patients have both small and large 40-55 of patients have both small and large intestines diseaseintestines disease
15-25 of patients have colitis alone15-25 of patients have colitis alone
In 75 of patients with small intestinal disease the In 75 of patients with small intestinal disease the terminal ileum in involved in 90terminal ileum in involved in 90
Crohnrsquos DiseaseCrohnrsquos DiseaseAnatomic DistributionAnatomic Distribution
Small bowelSmall bowelalonealone(33)(33)
IleocolicIleocolic(45)(45)
Colon aloneColon alone(20)(20)
Frequency of involvementFrequency of involvement
MostMost LeastLeast
Crohnrsquos disease ndash macroscopic Crohnrsquos disease ndash macroscopic featuresfeatures
CD is a CD is a transmuraltransmural process process
CD is CD is segmentalsegmental with skip areas in with skip areas in the midst of diseased intestinethe midst of diseased intestine
In one third of patients with CD In one third of patients with CD perirectal fistulas fissures perirectal fistulas fissures abscesses anal stenosis are presentabscesses anal stenosis are present
Crohnrsquos disease ndash macroscopic Crohnrsquos disease ndash macroscopic featuresfeatures
Active CD is characterized by focal Active CD is characterized by focal inflammation and formation of fistula inflammation and formation of fistula tractstracts
The bowel wall thickens and becomes The bowel wall thickens and becomes narrowed and fibrotic leading to narrowed and fibrotic leading to chronic recurrent bowel obstructionchronic recurrent bowel obstruction
Crohnrsquos Disease Activity Index(CDAI)
Incorporates 8 variables 1 liquid or very soft stools day 2 Abdominal pain amp cramping 3 Extraintestinal manifestations 4 Complications 5 Abdominal mass 6 Use of anti diarrheal medications anti- 7 Hematocrit 8 Body weight
Crohnrsquos Disease Red Crohnrsquos Disease Red FlagsFlags
Onset after stopping smokingOnset after stopping smoking Bleeding onlyBleeding only DiverticulosisDiverticulosis AtherosclerosisAtherosclerosis ProlapseProlapse
Extraintestinal Manifestations of IBD
SkinErythema nodosumPyoderma gangrenosum
JointsPeripheral arthritisSacroileitisAnkylosing spondylitis
EyeUveitisEpiscleritisIritis
Hepatobiliary complicationsGallstonesPSC
Renal complicationsNephrolithiasisRecurrent UTIs
Educational ObjectivesEducational Objectives Definitions and spectrum of inflammatory Definitions and spectrum of inflammatory
bowel disease (IBD)bowel disease (IBD) Epidemiology of IBDEpidemiology of IBD Etiopathogenesis of IBDEtiopathogenesis of IBD Clinical manifestations of ulcerative colitis Clinical manifestations of ulcerative colitis
(UC)(UC) Clinical manifestations of Crohnrsquos disease (CD)Clinical manifestations of Crohnrsquos disease (CD) Distinguishing features between UC and Distinguishing features between UC and
CDCD Diagnostic approach to IBDDiagnostic approach to IBD Medical management of IBDMedical management of IBD Indications for and role of surgeryIndications for and role of surgery
Symptoms of IBDUC vs CDUC vs CD
FeatureFeature UCUC CDCD
FeverFever UncommonUncommon CommonCommon
Rectal Rectal bleedingbleeding
CommonCommon lt frac12 of lt frac12 of patientspatients
Abdominal Abdominal tendernesstenderness
May be May be presentpresent
CommonCommon
Abdominal Abdominal massmass
UncommonUncommon CommonCommon
Abdominal Abdominal painpain
UncommonUncommon Very commonVery common
Weight lossWeight loss UncommonUncommon CommonCommon
TenesmusTenesmus Very commonVery common UncommonUncommon
UC vs CDUC vs CDComplicationsResponse to ComplicationsResponse to
TreatmentTreatmentUCUC CDCD
FistulasFistulas NoNo YesYes
Small Small intestine intestine obstructionobstruction
NoNo FrequentlyFrequently
Colonic Colonic obstructionobstruction
RarelyRarely FrequentlyFrequently
Response to Response to antibioticantibiotic
NoNo YesYes
Recurrence Recurrence after after surgerysurgery
NoNo YesYes
UC vs CDUC vs CDDifferent endoscopic featuresDifferent endoscopic features
UCUC CDCD
Rectal Rectal sparingsparing
RarelyRarely FrequentlyFrequently
Continuous Continuous diseasedisease
YesYes OccasionallyOccasionally
bdquobdquoCCobblestonobblestoningrdquoingrdquo
NoNo YesYes
Granuloma Granuloma on biopsyon biopsy
NoNo OccasionallyOccasionally
Criteria for Indeterminate Criteria for Indeterminate ColitisColitis
No evidence of No evidence of small bowel small bowel involvement involvement fistula or fistula or perianal diseaseperianal disease
Absence of Absence of diagnostic diagnostic criteria for CD criteria for CD or UC by or UC by microscopymicroscopy
Differential Diagnosis of Differential Diagnosis of Chronic Diarrhea and Weight Chronic Diarrhea and Weight
LossLoss Colonic diseasesColonic diseases
IBDIBD NeoplasiaNeoplasia Ischemic bowelIschemic bowel
PancreaticPancreatic Chronic pancreatitisChronic pancreatitis CancerCancer Cystic fibrosisCystic fibrosis
EnteropathicEnteropathic Celiac diseaseCeliac disease Tropical sprueTropical sprue LymphomaLymphoma Mesenteric ischemiaMesenteric ischemia Whipplersquos diseaseWhipplersquos disease
HormonaldrugsHormonaldrugs VipomaVipoma ZESZES Medullary CA of Medullary CA of
thyroidthyroid NSAIDS useNSAIDS use
Educational ObjectivesEducational Objectives Definitions and spectrum of inflammatory Definitions and spectrum of inflammatory
bowel disease (IBD)bowel disease (IBD) Epidemiology of IBDEpidemiology of IBD Etiopathogenesis of IBDEtiopathogenesis of IBD Clinical manifestations of ulcerative colitis Clinical manifestations of ulcerative colitis
(UC)(UC) Clinical manifestations of Crohnrsquos disease Clinical manifestations of Crohnrsquos disease
(CD)(CD) Distinguishing features between UC and CDDistinguishing features between UC and CD Diagnostic approach to IBDDiagnostic approach to IBD Medical management of IBDMedical management of IBD Indications for and role of surgeryIndications for and role of surgery
Diagnostic Approach to Diagnostic Approach to Patients with Suspected Patients with Suspected
IBDIBD HistoryhelliphelliphistoryhelliphelliphistoryHistoryhelliphelliphistoryhelliphelliphistory Clinical examClinical exam Laboratory testsLaboratory tests Radiological imagingRadiological imaging EndoscopyEndoscopy Special serological testingSpecial serological testing Genetic testingGenetic testing
Diagnosis-LAB Blood test
CD Mild anemia mild leukocytosis elevated ESR elevated CRP positive ASCA
UC Anemia hypokalemia hypoalbuminemia elevated ESR elevated LFTs positive p-ANCA
Stool analysis Many WBCs and or RBCs No ova or parasites
What are the Serological What are the Serological Markers in IBDMarkers in IBD
pANCA (perinuclear staining pattern)pANCA (perinuclear staining pattern) Loss of perinuclear pattern after Loss of perinuclear pattern after
DNAaseDNAase Differentiate from the ldquoother pANCAsrdquoDifferentiate from the ldquoother pANCAsrdquo
Antibody against myeloperoxidaseAntibody against myeloperoxidase Antibody against cathepsin G elastase lysozyme Antibody against cathepsin G elastase lysozyme
and lactoferrinand lactoferrin ASCA (anti-ASCA (anti-Saccharomyces cerevisiaeSaccharomyces cerevisiae))
Both IgG and IgABoth IgG and IgA Recognize mannose in the cell wall Recognize mannose in the cell wall
mannan of mannan of Saccharomyces cerevisiaeSaccharomyces cerevisiae
Why Use Serological Why Use Serological Markers in Clinical Markers in Clinical
PracticePractice Differentiate IBD from functional bowel Differentiate IBD from functional bowel
disordersdisorders Accurately diagnose Crohnrsquos or UC in a patient Accurately diagnose Crohnrsquos or UC in a patient
withwith Severe colitisSevere colitis Indeterminate colitisIndeterminate colitis
Predict disease course or complications in IBDPredict disease course or complications in IBD CD phenotypeCD phenotype Severity of diseaseSeverity of disease Risk of pouchitisRisk of pouchitis
SummarySummary
pANCA and ASCA are specific for UC pANCA and ASCA are specific for UC and CD respectivelyand CD respectively
Neither pANCA nor ASCA are sensitive Neither pANCA nor ASCA are sensitive enough to exclude IBDenough to exclude IBD
In patients with IC available In patients with IC available serological markers do not accurately serological markers do not accurately predict the subsequent disease coursepredict the subsequent disease course
Antibody profiles can predict disease Antibody profiles can predict disease behavior in IBDbehavior in IBD
Diagnostic ApproachDiagnostic ApproachEndoscopyEndoscopy
Endoscopy useful forEndoscopy useful for Initial diagnosisInitial diagnosis Assessment of severityAssessment of severity Tissue diagnosisTissue diagnosis FU during treatmentFU during treatment Assessment of disease exacerbationAssessment of disease exacerbation Surveillance for risk of cancerSurveillance for risk of cancer Treatment of certain complications (eg Treatment of certain complications (eg
strictures)strictures)
Crohnrsquos DiseaseCrohnrsquos DiseaseEndoscopic FeaturesEndoscopic Features
Asymmetric patchy inflammationAsymmetric patchy inflammation Skip lesionsSkip lesions Rectal sparingRectal sparing Ulcerations-deepserpiginousUlcerations-deepserpiginous Cobblestoning-commonCobblestoning-common Pseudopolyps-rarePseudopolyps-rare BiopsyBiopsy
Erosions and normal mucosaErosions and normal mucosa Granulomas in 15 to 35 of specimensGranulomas in 15 to 35 of specimens
Ulcerative ColitisUlcerative ColitisEndoscopic FeaturesEndoscopic Features
Diffuse involvementDiffuse involvement Rectum always diseasedRectum always diseased Superficial ulcerationsSuperficial ulcerations FriabilitybleedingFriabilitybleeding Flatteningdisappearance of haustral Flatteningdisappearance of haustral
foldsfolds PseudopolypsPseudopolyps No cobblestoningNo cobblestoning Bx No granulomasBx No granulomas
Imaging for Crohn Imaging for Crohn DiseaseDisease
Traditional TechniquesTraditional Techniques Abdominal RadiographsAbdominal Radiographs
Barium UGI Barium UGI
Barium small bowel follow throughBarium small bowel follow through
Barium EnteroclysisBarium Enteroclysis
Barium EnemaBarium Enema
Imaging for Crohn Disease Imaging for Crohn Disease Newer TechniquesNewer Techniques
CTCT
CT EnteroclysisCT Enteroclysis
CT EnterographyCT Enterography
Magnetic ResonanceMagnetic Resonance
UltrasoundUltrasound
Nuclear MedicineNuclear Medicine
Imaging for Crohns DiseaseImaging for Crohns Disease SummarySummary
Useful Newer TechniquesUseful Newer Techniques evolvingevolving CT EnterographyCT Enterography
Comprehensive evaluation of all bowel amp solid organsComprehensive evaluation of all bowel amp solid organs
Magnetic ResonanceMagnetic Resonance
Useful for ano-rectal diseaseUseful for ano-rectal disease
Real-time MR has potential for detection of stricturesReal-time MR has potential for detection of strictures
Traditional imaging techniques still of value in Traditional imaging techniques still of value in selected cases selected cases
The Capsule (WCE)The Capsule (WCE)
WCEWCE
bull Diameter 11mm Length 26mmDiameter 11mm Length 26mmbull Optical dome Intestinal illumination Optical dome Intestinal illumination
by white light emitting diodes (LEDrsquos)by white light emitting diodes (LEDrsquos)bull LensLensbull Complementary metal-oxide silicone Complementary metal-oxide silicone
imager (color camera chip)imager (color camera chip)bull TransmitterTransmitterbull Two batteries (silver oxide)Two batteries (silver oxide)
GE Junction Duodenum
Jejunum Ileocecal Valve
Educational ObjectivesEducational Objectives Definitions and spectrum of inflammatory Definitions and spectrum of inflammatory
bowel disease (IBD)bowel disease (IBD) Epidemiology of IBDEpidemiology of IBD Etiopathogenesis of IBDEtiopathogenesis of IBD Clinical manifestations of ulcerative colitis Clinical manifestations of ulcerative colitis
(UC)(UC) Clinical manifestations of Crohnrsquos disease Clinical manifestations of Crohnrsquos disease
(CD)(CD) Distinguishing features between UC and CDDistinguishing features between UC and CD Diagnostic approach to IBDDiagnostic approach to IBD Complications of IBDComplications of IBD IBD managementIBD management
IBD-ComplicationsIBD-Complications GI BleedingGI Bleeding Toxic megacolonToxic megacolon PerforationPerforation Thromboembolic phenomenaThromboembolic phenomena FistulasfissuresFistulasfissures AbscessAbscess StricturesobstructionStricturesobstruction MalabsorptionmalnutritionMalabsorptionmalnutrition CancerCancer
Best Protection
Surveillance colonoscopySurveillance colonoscopy
Procto-colectomy (for UC)Procto-colectomy (for UC)
Descending Colon Descending Colon StrictureStricture
Colonic StricturesColonic Strictures
Consider nonsurgical management Consider nonsurgical management ifif Endoscopically accessibleEndoscopically accessible Multiple prior resectionsMultiple prior resections Shorter strictures (less than 5 cm)Shorter strictures (less than 5 cm) Steroid injection if significant Steroid injection if significant
inflammationinflammation
Fistula DefinitionA communication between two epithelial-lined organsLifetime risk of fistula in CD30
Perianal FistulaPerianal Fistula
Pretreatment 2 Weeks
10 Weeks 18 weeks
Educational ObjectivesEducational Objectives Definitions and spectrum of inflammatory Definitions and spectrum of inflammatory
bowel disease (IBD)bowel disease (IBD) Epidemiology of IBDEpidemiology of IBD Etiopathogenesis of IBDEtiopathogenesis of IBD Clinical manifestations of ulcerative colitis Clinical manifestations of ulcerative colitis
(UC)(UC) Clinical manifestations of Crohnrsquos disease Clinical manifestations of Crohnrsquos disease
(CD)(CD) Distinguishing features between UC and CDDistinguishing features between UC and CD Diagnostic approach to IBDDiagnostic approach to IBD Complications of IBDComplications of IBD IBD managementIBD management
Goals of Therapy for IBDGoals of Therapy for IBD
Inducing remissionInducing remission Maintaining remissionMaintaining remission Restoring and maintaining nutritionRestoring and maintaining nutrition Maintaining patientrsquos quality of lifeMaintaining patientrsquos quality of life Prevention of complicationsPrevention of complications Surgical intervention (selection of Surgical intervention (selection of
optimal time for surgery)optimal time for surgery)
Inductive TherapiesInductive Therapies
For UCFor UC AminosalicylatesAminosalicylates CorticosteroidsCorticosteroids CyclosporinCyclosporin
For CDFor CD AminosalicylatesAminosalicylates CorticosteroidsCorticosteroids AntibioticsAntibiotics Anti-TNFAnti-TNF
Maintenance TherapiesMaintenance Therapies
ImmunosupressorsImmunosupressors AzathioprineAzathioprine 6-MP6-MP MethotrexateMethotrexate
AminosalicylatesAminosalicylates Anti-TNFAnti-TNF
NOT NOT corticosteroidscorticosteroids
IBD ManagementIBD ManagementSummarySummary
There is no ldquoone size fits allrdquo to IBD therapyThere is no ldquoone size fits allrdquo to IBD therapy Therapy and decision making are tailored to the Therapy and decision making are tailored to the
individualindividual
Algorithms are based upon available evidenceAlgorithms are based upon available evidence Evidence is in constant fluxEvidence is in constant flux
Success of algorithms depends upon Success of algorithms depends upon optimization of each step of therapy and optimization of each step of therapy and considerable judgment about each outcomeconsiderable judgment about each outcome Skillful application of medical therapy makes all Skillful application of medical therapy makes all
the difference in outcomesthe difference in outcomes
Surgery for IBDSurgery for IBDGeneral ConceptsGeneral Concepts
Majority will need surgery 78 over Majority will need surgery 78 over twenty yearstwenty years
Surgery generally indicated for Surgery generally indicated for complicationscomplications of disease of disease
Surgery must be directed at area of Surgery must be directed at area of bowel responsible for complicationbowel responsible for complication
Indications for SurgeryIndications for Surgery Intestinal obstruction (most Intestinal obstruction (most
common)common) Intractabilitysteroid Intractabilitysteroid
dependencedependence Non-healing fistulaAbscessNon-healing fistulaAbscess Toxic megacolonFree Toxic megacolonFree
perforationperforation Uncontrollable GI bleedingUncontrollable GI bleeding Severe perianal diseaseSevere perianal disease CancerCancer Growth retardation Growth retardation
(children)(children) Severe uncontrollable Severe uncontrollable
extraintestinal extraintestinal manifestationsmanifestations
Management of IBDSummary
The goals of therapy are Relieve symptoms Prevent relapse Correct nutritional deficiencies Control inflammation Prevent complications especially colon cancer
Treatment depends on 1048707 Type of disease 1048707 Site of disease 1048707 Disease severity
Treatment may include drugs nutrition supplements surgery or a combination of these options
Crohnrsquos disease ndash macroscopic Crohnrsquos disease ndash macroscopic featuresfeatures
Can affect any part of GI tract from the mouth to the Can affect any part of GI tract from the mouth to the anusanus
30-40 of patients have small bowel disease alone30-40 of patients have small bowel disease alone
40-55 of patients have both small and large 40-55 of patients have both small and large intestines diseaseintestines disease
15-25 of patients have colitis alone15-25 of patients have colitis alone
In 75 of patients with small intestinal disease the In 75 of patients with small intestinal disease the terminal ileum in involved in 90terminal ileum in involved in 90
Crohnrsquos DiseaseCrohnrsquos DiseaseAnatomic DistributionAnatomic Distribution
Small bowelSmall bowelalonealone(33)(33)
IleocolicIleocolic(45)(45)
Colon aloneColon alone(20)(20)
Frequency of involvementFrequency of involvement
MostMost LeastLeast
Crohnrsquos disease ndash macroscopic Crohnrsquos disease ndash macroscopic featuresfeatures
CD is a CD is a transmuraltransmural process process
CD is CD is segmentalsegmental with skip areas in with skip areas in the midst of diseased intestinethe midst of diseased intestine
In one third of patients with CD In one third of patients with CD perirectal fistulas fissures perirectal fistulas fissures abscesses anal stenosis are presentabscesses anal stenosis are present
Crohnrsquos disease ndash macroscopic Crohnrsquos disease ndash macroscopic featuresfeatures
Active CD is characterized by focal Active CD is characterized by focal inflammation and formation of fistula inflammation and formation of fistula tractstracts
The bowel wall thickens and becomes The bowel wall thickens and becomes narrowed and fibrotic leading to narrowed and fibrotic leading to chronic recurrent bowel obstructionchronic recurrent bowel obstruction
Crohnrsquos Disease Activity Index(CDAI)
Incorporates 8 variables 1 liquid or very soft stools day 2 Abdominal pain amp cramping 3 Extraintestinal manifestations 4 Complications 5 Abdominal mass 6 Use of anti diarrheal medications anti- 7 Hematocrit 8 Body weight
Crohnrsquos Disease Red Crohnrsquos Disease Red FlagsFlags
Onset after stopping smokingOnset after stopping smoking Bleeding onlyBleeding only DiverticulosisDiverticulosis AtherosclerosisAtherosclerosis ProlapseProlapse
Extraintestinal Manifestations of IBD
SkinErythema nodosumPyoderma gangrenosum
JointsPeripheral arthritisSacroileitisAnkylosing spondylitis
EyeUveitisEpiscleritisIritis
Hepatobiliary complicationsGallstonesPSC
Renal complicationsNephrolithiasisRecurrent UTIs
Educational ObjectivesEducational Objectives Definitions and spectrum of inflammatory Definitions and spectrum of inflammatory
bowel disease (IBD)bowel disease (IBD) Epidemiology of IBDEpidemiology of IBD Etiopathogenesis of IBDEtiopathogenesis of IBD Clinical manifestations of ulcerative colitis Clinical manifestations of ulcerative colitis
(UC)(UC) Clinical manifestations of Crohnrsquos disease (CD)Clinical manifestations of Crohnrsquos disease (CD) Distinguishing features between UC and Distinguishing features between UC and
CDCD Diagnostic approach to IBDDiagnostic approach to IBD Medical management of IBDMedical management of IBD Indications for and role of surgeryIndications for and role of surgery
Symptoms of IBDUC vs CDUC vs CD
FeatureFeature UCUC CDCD
FeverFever UncommonUncommon CommonCommon
Rectal Rectal bleedingbleeding
CommonCommon lt frac12 of lt frac12 of patientspatients
Abdominal Abdominal tendernesstenderness
May be May be presentpresent
CommonCommon
Abdominal Abdominal massmass
UncommonUncommon CommonCommon
Abdominal Abdominal painpain
UncommonUncommon Very commonVery common
Weight lossWeight loss UncommonUncommon CommonCommon
TenesmusTenesmus Very commonVery common UncommonUncommon
UC vs CDUC vs CDComplicationsResponse to ComplicationsResponse to
TreatmentTreatmentUCUC CDCD
FistulasFistulas NoNo YesYes
Small Small intestine intestine obstructionobstruction
NoNo FrequentlyFrequently
Colonic Colonic obstructionobstruction
RarelyRarely FrequentlyFrequently
Response to Response to antibioticantibiotic
NoNo YesYes
Recurrence Recurrence after after surgerysurgery
NoNo YesYes
UC vs CDUC vs CDDifferent endoscopic featuresDifferent endoscopic features
UCUC CDCD
Rectal Rectal sparingsparing
RarelyRarely FrequentlyFrequently
Continuous Continuous diseasedisease
YesYes OccasionallyOccasionally
bdquobdquoCCobblestonobblestoningrdquoingrdquo
NoNo YesYes
Granuloma Granuloma on biopsyon biopsy
NoNo OccasionallyOccasionally
Criteria for Indeterminate Criteria for Indeterminate ColitisColitis
No evidence of No evidence of small bowel small bowel involvement involvement fistula or fistula or perianal diseaseperianal disease
Absence of Absence of diagnostic diagnostic criteria for CD criteria for CD or UC by or UC by microscopymicroscopy
Differential Diagnosis of Differential Diagnosis of Chronic Diarrhea and Weight Chronic Diarrhea and Weight
LossLoss Colonic diseasesColonic diseases
IBDIBD NeoplasiaNeoplasia Ischemic bowelIschemic bowel
PancreaticPancreatic Chronic pancreatitisChronic pancreatitis CancerCancer Cystic fibrosisCystic fibrosis
EnteropathicEnteropathic Celiac diseaseCeliac disease Tropical sprueTropical sprue LymphomaLymphoma Mesenteric ischemiaMesenteric ischemia Whipplersquos diseaseWhipplersquos disease
HormonaldrugsHormonaldrugs VipomaVipoma ZESZES Medullary CA of Medullary CA of
thyroidthyroid NSAIDS useNSAIDS use
Educational ObjectivesEducational Objectives Definitions and spectrum of inflammatory Definitions and spectrum of inflammatory
bowel disease (IBD)bowel disease (IBD) Epidemiology of IBDEpidemiology of IBD Etiopathogenesis of IBDEtiopathogenesis of IBD Clinical manifestations of ulcerative colitis Clinical manifestations of ulcerative colitis
(UC)(UC) Clinical manifestations of Crohnrsquos disease Clinical manifestations of Crohnrsquos disease
(CD)(CD) Distinguishing features between UC and CDDistinguishing features between UC and CD Diagnostic approach to IBDDiagnostic approach to IBD Medical management of IBDMedical management of IBD Indications for and role of surgeryIndications for and role of surgery
Diagnostic Approach to Diagnostic Approach to Patients with Suspected Patients with Suspected
IBDIBD HistoryhelliphelliphistoryhelliphelliphistoryHistoryhelliphelliphistoryhelliphelliphistory Clinical examClinical exam Laboratory testsLaboratory tests Radiological imagingRadiological imaging EndoscopyEndoscopy Special serological testingSpecial serological testing Genetic testingGenetic testing
Diagnosis-LAB Blood test
CD Mild anemia mild leukocytosis elevated ESR elevated CRP positive ASCA
UC Anemia hypokalemia hypoalbuminemia elevated ESR elevated LFTs positive p-ANCA
Stool analysis Many WBCs and or RBCs No ova or parasites
What are the Serological What are the Serological Markers in IBDMarkers in IBD
pANCA (perinuclear staining pattern)pANCA (perinuclear staining pattern) Loss of perinuclear pattern after Loss of perinuclear pattern after
DNAaseDNAase Differentiate from the ldquoother pANCAsrdquoDifferentiate from the ldquoother pANCAsrdquo
Antibody against myeloperoxidaseAntibody against myeloperoxidase Antibody against cathepsin G elastase lysozyme Antibody against cathepsin G elastase lysozyme
and lactoferrinand lactoferrin ASCA (anti-ASCA (anti-Saccharomyces cerevisiaeSaccharomyces cerevisiae))
Both IgG and IgABoth IgG and IgA Recognize mannose in the cell wall Recognize mannose in the cell wall
mannan of mannan of Saccharomyces cerevisiaeSaccharomyces cerevisiae
Why Use Serological Why Use Serological Markers in Clinical Markers in Clinical
PracticePractice Differentiate IBD from functional bowel Differentiate IBD from functional bowel
disordersdisorders Accurately diagnose Crohnrsquos or UC in a patient Accurately diagnose Crohnrsquos or UC in a patient
withwith Severe colitisSevere colitis Indeterminate colitisIndeterminate colitis
Predict disease course or complications in IBDPredict disease course or complications in IBD CD phenotypeCD phenotype Severity of diseaseSeverity of disease Risk of pouchitisRisk of pouchitis
SummarySummary
pANCA and ASCA are specific for UC pANCA and ASCA are specific for UC and CD respectivelyand CD respectively
Neither pANCA nor ASCA are sensitive Neither pANCA nor ASCA are sensitive enough to exclude IBDenough to exclude IBD
In patients with IC available In patients with IC available serological markers do not accurately serological markers do not accurately predict the subsequent disease coursepredict the subsequent disease course
Antibody profiles can predict disease Antibody profiles can predict disease behavior in IBDbehavior in IBD
Diagnostic ApproachDiagnostic ApproachEndoscopyEndoscopy
Endoscopy useful forEndoscopy useful for Initial diagnosisInitial diagnosis Assessment of severityAssessment of severity Tissue diagnosisTissue diagnosis FU during treatmentFU during treatment Assessment of disease exacerbationAssessment of disease exacerbation Surveillance for risk of cancerSurveillance for risk of cancer Treatment of certain complications (eg Treatment of certain complications (eg
strictures)strictures)
Crohnrsquos DiseaseCrohnrsquos DiseaseEndoscopic FeaturesEndoscopic Features
Asymmetric patchy inflammationAsymmetric patchy inflammation Skip lesionsSkip lesions Rectal sparingRectal sparing Ulcerations-deepserpiginousUlcerations-deepserpiginous Cobblestoning-commonCobblestoning-common Pseudopolyps-rarePseudopolyps-rare BiopsyBiopsy
Erosions and normal mucosaErosions and normal mucosa Granulomas in 15 to 35 of specimensGranulomas in 15 to 35 of specimens
Ulcerative ColitisUlcerative ColitisEndoscopic FeaturesEndoscopic Features
Diffuse involvementDiffuse involvement Rectum always diseasedRectum always diseased Superficial ulcerationsSuperficial ulcerations FriabilitybleedingFriabilitybleeding Flatteningdisappearance of haustral Flatteningdisappearance of haustral
foldsfolds PseudopolypsPseudopolyps No cobblestoningNo cobblestoning Bx No granulomasBx No granulomas
Imaging for Crohn Imaging for Crohn DiseaseDisease
Traditional TechniquesTraditional Techniques Abdominal RadiographsAbdominal Radiographs
Barium UGI Barium UGI
Barium small bowel follow throughBarium small bowel follow through
Barium EnteroclysisBarium Enteroclysis
Barium EnemaBarium Enema
Imaging for Crohn Disease Imaging for Crohn Disease Newer TechniquesNewer Techniques
CTCT
CT EnteroclysisCT Enteroclysis
CT EnterographyCT Enterography
Magnetic ResonanceMagnetic Resonance
UltrasoundUltrasound
Nuclear MedicineNuclear Medicine
Imaging for Crohns DiseaseImaging for Crohns Disease SummarySummary
Useful Newer TechniquesUseful Newer Techniques evolvingevolving CT EnterographyCT Enterography
Comprehensive evaluation of all bowel amp solid organsComprehensive evaluation of all bowel amp solid organs
Magnetic ResonanceMagnetic Resonance
Useful for ano-rectal diseaseUseful for ano-rectal disease
Real-time MR has potential for detection of stricturesReal-time MR has potential for detection of strictures
Traditional imaging techniques still of value in Traditional imaging techniques still of value in selected cases selected cases
The Capsule (WCE)The Capsule (WCE)
WCEWCE
bull Diameter 11mm Length 26mmDiameter 11mm Length 26mmbull Optical dome Intestinal illumination Optical dome Intestinal illumination
by white light emitting diodes (LEDrsquos)by white light emitting diodes (LEDrsquos)bull LensLensbull Complementary metal-oxide silicone Complementary metal-oxide silicone
imager (color camera chip)imager (color camera chip)bull TransmitterTransmitterbull Two batteries (silver oxide)Two batteries (silver oxide)
GE Junction Duodenum
Jejunum Ileocecal Valve
Educational ObjectivesEducational Objectives Definitions and spectrum of inflammatory Definitions and spectrum of inflammatory
bowel disease (IBD)bowel disease (IBD) Epidemiology of IBDEpidemiology of IBD Etiopathogenesis of IBDEtiopathogenesis of IBD Clinical manifestations of ulcerative colitis Clinical manifestations of ulcerative colitis
(UC)(UC) Clinical manifestations of Crohnrsquos disease Clinical manifestations of Crohnrsquos disease
(CD)(CD) Distinguishing features between UC and CDDistinguishing features between UC and CD Diagnostic approach to IBDDiagnostic approach to IBD Complications of IBDComplications of IBD IBD managementIBD management
IBD-ComplicationsIBD-Complications GI BleedingGI Bleeding Toxic megacolonToxic megacolon PerforationPerforation Thromboembolic phenomenaThromboembolic phenomena FistulasfissuresFistulasfissures AbscessAbscess StricturesobstructionStricturesobstruction MalabsorptionmalnutritionMalabsorptionmalnutrition CancerCancer
Best Protection
Surveillance colonoscopySurveillance colonoscopy
Procto-colectomy (for UC)Procto-colectomy (for UC)
Descending Colon Descending Colon StrictureStricture
Colonic StricturesColonic Strictures
Consider nonsurgical management Consider nonsurgical management ifif Endoscopically accessibleEndoscopically accessible Multiple prior resectionsMultiple prior resections Shorter strictures (less than 5 cm)Shorter strictures (less than 5 cm) Steroid injection if significant Steroid injection if significant
inflammationinflammation
Fistula DefinitionA communication between two epithelial-lined organsLifetime risk of fistula in CD30
Perianal FistulaPerianal Fistula
Pretreatment 2 Weeks
10 Weeks 18 weeks
Educational ObjectivesEducational Objectives Definitions and spectrum of inflammatory Definitions and spectrum of inflammatory
bowel disease (IBD)bowel disease (IBD) Epidemiology of IBDEpidemiology of IBD Etiopathogenesis of IBDEtiopathogenesis of IBD Clinical manifestations of ulcerative colitis Clinical manifestations of ulcerative colitis
(UC)(UC) Clinical manifestations of Crohnrsquos disease Clinical manifestations of Crohnrsquos disease
(CD)(CD) Distinguishing features between UC and CDDistinguishing features between UC and CD Diagnostic approach to IBDDiagnostic approach to IBD Complications of IBDComplications of IBD IBD managementIBD management
Goals of Therapy for IBDGoals of Therapy for IBD
Inducing remissionInducing remission Maintaining remissionMaintaining remission Restoring and maintaining nutritionRestoring and maintaining nutrition Maintaining patientrsquos quality of lifeMaintaining patientrsquos quality of life Prevention of complicationsPrevention of complications Surgical intervention (selection of Surgical intervention (selection of
optimal time for surgery)optimal time for surgery)
Inductive TherapiesInductive Therapies
For UCFor UC AminosalicylatesAminosalicylates CorticosteroidsCorticosteroids CyclosporinCyclosporin
For CDFor CD AminosalicylatesAminosalicylates CorticosteroidsCorticosteroids AntibioticsAntibiotics Anti-TNFAnti-TNF
Maintenance TherapiesMaintenance Therapies
ImmunosupressorsImmunosupressors AzathioprineAzathioprine 6-MP6-MP MethotrexateMethotrexate
AminosalicylatesAminosalicylates Anti-TNFAnti-TNF
NOT NOT corticosteroidscorticosteroids
IBD ManagementIBD ManagementSummarySummary
There is no ldquoone size fits allrdquo to IBD therapyThere is no ldquoone size fits allrdquo to IBD therapy Therapy and decision making are tailored to the Therapy and decision making are tailored to the
individualindividual
Algorithms are based upon available evidenceAlgorithms are based upon available evidence Evidence is in constant fluxEvidence is in constant flux
Success of algorithms depends upon Success of algorithms depends upon optimization of each step of therapy and optimization of each step of therapy and considerable judgment about each outcomeconsiderable judgment about each outcome Skillful application of medical therapy makes all Skillful application of medical therapy makes all
the difference in outcomesthe difference in outcomes
Surgery for IBDSurgery for IBDGeneral ConceptsGeneral Concepts
Majority will need surgery 78 over Majority will need surgery 78 over twenty yearstwenty years
Surgery generally indicated for Surgery generally indicated for complicationscomplications of disease of disease
Surgery must be directed at area of Surgery must be directed at area of bowel responsible for complicationbowel responsible for complication
Indications for SurgeryIndications for Surgery Intestinal obstruction (most Intestinal obstruction (most
common)common) Intractabilitysteroid Intractabilitysteroid
dependencedependence Non-healing fistulaAbscessNon-healing fistulaAbscess Toxic megacolonFree Toxic megacolonFree
perforationperforation Uncontrollable GI bleedingUncontrollable GI bleeding Severe perianal diseaseSevere perianal disease CancerCancer Growth retardation Growth retardation
(children)(children) Severe uncontrollable Severe uncontrollable
extraintestinal extraintestinal manifestationsmanifestations
Management of IBDSummary
The goals of therapy are Relieve symptoms Prevent relapse Correct nutritional deficiencies Control inflammation Prevent complications especially colon cancer
Treatment depends on 1048707 Type of disease 1048707 Site of disease 1048707 Disease severity
Treatment may include drugs nutrition supplements surgery or a combination of these options
Crohnrsquos DiseaseCrohnrsquos DiseaseAnatomic DistributionAnatomic Distribution
Small bowelSmall bowelalonealone(33)(33)
IleocolicIleocolic(45)(45)
Colon aloneColon alone(20)(20)
Frequency of involvementFrequency of involvement
MostMost LeastLeast
Crohnrsquos disease ndash macroscopic Crohnrsquos disease ndash macroscopic featuresfeatures
CD is a CD is a transmuraltransmural process process
CD is CD is segmentalsegmental with skip areas in with skip areas in the midst of diseased intestinethe midst of diseased intestine
In one third of patients with CD In one third of patients with CD perirectal fistulas fissures perirectal fistulas fissures abscesses anal stenosis are presentabscesses anal stenosis are present
Crohnrsquos disease ndash macroscopic Crohnrsquos disease ndash macroscopic featuresfeatures
Active CD is characterized by focal Active CD is characterized by focal inflammation and formation of fistula inflammation and formation of fistula tractstracts
The bowel wall thickens and becomes The bowel wall thickens and becomes narrowed and fibrotic leading to narrowed and fibrotic leading to chronic recurrent bowel obstructionchronic recurrent bowel obstruction
Crohnrsquos Disease Activity Index(CDAI)
Incorporates 8 variables 1 liquid or very soft stools day 2 Abdominal pain amp cramping 3 Extraintestinal manifestations 4 Complications 5 Abdominal mass 6 Use of anti diarrheal medications anti- 7 Hematocrit 8 Body weight
Crohnrsquos Disease Red Crohnrsquos Disease Red FlagsFlags
Onset after stopping smokingOnset after stopping smoking Bleeding onlyBleeding only DiverticulosisDiverticulosis AtherosclerosisAtherosclerosis ProlapseProlapse
Extraintestinal Manifestations of IBD
SkinErythema nodosumPyoderma gangrenosum
JointsPeripheral arthritisSacroileitisAnkylosing spondylitis
EyeUveitisEpiscleritisIritis
Hepatobiliary complicationsGallstonesPSC
Renal complicationsNephrolithiasisRecurrent UTIs
Educational ObjectivesEducational Objectives Definitions and spectrum of inflammatory Definitions and spectrum of inflammatory
bowel disease (IBD)bowel disease (IBD) Epidemiology of IBDEpidemiology of IBD Etiopathogenesis of IBDEtiopathogenesis of IBD Clinical manifestations of ulcerative colitis Clinical manifestations of ulcerative colitis
(UC)(UC) Clinical manifestations of Crohnrsquos disease (CD)Clinical manifestations of Crohnrsquos disease (CD) Distinguishing features between UC and Distinguishing features between UC and
CDCD Diagnostic approach to IBDDiagnostic approach to IBD Medical management of IBDMedical management of IBD Indications for and role of surgeryIndications for and role of surgery
Symptoms of IBDUC vs CDUC vs CD
FeatureFeature UCUC CDCD
FeverFever UncommonUncommon CommonCommon
Rectal Rectal bleedingbleeding
CommonCommon lt frac12 of lt frac12 of patientspatients
Abdominal Abdominal tendernesstenderness
May be May be presentpresent
CommonCommon
Abdominal Abdominal massmass
UncommonUncommon CommonCommon
Abdominal Abdominal painpain
UncommonUncommon Very commonVery common
Weight lossWeight loss UncommonUncommon CommonCommon
TenesmusTenesmus Very commonVery common UncommonUncommon
UC vs CDUC vs CDComplicationsResponse to ComplicationsResponse to
TreatmentTreatmentUCUC CDCD
FistulasFistulas NoNo YesYes
Small Small intestine intestine obstructionobstruction
NoNo FrequentlyFrequently
Colonic Colonic obstructionobstruction
RarelyRarely FrequentlyFrequently
Response to Response to antibioticantibiotic
NoNo YesYes
Recurrence Recurrence after after surgerysurgery
NoNo YesYes
UC vs CDUC vs CDDifferent endoscopic featuresDifferent endoscopic features
UCUC CDCD
Rectal Rectal sparingsparing
RarelyRarely FrequentlyFrequently
Continuous Continuous diseasedisease
YesYes OccasionallyOccasionally
bdquobdquoCCobblestonobblestoningrdquoingrdquo
NoNo YesYes
Granuloma Granuloma on biopsyon biopsy
NoNo OccasionallyOccasionally
Criteria for Indeterminate Criteria for Indeterminate ColitisColitis
No evidence of No evidence of small bowel small bowel involvement involvement fistula or fistula or perianal diseaseperianal disease
Absence of Absence of diagnostic diagnostic criteria for CD criteria for CD or UC by or UC by microscopymicroscopy
Differential Diagnosis of Differential Diagnosis of Chronic Diarrhea and Weight Chronic Diarrhea and Weight
LossLoss Colonic diseasesColonic diseases
IBDIBD NeoplasiaNeoplasia Ischemic bowelIschemic bowel
PancreaticPancreatic Chronic pancreatitisChronic pancreatitis CancerCancer Cystic fibrosisCystic fibrosis
EnteropathicEnteropathic Celiac diseaseCeliac disease Tropical sprueTropical sprue LymphomaLymphoma Mesenteric ischemiaMesenteric ischemia Whipplersquos diseaseWhipplersquos disease
HormonaldrugsHormonaldrugs VipomaVipoma ZESZES Medullary CA of Medullary CA of
thyroidthyroid NSAIDS useNSAIDS use
Educational ObjectivesEducational Objectives Definitions and spectrum of inflammatory Definitions and spectrum of inflammatory
bowel disease (IBD)bowel disease (IBD) Epidemiology of IBDEpidemiology of IBD Etiopathogenesis of IBDEtiopathogenesis of IBD Clinical manifestations of ulcerative colitis Clinical manifestations of ulcerative colitis
(UC)(UC) Clinical manifestations of Crohnrsquos disease Clinical manifestations of Crohnrsquos disease
(CD)(CD) Distinguishing features between UC and CDDistinguishing features between UC and CD Diagnostic approach to IBDDiagnostic approach to IBD Medical management of IBDMedical management of IBD Indications for and role of surgeryIndications for and role of surgery
Diagnostic Approach to Diagnostic Approach to Patients with Suspected Patients with Suspected
IBDIBD HistoryhelliphelliphistoryhelliphelliphistoryHistoryhelliphelliphistoryhelliphelliphistory Clinical examClinical exam Laboratory testsLaboratory tests Radiological imagingRadiological imaging EndoscopyEndoscopy Special serological testingSpecial serological testing Genetic testingGenetic testing
Diagnosis-LAB Blood test
CD Mild anemia mild leukocytosis elevated ESR elevated CRP positive ASCA
UC Anemia hypokalemia hypoalbuminemia elevated ESR elevated LFTs positive p-ANCA
Stool analysis Many WBCs and or RBCs No ova or parasites
What are the Serological What are the Serological Markers in IBDMarkers in IBD
pANCA (perinuclear staining pattern)pANCA (perinuclear staining pattern) Loss of perinuclear pattern after Loss of perinuclear pattern after
DNAaseDNAase Differentiate from the ldquoother pANCAsrdquoDifferentiate from the ldquoother pANCAsrdquo
Antibody against myeloperoxidaseAntibody against myeloperoxidase Antibody against cathepsin G elastase lysozyme Antibody against cathepsin G elastase lysozyme
and lactoferrinand lactoferrin ASCA (anti-ASCA (anti-Saccharomyces cerevisiaeSaccharomyces cerevisiae))
Both IgG and IgABoth IgG and IgA Recognize mannose in the cell wall Recognize mannose in the cell wall
mannan of mannan of Saccharomyces cerevisiaeSaccharomyces cerevisiae
Why Use Serological Why Use Serological Markers in Clinical Markers in Clinical
PracticePractice Differentiate IBD from functional bowel Differentiate IBD from functional bowel
disordersdisorders Accurately diagnose Crohnrsquos or UC in a patient Accurately diagnose Crohnrsquos or UC in a patient
withwith Severe colitisSevere colitis Indeterminate colitisIndeterminate colitis
Predict disease course or complications in IBDPredict disease course or complications in IBD CD phenotypeCD phenotype Severity of diseaseSeverity of disease Risk of pouchitisRisk of pouchitis
SummarySummary
pANCA and ASCA are specific for UC pANCA and ASCA are specific for UC and CD respectivelyand CD respectively
Neither pANCA nor ASCA are sensitive Neither pANCA nor ASCA are sensitive enough to exclude IBDenough to exclude IBD
In patients with IC available In patients with IC available serological markers do not accurately serological markers do not accurately predict the subsequent disease coursepredict the subsequent disease course
Antibody profiles can predict disease Antibody profiles can predict disease behavior in IBDbehavior in IBD
Diagnostic ApproachDiagnostic ApproachEndoscopyEndoscopy
Endoscopy useful forEndoscopy useful for Initial diagnosisInitial diagnosis Assessment of severityAssessment of severity Tissue diagnosisTissue diagnosis FU during treatmentFU during treatment Assessment of disease exacerbationAssessment of disease exacerbation Surveillance for risk of cancerSurveillance for risk of cancer Treatment of certain complications (eg Treatment of certain complications (eg
strictures)strictures)
Crohnrsquos DiseaseCrohnrsquos DiseaseEndoscopic FeaturesEndoscopic Features
Asymmetric patchy inflammationAsymmetric patchy inflammation Skip lesionsSkip lesions Rectal sparingRectal sparing Ulcerations-deepserpiginousUlcerations-deepserpiginous Cobblestoning-commonCobblestoning-common Pseudopolyps-rarePseudopolyps-rare BiopsyBiopsy
Erosions and normal mucosaErosions and normal mucosa Granulomas in 15 to 35 of specimensGranulomas in 15 to 35 of specimens
Ulcerative ColitisUlcerative ColitisEndoscopic FeaturesEndoscopic Features
Diffuse involvementDiffuse involvement Rectum always diseasedRectum always diseased Superficial ulcerationsSuperficial ulcerations FriabilitybleedingFriabilitybleeding Flatteningdisappearance of haustral Flatteningdisappearance of haustral
foldsfolds PseudopolypsPseudopolyps No cobblestoningNo cobblestoning Bx No granulomasBx No granulomas
Imaging for Crohn Imaging for Crohn DiseaseDisease
Traditional TechniquesTraditional Techniques Abdominal RadiographsAbdominal Radiographs
Barium UGI Barium UGI
Barium small bowel follow throughBarium small bowel follow through
Barium EnteroclysisBarium Enteroclysis
Barium EnemaBarium Enema
Imaging for Crohn Disease Imaging for Crohn Disease Newer TechniquesNewer Techniques
CTCT
CT EnteroclysisCT Enteroclysis
CT EnterographyCT Enterography
Magnetic ResonanceMagnetic Resonance
UltrasoundUltrasound
Nuclear MedicineNuclear Medicine
Imaging for Crohns DiseaseImaging for Crohns Disease SummarySummary
Useful Newer TechniquesUseful Newer Techniques evolvingevolving CT EnterographyCT Enterography
Comprehensive evaluation of all bowel amp solid organsComprehensive evaluation of all bowel amp solid organs
Magnetic ResonanceMagnetic Resonance
Useful for ano-rectal diseaseUseful for ano-rectal disease
Real-time MR has potential for detection of stricturesReal-time MR has potential for detection of strictures
Traditional imaging techniques still of value in Traditional imaging techniques still of value in selected cases selected cases
The Capsule (WCE)The Capsule (WCE)
WCEWCE
bull Diameter 11mm Length 26mmDiameter 11mm Length 26mmbull Optical dome Intestinal illumination Optical dome Intestinal illumination
by white light emitting diodes (LEDrsquos)by white light emitting diodes (LEDrsquos)bull LensLensbull Complementary metal-oxide silicone Complementary metal-oxide silicone
imager (color camera chip)imager (color camera chip)bull TransmitterTransmitterbull Two batteries (silver oxide)Two batteries (silver oxide)
GE Junction Duodenum
Jejunum Ileocecal Valve
Educational ObjectivesEducational Objectives Definitions and spectrum of inflammatory Definitions and spectrum of inflammatory
bowel disease (IBD)bowel disease (IBD) Epidemiology of IBDEpidemiology of IBD Etiopathogenesis of IBDEtiopathogenesis of IBD Clinical manifestations of ulcerative colitis Clinical manifestations of ulcerative colitis
(UC)(UC) Clinical manifestations of Crohnrsquos disease Clinical manifestations of Crohnrsquos disease
(CD)(CD) Distinguishing features between UC and CDDistinguishing features between UC and CD Diagnostic approach to IBDDiagnostic approach to IBD Complications of IBDComplications of IBD IBD managementIBD management
IBD-ComplicationsIBD-Complications GI BleedingGI Bleeding Toxic megacolonToxic megacolon PerforationPerforation Thromboembolic phenomenaThromboembolic phenomena FistulasfissuresFistulasfissures AbscessAbscess StricturesobstructionStricturesobstruction MalabsorptionmalnutritionMalabsorptionmalnutrition CancerCancer
Best Protection
Surveillance colonoscopySurveillance colonoscopy
Procto-colectomy (for UC)Procto-colectomy (for UC)
Descending Colon Descending Colon StrictureStricture
Colonic StricturesColonic Strictures
Consider nonsurgical management Consider nonsurgical management ifif Endoscopically accessibleEndoscopically accessible Multiple prior resectionsMultiple prior resections Shorter strictures (less than 5 cm)Shorter strictures (less than 5 cm) Steroid injection if significant Steroid injection if significant
inflammationinflammation
Fistula DefinitionA communication between two epithelial-lined organsLifetime risk of fistula in CD30
Perianal FistulaPerianal Fistula
Pretreatment 2 Weeks
10 Weeks 18 weeks
Educational ObjectivesEducational Objectives Definitions and spectrum of inflammatory Definitions and spectrum of inflammatory
bowel disease (IBD)bowel disease (IBD) Epidemiology of IBDEpidemiology of IBD Etiopathogenesis of IBDEtiopathogenesis of IBD Clinical manifestations of ulcerative colitis Clinical manifestations of ulcerative colitis
(UC)(UC) Clinical manifestations of Crohnrsquos disease Clinical manifestations of Crohnrsquos disease
(CD)(CD) Distinguishing features between UC and CDDistinguishing features between UC and CD Diagnostic approach to IBDDiagnostic approach to IBD Complications of IBDComplications of IBD IBD managementIBD management
Goals of Therapy for IBDGoals of Therapy for IBD
Inducing remissionInducing remission Maintaining remissionMaintaining remission Restoring and maintaining nutritionRestoring and maintaining nutrition Maintaining patientrsquos quality of lifeMaintaining patientrsquos quality of life Prevention of complicationsPrevention of complications Surgical intervention (selection of Surgical intervention (selection of
optimal time for surgery)optimal time for surgery)
Inductive TherapiesInductive Therapies
For UCFor UC AminosalicylatesAminosalicylates CorticosteroidsCorticosteroids CyclosporinCyclosporin
For CDFor CD AminosalicylatesAminosalicylates CorticosteroidsCorticosteroids AntibioticsAntibiotics Anti-TNFAnti-TNF
Maintenance TherapiesMaintenance Therapies
ImmunosupressorsImmunosupressors AzathioprineAzathioprine 6-MP6-MP MethotrexateMethotrexate
AminosalicylatesAminosalicylates Anti-TNFAnti-TNF
NOT NOT corticosteroidscorticosteroids
IBD ManagementIBD ManagementSummarySummary
There is no ldquoone size fits allrdquo to IBD therapyThere is no ldquoone size fits allrdquo to IBD therapy Therapy and decision making are tailored to the Therapy and decision making are tailored to the
individualindividual
Algorithms are based upon available evidenceAlgorithms are based upon available evidence Evidence is in constant fluxEvidence is in constant flux
Success of algorithms depends upon Success of algorithms depends upon optimization of each step of therapy and optimization of each step of therapy and considerable judgment about each outcomeconsiderable judgment about each outcome Skillful application of medical therapy makes all Skillful application of medical therapy makes all
the difference in outcomesthe difference in outcomes
Surgery for IBDSurgery for IBDGeneral ConceptsGeneral Concepts
Majority will need surgery 78 over Majority will need surgery 78 over twenty yearstwenty years
Surgery generally indicated for Surgery generally indicated for complicationscomplications of disease of disease
Surgery must be directed at area of Surgery must be directed at area of bowel responsible for complicationbowel responsible for complication
Indications for SurgeryIndications for Surgery Intestinal obstruction (most Intestinal obstruction (most
common)common) Intractabilitysteroid Intractabilitysteroid
dependencedependence Non-healing fistulaAbscessNon-healing fistulaAbscess Toxic megacolonFree Toxic megacolonFree
perforationperforation Uncontrollable GI bleedingUncontrollable GI bleeding Severe perianal diseaseSevere perianal disease CancerCancer Growth retardation Growth retardation
(children)(children) Severe uncontrollable Severe uncontrollable
extraintestinal extraintestinal manifestationsmanifestations
Management of IBDSummary
The goals of therapy are Relieve symptoms Prevent relapse Correct nutritional deficiencies Control inflammation Prevent complications especially colon cancer
Treatment depends on 1048707 Type of disease 1048707 Site of disease 1048707 Disease severity
Treatment may include drugs nutrition supplements surgery or a combination of these options
Crohnrsquos disease ndash macroscopic Crohnrsquos disease ndash macroscopic featuresfeatures
CD is a CD is a transmuraltransmural process process
CD is CD is segmentalsegmental with skip areas in with skip areas in the midst of diseased intestinethe midst of diseased intestine
In one third of patients with CD In one third of patients with CD perirectal fistulas fissures perirectal fistulas fissures abscesses anal stenosis are presentabscesses anal stenosis are present
Crohnrsquos disease ndash macroscopic Crohnrsquos disease ndash macroscopic featuresfeatures
Active CD is characterized by focal Active CD is characterized by focal inflammation and formation of fistula inflammation and formation of fistula tractstracts
The bowel wall thickens and becomes The bowel wall thickens and becomes narrowed and fibrotic leading to narrowed and fibrotic leading to chronic recurrent bowel obstructionchronic recurrent bowel obstruction
Crohnrsquos Disease Activity Index(CDAI)
Incorporates 8 variables 1 liquid or very soft stools day 2 Abdominal pain amp cramping 3 Extraintestinal manifestations 4 Complications 5 Abdominal mass 6 Use of anti diarrheal medications anti- 7 Hematocrit 8 Body weight
Crohnrsquos Disease Red Crohnrsquos Disease Red FlagsFlags
Onset after stopping smokingOnset after stopping smoking Bleeding onlyBleeding only DiverticulosisDiverticulosis AtherosclerosisAtherosclerosis ProlapseProlapse
Extraintestinal Manifestations of IBD
SkinErythema nodosumPyoderma gangrenosum
JointsPeripheral arthritisSacroileitisAnkylosing spondylitis
EyeUveitisEpiscleritisIritis
Hepatobiliary complicationsGallstonesPSC
Renal complicationsNephrolithiasisRecurrent UTIs
Educational ObjectivesEducational Objectives Definitions and spectrum of inflammatory Definitions and spectrum of inflammatory
bowel disease (IBD)bowel disease (IBD) Epidemiology of IBDEpidemiology of IBD Etiopathogenesis of IBDEtiopathogenesis of IBD Clinical manifestations of ulcerative colitis Clinical manifestations of ulcerative colitis
(UC)(UC) Clinical manifestations of Crohnrsquos disease (CD)Clinical manifestations of Crohnrsquos disease (CD) Distinguishing features between UC and Distinguishing features between UC and
CDCD Diagnostic approach to IBDDiagnostic approach to IBD Medical management of IBDMedical management of IBD Indications for and role of surgeryIndications for and role of surgery
Symptoms of IBDUC vs CDUC vs CD
FeatureFeature UCUC CDCD
FeverFever UncommonUncommon CommonCommon
Rectal Rectal bleedingbleeding
CommonCommon lt frac12 of lt frac12 of patientspatients
Abdominal Abdominal tendernesstenderness
May be May be presentpresent
CommonCommon
Abdominal Abdominal massmass
UncommonUncommon CommonCommon
Abdominal Abdominal painpain
UncommonUncommon Very commonVery common
Weight lossWeight loss UncommonUncommon CommonCommon
TenesmusTenesmus Very commonVery common UncommonUncommon
UC vs CDUC vs CDComplicationsResponse to ComplicationsResponse to
TreatmentTreatmentUCUC CDCD
FistulasFistulas NoNo YesYes
Small Small intestine intestine obstructionobstruction
NoNo FrequentlyFrequently
Colonic Colonic obstructionobstruction
RarelyRarely FrequentlyFrequently
Response to Response to antibioticantibiotic
NoNo YesYes
Recurrence Recurrence after after surgerysurgery
NoNo YesYes
UC vs CDUC vs CDDifferent endoscopic featuresDifferent endoscopic features
UCUC CDCD
Rectal Rectal sparingsparing
RarelyRarely FrequentlyFrequently
Continuous Continuous diseasedisease
YesYes OccasionallyOccasionally
bdquobdquoCCobblestonobblestoningrdquoingrdquo
NoNo YesYes
Granuloma Granuloma on biopsyon biopsy
NoNo OccasionallyOccasionally
Criteria for Indeterminate Criteria for Indeterminate ColitisColitis
No evidence of No evidence of small bowel small bowel involvement involvement fistula or fistula or perianal diseaseperianal disease
Absence of Absence of diagnostic diagnostic criteria for CD criteria for CD or UC by or UC by microscopymicroscopy
Differential Diagnosis of Differential Diagnosis of Chronic Diarrhea and Weight Chronic Diarrhea and Weight
LossLoss Colonic diseasesColonic diseases
IBDIBD NeoplasiaNeoplasia Ischemic bowelIschemic bowel
PancreaticPancreatic Chronic pancreatitisChronic pancreatitis CancerCancer Cystic fibrosisCystic fibrosis
EnteropathicEnteropathic Celiac diseaseCeliac disease Tropical sprueTropical sprue LymphomaLymphoma Mesenteric ischemiaMesenteric ischemia Whipplersquos diseaseWhipplersquos disease
HormonaldrugsHormonaldrugs VipomaVipoma ZESZES Medullary CA of Medullary CA of
thyroidthyroid NSAIDS useNSAIDS use
Educational ObjectivesEducational Objectives Definitions and spectrum of inflammatory Definitions and spectrum of inflammatory
bowel disease (IBD)bowel disease (IBD) Epidemiology of IBDEpidemiology of IBD Etiopathogenesis of IBDEtiopathogenesis of IBD Clinical manifestations of ulcerative colitis Clinical manifestations of ulcerative colitis
(UC)(UC) Clinical manifestations of Crohnrsquos disease Clinical manifestations of Crohnrsquos disease
(CD)(CD) Distinguishing features between UC and CDDistinguishing features between UC and CD Diagnostic approach to IBDDiagnostic approach to IBD Medical management of IBDMedical management of IBD Indications for and role of surgeryIndications for and role of surgery
Diagnostic Approach to Diagnostic Approach to Patients with Suspected Patients with Suspected
IBDIBD HistoryhelliphelliphistoryhelliphelliphistoryHistoryhelliphelliphistoryhelliphelliphistory Clinical examClinical exam Laboratory testsLaboratory tests Radiological imagingRadiological imaging EndoscopyEndoscopy Special serological testingSpecial serological testing Genetic testingGenetic testing
Diagnosis-LAB Blood test
CD Mild anemia mild leukocytosis elevated ESR elevated CRP positive ASCA
UC Anemia hypokalemia hypoalbuminemia elevated ESR elevated LFTs positive p-ANCA
Stool analysis Many WBCs and or RBCs No ova or parasites
What are the Serological What are the Serological Markers in IBDMarkers in IBD
pANCA (perinuclear staining pattern)pANCA (perinuclear staining pattern) Loss of perinuclear pattern after Loss of perinuclear pattern after
DNAaseDNAase Differentiate from the ldquoother pANCAsrdquoDifferentiate from the ldquoother pANCAsrdquo
Antibody against myeloperoxidaseAntibody against myeloperoxidase Antibody against cathepsin G elastase lysozyme Antibody against cathepsin G elastase lysozyme
and lactoferrinand lactoferrin ASCA (anti-ASCA (anti-Saccharomyces cerevisiaeSaccharomyces cerevisiae))
Both IgG and IgABoth IgG and IgA Recognize mannose in the cell wall Recognize mannose in the cell wall
mannan of mannan of Saccharomyces cerevisiaeSaccharomyces cerevisiae
Why Use Serological Why Use Serological Markers in Clinical Markers in Clinical
PracticePractice Differentiate IBD from functional bowel Differentiate IBD from functional bowel
disordersdisorders Accurately diagnose Crohnrsquos or UC in a patient Accurately diagnose Crohnrsquos or UC in a patient
withwith Severe colitisSevere colitis Indeterminate colitisIndeterminate colitis
Predict disease course or complications in IBDPredict disease course or complications in IBD CD phenotypeCD phenotype Severity of diseaseSeverity of disease Risk of pouchitisRisk of pouchitis
SummarySummary
pANCA and ASCA are specific for UC pANCA and ASCA are specific for UC and CD respectivelyand CD respectively
Neither pANCA nor ASCA are sensitive Neither pANCA nor ASCA are sensitive enough to exclude IBDenough to exclude IBD
In patients with IC available In patients with IC available serological markers do not accurately serological markers do not accurately predict the subsequent disease coursepredict the subsequent disease course
Antibody profiles can predict disease Antibody profiles can predict disease behavior in IBDbehavior in IBD
Diagnostic ApproachDiagnostic ApproachEndoscopyEndoscopy
Endoscopy useful forEndoscopy useful for Initial diagnosisInitial diagnosis Assessment of severityAssessment of severity Tissue diagnosisTissue diagnosis FU during treatmentFU during treatment Assessment of disease exacerbationAssessment of disease exacerbation Surveillance for risk of cancerSurveillance for risk of cancer Treatment of certain complications (eg Treatment of certain complications (eg
strictures)strictures)
Crohnrsquos DiseaseCrohnrsquos DiseaseEndoscopic FeaturesEndoscopic Features
Asymmetric patchy inflammationAsymmetric patchy inflammation Skip lesionsSkip lesions Rectal sparingRectal sparing Ulcerations-deepserpiginousUlcerations-deepserpiginous Cobblestoning-commonCobblestoning-common Pseudopolyps-rarePseudopolyps-rare BiopsyBiopsy
Erosions and normal mucosaErosions and normal mucosa Granulomas in 15 to 35 of specimensGranulomas in 15 to 35 of specimens
Ulcerative ColitisUlcerative ColitisEndoscopic FeaturesEndoscopic Features
Diffuse involvementDiffuse involvement Rectum always diseasedRectum always diseased Superficial ulcerationsSuperficial ulcerations FriabilitybleedingFriabilitybleeding Flatteningdisappearance of haustral Flatteningdisappearance of haustral
foldsfolds PseudopolypsPseudopolyps No cobblestoningNo cobblestoning Bx No granulomasBx No granulomas
Imaging for Crohn Imaging for Crohn DiseaseDisease
Traditional TechniquesTraditional Techniques Abdominal RadiographsAbdominal Radiographs
Barium UGI Barium UGI
Barium small bowel follow throughBarium small bowel follow through
Barium EnteroclysisBarium Enteroclysis
Barium EnemaBarium Enema
Imaging for Crohn Disease Imaging for Crohn Disease Newer TechniquesNewer Techniques
CTCT
CT EnteroclysisCT Enteroclysis
CT EnterographyCT Enterography
Magnetic ResonanceMagnetic Resonance
UltrasoundUltrasound
Nuclear MedicineNuclear Medicine
Imaging for Crohns DiseaseImaging for Crohns Disease SummarySummary
Useful Newer TechniquesUseful Newer Techniques evolvingevolving CT EnterographyCT Enterography
Comprehensive evaluation of all bowel amp solid organsComprehensive evaluation of all bowel amp solid organs
Magnetic ResonanceMagnetic Resonance
Useful for ano-rectal diseaseUseful for ano-rectal disease
Real-time MR has potential for detection of stricturesReal-time MR has potential for detection of strictures
Traditional imaging techniques still of value in Traditional imaging techniques still of value in selected cases selected cases
The Capsule (WCE)The Capsule (WCE)
WCEWCE
bull Diameter 11mm Length 26mmDiameter 11mm Length 26mmbull Optical dome Intestinal illumination Optical dome Intestinal illumination
by white light emitting diodes (LEDrsquos)by white light emitting diodes (LEDrsquos)bull LensLensbull Complementary metal-oxide silicone Complementary metal-oxide silicone
imager (color camera chip)imager (color camera chip)bull TransmitterTransmitterbull Two batteries (silver oxide)Two batteries (silver oxide)
GE Junction Duodenum
Jejunum Ileocecal Valve
Educational ObjectivesEducational Objectives Definitions and spectrum of inflammatory Definitions and spectrum of inflammatory
bowel disease (IBD)bowel disease (IBD) Epidemiology of IBDEpidemiology of IBD Etiopathogenesis of IBDEtiopathogenesis of IBD Clinical manifestations of ulcerative colitis Clinical manifestations of ulcerative colitis
(UC)(UC) Clinical manifestations of Crohnrsquos disease Clinical manifestations of Crohnrsquos disease
(CD)(CD) Distinguishing features between UC and CDDistinguishing features between UC and CD Diagnostic approach to IBDDiagnostic approach to IBD Complications of IBDComplications of IBD IBD managementIBD management
IBD-ComplicationsIBD-Complications GI BleedingGI Bleeding Toxic megacolonToxic megacolon PerforationPerforation Thromboembolic phenomenaThromboembolic phenomena FistulasfissuresFistulasfissures AbscessAbscess StricturesobstructionStricturesobstruction MalabsorptionmalnutritionMalabsorptionmalnutrition CancerCancer
Best Protection
Surveillance colonoscopySurveillance colonoscopy
Procto-colectomy (for UC)Procto-colectomy (for UC)
Descending Colon Descending Colon StrictureStricture
Colonic StricturesColonic Strictures
Consider nonsurgical management Consider nonsurgical management ifif Endoscopically accessibleEndoscopically accessible Multiple prior resectionsMultiple prior resections Shorter strictures (less than 5 cm)Shorter strictures (less than 5 cm) Steroid injection if significant Steroid injection if significant
inflammationinflammation
Fistula DefinitionA communication between two epithelial-lined organsLifetime risk of fistula in CD30
Perianal FistulaPerianal Fistula
Pretreatment 2 Weeks
10 Weeks 18 weeks
Educational ObjectivesEducational Objectives Definitions and spectrum of inflammatory Definitions and spectrum of inflammatory
bowel disease (IBD)bowel disease (IBD) Epidemiology of IBDEpidemiology of IBD Etiopathogenesis of IBDEtiopathogenesis of IBD Clinical manifestations of ulcerative colitis Clinical manifestations of ulcerative colitis
(UC)(UC) Clinical manifestations of Crohnrsquos disease Clinical manifestations of Crohnrsquos disease
(CD)(CD) Distinguishing features between UC and CDDistinguishing features between UC and CD Diagnostic approach to IBDDiagnostic approach to IBD Complications of IBDComplications of IBD IBD managementIBD management
Goals of Therapy for IBDGoals of Therapy for IBD
Inducing remissionInducing remission Maintaining remissionMaintaining remission Restoring and maintaining nutritionRestoring and maintaining nutrition Maintaining patientrsquos quality of lifeMaintaining patientrsquos quality of life Prevention of complicationsPrevention of complications Surgical intervention (selection of Surgical intervention (selection of
optimal time for surgery)optimal time for surgery)
Inductive TherapiesInductive Therapies
For UCFor UC AminosalicylatesAminosalicylates CorticosteroidsCorticosteroids CyclosporinCyclosporin
For CDFor CD AminosalicylatesAminosalicylates CorticosteroidsCorticosteroids AntibioticsAntibiotics Anti-TNFAnti-TNF
Maintenance TherapiesMaintenance Therapies
ImmunosupressorsImmunosupressors AzathioprineAzathioprine 6-MP6-MP MethotrexateMethotrexate
AminosalicylatesAminosalicylates Anti-TNFAnti-TNF
NOT NOT corticosteroidscorticosteroids
IBD ManagementIBD ManagementSummarySummary
There is no ldquoone size fits allrdquo to IBD therapyThere is no ldquoone size fits allrdquo to IBD therapy Therapy and decision making are tailored to the Therapy and decision making are tailored to the
individualindividual
Algorithms are based upon available evidenceAlgorithms are based upon available evidence Evidence is in constant fluxEvidence is in constant flux
Success of algorithms depends upon Success of algorithms depends upon optimization of each step of therapy and optimization of each step of therapy and considerable judgment about each outcomeconsiderable judgment about each outcome Skillful application of medical therapy makes all Skillful application of medical therapy makes all
the difference in outcomesthe difference in outcomes
Surgery for IBDSurgery for IBDGeneral ConceptsGeneral Concepts
Majority will need surgery 78 over Majority will need surgery 78 over twenty yearstwenty years
Surgery generally indicated for Surgery generally indicated for complicationscomplications of disease of disease
Surgery must be directed at area of Surgery must be directed at area of bowel responsible for complicationbowel responsible for complication
Indications for SurgeryIndications for Surgery Intestinal obstruction (most Intestinal obstruction (most
common)common) Intractabilitysteroid Intractabilitysteroid
dependencedependence Non-healing fistulaAbscessNon-healing fistulaAbscess Toxic megacolonFree Toxic megacolonFree
perforationperforation Uncontrollable GI bleedingUncontrollable GI bleeding Severe perianal diseaseSevere perianal disease CancerCancer Growth retardation Growth retardation
(children)(children) Severe uncontrollable Severe uncontrollable
extraintestinal extraintestinal manifestationsmanifestations
Management of IBDSummary
The goals of therapy are Relieve symptoms Prevent relapse Correct nutritional deficiencies Control inflammation Prevent complications especially colon cancer
Treatment depends on 1048707 Type of disease 1048707 Site of disease 1048707 Disease severity
Treatment may include drugs nutrition supplements surgery or a combination of these options
Crohnrsquos disease ndash macroscopic Crohnrsquos disease ndash macroscopic featuresfeatures
Active CD is characterized by focal Active CD is characterized by focal inflammation and formation of fistula inflammation and formation of fistula tractstracts
The bowel wall thickens and becomes The bowel wall thickens and becomes narrowed and fibrotic leading to narrowed and fibrotic leading to chronic recurrent bowel obstructionchronic recurrent bowel obstruction
Crohnrsquos Disease Activity Index(CDAI)
Incorporates 8 variables 1 liquid or very soft stools day 2 Abdominal pain amp cramping 3 Extraintestinal manifestations 4 Complications 5 Abdominal mass 6 Use of anti diarrheal medications anti- 7 Hematocrit 8 Body weight
Crohnrsquos Disease Red Crohnrsquos Disease Red FlagsFlags
Onset after stopping smokingOnset after stopping smoking Bleeding onlyBleeding only DiverticulosisDiverticulosis AtherosclerosisAtherosclerosis ProlapseProlapse
Extraintestinal Manifestations of IBD
SkinErythema nodosumPyoderma gangrenosum
JointsPeripheral arthritisSacroileitisAnkylosing spondylitis
EyeUveitisEpiscleritisIritis
Hepatobiliary complicationsGallstonesPSC
Renal complicationsNephrolithiasisRecurrent UTIs
Educational ObjectivesEducational Objectives Definitions and spectrum of inflammatory Definitions and spectrum of inflammatory
bowel disease (IBD)bowel disease (IBD) Epidemiology of IBDEpidemiology of IBD Etiopathogenesis of IBDEtiopathogenesis of IBD Clinical manifestations of ulcerative colitis Clinical manifestations of ulcerative colitis
(UC)(UC) Clinical manifestations of Crohnrsquos disease (CD)Clinical manifestations of Crohnrsquos disease (CD) Distinguishing features between UC and Distinguishing features between UC and
CDCD Diagnostic approach to IBDDiagnostic approach to IBD Medical management of IBDMedical management of IBD Indications for and role of surgeryIndications for and role of surgery
Symptoms of IBDUC vs CDUC vs CD
FeatureFeature UCUC CDCD
FeverFever UncommonUncommon CommonCommon
Rectal Rectal bleedingbleeding
CommonCommon lt frac12 of lt frac12 of patientspatients
Abdominal Abdominal tendernesstenderness
May be May be presentpresent
CommonCommon
Abdominal Abdominal massmass
UncommonUncommon CommonCommon
Abdominal Abdominal painpain
UncommonUncommon Very commonVery common
Weight lossWeight loss UncommonUncommon CommonCommon
TenesmusTenesmus Very commonVery common UncommonUncommon
UC vs CDUC vs CDComplicationsResponse to ComplicationsResponse to
TreatmentTreatmentUCUC CDCD
FistulasFistulas NoNo YesYes
Small Small intestine intestine obstructionobstruction
NoNo FrequentlyFrequently
Colonic Colonic obstructionobstruction
RarelyRarely FrequentlyFrequently
Response to Response to antibioticantibiotic
NoNo YesYes
Recurrence Recurrence after after surgerysurgery
NoNo YesYes
UC vs CDUC vs CDDifferent endoscopic featuresDifferent endoscopic features
UCUC CDCD
Rectal Rectal sparingsparing
RarelyRarely FrequentlyFrequently
Continuous Continuous diseasedisease
YesYes OccasionallyOccasionally
bdquobdquoCCobblestonobblestoningrdquoingrdquo
NoNo YesYes
Granuloma Granuloma on biopsyon biopsy
NoNo OccasionallyOccasionally
Criteria for Indeterminate Criteria for Indeterminate ColitisColitis
No evidence of No evidence of small bowel small bowel involvement involvement fistula or fistula or perianal diseaseperianal disease
Absence of Absence of diagnostic diagnostic criteria for CD criteria for CD or UC by or UC by microscopymicroscopy
Differential Diagnosis of Differential Diagnosis of Chronic Diarrhea and Weight Chronic Diarrhea and Weight
LossLoss Colonic diseasesColonic diseases
IBDIBD NeoplasiaNeoplasia Ischemic bowelIschemic bowel
PancreaticPancreatic Chronic pancreatitisChronic pancreatitis CancerCancer Cystic fibrosisCystic fibrosis
EnteropathicEnteropathic Celiac diseaseCeliac disease Tropical sprueTropical sprue LymphomaLymphoma Mesenteric ischemiaMesenteric ischemia Whipplersquos diseaseWhipplersquos disease
HormonaldrugsHormonaldrugs VipomaVipoma ZESZES Medullary CA of Medullary CA of
thyroidthyroid NSAIDS useNSAIDS use
Educational ObjectivesEducational Objectives Definitions and spectrum of inflammatory Definitions and spectrum of inflammatory
bowel disease (IBD)bowel disease (IBD) Epidemiology of IBDEpidemiology of IBD Etiopathogenesis of IBDEtiopathogenesis of IBD Clinical manifestations of ulcerative colitis Clinical manifestations of ulcerative colitis
(UC)(UC) Clinical manifestations of Crohnrsquos disease Clinical manifestations of Crohnrsquos disease
(CD)(CD) Distinguishing features between UC and CDDistinguishing features between UC and CD Diagnostic approach to IBDDiagnostic approach to IBD Medical management of IBDMedical management of IBD Indications for and role of surgeryIndications for and role of surgery
Diagnostic Approach to Diagnostic Approach to Patients with Suspected Patients with Suspected
IBDIBD HistoryhelliphelliphistoryhelliphelliphistoryHistoryhelliphelliphistoryhelliphelliphistory Clinical examClinical exam Laboratory testsLaboratory tests Radiological imagingRadiological imaging EndoscopyEndoscopy Special serological testingSpecial serological testing Genetic testingGenetic testing
Diagnosis-LAB Blood test
CD Mild anemia mild leukocytosis elevated ESR elevated CRP positive ASCA
UC Anemia hypokalemia hypoalbuminemia elevated ESR elevated LFTs positive p-ANCA
Stool analysis Many WBCs and or RBCs No ova or parasites
What are the Serological What are the Serological Markers in IBDMarkers in IBD
pANCA (perinuclear staining pattern)pANCA (perinuclear staining pattern) Loss of perinuclear pattern after Loss of perinuclear pattern after
DNAaseDNAase Differentiate from the ldquoother pANCAsrdquoDifferentiate from the ldquoother pANCAsrdquo
Antibody against myeloperoxidaseAntibody against myeloperoxidase Antibody against cathepsin G elastase lysozyme Antibody against cathepsin G elastase lysozyme
and lactoferrinand lactoferrin ASCA (anti-ASCA (anti-Saccharomyces cerevisiaeSaccharomyces cerevisiae))
Both IgG and IgABoth IgG and IgA Recognize mannose in the cell wall Recognize mannose in the cell wall
mannan of mannan of Saccharomyces cerevisiaeSaccharomyces cerevisiae
Why Use Serological Why Use Serological Markers in Clinical Markers in Clinical
PracticePractice Differentiate IBD from functional bowel Differentiate IBD from functional bowel
disordersdisorders Accurately diagnose Crohnrsquos or UC in a patient Accurately diagnose Crohnrsquos or UC in a patient
withwith Severe colitisSevere colitis Indeterminate colitisIndeterminate colitis
Predict disease course or complications in IBDPredict disease course or complications in IBD CD phenotypeCD phenotype Severity of diseaseSeverity of disease Risk of pouchitisRisk of pouchitis
SummarySummary
pANCA and ASCA are specific for UC pANCA and ASCA are specific for UC and CD respectivelyand CD respectively
Neither pANCA nor ASCA are sensitive Neither pANCA nor ASCA are sensitive enough to exclude IBDenough to exclude IBD
In patients with IC available In patients with IC available serological markers do not accurately serological markers do not accurately predict the subsequent disease coursepredict the subsequent disease course
Antibody profiles can predict disease Antibody profiles can predict disease behavior in IBDbehavior in IBD
Diagnostic ApproachDiagnostic ApproachEndoscopyEndoscopy
Endoscopy useful forEndoscopy useful for Initial diagnosisInitial diagnosis Assessment of severityAssessment of severity Tissue diagnosisTissue diagnosis FU during treatmentFU during treatment Assessment of disease exacerbationAssessment of disease exacerbation Surveillance for risk of cancerSurveillance for risk of cancer Treatment of certain complications (eg Treatment of certain complications (eg
strictures)strictures)
Crohnrsquos DiseaseCrohnrsquos DiseaseEndoscopic FeaturesEndoscopic Features
Asymmetric patchy inflammationAsymmetric patchy inflammation Skip lesionsSkip lesions Rectal sparingRectal sparing Ulcerations-deepserpiginousUlcerations-deepserpiginous Cobblestoning-commonCobblestoning-common Pseudopolyps-rarePseudopolyps-rare BiopsyBiopsy
Erosions and normal mucosaErosions and normal mucosa Granulomas in 15 to 35 of specimensGranulomas in 15 to 35 of specimens
Ulcerative ColitisUlcerative ColitisEndoscopic FeaturesEndoscopic Features
Diffuse involvementDiffuse involvement Rectum always diseasedRectum always diseased Superficial ulcerationsSuperficial ulcerations FriabilitybleedingFriabilitybleeding Flatteningdisappearance of haustral Flatteningdisappearance of haustral
foldsfolds PseudopolypsPseudopolyps No cobblestoningNo cobblestoning Bx No granulomasBx No granulomas
Imaging for Crohn Imaging for Crohn DiseaseDisease
Traditional TechniquesTraditional Techniques Abdominal RadiographsAbdominal Radiographs
Barium UGI Barium UGI
Barium small bowel follow throughBarium small bowel follow through
Barium EnteroclysisBarium Enteroclysis
Barium EnemaBarium Enema
Imaging for Crohn Disease Imaging for Crohn Disease Newer TechniquesNewer Techniques
CTCT
CT EnteroclysisCT Enteroclysis
CT EnterographyCT Enterography
Magnetic ResonanceMagnetic Resonance
UltrasoundUltrasound
Nuclear MedicineNuclear Medicine
Imaging for Crohns DiseaseImaging for Crohns Disease SummarySummary
Useful Newer TechniquesUseful Newer Techniques evolvingevolving CT EnterographyCT Enterography
Comprehensive evaluation of all bowel amp solid organsComprehensive evaluation of all bowel amp solid organs
Magnetic ResonanceMagnetic Resonance
Useful for ano-rectal diseaseUseful for ano-rectal disease
Real-time MR has potential for detection of stricturesReal-time MR has potential for detection of strictures
Traditional imaging techniques still of value in Traditional imaging techniques still of value in selected cases selected cases
The Capsule (WCE)The Capsule (WCE)
WCEWCE
bull Diameter 11mm Length 26mmDiameter 11mm Length 26mmbull Optical dome Intestinal illumination Optical dome Intestinal illumination
by white light emitting diodes (LEDrsquos)by white light emitting diodes (LEDrsquos)bull LensLensbull Complementary metal-oxide silicone Complementary metal-oxide silicone
imager (color camera chip)imager (color camera chip)bull TransmitterTransmitterbull Two batteries (silver oxide)Two batteries (silver oxide)
GE Junction Duodenum
Jejunum Ileocecal Valve
Educational ObjectivesEducational Objectives Definitions and spectrum of inflammatory Definitions and spectrum of inflammatory
bowel disease (IBD)bowel disease (IBD) Epidemiology of IBDEpidemiology of IBD Etiopathogenesis of IBDEtiopathogenesis of IBD Clinical manifestations of ulcerative colitis Clinical manifestations of ulcerative colitis
(UC)(UC) Clinical manifestations of Crohnrsquos disease Clinical manifestations of Crohnrsquos disease
(CD)(CD) Distinguishing features between UC and CDDistinguishing features between UC and CD Diagnostic approach to IBDDiagnostic approach to IBD Complications of IBDComplications of IBD IBD managementIBD management
IBD-ComplicationsIBD-Complications GI BleedingGI Bleeding Toxic megacolonToxic megacolon PerforationPerforation Thromboembolic phenomenaThromboembolic phenomena FistulasfissuresFistulasfissures AbscessAbscess StricturesobstructionStricturesobstruction MalabsorptionmalnutritionMalabsorptionmalnutrition CancerCancer
Best Protection
Surveillance colonoscopySurveillance colonoscopy
Procto-colectomy (for UC)Procto-colectomy (for UC)
Descending Colon Descending Colon StrictureStricture
Colonic StricturesColonic Strictures
Consider nonsurgical management Consider nonsurgical management ifif Endoscopically accessibleEndoscopically accessible Multiple prior resectionsMultiple prior resections Shorter strictures (less than 5 cm)Shorter strictures (less than 5 cm) Steroid injection if significant Steroid injection if significant
inflammationinflammation
Fistula DefinitionA communication between two epithelial-lined organsLifetime risk of fistula in CD30
Perianal FistulaPerianal Fistula
Pretreatment 2 Weeks
10 Weeks 18 weeks
Educational ObjectivesEducational Objectives Definitions and spectrum of inflammatory Definitions and spectrum of inflammatory
bowel disease (IBD)bowel disease (IBD) Epidemiology of IBDEpidemiology of IBD Etiopathogenesis of IBDEtiopathogenesis of IBD Clinical manifestations of ulcerative colitis Clinical manifestations of ulcerative colitis
(UC)(UC) Clinical manifestations of Crohnrsquos disease Clinical manifestations of Crohnrsquos disease
(CD)(CD) Distinguishing features between UC and CDDistinguishing features between UC and CD Diagnostic approach to IBDDiagnostic approach to IBD Complications of IBDComplications of IBD IBD managementIBD management
Goals of Therapy for IBDGoals of Therapy for IBD
Inducing remissionInducing remission Maintaining remissionMaintaining remission Restoring and maintaining nutritionRestoring and maintaining nutrition Maintaining patientrsquos quality of lifeMaintaining patientrsquos quality of life Prevention of complicationsPrevention of complications Surgical intervention (selection of Surgical intervention (selection of
optimal time for surgery)optimal time for surgery)
Inductive TherapiesInductive Therapies
For UCFor UC AminosalicylatesAminosalicylates CorticosteroidsCorticosteroids CyclosporinCyclosporin
For CDFor CD AminosalicylatesAminosalicylates CorticosteroidsCorticosteroids AntibioticsAntibiotics Anti-TNFAnti-TNF
Maintenance TherapiesMaintenance Therapies
ImmunosupressorsImmunosupressors AzathioprineAzathioprine 6-MP6-MP MethotrexateMethotrexate
AminosalicylatesAminosalicylates Anti-TNFAnti-TNF
NOT NOT corticosteroidscorticosteroids
IBD ManagementIBD ManagementSummarySummary
There is no ldquoone size fits allrdquo to IBD therapyThere is no ldquoone size fits allrdquo to IBD therapy Therapy and decision making are tailored to the Therapy and decision making are tailored to the
individualindividual
Algorithms are based upon available evidenceAlgorithms are based upon available evidence Evidence is in constant fluxEvidence is in constant flux
Success of algorithms depends upon Success of algorithms depends upon optimization of each step of therapy and optimization of each step of therapy and considerable judgment about each outcomeconsiderable judgment about each outcome Skillful application of medical therapy makes all Skillful application of medical therapy makes all
the difference in outcomesthe difference in outcomes
Surgery for IBDSurgery for IBDGeneral ConceptsGeneral Concepts
Majority will need surgery 78 over Majority will need surgery 78 over twenty yearstwenty years
Surgery generally indicated for Surgery generally indicated for complicationscomplications of disease of disease
Surgery must be directed at area of Surgery must be directed at area of bowel responsible for complicationbowel responsible for complication
Indications for SurgeryIndications for Surgery Intestinal obstruction (most Intestinal obstruction (most
common)common) Intractabilitysteroid Intractabilitysteroid
dependencedependence Non-healing fistulaAbscessNon-healing fistulaAbscess Toxic megacolonFree Toxic megacolonFree
perforationperforation Uncontrollable GI bleedingUncontrollable GI bleeding Severe perianal diseaseSevere perianal disease CancerCancer Growth retardation Growth retardation
(children)(children) Severe uncontrollable Severe uncontrollable
extraintestinal extraintestinal manifestationsmanifestations
Management of IBDSummary
The goals of therapy are Relieve symptoms Prevent relapse Correct nutritional deficiencies Control inflammation Prevent complications especially colon cancer
Treatment depends on 1048707 Type of disease 1048707 Site of disease 1048707 Disease severity
Treatment may include drugs nutrition supplements surgery or a combination of these options
Crohnrsquos Disease Activity Index(CDAI)
Incorporates 8 variables 1 liquid or very soft stools day 2 Abdominal pain amp cramping 3 Extraintestinal manifestations 4 Complications 5 Abdominal mass 6 Use of anti diarrheal medications anti- 7 Hematocrit 8 Body weight
Crohnrsquos Disease Red Crohnrsquos Disease Red FlagsFlags
Onset after stopping smokingOnset after stopping smoking Bleeding onlyBleeding only DiverticulosisDiverticulosis AtherosclerosisAtherosclerosis ProlapseProlapse
Extraintestinal Manifestations of IBD
SkinErythema nodosumPyoderma gangrenosum
JointsPeripheral arthritisSacroileitisAnkylosing spondylitis
EyeUveitisEpiscleritisIritis
Hepatobiliary complicationsGallstonesPSC
Renal complicationsNephrolithiasisRecurrent UTIs
Educational ObjectivesEducational Objectives Definitions and spectrum of inflammatory Definitions and spectrum of inflammatory
bowel disease (IBD)bowel disease (IBD) Epidemiology of IBDEpidemiology of IBD Etiopathogenesis of IBDEtiopathogenesis of IBD Clinical manifestations of ulcerative colitis Clinical manifestations of ulcerative colitis
(UC)(UC) Clinical manifestations of Crohnrsquos disease (CD)Clinical manifestations of Crohnrsquos disease (CD) Distinguishing features between UC and Distinguishing features between UC and
CDCD Diagnostic approach to IBDDiagnostic approach to IBD Medical management of IBDMedical management of IBD Indications for and role of surgeryIndications for and role of surgery
Symptoms of IBDUC vs CDUC vs CD
FeatureFeature UCUC CDCD
FeverFever UncommonUncommon CommonCommon
Rectal Rectal bleedingbleeding
CommonCommon lt frac12 of lt frac12 of patientspatients
Abdominal Abdominal tendernesstenderness
May be May be presentpresent
CommonCommon
Abdominal Abdominal massmass
UncommonUncommon CommonCommon
Abdominal Abdominal painpain
UncommonUncommon Very commonVery common
Weight lossWeight loss UncommonUncommon CommonCommon
TenesmusTenesmus Very commonVery common UncommonUncommon
UC vs CDUC vs CDComplicationsResponse to ComplicationsResponse to
TreatmentTreatmentUCUC CDCD
FistulasFistulas NoNo YesYes
Small Small intestine intestine obstructionobstruction
NoNo FrequentlyFrequently
Colonic Colonic obstructionobstruction
RarelyRarely FrequentlyFrequently
Response to Response to antibioticantibiotic
NoNo YesYes
Recurrence Recurrence after after surgerysurgery
NoNo YesYes
UC vs CDUC vs CDDifferent endoscopic featuresDifferent endoscopic features
UCUC CDCD
Rectal Rectal sparingsparing
RarelyRarely FrequentlyFrequently
Continuous Continuous diseasedisease
YesYes OccasionallyOccasionally
bdquobdquoCCobblestonobblestoningrdquoingrdquo
NoNo YesYes
Granuloma Granuloma on biopsyon biopsy
NoNo OccasionallyOccasionally
Criteria for Indeterminate Criteria for Indeterminate ColitisColitis
No evidence of No evidence of small bowel small bowel involvement involvement fistula or fistula or perianal diseaseperianal disease
Absence of Absence of diagnostic diagnostic criteria for CD criteria for CD or UC by or UC by microscopymicroscopy
Differential Diagnosis of Differential Diagnosis of Chronic Diarrhea and Weight Chronic Diarrhea and Weight
LossLoss Colonic diseasesColonic diseases
IBDIBD NeoplasiaNeoplasia Ischemic bowelIschemic bowel
PancreaticPancreatic Chronic pancreatitisChronic pancreatitis CancerCancer Cystic fibrosisCystic fibrosis
EnteropathicEnteropathic Celiac diseaseCeliac disease Tropical sprueTropical sprue LymphomaLymphoma Mesenteric ischemiaMesenteric ischemia Whipplersquos diseaseWhipplersquos disease
HormonaldrugsHormonaldrugs VipomaVipoma ZESZES Medullary CA of Medullary CA of
thyroidthyroid NSAIDS useNSAIDS use
Educational ObjectivesEducational Objectives Definitions and spectrum of inflammatory Definitions and spectrum of inflammatory
bowel disease (IBD)bowel disease (IBD) Epidemiology of IBDEpidemiology of IBD Etiopathogenesis of IBDEtiopathogenesis of IBD Clinical manifestations of ulcerative colitis Clinical manifestations of ulcerative colitis
(UC)(UC) Clinical manifestations of Crohnrsquos disease Clinical manifestations of Crohnrsquos disease
(CD)(CD) Distinguishing features between UC and CDDistinguishing features between UC and CD Diagnostic approach to IBDDiagnostic approach to IBD Medical management of IBDMedical management of IBD Indications for and role of surgeryIndications for and role of surgery
Diagnostic Approach to Diagnostic Approach to Patients with Suspected Patients with Suspected
IBDIBD HistoryhelliphelliphistoryhelliphelliphistoryHistoryhelliphelliphistoryhelliphelliphistory Clinical examClinical exam Laboratory testsLaboratory tests Radiological imagingRadiological imaging EndoscopyEndoscopy Special serological testingSpecial serological testing Genetic testingGenetic testing
Diagnosis-LAB Blood test
CD Mild anemia mild leukocytosis elevated ESR elevated CRP positive ASCA
UC Anemia hypokalemia hypoalbuminemia elevated ESR elevated LFTs positive p-ANCA
Stool analysis Many WBCs and or RBCs No ova or parasites
What are the Serological What are the Serological Markers in IBDMarkers in IBD
pANCA (perinuclear staining pattern)pANCA (perinuclear staining pattern) Loss of perinuclear pattern after Loss of perinuclear pattern after
DNAaseDNAase Differentiate from the ldquoother pANCAsrdquoDifferentiate from the ldquoother pANCAsrdquo
Antibody against myeloperoxidaseAntibody against myeloperoxidase Antibody against cathepsin G elastase lysozyme Antibody against cathepsin G elastase lysozyme
and lactoferrinand lactoferrin ASCA (anti-ASCA (anti-Saccharomyces cerevisiaeSaccharomyces cerevisiae))
Both IgG and IgABoth IgG and IgA Recognize mannose in the cell wall Recognize mannose in the cell wall
mannan of mannan of Saccharomyces cerevisiaeSaccharomyces cerevisiae
Why Use Serological Why Use Serological Markers in Clinical Markers in Clinical
PracticePractice Differentiate IBD from functional bowel Differentiate IBD from functional bowel
disordersdisorders Accurately diagnose Crohnrsquos or UC in a patient Accurately diagnose Crohnrsquos or UC in a patient
withwith Severe colitisSevere colitis Indeterminate colitisIndeterminate colitis
Predict disease course or complications in IBDPredict disease course or complications in IBD CD phenotypeCD phenotype Severity of diseaseSeverity of disease Risk of pouchitisRisk of pouchitis
SummarySummary
pANCA and ASCA are specific for UC pANCA and ASCA are specific for UC and CD respectivelyand CD respectively
Neither pANCA nor ASCA are sensitive Neither pANCA nor ASCA are sensitive enough to exclude IBDenough to exclude IBD
In patients with IC available In patients with IC available serological markers do not accurately serological markers do not accurately predict the subsequent disease coursepredict the subsequent disease course
Antibody profiles can predict disease Antibody profiles can predict disease behavior in IBDbehavior in IBD
Diagnostic ApproachDiagnostic ApproachEndoscopyEndoscopy
Endoscopy useful forEndoscopy useful for Initial diagnosisInitial diagnosis Assessment of severityAssessment of severity Tissue diagnosisTissue diagnosis FU during treatmentFU during treatment Assessment of disease exacerbationAssessment of disease exacerbation Surveillance for risk of cancerSurveillance for risk of cancer Treatment of certain complications (eg Treatment of certain complications (eg
strictures)strictures)
Crohnrsquos DiseaseCrohnrsquos DiseaseEndoscopic FeaturesEndoscopic Features
Asymmetric patchy inflammationAsymmetric patchy inflammation Skip lesionsSkip lesions Rectal sparingRectal sparing Ulcerations-deepserpiginousUlcerations-deepserpiginous Cobblestoning-commonCobblestoning-common Pseudopolyps-rarePseudopolyps-rare BiopsyBiopsy
Erosions and normal mucosaErosions and normal mucosa Granulomas in 15 to 35 of specimensGranulomas in 15 to 35 of specimens
Ulcerative ColitisUlcerative ColitisEndoscopic FeaturesEndoscopic Features
Diffuse involvementDiffuse involvement Rectum always diseasedRectum always diseased Superficial ulcerationsSuperficial ulcerations FriabilitybleedingFriabilitybleeding Flatteningdisappearance of haustral Flatteningdisappearance of haustral
foldsfolds PseudopolypsPseudopolyps No cobblestoningNo cobblestoning Bx No granulomasBx No granulomas
Imaging for Crohn Imaging for Crohn DiseaseDisease
Traditional TechniquesTraditional Techniques Abdominal RadiographsAbdominal Radiographs
Barium UGI Barium UGI
Barium small bowel follow throughBarium small bowel follow through
Barium EnteroclysisBarium Enteroclysis
Barium EnemaBarium Enema
Imaging for Crohn Disease Imaging for Crohn Disease Newer TechniquesNewer Techniques
CTCT
CT EnteroclysisCT Enteroclysis
CT EnterographyCT Enterography
Magnetic ResonanceMagnetic Resonance
UltrasoundUltrasound
Nuclear MedicineNuclear Medicine
Imaging for Crohns DiseaseImaging for Crohns Disease SummarySummary
Useful Newer TechniquesUseful Newer Techniques evolvingevolving CT EnterographyCT Enterography
Comprehensive evaluation of all bowel amp solid organsComprehensive evaluation of all bowel amp solid organs
Magnetic ResonanceMagnetic Resonance
Useful for ano-rectal diseaseUseful for ano-rectal disease
Real-time MR has potential for detection of stricturesReal-time MR has potential for detection of strictures
Traditional imaging techniques still of value in Traditional imaging techniques still of value in selected cases selected cases
The Capsule (WCE)The Capsule (WCE)
WCEWCE
bull Diameter 11mm Length 26mmDiameter 11mm Length 26mmbull Optical dome Intestinal illumination Optical dome Intestinal illumination
by white light emitting diodes (LEDrsquos)by white light emitting diodes (LEDrsquos)bull LensLensbull Complementary metal-oxide silicone Complementary metal-oxide silicone
imager (color camera chip)imager (color camera chip)bull TransmitterTransmitterbull Two batteries (silver oxide)Two batteries (silver oxide)
GE Junction Duodenum
Jejunum Ileocecal Valve
Educational ObjectivesEducational Objectives Definitions and spectrum of inflammatory Definitions and spectrum of inflammatory
bowel disease (IBD)bowel disease (IBD) Epidemiology of IBDEpidemiology of IBD Etiopathogenesis of IBDEtiopathogenesis of IBD Clinical manifestations of ulcerative colitis Clinical manifestations of ulcerative colitis
(UC)(UC) Clinical manifestations of Crohnrsquos disease Clinical manifestations of Crohnrsquos disease
(CD)(CD) Distinguishing features between UC and CDDistinguishing features between UC and CD Diagnostic approach to IBDDiagnostic approach to IBD Complications of IBDComplications of IBD IBD managementIBD management
IBD-ComplicationsIBD-Complications GI BleedingGI Bleeding Toxic megacolonToxic megacolon PerforationPerforation Thromboembolic phenomenaThromboembolic phenomena FistulasfissuresFistulasfissures AbscessAbscess StricturesobstructionStricturesobstruction MalabsorptionmalnutritionMalabsorptionmalnutrition CancerCancer
Best Protection
Surveillance colonoscopySurveillance colonoscopy
Procto-colectomy (for UC)Procto-colectomy (for UC)
Descending Colon Descending Colon StrictureStricture
Colonic StricturesColonic Strictures
Consider nonsurgical management Consider nonsurgical management ifif Endoscopically accessibleEndoscopically accessible Multiple prior resectionsMultiple prior resections Shorter strictures (less than 5 cm)Shorter strictures (less than 5 cm) Steroid injection if significant Steroid injection if significant
inflammationinflammation
Fistula DefinitionA communication between two epithelial-lined organsLifetime risk of fistula in CD30
Perianal FistulaPerianal Fistula
Pretreatment 2 Weeks
10 Weeks 18 weeks
Educational ObjectivesEducational Objectives Definitions and spectrum of inflammatory Definitions and spectrum of inflammatory
bowel disease (IBD)bowel disease (IBD) Epidemiology of IBDEpidemiology of IBD Etiopathogenesis of IBDEtiopathogenesis of IBD Clinical manifestations of ulcerative colitis Clinical manifestations of ulcerative colitis
(UC)(UC) Clinical manifestations of Crohnrsquos disease Clinical manifestations of Crohnrsquos disease
(CD)(CD) Distinguishing features between UC and CDDistinguishing features between UC and CD Diagnostic approach to IBDDiagnostic approach to IBD Complications of IBDComplications of IBD IBD managementIBD management
Goals of Therapy for IBDGoals of Therapy for IBD
Inducing remissionInducing remission Maintaining remissionMaintaining remission Restoring and maintaining nutritionRestoring and maintaining nutrition Maintaining patientrsquos quality of lifeMaintaining patientrsquos quality of life Prevention of complicationsPrevention of complications Surgical intervention (selection of Surgical intervention (selection of
optimal time for surgery)optimal time for surgery)
Inductive TherapiesInductive Therapies
For UCFor UC AminosalicylatesAminosalicylates CorticosteroidsCorticosteroids CyclosporinCyclosporin
For CDFor CD AminosalicylatesAminosalicylates CorticosteroidsCorticosteroids AntibioticsAntibiotics Anti-TNFAnti-TNF
Maintenance TherapiesMaintenance Therapies
ImmunosupressorsImmunosupressors AzathioprineAzathioprine 6-MP6-MP MethotrexateMethotrexate
AminosalicylatesAminosalicylates Anti-TNFAnti-TNF
NOT NOT corticosteroidscorticosteroids
IBD ManagementIBD ManagementSummarySummary
There is no ldquoone size fits allrdquo to IBD therapyThere is no ldquoone size fits allrdquo to IBD therapy Therapy and decision making are tailored to the Therapy and decision making are tailored to the
individualindividual
Algorithms are based upon available evidenceAlgorithms are based upon available evidence Evidence is in constant fluxEvidence is in constant flux
Success of algorithms depends upon Success of algorithms depends upon optimization of each step of therapy and optimization of each step of therapy and considerable judgment about each outcomeconsiderable judgment about each outcome Skillful application of medical therapy makes all Skillful application of medical therapy makes all
the difference in outcomesthe difference in outcomes
Surgery for IBDSurgery for IBDGeneral ConceptsGeneral Concepts
Majority will need surgery 78 over Majority will need surgery 78 over twenty yearstwenty years
Surgery generally indicated for Surgery generally indicated for complicationscomplications of disease of disease
Surgery must be directed at area of Surgery must be directed at area of bowel responsible for complicationbowel responsible for complication
Indications for SurgeryIndications for Surgery Intestinal obstruction (most Intestinal obstruction (most
common)common) Intractabilitysteroid Intractabilitysteroid
dependencedependence Non-healing fistulaAbscessNon-healing fistulaAbscess Toxic megacolonFree Toxic megacolonFree
perforationperforation Uncontrollable GI bleedingUncontrollable GI bleeding Severe perianal diseaseSevere perianal disease CancerCancer Growth retardation Growth retardation
(children)(children) Severe uncontrollable Severe uncontrollable
extraintestinal extraintestinal manifestationsmanifestations
Management of IBDSummary
The goals of therapy are Relieve symptoms Prevent relapse Correct nutritional deficiencies Control inflammation Prevent complications especially colon cancer
Treatment depends on 1048707 Type of disease 1048707 Site of disease 1048707 Disease severity
Treatment may include drugs nutrition supplements surgery or a combination of these options
Crohnrsquos Disease Red Crohnrsquos Disease Red FlagsFlags
Onset after stopping smokingOnset after stopping smoking Bleeding onlyBleeding only DiverticulosisDiverticulosis AtherosclerosisAtherosclerosis ProlapseProlapse
Extraintestinal Manifestations of IBD
SkinErythema nodosumPyoderma gangrenosum
JointsPeripheral arthritisSacroileitisAnkylosing spondylitis
EyeUveitisEpiscleritisIritis
Hepatobiliary complicationsGallstonesPSC
Renal complicationsNephrolithiasisRecurrent UTIs
Educational ObjectivesEducational Objectives Definitions and spectrum of inflammatory Definitions and spectrum of inflammatory
bowel disease (IBD)bowel disease (IBD) Epidemiology of IBDEpidemiology of IBD Etiopathogenesis of IBDEtiopathogenesis of IBD Clinical manifestations of ulcerative colitis Clinical manifestations of ulcerative colitis
(UC)(UC) Clinical manifestations of Crohnrsquos disease (CD)Clinical manifestations of Crohnrsquos disease (CD) Distinguishing features between UC and Distinguishing features between UC and
CDCD Diagnostic approach to IBDDiagnostic approach to IBD Medical management of IBDMedical management of IBD Indications for and role of surgeryIndications for and role of surgery
Symptoms of IBDUC vs CDUC vs CD
FeatureFeature UCUC CDCD
FeverFever UncommonUncommon CommonCommon
Rectal Rectal bleedingbleeding
CommonCommon lt frac12 of lt frac12 of patientspatients
Abdominal Abdominal tendernesstenderness
May be May be presentpresent
CommonCommon
Abdominal Abdominal massmass
UncommonUncommon CommonCommon
Abdominal Abdominal painpain
UncommonUncommon Very commonVery common
Weight lossWeight loss UncommonUncommon CommonCommon
TenesmusTenesmus Very commonVery common UncommonUncommon
UC vs CDUC vs CDComplicationsResponse to ComplicationsResponse to
TreatmentTreatmentUCUC CDCD
FistulasFistulas NoNo YesYes
Small Small intestine intestine obstructionobstruction
NoNo FrequentlyFrequently
Colonic Colonic obstructionobstruction
RarelyRarely FrequentlyFrequently
Response to Response to antibioticantibiotic
NoNo YesYes
Recurrence Recurrence after after surgerysurgery
NoNo YesYes
UC vs CDUC vs CDDifferent endoscopic featuresDifferent endoscopic features
UCUC CDCD
Rectal Rectal sparingsparing
RarelyRarely FrequentlyFrequently
Continuous Continuous diseasedisease
YesYes OccasionallyOccasionally
bdquobdquoCCobblestonobblestoningrdquoingrdquo
NoNo YesYes
Granuloma Granuloma on biopsyon biopsy
NoNo OccasionallyOccasionally
Criteria for Indeterminate Criteria for Indeterminate ColitisColitis
No evidence of No evidence of small bowel small bowel involvement involvement fistula or fistula or perianal diseaseperianal disease
Absence of Absence of diagnostic diagnostic criteria for CD criteria for CD or UC by or UC by microscopymicroscopy
Differential Diagnosis of Differential Diagnosis of Chronic Diarrhea and Weight Chronic Diarrhea and Weight
LossLoss Colonic diseasesColonic diseases
IBDIBD NeoplasiaNeoplasia Ischemic bowelIschemic bowel
PancreaticPancreatic Chronic pancreatitisChronic pancreatitis CancerCancer Cystic fibrosisCystic fibrosis
EnteropathicEnteropathic Celiac diseaseCeliac disease Tropical sprueTropical sprue LymphomaLymphoma Mesenteric ischemiaMesenteric ischemia Whipplersquos diseaseWhipplersquos disease
HormonaldrugsHormonaldrugs VipomaVipoma ZESZES Medullary CA of Medullary CA of
thyroidthyroid NSAIDS useNSAIDS use
Educational ObjectivesEducational Objectives Definitions and spectrum of inflammatory Definitions and spectrum of inflammatory
bowel disease (IBD)bowel disease (IBD) Epidemiology of IBDEpidemiology of IBD Etiopathogenesis of IBDEtiopathogenesis of IBD Clinical manifestations of ulcerative colitis Clinical manifestations of ulcerative colitis
(UC)(UC) Clinical manifestations of Crohnrsquos disease Clinical manifestations of Crohnrsquos disease
(CD)(CD) Distinguishing features between UC and CDDistinguishing features between UC and CD Diagnostic approach to IBDDiagnostic approach to IBD Medical management of IBDMedical management of IBD Indications for and role of surgeryIndications for and role of surgery
Diagnostic Approach to Diagnostic Approach to Patients with Suspected Patients with Suspected
IBDIBD HistoryhelliphelliphistoryhelliphelliphistoryHistoryhelliphelliphistoryhelliphelliphistory Clinical examClinical exam Laboratory testsLaboratory tests Radiological imagingRadiological imaging EndoscopyEndoscopy Special serological testingSpecial serological testing Genetic testingGenetic testing
Diagnosis-LAB Blood test
CD Mild anemia mild leukocytosis elevated ESR elevated CRP positive ASCA
UC Anemia hypokalemia hypoalbuminemia elevated ESR elevated LFTs positive p-ANCA
Stool analysis Many WBCs and or RBCs No ova or parasites
What are the Serological What are the Serological Markers in IBDMarkers in IBD
pANCA (perinuclear staining pattern)pANCA (perinuclear staining pattern) Loss of perinuclear pattern after Loss of perinuclear pattern after
DNAaseDNAase Differentiate from the ldquoother pANCAsrdquoDifferentiate from the ldquoother pANCAsrdquo
Antibody against myeloperoxidaseAntibody against myeloperoxidase Antibody against cathepsin G elastase lysozyme Antibody against cathepsin G elastase lysozyme
and lactoferrinand lactoferrin ASCA (anti-ASCA (anti-Saccharomyces cerevisiaeSaccharomyces cerevisiae))
Both IgG and IgABoth IgG and IgA Recognize mannose in the cell wall Recognize mannose in the cell wall
mannan of mannan of Saccharomyces cerevisiaeSaccharomyces cerevisiae
Why Use Serological Why Use Serological Markers in Clinical Markers in Clinical
PracticePractice Differentiate IBD from functional bowel Differentiate IBD from functional bowel
disordersdisorders Accurately diagnose Crohnrsquos or UC in a patient Accurately diagnose Crohnrsquos or UC in a patient
withwith Severe colitisSevere colitis Indeterminate colitisIndeterminate colitis
Predict disease course or complications in IBDPredict disease course or complications in IBD CD phenotypeCD phenotype Severity of diseaseSeverity of disease Risk of pouchitisRisk of pouchitis
SummarySummary
pANCA and ASCA are specific for UC pANCA and ASCA are specific for UC and CD respectivelyand CD respectively
Neither pANCA nor ASCA are sensitive Neither pANCA nor ASCA are sensitive enough to exclude IBDenough to exclude IBD
In patients with IC available In patients with IC available serological markers do not accurately serological markers do not accurately predict the subsequent disease coursepredict the subsequent disease course
Antibody profiles can predict disease Antibody profiles can predict disease behavior in IBDbehavior in IBD
Diagnostic ApproachDiagnostic ApproachEndoscopyEndoscopy
Endoscopy useful forEndoscopy useful for Initial diagnosisInitial diagnosis Assessment of severityAssessment of severity Tissue diagnosisTissue diagnosis FU during treatmentFU during treatment Assessment of disease exacerbationAssessment of disease exacerbation Surveillance for risk of cancerSurveillance for risk of cancer Treatment of certain complications (eg Treatment of certain complications (eg
strictures)strictures)
Crohnrsquos DiseaseCrohnrsquos DiseaseEndoscopic FeaturesEndoscopic Features
Asymmetric patchy inflammationAsymmetric patchy inflammation Skip lesionsSkip lesions Rectal sparingRectal sparing Ulcerations-deepserpiginousUlcerations-deepserpiginous Cobblestoning-commonCobblestoning-common Pseudopolyps-rarePseudopolyps-rare BiopsyBiopsy
Erosions and normal mucosaErosions and normal mucosa Granulomas in 15 to 35 of specimensGranulomas in 15 to 35 of specimens
Ulcerative ColitisUlcerative ColitisEndoscopic FeaturesEndoscopic Features
Diffuse involvementDiffuse involvement Rectum always diseasedRectum always diseased Superficial ulcerationsSuperficial ulcerations FriabilitybleedingFriabilitybleeding Flatteningdisappearance of haustral Flatteningdisappearance of haustral
foldsfolds PseudopolypsPseudopolyps No cobblestoningNo cobblestoning Bx No granulomasBx No granulomas
Imaging for Crohn Imaging for Crohn DiseaseDisease
Traditional TechniquesTraditional Techniques Abdominal RadiographsAbdominal Radiographs
Barium UGI Barium UGI
Barium small bowel follow throughBarium small bowel follow through
Barium EnteroclysisBarium Enteroclysis
Barium EnemaBarium Enema
Imaging for Crohn Disease Imaging for Crohn Disease Newer TechniquesNewer Techniques
CTCT
CT EnteroclysisCT Enteroclysis
CT EnterographyCT Enterography
Magnetic ResonanceMagnetic Resonance
UltrasoundUltrasound
Nuclear MedicineNuclear Medicine
Imaging for Crohns DiseaseImaging for Crohns Disease SummarySummary
Useful Newer TechniquesUseful Newer Techniques evolvingevolving CT EnterographyCT Enterography
Comprehensive evaluation of all bowel amp solid organsComprehensive evaluation of all bowel amp solid organs
Magnetic ResonanceMagnetic Resonance
Useful for ano-rectal diseaseUseful for ano-rectal disease
Real-time MR has potential for detection of stricturesReal-time MR has potential for detection of strictures
Traditional imaging techniques still of value in Traditional imaging techniques still of value in selected cases selected cases
The Capsule (WCE)The Capsule (WCE)
WCEWCE
bull Diameter 11mm Length 26mmDiameter 11mm Length 26mmbull Optical dome Intestinal illumination Optical dome Intestinal illumination
by white light emitting diodes (LEDrsquos)by white light emitting diodes (LEDrsquos)bull LensLensbull Complementary metal-oxide silicone Complementary metal-oxide silicone
imager (color camera chip)imager (color camera chip)bull TransmitterTransmitterbull Two batteries (silver oxide)Two batteries (silver oxide)
GE Junction Duodenum
Jejunum Ileocecal Valve
Educational ObjectivesEducational Objectives Definitions and spectrum of inflammatory Definitions and spectrum of inflammatory
bowel disease (IBD)bowel disease (IBD) Epidemiology of IBDEpidemiology of IBD Etiopathogenesis of IBDEtiopathogenesis of IBD Clinical manifestations of ulcerative colitis Clinical manifestations of ulcerative colitis
(UC)(UC) Clinical manifestations of Crohnrsquos disease Clinical manifestations of Crohnrsquos disease
(CD)(CD) Distinguishing features between UC and CDDistinguishing features between UC and CD Diagnostic approach to IBDDiagnostic approach to IBD Complications of IBDComplications of IBD IBD managementIBD management
IBD-ComplicationsIBD-Complications GI BleedingGI Bleeding Toxic megacolonToxic megacolon PerforationPerforation Thromboembolic phenomenaThromboembolic phenomena FistulasfissuresFistulasfissures AbscessAbscess StricturesobstructionStricturesobstruction MalabsorptionmalnutritionMalabsorptionmalnutrition CancerCancer
Best Protection
Surveillance colonoscopySurveillance colonoscopy
Procto-colectomy (for UC)Procto-colectomy (for UC)
Descending Colon Descending Colon StrictureStricture
Colonic StricturesColonic Strictures
Consider nonsurgical management Consider nonsurgical management ifif Endoscopically accessibleEndoscopically accessible Multiple prior resectionsMultiple prior resections Shorter strictures (less than 5 cm)Shorter strictures (less than 5 cm) Steroid injection if significant Steroid injection if significant
inflammationinflammation
Fistula DefinitionA communication between two epithelial-lined organsLifetime risk of fistula in CD30
Perianal FistulaPerianal Fistula
Pretreatment 2 Weeks
10 Weeks 18 weeks
Educational ObjectivesEducational Objectives Definitions and spectrum of inflammatory Definitions and spectrum of inflammatory
bowel disease (IBD)bowel disease (IBD) Epidemiology of IBDEpidemiology of IBD Etiopathogenesis of IBDEtiopathogenesis of IBD Clinical manifestations of ulcerative colitis Clinical manifestations of ulcerative colitis
(UC)(UC) Clinical manifestations of Crohnrsquos disease Clinical manifestations of Crohnrsquos disease
(CD)(CD) Distinguishing features between UC and CDDistinguishing features between UC and CD Diagnostic approach to IBDDiagnostic approach to IBD Complications of IBDComplications of IBD IBD managementIBD management
Goals of Therapy for IBDGoals of Therapy for IBD
Inducing remissionInducing remission Maintaining remissionMaintaining remission Restoring and maintaining nutritionRestoring and maintaining nutrition Maintaining patientrsquos quality of lifeMaintaining patientrsquos quality of life Prevention of complicationsPrevention of complications Surgical intervention (selection of Surgical intervention (selection of
optimal time for surgery)optimal time for surgery)
Inductive TherapiesInductive Therapies
For UCFor UC AminosalicylatesAminosalicylates CorticosteroidsCorticosteroids CyclosporinCyclosporin
For CDFor CD AminosalicylatesAminosalicylates CorticosteroidsCorticosteroids AntibioticsAntibiotics Anti-TNFAnti-TNF
Maintenance TherapiesMaintenance Therapies
ImmunosupressorsImmunosupressors AzathioprineAzathioprine 6-MP6-MP MethotrexateMethotrexate
AminosalicylatesAminosalicylates Anti-TNFAnti-TNF
NOT NOT corticosteroidscorticosteroids
IBD ManagementIBD ManagementSummarySummary
There is no ldquoone size fits allrdquo to IBD therapyThere is no ldquoone size fits allrdquo to IBD therapy Therapy and decision making are tailored to the Therapy and decision making are tailored to the
individualindividual
Algorithms are based upon available evidenceAlgorithms are based upon available evidence Evidence is in constant fluxEvidence is in constant flux
Success of algorithms depends upon Success of algorithms depends upon optimization of each step of therapy and optimization of each step of therapy and considerable judgment about each outcomeconsiderable judgment about each outcome Skillful application of medical therapy makes all Skillful application of medical therapy makes all
the difference in outcomesthe difference in outcomes
Surgery for IBDSurgery for IBDGeneral ConceptsGeneral Concepts
Majority will need surgery 78 over Majority will need surgery 78 over twenty yearstwenty years
Surgery generally indicated for Surgery generally indicated for complicationscomplications of disease of disease
Surgery must be directed at area of Surgery must be directed at area of bowel responsible for complicationbowel responsible for complication
Indications for SurgeryIndications for Surgery Intestinal obstruction (most Intestinal obstruction (most
common)common) Intractabilitysteroid Intractabilitysteroid
dependencedependence Non-healing fistulaAbscessNon-healing fistulaAbscess Toxic megacolonFree Toxic megacolonFree
perforationperforation Uncontrollable GI bleedingUncontrollable GI bleeding Severe perianal diseaseSevere perianal disease CancerCancer Growth retardation Growth retardation
(children)(children) Severe uncontrollable Severe uncontrollable
extraintestinal extraintestinal manifestationsmanifestations
Management of IBDSummary
The goals of therapy are Relieve symptoms Prevent relapse Correct nutritional deficiencies Control inflammation Prevent complications especially colon cancer
Treatment depends on 1048707 Type of disease 1048707 Site of disease 1048707 Disease severity
Treatment may include drugs nutrition supplements surgery or a combination of these options
Extraintestinal Manifestations of IBD
SkinErythema nodosumPyoderma gangrenosum
JointsPeripheral arthritisSacroileitisAnkylosing spondylitis
EyeUveitisEpiscleritisIritis
Hepatobiliary complicationsGallstonesPSC
Renal complicationsNephrolithiasisRecurrent UTIs
Educational ObjectivesEducational Objectives Definitions and spectrum of inflammatory Definitions and spectrum of inflammatory
bowel disease (IBD)bowel disease (IBD) Epidemiology of IBDEpidemiology of IBD Etiopathogenesis of IBDEtiopathogenesis of IBD Clinical manifestations of ulcerative colitis Clinical manifestations of ulcerative colitis
(UC)(UC) Clinical manifestations of Crohnrsquos disease (CD)Clinical manifestations of Crohnrsquos disease (CD) Distinguishing features between UC and Distinguishing features between UC and
CDCD Diagnostic approach to IBDDiagnostic approach to IBD Medical management of IBDMedical management of IBD Indications for and role of surgeryIndications for and role of surgery
Symptoms of IBDUC vs CDUC vs CD
FeatureFeature UCUC CDCD
FeverFever UncommonUncommon CommonCommon
Rectal Rectal bleedingbleeding
CommonCommon lt frac12 of lt frac12 of patientspatients
Abdominal Abdominal tendernesstenderness
May be May be presentpresent
CommonCommon
Abdominal Abdominal massmass
UncommonUncommon CommonCommon
Abdominal Abdominal painpain
UncommonUncommon Very commonVery common
Weight lossWeight loss UncommonUncommon CommonCommon
TenesmusTenesmus Very commonVery common UncommonUncommon
UC vs CDUC vs CDComplicationsResponse to ComplicationsResponse to
TreatmentTreatmentUCUC CDCD
FistulasFistulas NoNo YesYes
Small Small intestine intestine obstructionobstruction
NoNo FrequentlyFrequently
Colonic Colonic obstructionobstruction
RarelyRarely FrequentlyFrequently
Response to Response to antibioticantibiotic
NoNo YesYes
Recurrence Recurrence after after surgerysurgery
NoNo YesYes
UC vs CDUC vs CDDifferent endoscopic featuresDifferent endoscopic features
UCUC CDCD
Rectal Rectal sparingsparing
RarelyRarely FrequentlyFrequently
Continuous Continuous diseasedisease
YesYes OccasionallyOccasionally
bdquobdquoCCobblestonobblestoningrdquoingrdquo
NoNo YesYes
Granuloma Granuloma on biopsyon biopsy
NoNo OccasionallyOccasionally
Criteria for Indeterminate Criteria for Indeterminate ColitisColitis
No evidence of No evidence of small bowel small bowel involvement involvement fistula or fistula or perianal diseaseperianal disease
Absence of Absence of diagnostic diagnostic criteria for CD criteria for CD or UC by or UC by microscopymicroscopy
Differential Diagnosis of Differential Diagnosis of Chronic Diarrhea and Weight Chronic Diarrhea and Weight
LossLoss Colonic diseasesColonic diseases
IBDIBD NeoplasiaNeoplasia Ischemic bowelIschemic bowel
PancreaticPancreatic Chronic pancreatitisChronic pancreatitis CancerCancer Cystic fibrosisCystic fibrosis
EnteropathicEnteropathic Celiac diseaseCeliac disease Tropical sprueTropical sprue LymphomaLymphoma Mesenteric ischemiaMesenteric ischemia Whipplersquos diseaseWhipplersquos disease
HormonaldrugsHormonaldrugs VipomaVipoma ZESZES Medullary CA of Medullary CA of
thyroidthyroid NSAIDS useNSAIDS use
Educational ObjectivesEducational Objectives Definitions and spectrum of inflammatory Definitions and spectrum of inflammatory
bowel disease (IBD)bowel disease (IBD) Epidemiology of IBDEpidemiology of IBD Etiopathogenesis of IBDEtiopathogenesis of IBD Clinical manifestations of ulcerative colitis Clinical manifestations of ulcerative colitis
(UC)(UC) Clinical manifestations of Crohnrsquos disease Clinical manifestations of Crohnrsquos disease
(CD)(CD) Distinguishing features between UC and CDDistinguishing features between UC and CD Diagnostic approach to IBDDiagnostic approach to IBD Medical management of IBDMedical management of IBD Indications for and role of surgeryIndications for and role of surgery
Diagnostic Approach to Diagnostic Approach to Patients with Suspected Patients with Suspected
IBDIBD HistoryhelliphelliphistoryhelliphelliphistoryHistoryhelliphelliphistoryhelliphelliphistory Clinical examClinical exam Laboratory testsLaboratory tests Radiological imagingRadiological imaging EndoscopyEndoscopy Special serological testingSpecial serological testing Genetic testingGenetic testing
Diagnosis-LAB Blood test
CD Mild anemia mild leukocytosis elevated ESR elevated CRP positive ASCA
UC Anemia hypokalemia hypoalbuminemia elevated ESR elevated LFTs positive p-ANCA
Stool analysis Many WBCs and or RBCs No ova or parasites
What are the Serological What are the Serological Markers in IBDMarkers in IBD
pANCA (perinuclear staining pattern)pANCA (perinuclear staining pattern) Loss of perinuclear pattern after Loss of perinuclear pattern after
DNAaseDNAase Differentiate from the ldquoother pANCAsrdquoDifferentiate from the ldquoother pANCAsrdquo
Antibody against myeloperoxidaseAntibody against myeloperoxidase Antibody against cathepsin G elastase lysozyme Antibody against cathepsin G elastase lysozyme
and lactoferrinand lactoferrin ASCA (anti-ASCA (anti-Saccharomyces cerevisiaeSaccharomyces cerevisiae))
Both IgG and IgABoth IgG and IgA Recognize mannose in the cell wall Recognize mannose in the cell wall
mannan of mannan of Saccharomyces cerevisiaeSaccharomyces cerevisiae
Why Use Serological Why Use Serological Markers in Clinical Markers in Clinical
PracticePractice Differentiate IBD from functional bowel Differentiate IBD from functional bowel
disordersdisorders Accurately diagnose Crohnrsquos or UC in a patient Accurately diagnose Crohnrsquos or UC in a patient
withwith Severe colitisSevere colitis Indeterminate colitisIndeterminate colitis
Predict disease course or complications in IBDPredict disease course or complications in IBD CD phenotypeCD phenotype Severity of diseaseSeverity of disease Risk of pouchitisRisk of pouchitis
SummarySummary
pANCA and ASCA are specific for UC pANCA and ASCA are specific for UC and CD respectivelyand CD respectively
Neither pANCA nor ASCA are sensitive Neither pANCA nor ASCA are sensitive enough to exclude IBDenough to exclude IBD
In patients with IC available In patients with IC available serological markers do not accurately serological markers do not accurately predict the subsequent disease coursepredict the subsequent disease course
Antibody profiles can predict disease Antibody profiles can predict disease behavior in IBDbehavior in IBD
Diagnostic ApproachDiagnostic ApproachEndoscopyEndoscopy
Endoscopy useful forEndoscopy useful for Initial diagnosisInitial diagnosis Assessment of severityAssessment of severity Tissue diagnosisTissue diagnosis FU during treatmentFU during treatment Assessment of disease exacerbationAssessment of disease exacerbation Surveillance for risk of cancerSurveillance for risk of cancer Treatment of certain complications (eg Treatment of certain complications (eg
strictures)strictures)
Crohnrsquos DiseaseCrohnrsquos DiseaseEndoscopic FeaturesEndoscopic Features
Asymmetric patchy inflammationAsymmetric patchy inflammation Skip lesionsSkip lesions Rectal sparingRectal sparing Ulcerations-deepserpiginousUlcerations-deepserpiginous Cobblestoning-commonCobblestoning-common Pseudopolyps-rarePseudopolyps-rare BiopsyBiopsy
Erosions and normal mucosaErosions and normal mucosa Granulomas in 15 to 35 of specimensGranulomas in 15 to 35 of specimens
Ulcerative ColitisUlcerative ColitisEndoscopic FeaturesEndoscopic Features
Diffuse involvementDiffuse involvement Rectum always diseasedRectum always diseased Superficial ulcerationsSuperficial ulcerations FriabilitybleedingFriabilitybleeding Flatteningdisappearance of haustral Flatteningdisappearance of haustral
foldsfolds PseudopolypsPseudopolyps No cobblestoningNo cobblestoning Bx No granulomasBx No granulomas
Imaging for Crohn Imaging for Crohn DiseaseDisease
Traditional TechniquesTraditional Techniques Abdominal RadiographsAbdominal Radiographs
Barium UGI Barium UGI
Barium small bowel follow throughBarium small bowel follow through
Barium EnteroclysisBarium Enteroclysis
Barium EnemaBarium Enema
Imaging for Crohn Disease Imaging for Crohn Disease Newer TechniquesNewer Techniques
CTCT
CT EnteroclysisCT Enteroclysis
CT EnterographyCT Enterography
Magnetic ResonanceMagnetic Resonance
UltrasoundUltrasound
Nuclear MedicineNuclear Medicine
Imaging for Crohns DiseaseImaging for Crohns Disease SummarySummary
Useful Newer TechniquesUseful Newer Techniques evolvingevolving CT EnterographyCT Enterography
Comprehensive evaluation of all bowel amp solid organsComprehensive evaluation of all bowel amp solid organs
Magnetic ResonanceMagnetic Resonance
Useful for ano-rectal diseaseUseful for ano-rectal disease
Real-time MR has potential for detection of stricturesReal-time MR has potential for detection of strictures
Traditional imaging techniques still of value in Traditional imaging techniques still of value in selected cases selected cases
The Capsule (WCE)The Capsule (WCE)
WCEWCE
bull Diameter 11mm Length 26mmDiameter 11mm Length 26mmbull Optical dome Intestinal illumination Optical dome Intestinal illumination
by white light emitting diodes (LEDrsquos)by white light emitting diodes (LEDrsquos)bull LensLensbull Complementary metal-oxide silicone Complementary metal-oxide silicone
imager (color camera chip)imager (color camera chip)bull TransmitterTransmitterbull Two batteries (silver oxide)Two batteries (silver oxide)
GE Junction Duodenum
Jejunum Ileocecal Valve
Educational ObjectivesEducational Objectives Definitions and spectrum of inflammatory Definitions and spectrum of inflammatory
bowel disease (IBD)bowel disease (IBD) Epidemiology of IBDEpidemiology of IBD Etiopathogenesis of IBDEtiopathogenesis of IBD Clinical manifestations of ulcerative colitis Clinical manifestations of ulcerative colitis
(UC)(UC) Clinical manifestations of Crohnrsquos disease Clinical manifestations of Crohnrsquos disease
(CD)(CD) Distinguishing features between UC and CDDistinguishing features between UC and CD Diagnostic approach to IBDDiagnostic approach to IBD Complications of IBDComplications of IBD IBD managementIBD management
IBD-ComplicationsIBD-Complications GI BleedingGI Bleeding Toxic megacolonToxic megacolon PerforationPerforation Thromboembolic phenomenaThromboembolic phenomena FistulasfissuresFistulasfissures AbscessAbscess StricturesobstructionStricturesobstruction MalabsorptionmalnutritionMalabsorptionmalnutrition CancerCancer
Best Protection
Surveillance colonoscopySurveillance colonoscopy
Procto-colectomy (for UC)Procto-colectomy (for UC)
Descending Colon Descending Colon StrictureStricture
Colonic StricturesColonic Strictures
Consider nonsurgical management Consider nonsurgical management ifif Endoscopically accessibleEndoscopically accessible Multiple prior resectionsMultiple prior resections Shorter strictures (less than 5 cm)Shorter strictures (less than 5 cm) Steroid injection if significant Steroid injection if significant
inflammationinflammation
Fistula DefinitionA communication between two epithelial-lined organsLifetime risk of fistula in CD30
Perianal FistulaPerianal Fistula
Pretreatment 2 Weeks
10 Weeks 18 weeks
Educational ObjectivesEducational Objectives Definitions and spectrum of inflammatory Definitions and spectrum of inflammatory
bowel disease (IBD)bowel disease (IBD) Epidemiology of IBDEpidemiology of IBD Etiopathogenesis of IBDEtiopathogenesis of IBD Clinical manifestations of ulcerative colitis Clinical manifestations of ulcerative colitis
(UC)(UC) Clinical manifestations of Crohnrsquos disease Clinical manifestations of Crohnrsquos disease
(CD)(CD) Distinguishing features between UC and CDDistinguishing features between UC and CD Diagnostic approach to IBDDiagnostic approach to IBD Complications of IBDComplications of IBD IBD managementIBD management
Goals of Therapy for IBDGoals of Therapy for IBD
Inducing remissionInducing remission Maintaining remissionMaintaining remission Restoring and maintaining nutritionRestoring and maintaining nutrition Maintaining patientrsquos quality of lifeMaintaining patientrsquos quality of life Prevention of complicationsPrevention of complications Surgical intervention (selection of Surgical intervention (selection of
optimal time for surgery)optimal time for surgery)
Inductive TherapiesInductive Therapies
For UCFor UC AminosalicylatesAminosalicylates CorticosteroidsCorticosteroids CyclosporinCyclosporin
For CDFor CD AminosalicylatesAminosalicylates CorticosteroidsCorticosteroids AntibioticsAntibiotics Anti-TNFAnti-TNF
Maintenance TherapiesMaintenance Therapies
ImmunosupressorsImmunosupressors AzathioprineAzathioprine 6-MP6-MP MethotrexateMethotrexate
AminosalicylatesAminosalicylates Anti-TNFAnti-TNF
NOT NOT corticosteroidscorticosteroids
IBD ManagementIBD ManagementSummarySummary
There is no ldquoone size fits allrdquo to IBD therapyThere is no ldquoone size fits allrdquo to IBD therapy Therapy and decision making are tailored to the Therapy and decision making are tailored to the
individualindividual
Algorithms are based upon available evidenceAlgorithms are based upon available evidence Evidence is in constant fluxEvidence is in constant flux
Success of algorithms depends upon Success of algorithms depends upon optimization of each step of therapy and optimization of each step of therapy and considerable judgment about each outcomeconsiderable judgment about each outcome Skillful application of medical therapy makes all Skillful application of medical therapy makes all
the difference in outcomesthe difference in outcomes
Surgery for IBDSurgery for IBDGeneral ConceptsGeneral Concepts
Majority will need surgery 78 over Majority will need surgery 78 over twenty yearstwenty years
Surgery generally indicated for Surgery generally indicated for complicationscomplications of disease of disease
Surgery must be directed at area of Surgery must be directed at area of bowel responsible for complicationbowel responsible for complication
Indications for SurgeryIndications for Surgery Intestinal obstruction (most Intestinal obstruction (most
common)common) Intractabilitysteroid Intractabilitysteroid
dependencedependence Non-healing fistulaAbscessNon-healing fistulaAbscess Toxic megacolonFree Toxic megacolonFree
perforationperforation Uncontrollable GI bleedingUncontrollable GI bleeding Severe perianal diseaseSevere perianal disease CancerCancer Growth retardation Growth retardation
(children)(children) Severe uncontrollable Severe uncontrollable
extraintestinal extraintestinal manifestationsmanifestations
Management of IBDSummary
The goals of therapy are Relieve symptoms Prevent relapse Correct nutritional deficiencies Control inflammation Prevent complications especially colon cancer
Treatment depends on 1048707 Type of disease 1048707 Site of disease 1048707 Disease severity
Treatment may include drugs nutrition supplements surgery or a combination of these options
Educational ObjectivesEducational Objectives Definitions and spectrum of inflammatory Definitions and spectrum of inflammatory
bowel disease (IBD)bowel disease (IBD) Epidemiology of IBDEpidemiology of IBD Etiopathogenesis of IBDEtiopathogenesis of IBD Clinical manifestations of ulcerative colitis Clinical manifestations of ulcerative colitis
(UC)(UC) Clinical manifestations of Crohnrsquos disease (CD)Clinical manifestations of Crohnrsquos disease (CD) Distinguishing features between UC and Distinguishing features between UC and
CDCD Diagnostic approach to IBDDiagnostic approach to IBD Medical management of IBDMedical management of IBD Indications for and role of surgeryIndications for and role of surgery
Symptoms of IBDUC vs CDUC vs CD
FeatureFeature UCUC CDCD
FeverFever UncommonUncommon CommonCommon
Rectal Rectal bleedingbleeding
CommonCommon lt frac12 of lt frac12 of patientspatients
Abdominal Abdominal tendernesstenderness
May be May be presentpresent
CommonCommon
Abdominal Abdominal massmass
UncommonUncommon CommonCommon
Abdominal Abdominal painpain
UncommonUncommon Very commonVery common
Weight lossWeight loss UncommonUncommon CommonCommon
TenesmusTenesmus Very commonVery common UncommonUncommon
UC vs CDUC vs CDComplicationsResponse to ComplicationsResponse to
TreatmentTreatmentUCUC CDCD
FistulasFistulas NoNo YesYes
Small Small intestine intestine obstructionobstruction
NoNo FrequentlyFrequently
Colonic Colonic obstructionobstruction
RarelyRarely FrequentlyFrequently
Response to Response to antibioticantibiotic
NoNo YesYes
Recurrence Recurrence after after surgerysurgery
NoNo YesYes
UC vs CDUC vs CDDifferent endoscopic featuresDifferent endoscopic features
UCUC CDCD
Rectal Rectal sparingsparing
RarelyRarely FrequentlyFrequently
Continuous Continuous diseasedisease
YesYes OccasionallyOccasionally
bdquobdquoCCobblestonobblestoningrdquoingrdquo
NoNo YesYes
Granuloma Granuloma on biopsyon biopsy
NoNo OccasionallyOccasionally
Criteria for Indeterminate Criteria for Indeterminate ColitisColitis
No evidence of No evidence of small bowel small bowel involvement involvement fistula or fistula or perianal diseaseperianal disease
Absence of Absence of diagnostic diagnostic criteria for CD criteria for CD or UC by or UC by microscopymicroscopy
Differential Diagnosis of Differential Diagnosis of Chronic Diarrhea and Weight Chronic Diarrhea and Weight
LossLoss Colonic diseasesColonic diseases
IBDIBD NeoplasiaNeoplasia Ischemic bowelIschemic bowel
PancreaticPancreatic Chronic pancreatitisChronic pancreatitis CancerCancer Cystic fibrosisCystic fibrosis
EnteropathicEnteropathic Celiac diseaseCeliac disease Tropical sprueTropical sprue LymphomaLymphoma Mesenteric ischemiaMesenteric ischemia Whipplersquos diseaseWhipplersquos disease
HormonaldrugsHormonaldrugs VipomaVipoma ZESZES Medullary CA of Medullary CA of
thyroidthyroid NSAIDS useNSAIDS use
Educational ObjectivesEducational Objectives Definitions and spectrum of inflammatory Definitions and spectrum of inflammatory
bowel disease (IBD)bowel disease (IBD) Epidemiology of IBDEpidemiology of IBD Etiopathogenesis of IBDEtiopathogenesis of IBD Clinical manifestations of ulcerative colitis Clinical manifestations of ulcerative colitis
(UC)(UC) Clinical manifestations of Crohnrsquos disease Clinical manifestations of Crohnrsquos disease
(CD)(CD) Distinguishing features between UC and CDDistinguishing features between UC and CD Diagnostic approach to IBDDiagnostic approach to IBD Medical management of IBDMedical management of IBD Indications for and role of surgeryIndications for and role of surgery
Diagnostic Approach to Diagnostic Approach to Patients with Suspected Patients with Suspected
IBDIBD HistoryhelliphelliphistoryhelliphelliphistoryHistoryhelliphelliphistoryhelliphelliphistory Clinical examClinical exam Laboratory testsLaboratory tests Radiological imagingRadiological imaging EndoscopyEndoscopy Special serological testingSpecial serological testing Genetic testingGenetic testing
Diagnosis-LAB Blood test
CD Mild anemia mild leukocytosis elevated ESR elevated CRP positive ASCA
UC Anemia hypokalemia hypoalbuminemia elevated ESR elevated LFTs positive p-ANCA
Stool analysis Many WBCs and or RBCs No ova or parasites
What are the Serological What are the Serological Markers in IBDMarkers in IBD
pANCA (perinuclear staining pattern)pANCA (perinuclear staining pattern) Loss of perinuclear pattern after Loss of perinuclear pattern after
DNAaseDNAase Differentiate from the ldquoother pANCAsrdquoDifferentiate from the ldquoother pANCAsrdquo
Antibody against myeloperoxidaseAntibody against myeloperoxidase Antibody against cathepsin G elastase lysozyme Antibody against cathepsin G elastase lysozyme
and lactoferrinand lactoferrin ASCA (anti-ASCA (anti-Saccharomyces cerevisiaeSaccharomyces cerevisiae))
Both IgG and IgABoth IgG and IgA Recognize mannose in the cell wall Recognize mannose in the cell wall
mannan of mannan of Saccharomyces cerevisiaeSaccharomyces cerevisiae
Why Use Serological Why Use Serological Markers in Clinical Markers in Clinical
PracticePractice Differentiate IBD from functional bowel Differentiate IBD from functional bowel
disordersdisorders Accurately diagnose Crohnrsquos or UC in a patient Accurately diagnose Crohnrsquos or UC in a patient
withwith Severe colitisSevere colitis Indeterminate colitisIndeterminate colitis
Predict disease course or complications in IBDPredict disease course or complications in IBD CD phenotypeCD phenotype Severity of diseaseSeverity of disease Risk of pouchitisRisk of pouchitis
SummarySummary
pANCA and ASCA are specific for UC pANCA and ASCA are specific for UC and CD respectivelyand CD respectively
Neither pANCA nor ASCA are sensitive Neither pANCA nor ASCA are sensitive enough to exclude IBDenough to exclude IBD
In patients with IC available In patients with IC available serological markers do not accurately serological markers do not accurately predict the subsequent disease coursepredict the subsequent disease course
Antibody profiles can predict disease Antibody profiles can predict disease behavior in IBDbehavior in IBD
Diagnostic ApproachDiagnostic ApproachEndoscopyEndoscopy
Endoscopy useful forEndoscopy useful for Initial diagnosisInitial diagnosis Assessment of severityAssessment of severity Tissue diagnosisTissue diagnosis FU during treatmentFU during treatment Assessment of disease exacerbationAssessment of disease exacerbation Surveillance for risk of cancerSurveillance for risk of cancer Treatment of certain complications (eg Treatment of certain complications (eg
strictures)strictures)
Crohnrsquos DiseaseCrohnrsquos DiseaseEndoscopic FeaturesEndoscopic Features
Asymmetric patchy inflammationAsymmetric patchy inflammation Skip lesionsSkip lesions Rectal sparingRectal sparing Ulcerations-deepserpiginousUlcerations-deepserpiginous Cobblestoning-commonCobblestoning-common Pseudopolyps-rarePseudopolyps-rare BiopsyBiopsy
Erosions and normal mucosaErosions and normal mucosa Granulomas in 15 to 35 of specimensGranulomas in 15 to 35 of specimens
Ulcerative ColitisUlcerative ColitisEndoscopic FeaturesEndoscopic Features
Diffuse involvementDiffuse involvement Rectum always diseasedRectum always diseased Superficial ulcerationsSuperficial ulcerations FriabilitybleedingFriabilitybleeding Flatteningdisappearance of haustral Flatteningdisappearance of haustral
foldsfolds PseudopolypsPseudopolyps No cobblestoningNo cobblestoning Bx No granulomasBx No granulomas
Imaging for Crohn Imaging for Crohn DiseaseDisease
Traditional TechniquesTraditional Techniques Abdominal RadiographsAbdominal Radiographs
Barium UGI Barium UGI
Barium small bowel follow throughBarium small bowel follow through
Barium EnteroclysisBarium Enteroclysis
Barium EnemaBarium Enema
Imaging for Crohn Disease Imaging for Crohn Disease Newer TechniquesNewer Techniques
CTCT
CT EnteroclysisCT Enteroclysis
CT EnterographyCT Enterography
Magnetic ResonanceMagnetic Resonance
UltrasoundUltrasound
Nuclear MedicineNuclear Medicine
Imaging for Crohns DiseaseImaging for Crohns Disease SummarySummary
Useful Newer TechniquesUseful Newer Techniques evolvingevolving CT EnterographyCT Enterography
Comprehensive evaluation of all bowel amp solid organsComprehensive evaluation of all bowel amp solid organs
Magnetic ResonanceMagnetic Resonance
Useful for ano-rectal diseaseUseful for ano-rectal disease
Real-time MR has potential for detection of stricturesReal-time MR has potential for detection of strictures
Traditional imaging techniques still of value in Traditional imaging techniques still of value in selected cases selected cases
The Capsule (WCE)The Capsule (WCE)
WCEWCE
bull Diameter 11mm Length 26mmDiameter 11mm Length 26mmbull Optical dome Intestinal illumination Optical dome Intestinal illumination
by white light emitting diodes (LEDrsquos)by white light emitting diodes (LEDrsquos)bull LensLensbull Complementary metal-oxide silicone Complementary metal-oxide silicone
imager (color camera chip)imager (color camera chip)bull TransmitterTransmitterbull Two batteries (silver oxide)Two batteries (silver oxide)
GE Junction Duodenum
Jejunum Ileocecal Valve
Educational ObjectivesEducational Objectives Definitions and spectrum of inflammatory Definitions and spectrum of inflammatory
bowel disease (IBD)bowel disease (IBD) Epidemiology of IBDEpidemiology of IBD Etiopathogenesis of IBDEtiopathogenesis of IBD Clinical manifestations of ulcerative colitis Clinical manifestations of ulcerative colitis
(UC)(UC) Clinical manifestations of Crohnrsquos disease Clinical manifestations of Crohnrsquos disease
(CD)(CD) Distinguishing features between UC and CDDistinguishing features between UC and CD Diagnostic approach to IBDDiagnostic approach to IBD Complications of IBDComplications of IBD IBD managementIBD management
IBD-ComplicationsIBD-Complications GI BleedingGI Bleeding Toxic megacolonToxic megacolon PerforationPerforation Thromboembolic phenomenaThromboembolic phenomena FistulasfissuresFistulasfissures AbscessAbscess StricturesobstructionStricturesobstruction MalabsorptionmalnutritionMalabsorptionmalnutrition CancerCancer
Best Protection
Surveillance colonoscopySurveillance colonoscopy
Procto-colectomy (for UC)Procto-colectomy (for UC)
Descending Colon Descending Colon StrictureStricture
Colonic StricturesColonic Strictures
Consider nonsurgical management Consider nonsurgical management ifif Endoscopically accessibleEndoscopically accessible Multiple prior resectionsMultiple prior resections Shorter strictures (less than 5 cm)Shorter strictures (less than 5 cm) Steroid injection if significant Steroid injection if significant
inflammationinflammation
Fistula DefinitionA communication between two epithelial-lined organsLifetime risk of fistula in CD30
Perianal FistulaPerianal Fistula
Pretreatment 2 Weeks
10 Weeks 18 weeks
Educational ObjectivesEducational Objectives Definitions and spectrum of inflammatory Definitions and spectrum of inflammatory
bowel disease (IBD)bowel disease (IBD) Epidemiology of IBDEpidemiology of IBD Etiopathogenesis of IBDEtiopathogenesis of IBD Clinical manifestations of ulcerative colitis Clinical manifestations of ulcerative colitis
(UC)(UC) Clinical manifestations of Crohnrsquos disease Clinical manifestations of Crohnrsquos disease
(CD)(CD) Distinguishing features between UC and CDDistinguishing features between UC and CD Diagnostic approach to IBDDiagnostic approach to IBD Complications of IBDComplications of IBD IBD managementIBD management
Goals of Therapy for IBDGoals of Therapy for IBD
Inducing remissionInducing remission Maintaining remissionMaintaining remission Restoring and maintaining nutritionRestoring and maintaining nutrition Maintaining patientrsquos quality of lifeMaintaining patientrsquos quality of life Prevention of complicationsPrevention of complications Surgical intervention (selection of Surgical intervention (selection of
optimal time for surgery)optimal time for surgery)
Inductive TherapiesInductive Therapies
For UCFor UC AminosalicylatesAminosalicylates CorticosteroidsCorticosteroids CyclosporinCyclosporin
For CDFor CD AminosalicylatesAminosalicylates CorticosteroidsCorticosteroids AntibioticsAntibiotics Anti-TNFAnti-TNF
Maintenance TherapiesMaintenance Therapies
ImmunosupressorsImmunosupressors AzathioprineAzathioprine 6-MP6-MP MethotrexateMethotrexate
AminosalicylatesAminosalicylates Anti-TNFAnti-TNF
NOT NOT corticosteroidscorticosteroids
IBD ManagementIBD ManagementSummarySummary
There is no ldquoone size fits allrdquo to IBD therapyThere is no ldquoone size fits allrdquo to IBD therapy Therapy and decision making are tailored to the Therapy and decision making are tailored to the
individualindividual
Algorithms are based upon available evidenceAlgorithms are based upon available evidence Evidence is in constant fluxEvidence is in constant flux
Success of algorithms depends upon Success of algorithms depends upon optimization of each step of therapy and optimization of each step of therapy and considerable judgment about each outcomeconsiderable judgment about each outcome Skillful application of medical therapy makes all Skillful application of medical therapy makes all
the difference in outcomesthe difference in outcomes
Surgery for IBDSurgery for IBDGeneral ConceptsGeneral Concepts
Majority will need surgery 78 over Majority will need surgery 78 over twenty yearstwenty years
Surgery generally indicated for Surgery generally indicated for complicationscomplications of disease of disease
Surgery must be directed at area of Surgery must be directed at area of bowel responsible for complicationbowel responsible for complication
Indications for SurgeryIndications for Surgery Intestinal obstruction (most Intestinal obstruction (most
common)common) Intractabilitysteroid Intractabilitysteroid
dependencedependence Non-healing fistulaAbscessNon-healing fistulaAbscess Toxic megacolonFree Toxic megacolonFree
perforationperforation Uncontrollable GI bleedingUncontrollable GI bleeding Severe perianal diseaseSevere perianal disease CancerCancer Growth retardation Growth retardation
(children)(children) Severe uncontrollable Severe uncontrollable
extraintestinal extraintestinal manifestationsmanifestations
Management of IBDSummary
The goals of therapy are Relieve symptoms Prevent relapse Correct nutritional deficiencies Control inflammation Prevent complications especially colon cancer
Treatment depends on 1048707 Type of disease 1048707 Site of disease 1048707 Disease severity
Treatment may include drugs nutrition supplements surgery or a combination of these options
Symptoms of IBDUC vs CDUC vs CD
FeatureFeature UCUC CDCD
FeverFever UncommonUncommon CommonCommon
Rectal Rectal bleedingbleeding
CommonCommon lt frac12 of lt frac12 of patientspatients
Abdominal Abdominal tendernesstenderness
May be May be presentpresent
CommonCommon
Abdominal Abdominal massmass
UncommonUncommon CommonCommon
Abdominal Abdominal painpain
UncommonUncommon Very commonVery common
Weight lossWeight loss UncommonUncommon CommonCommon
TenesmusTenesmus Very commonVery common UncommonUncommon
UC vs CDUC vs CDComplicationsResponse to ComplicationsResponse to
TreatmentTreatmentUCUC CDCD
FistulasFistulas NoNo YesYes
Small Small intestine intestine obstructionobstruction
NoNo FrequentlyFrequently
Colonic Colonic obstructionobstruction
RarelyRarely FrequentlyFrequently
Response to Response to antibioticantibiotic
NoNo YesYes
Recurrence Recurrence after after surgerysurgery
NoNo YesYes
UC vs CDUC vs CDDifferent endoscopic featuresDifferent endoscopic features
UCUC CDCD
Rectal Rectal sparingsparing
RarelyRarely FrequentlyFrequently
Continuous Continuous diseasedisease
YesYes OccasionallyOccasionally
bdquobdquoCCobblestonobblestoningrdquoingrdquo
NoNo YesYes
Granuloma Granuloma on biopsyon biopsy
NoNo OccasionallyOccasionally
Criteria for Indeterminate Criteria for Indeterminate ColitisColitis
No evidence of No evidence of small bowel small bowel involvement involvement fistula or fistula or perianal diseaseperianal disease
Absence of Absence of diagnostic diagnostic criteria for CD criteria for CD or UC by or UC by microscopymicroscopy
Differential Diagnosis of Differential Diagnosis of Chronic Diarrhea and Weight Chronic Diarrhea and Weight
LossLoss Colonic diseasesColonic diseases
IBDIBD NeoplasiaNeoplasia Ischemic bowelIschemic bowel
PancreaticPancreatic Chronic pancreatitisChronic pancreatitis CancerCancer Cystic fibrosisCystic fibrosis
EnteropathicEnteropathic Celiac diseaseCeliac disease Tropical sprueTropical sprue LymphomaLymphoma Mesenteric ischemiaMesenteric ischemia Whipplersquos diseaseWhipplersquos disease
HormonaldrugsHormonaldrugs VipomaVipoma ZESZES Medullary CA of Medullary CA of
thyroidthyroid NSAIDS useNSAIDS use
Educational ObjectivesEducational Objectives Definitions and spectrum of inflammatory Definitions and spectrum of inflammatory
bowel disease (IBD)bowel disease (IBD) Epidemiology of IBDEpidemiology of IBD Etiopathogenesis of IBDEtiopathogenesis of IBD Clinical manifestations of ulcerative colitis Clinical manifestations of ulcerative colitis
(UC)(UC) Clinical manifestations of Crohnrsquos disease Clinical manifestations of Crohnrsquos disease
(CD)(CD) Distinguishing features between UC and CDDistinguishing features between UC and CD Diagnostic approach to IBDDiagnostic approach to IBD Medical management of IBDMedical management of IBD Indications for and role of surgeryIndications for and role of surgery
Diagnostic Approach to Diagnostic Approach to Patients with Suspected Patients with Suspected
IBDIBD HistoryhelliphelliphistoryhelliphelliphistoryHistoryhelliphelliphistoryhelliphelliphistory Clinical examClinical exam Laboratory testsLaboratory tests Radiological imagingRadiological imaging EndoscopyEndoscopy Special serological testingSpecial serological testing Genetic testingGenetic testing
Diagnosis-LAB Blood test
CD Mild anemia mild leukocytosis elevated ESR elevated CRP positive ASCA
UC Anemia hypokalemia hypoalbuminemia elevated ESR elevated LFTs positive p-ANCA
Stool analysis Many WBCs and or RBCs No ova or parasites
What are the Serological What are the Serological Markers in IBDMarkers in IBD
pANCA (perinuclear staining pattern)pANCA (perinuclear staining pattern) Loss of perinuclear pattern after Loss of perinuclear pattern after
DNAaseDNAase Differentiate from the ldquoother pANCAsrdquoDifferentiate from the ldquoother pANCAsrdquo
Antibody against myeloperoxidaseAntibody against myeloperoxidase Antibody against cathepsin G elastase lysozyme Antibody against cathepsin G elastase lysozyme
and lactoferrinand lactoferrin ASCA (anti-ASCA (anti-Saccharomyces cerevisiaeSaccharomyces cerevisiae))
Both IgG and IgABoth IgG and IgA Recognize mannose in the cell wall Recognize mannose in the cell wall
mannan of mannan of Saccharomyces cerevisiaeSaccharomyces cerevisiae
Why Use Serological Why Use Serological Markers in Clinical Markers in Clinical
PracticePractice Differentiate IBD from functional bowel Differentiate IBD from functional bowel
disordersdisorders Accurately diagnose Crohnrsquos or UC in a patient Accurately diagnose Crohnrsquos or UC in a patient
withwith Severe colitisSevere colitis Indeterminate colitisIndeterminate colitis
Predict disease course or complications in IBDPredict disease course or complications in IBD CD phenotypeCD phenotype Severity of diseaseSeverity of disease Risk of pouchitisRisk of pouchitis
SummarySummary
pANCA and ASCA are specific for UC pANCA and ASCA are specific for UC and CD respectivelyand CD respectively
Neither pANCA nor ASCA are sensitive Neither pANCA nor ASCA are sensitive enough to exclude IBDenough to exclude IBD
In patients with IC available In patients with IC available serological markers do not accurately serological markers do not accurately predict the subsequent disease coursepredict the subsequent disease course
Antibody profiles can predict disease Antibody profiles can predict disease behavior in IBDbehavior in IBD
Diagnostic ApproachDiagnostic ApproachEndoscopyEndoscopy
Endoscopy useful forEndoscopy useful for Initial diagnosisInitial diagnosis Assessment of severityAssessment of severity Tissue diagnosisTissue diagnosis FU during treatmentFU during treatment Assessment of disease exacerbationAssessment of disease exacerbation Surveillance for risk of cancerSurveillance for risk of cancer Treatment of certain complications (eg Treatment of certain complications (eg
strictures)strictures)
Crohnrsquos DiseaseCrohnrsquos DiseaseEndoscopic FeaturesEndoscopic Features
Asymmetric patchy inflammationAsymmetric patchy inflammation Skip lesionsSkip lesions Rectal sparingRectal sparing Ulcerations-deepserpiginousUlcerations-deepserpiginous Cobblestoning-commonCobblestoning-common Pseudopolyps-rarePseudopolyps-rare BiopsyBiopsy
Erosions and normal mucosaErosions and normal mucosa Granulomas in 15 to 35 of specimensGranulomas in 15 to 35 of specimens
Ulcerative ColitisUlcerative ColitisEndoscopic FeaturesEndoscopic Features
Diffuse involvementDiffuse involvement Rectum always diseasedRectum always diseased Superficial ulcerationsSuperficial ulcerations FriabilitybleedingFriabilitybleeding Flatteningdisappearance of haustral Flatteningdisappearance of haustral
foldsfolds PseudopolypsPseudopolyps No cobblestoningNo cobblestoning Bx No granulomasBx No granulomas
Imaging for Crohn Imaging for Crohn DiseaseDisease
Traditional TechniquesTraditional Techniques Abdominal RadiographsAbdominal Radiographs
Barium UGI Barium UGI
Barium small bowel follow throughBarium small bowel follow through
Barium EnteroclysisBarium Enteroclysis
Barium EnemaBarium Enema
Imaging for Crohn Disease Imaging for Crohn Disease Newer TechniquesNewer Techniques
CTCT
CT EnteroclysisCT Enteroclysis
CT EnterographyCT Enterography
Magnetic ResonanceMagnetic Resonance
UltrasoundUltrasound
Nuclear MedicineNuclear Medicine
Imaging for Crohns DiseaseImaging for Crohns Disease SummarySummary
Useful Newer TechniquesUseful Newer Techniques evolvingevolving CT EnterographyCT Enterography
Comprehensive evaluation of all bowel amp solid organsComprehensive evaluation of all bowel amp solid organs
Magnetic ResonanceMagnetic Resonance
Useful for ano-rectal diseaseUseful for ano-rectal disease
Real-time MR has potential for detection of stricturesReal-time MR has potential for detection of strictures
Traditional imaging techniques still of value in Traditional imaging techniques still of value in selected cases selected cases
The Capsule (WCE)The Capsule (WCE)
WCEWCE
bull Diameter 11mm Length 26mmDiameter 11mm Length 26mmbull Optical dome Intestinal illumination Optical dome Intestinal illumination
by white light emitting diodes (LEDrsquos)by white light emitting diodes (LEDrsquos)bull LensLensbull Complementary metal-oxide silicone Complementary metal-oxide silicone
imager (color camera chip)imager (color camera chip)bull TransmitterTransmitterbull Two batteries (silver oxide)Two batteries (silver oxide)
GE Junction Duodenum
Jejunum Ileocecal Valve
Educational ObjectivesEducational Objectives Definitions and spectrum of inflammatory Definitions and spectrum of inflammatory
bowel disease (IBD)bowel disease (IBD) Epidemiology of IBDEpidemiology of IBD Etiopathogenesis of IBDEtiopathogenesis of IBD Clinical manifestations of ulcerative colitis Clinical manifestations of ulcerative colitis
(UC)(UC) Clinical manifestations of Crohnrsquos disease Clinical manifestations of Crohnrsquos disease
(CD)(CD) Distinguishing features between UC and CDDistinguishing features between UC and CD Diagnostic approach to IBDDiagnostic approach to IBD Complications of IBDComplications of IBD IBD managementIBD management
IBD-ComplicationsIBD-Complications GI BleedingGI Bleeding Toxic megacolonToxic megacolon PerforationPerforation Thromboembolic phenomenaThromboembolic phenomena FistulasfissuresFistulasfissures AbscessAbscess StricturesobstructionStricturesobstruction MalabsorptionmalnutritionMalabsorptionmalnutrition CancerCancer
Best Protection
Surveillance colonoscopySurveillance colonoscopy
Procto-colectomy (for UC)Procto-colectomy (for UC)
Descending Colon Descending Colon StrictureStricture
Colonic StricturesColonic Strictures
Consider nonsurgical management Consider nonsurgical management ifif Endoscopically accessibleEndoscopically accessible Multiple prior resectionsMultiple prior resections Shorter strictures (less than 5 cm)Shorter strictures (less than 5 cm) Steroid injection if significant Steroid injection if significant
inflammationinflammation
Fistula DefinitionA communication between two epithelial-lined organsLifetime risk of fistula in CD30
Perianal FistulaPerianal Fistula
Pretreatment 2 Weeks
10 Weeks 18 weeks
Educational ObjectivesEducational Objectives Definitions and spectrum of inflammatory Definitions and spectrum of inflammatory
bowel disease (IBD)bowel disease (IBD) Epidemiology of IBDEpidemiology of IBD Etiopathogenesis of IBDEtiopathogenesis of IBD Clinical manifestations of ulcerative colitis Clinical manifestations of ulcerative colitis
(UC)(UC) Clinical manifestations of Crohnrsquos disease Clinical manifestations of Crohnrsquos disease
(CD)(CD) Distinguishing features between UC and CDDistinguishing features between UC and CD Diagnostic approach to IBDDiagnostic approach to IBD Complications of IBDComplications of IBD IBD managementIBD management
Goals of Therapy for IBDGoals of Therapy for IBD
Inducing remissionInducing remission Maintaining remissionMaintaining remission Restoring and maintaining nutritionRestoring and maintaining nutrition Maintaining patientrsquos quality of lifeMaintaining patientrsquos quality of life Prevention of complicationsPrevention of complications Surgical intervention (selection of Surgical intervention (selection of
optimal time for surgery)optimal time for surgery)
Inductive TherapiesInductive Therapies
For UCFor UC AminosalicylatesAminosalicylates CorticosteroidsCorticosteroids CyclosporinCyclosporin
For CDFor CD AminosalicylatesAminosalicylates CorticosteroidsCorticosteroids AntibioticsAntibiotics Anti-TNFAnti-TNF
Maintenance TherapiesMaintenance Therapies
ImmunosupressorsImmunosupressors AzathioprineAzathioprine 6-MP6-MP MethotrexateMethotrexate
AminosalicylatesAminosalicylates Anti-TNFAnti-TNF
NOT NOT corticosteroidscorticosteroids
IBD ManagementIBD ManagementSummarySummary
There is no ldquoone size fits allrdquo to IBD therapyThere is no ldquoone size fits allrdquo to IBD therapy Therapy and decision making are tailored to the Therapy and decision making are tailored to the
individualindividual
Algorithms are based upon available evidenceAlgorithms are based upon available evidence Evidence is in constant fluxEvidence is in constant flux
Success of algorithms depends upon Success of algorithms depends upon optimization of each step of therapy and optimization of each step of therapy and considerable judgment about each outcomeconsiderable judgment about each outcome Skillful application of medical therapy makes all Skillful application of medical therapy makes all
the difference in outcomesthe difference in outcomes
Surgery for IBDSurgery for IBDGeneral ConceptsGeneral Concepts
Majority will need surgery 78 over Majority will need surgery 78 over twenty yearstwenty years
Surgery generally indicated for Surgery generally indicated for complicationscomplications of disease of disease
Surgery must be directed at area of Surgery must be directed at area of bowel responsible for complicationbowel responsible for complication
Indications for SurgeryIndications for Surgery Intestinal obstruction (most Intestinal obstruction (most
common)common) Intractabilitysteroid Intractabilitysteroid
dependencedependence Non-healing fistulaAbscessNon-healing fistulaAbscess Toxic megacolonFree Toxic megacolonFree
perforationperforation Uncontrollable GI bleedingUncontrollable GI bleeding Severe perianal diseaseSevere perianal disease CancerCancer Growth retardation Growth retardation
(children)(children) Severe uncontrollable Severe uncontrollable
extraintestinal extraintestinal manifestationsmanifestations
Management of IBDSummary
The goals of therapy are Relieve symptoms Prevent relapse Correct nutritional deficiencies Control inflammation Prevent complications especially colon cancer
Treatment depends on 1048707 Type of disease 1048707 Site of disease 1048707 Disease severity
Treatment may include drugs nutrition supplements surgery or a combination of these options
UC vs CDUC vs CDComplicationsResponse to ComplicationsResponse to
TreatmentTreatmentUCUC CDCD
FistulasFistulas NoNo YesYes
Small Small intestine intestine obstructionobstruction
NoNo FrequentlyFrequently
Colonic Colonic obstructionobstruction
RarelyRarely FrequentlyFrequently
Response to Response to antibioticantibiotic
NoNo YesYes
Recurrence Recurrence after after surgerysurgery
NoNo YesYes
UC vs CDUC vs CDDifferent endoscopic featuresDifferent endoscopic features
UCUC CDCD
Rectal Rectal sparingsparing
RarelyRarely FrequentlyFrequently
Continuous Continuous diseasedisease
YesYes OccasionallyOccasionally
bdquobdquoCCobblestonobblestoningrdquoingrdquo
NoNo YesYes
Granuloma Granuloma on biopsyon biopsy
NoNo OccasionallyOccasionally
Criteria for Indeterminate Criteria for Indeterminate ColitisColitis
No evidence of No evidence of small bowel small bowel involvement involvement fistula or fistula or perianal diseaseperianal disease
Absence of Absence of diagnostic diagnostic criteria for CD criteria for CD or UC by or UC by microscopymicroscopy
Differential Diagnosis of Differential Diagnosis of Chronic Diarrhea and Weight Chronic Diarrhea and Weight
LossLoss Colonic diseasesColonic diseases
IBDIBD NeoplasiaNeoplasia Ischemic bowelIschemic bowel
PancreaticPancreatic Chronic pancreatitisChronic pancreatitis CancerCancer Cystic fibrosisCystic fibrosis
EnteropathicEnteropathic Celiac diseaseCeliac disease Tropical sprueTropical sprue LymphomaLymphoma Mesenteric ischemiaMesenteric ischemia Whipplersquos diseaseWhipplersquos disease
HormonaldrugsHormonaldrugs VipomaVipoma ZESZES Medullary CA of Medullary CA of
thyroidthyroid NSAIDS useNSAIDS use
Educational ObjectivesEducational Objectives Definitions and spectrum of inflammatory Definitions and spectrum of inflammatory
bowel disease (IBD)bowel disease (IBD) Epidemiology of IBDEpidemiology of IBD Etiopathogenesis of IBDEtiopathogenesis of IBD Clinical manifestations of ulcerative colitis Clinical manifestations of ulcerative colitis
(UC)(UC) Clinical manifestations of Crohnrsquos disease Clinical manifestations of Crohnrsquos disease
(CD)(CD) Distinguishing features between UC and CDDistinguishing features between UC and CD Diagnostic approach to IBDDiagnostic approach to IBD Medical management of IBDMedical management of IBD Indications for and role of surgeryIndications for and role of surgery
Diagnostic Approach to Diagnostic Approach to Patients with Suspected Patients with Suspected
IBDIBD HistoryhelliphelliphistoryhelliphelliphistoryHistoryhelliphelliphistoryhelliphelliphistory Clinical examClinical exam Laboratory testsLaboratory tests Radiological imagingRadiological imaging EndoscopyEndoscopy Special serological testingSpecial serological testing Genetic testingGenetic testing
Diagnosis-LAB Blood test
CD Mild anemia mild leukocytosis elevated ESR elevated CRP positive ASCA
UC Anemia hypokalemia hypoalbuminemia elevated ESR elevated LFTs positive p-ANCA
Stool analysis Many WBCs and or RBCs No ova or parasites
What are the Serological What are the Serological Markers in IBDMarkers in IBD
pANCA (perinuclear staining pattern)pANCA (perinuclear staining pattern) Loss of perinuclear pattern after Loss of perinuclear pattern after
DNAaseDNAase Differentiate from the ldquoother pANCAsrdquoDifferentiate from the ldquoother pANCAsrdquo
Antibody against myeloperoxidaseAntibody against myeloperoxidase Antibody against cathepsin G elastase lysozyme Antibody against cathepsin G elastase lysozyme
and lactoferrinand lactoferrin ASCA (anti-ASCA (anti-Saccharomyces cerevisiaeSaccharomyces cerevisiae))
Both IgG and IgABoth IgG and IgA Recognize mannose in the cell wall Recognize mannose in the cell wall
mannan of mannan of Saccharomyces cerevisiaeSaccharomyces cerevisiae
Why Use Serological Why Use Serological Markers in Clinical Markers in Clinical
PracticePractice Differentiate IBD from functional bowel Differentiate IBD from functional bowel
disordersdisorders Accurately diagnose Crohnrsquos or UC in a patient Accurately diagnose Crohnrsquos or UC in a patient
withwith Severe colitisSevere colitis Indeterminate colitisIndeterminate colitis
Predict disease course or complications in IBDPredict disease course or complications in IBD CD phenotypeCD phenotype Severity of diseaseSeverity of disease Risk of pouchitisRisk of pouchitis
SummarySummary
pANCA and ASCA are specific for UC pANCA and ASCA are specific for UC and CD respectivelyand CD respectively
Neither pANCA nor ASCA are sensitive Neither pANCA nor ASCA are sensitive enough to exclude IBDenough to exclude IBD
In patients with IC available In patients with IC available serological markers do not accurately serological markers do not accurately predict the subsequent disease coursepredict the subsequent disease course
Antibody profiles can predict disease Antibody profiles can predict disease behavior in IBDbehavior in IBD
Diagnostic ApproachDiagnostic ApproachEndoscopyEndoscopy
Endoscopy useful forEndoscopy useful for Initial diagnosisInitial diagnosis Assessment of severityAssessment of severity Tissue diagnosisTissue diagnosis FU during treatmentFU during treatment Assessment of disease exacerbationAssessment of disease exacerbation Surveillance for risk of cancerSurveillance for risk of cancer Treatment of certain complications (eg Treatment of certain complications (eg
strictures)strictures)
Crohnrsquos DiseaseCrohnrsquos DiseaseEndoscopic FeaturesEndoscopic Features
Asymmetric patchy inflammationAsymmetric patchy inflammation Skip lesionsSkip lesions Rectal sparingRectal sparing Ulcerations-deepserpiginousUlcerations-deepserpiginous Cobblestoning-commonCobblestoning-common Pseudopolyps-rarePseudopolyps-rare BiopsyBiopsy
Erosions and normal mucosaErosions and normal mucosa Granulomas in 15 to 35 of specimensGranulomas in 15 to 35 of specimens
Ulcerative ColitisUlcerative ColitisEndoscopic FeaturesEndoscopic Features
Diffuse involvementDiffuse involvement Rectum always diseasedRectum always diseased Superficial ulcerationsSuperficial ulcerations FriabilitybleedingFriabilitybleeding Flatteningdisappearance of haustral Flatteningdisappearance of haustral
foldsfolds PseudopolypsPseudopolyps No cobblestoningNo cobblestoning Bx No granulomasBx No granulomas
Imaging for Crohn Imaging for Crohn DiseaseDisease
Traditional TechniquesTraditional Techniques Abdominal RadiographsAbdominal Radiographs
Barium UGI Barium UGI
Barium small bowel follow throughBarium small bowel follow through
Barium EnteroclysisBarium Enteroclysis
Barium EnemaBarium Enema
Imaging for Crohn Disease Imaging for Crohn Disease Newer TechniquesNewer Techniques
CTCT
CT EnteroclysisCT Enteroclysis
CT EnterographyCT Enterography
Magnetic ResonanceMagnetic Resonance
UltrasoundUltrasound
Nuclear MedicineNuclear Medicine
Imaging for Crohns DiseaseImaging for Crohns Disease SummarySummary
Useful Newer TechniquesUseful Newer Techniques evolvingevolving CT EnterographyCT Enterography
Comprehensive evaluation of all bowel amp solid organsComprehensive evaluation of all bowel amp solid organs
Magnetic ResonanceMagnetic Resonance
Useful for ano-rectal diseaseUseful for ano-rectal disease
Real-time MR has potential for detection of stricturesReal-time MR has potential for detection of strictures
Traditional imaging techniques still of value in Traditional imaging techniques still of value in selected cases selected cases
The Capsule (WCE)The Capsule (WCE)
WCEWCE
bull Diameter 11mm Length 26mmDiameter 11mm Length 26mmbull Optical dome Intestinal illumination Optical dome Intestinal illumination
by white light emitting diodes (LEDrsquos)by white light emitting diodes (LEDrsquos)bull LensLensbull Complementary metal-oxide silicone Complementary metal-oxide silicone
imager (color camera chip)imager (color camera chip)bull TransmitterTransmitterbull Two batteries (silver oxide)Two batteries (silver oxide)
GE Junction Duodenum
Jejunum Ileocecal Valve
Educational ObjectivesEducational Objectives Definitions and spectrum of inflammatory Definitions and spectrum of inflammatory
bowel disease (IBD)bowel disease (IBD) Epidemiology of IBDEpidemiology of IBD Etiopathogenesis of IBDEtiopathogenesis of IBD Clinical manifestations of ulcerative colitis Clinical manifestations of ulcerative colitis
(UC)(UC) Clinical manifestations of Crohnrsquos disease Clinical manifestations of Crohnrsquos disease
(CD)(CD) Distinguishing features between UC and CDDistinguishing features between UC and CD Diagnostic approach to IBDDiagnostic approach to IBD Complications of IBDComplications of IBD IBD managementIBD management
IBD-ComplicationsIBD-Complications GI BleedingGI Bleeding Toxic megacolonToxic megacolon PerforationPerforation Thromboembolic phenomenaThromboembolic phenomena FistulasfissuresFistulasfissures AbscessAbscess StricturesobstructionStricturesobstruction MalabsorptionmalnutritionMalabsorptionmalnutrition CancerCancer
Best Protection
Surveillance colonoscopySurveillance colonoscopy
Procto-colectomy (for UC)Procto-colectomy (for UC)
Descending Colon Descending Colon StrictureStricture
Colonic StricturesColonic Strictures
Consider nonsurgical management Consider nonsurgical management ifif Endoscopically accessibleEndoscopically accessible Multiple prior resectionsMultiple prior resections Shorter strictures (less than 5 cm)Shorter strictures (less than 5 cm) Steroid injection if significant Steroid injection if significant
inflammationinflammation
Fistula DefinitionA communication between two epithelial-lined organsLifetime risk of fistula in CD30
Perianal FistulaPerianal Fistula
Pretreatment 2 Weeks
10 Weeks 18 weeks
Educational ObjectivesEducational Objectives Definitions and spectrum of inflammatory Definitions and spectrum of inflammatory
bowel disease (IBD)bowel disease (IBD) Epidemiology of IBDEpidemiology of IBD Etiopathogenesis of IBDEtiopathogenesis of IBD Clinical manifestations of ulcerative colitis Clinical manifestations of ulcerative colitis
(UC)(UC) Clinical manifestations of Crohnrsquos disease Clinical manifestations of Crohnrsquos disease
(CD)(CD) Distinguishing features between UC and CDDistinguishing features between UC and CD Diagnostic approach to IBDDiagnostic approach to IBD Complications of IBDComplications of IBD IBD managementIBD management
Goals of Therapy for IBDGoals of Therapy for IBD
Inducing remissionInducing remission Maintaining remissionMaintaining remission Restoring and maintaining nutritionRestoring and maintaining nutrition Maintaining patientrsquos quality of lifeMaintaining patientrsquos quality of life Prevention of complicationsPrevention of complications Surgical intervention (selection of Surgical intervention (selection of
optimal time for surgery)optimal time for surgery)
Inductive TherapiesInductive Therapies
For UCFor UC AminosalicylatesAminosalicylates CorticosteroidsCorticosteroids CyclosporinCyclosporin
For CDFor CD AminosalicylatesAminosalicylates CorticosteroidsCorticosteroids AntibioticsAntibiotics Anti-TNFAnti-TNF
Maintenance TherapiesMaintenance Therapies
ImmunosupressorsImmunosupressors AzathioprineAzathioprine 6-MP6-MP MethotrexateMethotrexate
AminosalicylatesAminosalicylates Anti-TNFAnti-TNF
NOT NOT corticosteroidscorticosteroids
IBD ManagementIBD ManagementSummarySummary
There is no ldquoone size fits allrdquo to IBD therapyThere is no ldquoone size fits allrdquo to IBD therapy Therapy and decision making are tailored to the Therapy and decision making are tailored to the
individualindividual
Algorithms are based upon available evidenceAlgorithms are based upon available evidence Evidence is in constant fluxEvidence is in constant flux
Success of algorithms depends upon Success of algorithms depends upon optimization of each step of therapy and optimization of each step of therapy and considerable judgment about each outcomeconsiderable judgment about each outcome Skillful application of medical therapy makes all Skillful application of medical therapy makes all
the difference in outcomesthe difference in outcomes
Surgery for IBDSurgery for IBDGeneral ConceptsGeneral Concepts
Majority will need surgery 78 over Majority will need surgery 78 over twenty yearstwenty years
Surgery generally indicated for Surgery generally indicated for complicationscomplications of disease of disease
Surgery must be directed at area of Surgery must be directed at area of bowel responsible for complicationbowel responsible for complication
Indications for SurgeryIndications for Surgery Intestinal obstruction (most Intestinal obstruction (most
common)common) Intractabilitysteroid Intractabilitysteroid
dependencedependence Non-healing fistulaAbscessNon-healing fistulaAbscess Toxic megacolonFree Toxic megacolonFree
perforationperforation Uncontrollable GI bleedingUncontrollable GI bleeding Severe perianal diseaseSevere perianal disease CancerCancer Growth retardation Growth retardation
(children)(children) Severe uncontrollable Severe uncontrollable
extraintestinal extraintestinal manifestationsmanifestations
Management of IBDSummary
The goals of therapy are Relieve symptoms Prevent relapse Correct nutritional deficiencies Control inflammation Prevent complications especially colon cancer
Treatment depends on 1048707 Type of disease 1048707 Site of disease 1048707 Disease severity
Treatment may include drugs nutrition supplements surgery or a combination of these options
UC vs CDUC vs CDDifferent endoscopic featuresDifferent endoscopic features
UCUC CDCD
Rectal Rectal sparingsparing
RarelyRarely FrequentlyFrequently
Continuous Continuous diseasedisease
YesYes OccasionallyOccasionally
bdquobdquoCCobblestonobblestoningrdquoingrdquo
NoNo YesYes
Granuloma Granuloma on biopsyon biopsy
NoNo OccasionallyOccasionally
Criteria for Indeterminate Criteria for Indeterminate ColitisColitis
No evidence of No evidence of small bowel small bowel involvement involvement fistula or fistula or perianal diseaseperianal disease
Absence of Absence of diagnostic diagnostic criteria for CD criteria for CD or UC by or UC by microscopymicroscopy
Differential Diagnosis of Differential Diagnosis of Chronic Diarrhea and Weight Chronic Diarrhea and Weight
LossLoss Colonic diseasesColonic diseases
IBDIBD NeoplasiaNeoplasia Ischemic bowelIschemic bowel
PancreaticPancreatic Chronic pancreatitisChronic pancreatitis CancerCancer Cystic fibrosisCystic fibrosis
EnteropathicEnteropathic Celiac diseaseCeliac disease Tropical sprueTropical sprue LymphomaLymphoma Mesenteric ischemiaMesenteric ischemia Whipplersquos diseaseWhipplersquos disease
HormonaldrugsHormonaldrugs VipomaVipoma ZESZES Medullary CA of Medullary CA of
thyroidthyroid NSAIDS useNSAIDS use
Educational ObjectivesEducational Objectives Definitions and spectrum of inflammatory Definitions and spectrum of inflammatory
bowel disease (IBD)bowel disease (IBD) Epidemiology of IBDEpidemiology of IBD Etiopathogenesis of IBDEtiopathogenesis of IBD Clinical manifestations of ulcerative colitis Clinical manifestations of ulcerative colitis
(UC)(UC) Clinical manifestations of Crohnrsquos disease Clinical manifestations of Crohnrsquos disease
(CD)(CD) Distinguishing features between UC and CDDistinguishing features between UC and CD Diagnostic approach to IBDDiagnostic approach to IBD Medical management of IBDMedical management of IBD Indications for and role of surgeryIndications for and role of surgery
Diagnostic Approach to Diagnostic Approach to Patients with Suspected Patients with Suspected
IBDIBD HistoryhelliphelliphistoryhelliphelliphistoryHistoryhelliphelliphistoryhelliphelliphistory Clinical examClinical exam Laboratory testsLaboratory tests Radiological imagingRadiological imaging EndoscopyEndoscopy Special serological testingSpecial serological testing Genetic testingGenetic testing
Diagnosis-LAB Blood test
CD Mild anemia mild leukocytosis elevated ESR elevated CRP positive ASCA
UC Anemia hypokalemia hypoalbuminemia elevated ESR elevated LFTs positive p-ANCA
Stool analysis Many WBCs and or RBCs No ova or parasites
What are the Serological What are the Serological Markers in IBDMarkers in IBD
pANCA (perinuclear staining pattern)pANCA (perinuclear staining pattern) Loss of perinuclear pattern after Loss of perinuclear pattern after
DNAaseDNAase Differentiate from the ldquoother pANCAsrdquoDifferentiate from the ldquoother pANCAsrdquo
Antibody against myeloperoxidaseAntibody against myeloperoxidase Antibody against cathepsin G elastase lysozyme Antibody against cathepsin G elastase lysozyme
and lactoferrinand lactoferrin ASCA (anti-ASCA (anti-Saccharomyces cerevisiaeSaccharomyces cerevisiae))
Both IgG and IgABoth IgG and IgA Recognize mannose in the cell wall Recognize mannose in the cell wall
mannan of mannan of Saccharomyces cerevisiaeSaccharomyces cerevisiae
Why Use Serological Why Use Serological Markers in Clinical Markers in Clinical
PracticePractice Differentiate IBD from functional bowel Differentiate IBD from functional bowel
disordersdisorders Accurately diagnose Crohnrsquos or UC in a patient Accurately diagnose Crohnrsquos or UC in a patient
withwith Severe colitisSevere colitis Indeterminate colitisIndeterminate colitis
Predict disease course or complications in IBDPredict disease course or complications in IBD CD phenotypeCD phenotype Severity of diseaseSeverity of disease Risk of pouchitisRisk of pouchitis
SummarySummary
pANCA and ASCA are specific for UC pANCA and ASCA are specific for UC and CD respectivelyand CD respectively
Neither pANCA nor ASCA are sensitive Neither pANCA nor ASCA are sensitive enough to exclude IBDenough to exclude IBD
In patients with IC available In patients with IC available serological markers do not accurately serological markers do not accurately predict the subsequent disease coursepredict the subsequent disease course
Antibody profiles can predict disease Antibody profiles can predict disease behavior in IBDbehavior in IBD
Diagnostic ApproachDiagnostic ApproachEndoscopyEndoscopy
Endoscopy useful forEndoscopy useful for Initial diagnosisInitial diagnosis Assessment of severityAssessment of severity Tissue diagnosisTissue diagnosis FU during treatmentFU during treatment Assessment of disease exacerbationAssessment of disease exacerbation Surveillance for risk of cancerSurveillance for risk of cancer Treatment of certain complications (eg Treatment of certain complications (eg
strictures)strictures)
Crohnrsquos DiseaseCrohnrsquos DiseaseEndoscopic FeaturesEndoscopic Features
Asymmetric patchy inflammationAsymmetric patchy inflammation Skip lesionsSkip lesions Rectal sparingRectal sparing Ulcerations-deepserpiginousUlcerations-deepserpiginous Cobblestoning-commonCobblestoning-common Pseudopolyps-rarePseudopolyps-rare BiopsyBiopsy
Erosions and normal mucosaErosions and normal mucosa Granulomas in 15 to 35 of specimensGranulomas in 15 to 35 of specimens
Ulcerative ColitisUlcerative ColitisEndoscopic FeaturesEndoscopic Features
Diffuse involvementDiffuse involvement Rectum always diseasedRectum always diseased Superficial ulcerationsSuperficial ulcerations FriabilitybleedingFriabilitybleeding Flatteningdisappearance of haustral Flatteningdisappearance of haustral
foldsfolds PseudopolypsPseudopolyps No cobblestoningNo cobblestoning Bx No granulomasBx No granulomas
Imaging for Crohn Imaging for Crohn DiseaseDisease
Traditional TechniquesTraditional Techniques Abdominal RadiographsAbdominal Radiographs
Barium UGI Barium UGI
Barium small bowel follow throughBarium small bowel follow through
Barium EnteroclysisBarium Enteroclysis
Barium EnemaBarium Enema
Imaging for Crohn Disease Imaging for Crohn Disease Newer TechniquesNewer Techniques
CTCT
CT EnteroclysisCT Enteroclysis
CT EnterographyCT Enterography
Magnetic ResonanceMagnetic Resonance
UltrasoundUltrasound
Nuclear MedicineNuclear Medicine
Imaging for Crohns DiseaseImaging for Crohns Disease SummarySummary
Useful Newer TechniquesUseful Newer Techniques evolvingevolving CT EnterographyCT Enterography
Comprehensive evaluation of all bowel amp solid organsComprehensive evaluation of all bowel amp solid organs
Magnetic ResonanceMagnetic Resonance
Useful for ano-rectal diseaseUseful for ano-rectal disease
Real-time MR has potential for detection of stricturesReal-time MR has potential for detection of strictures
Traditional imaging techniques still of value in Traditional imaging techniques still of value in selected cases selected cases
The Capsule (WCE)The Capsule (WCE)
WCEWCE
bull Diameter 11mm Length 26mmDiameter 11mm Length 26mmbull Optical dome Intestinal illumination Optical dome Intestinal illumination
by white light emitting diodes (LEDrsquos)by white light emitting diodes (LEDrsquos)bull LensLensbull Complementary metal-oxide silicone Complementary metal-oxide silicone
imager (color camera chip)imager (color camera chip)bull TransmitterTransmitterbull Two batteries (silver oxide)Two batteries (silver oxide)
GE Junction Duodenum
Jejunum Ileocecal Valve
Educational ObjectivesEducational Objectives Definitions and spectrum of inflammatory Definitions and spectrum of inflammatory
bowel disease (IBD)bowel disease (IBD) Epidemiology of IBDEpidemiology of IBD Etiopathogenesis of IBDEtiopathogenesis of IBD Clinical manifestations of ulcerative colitis Clinical manifestations of ulcerative colitis
(UC)(UC) Clinical manifestations of Crohnrsquos disease Clinical manifestations of Crohnrsquos disease
(CD)(CD) Distinguishing features between UC and CDDistinguishing features between UC and CD Diagnostic approach to IBDDiagnostic approach to IBD Complications of IBDComplications of IBD IBD managementIBD management
IBD-ComplicationsIBD-Complications GI BleedingGI Bleeding Toxic megacolonToxic megacolon PerforationPerforation Thromboembolic phenomenaThromboembolic phenomena FistulasfissuresFistulasfissures AbscessAbscess StricturesobstructionStricturesobstruction MalabsorptionmalnutritionMalabsorptionmalnutrition CancerCancer
Best Protection
Surveillance colonoscopySurveillance colonoscopy
Procto-colectomy (for UC)Procto-colectomy (for UC)
Descending Colon Descending Colon StrictureStricture
Colonic StricturesColonic Strictures
Consider nonsurgical management Consider nonsurgical management ifif Endoscopically accessibleEndoscopically accessible Multiple prior resectionsMultiple prior resections Shorter strictures (less than 5 cm)Shorter strictures (less than 5 cm) Steroid injection if significant Steroid injection if significant
inflammationinflammation
Fistula DefinitionA communication between two epithelial-lined organsLifetime risk of fistula in CD30
Perianal FistulaPerianal Fistula
Pretreatment 2 Weeks
10 Weeks 18 weeks
Educational ObjectivesEducational Objectives Definitions and spectrum of inflammatory Definitions and spectrum of inflammatory
bowel disease (IBD)bowel disease (IBD) Epidemiology of IBDEpidemiology of IBD Etiopathogenesis of IBDEtiopathogenesis of IBD Clinical manifestations of ulcerative colitis Clinical manifestations of ulcerative colitis
(UC)(UC) Clinical manifestations of Crohnrsquos disease Clinical manifestations of Crohnrsquos disease
(CD)(CD) Distinguishing features between UC and CDDistinguishing features between UC and CD Diagnostic approach to IBDDiagnostic approach to IBD Complications of IBDComplications of IBD IBD managementIBD management
Goals of Therapy for IBDGoals of Therapy for IBD
Inducing remissionInducing remission Maintaining remissionMaintaining remission Restoring and maintaining nutritionRestoring and maintaining nutrition Maintaining patientrsquos quality of lifeMaintaining patientrsquos quality of life Prevention of complicationsPrevention of complications Surgical intervention (selection of Surgical intervention (selection of
optimal time for surgery)optimal time for surgery)
Inductive TherapiesInductive Therapies
For UCFor UC AminosalicylatesAminosalicylates CorticosteroidsCorticosteroids CyclosporinCyclosporin
For CDFor CD AminosalicylatesAminosalicylates CorticosteroidsCorticosteroids AntibioticsAntibiotics Anti-TNFAnti-TNF
Maintenance TherapiesMaintenance Therapies
ImmunosupressorsImmunosupressors AzathioprineAzathioprine 6-MP6-MP MethotrexateMethotrexate
AminosalicylatesAminosalicylates Anti-TNFAnti-TNF
NOT NOT corticosteroidscorticosteroids
IBD ManagementIBD ManagementSummarySummary
There is no ldquoone size fits allrdquo to IBD therapyThere is no ldquoone size fits allrdquo to IBD therapy Therapy and decision making are tailored to the Therapy and decision making are tailored to the
individualindividual
Algorithms are based upon available evidenceAlgorithms are based upon available evidence Evidence is in constant fluxEvidence is in constant flux
Success of algorithms depends upon Success of algorithms depends upon optimization of each step of therapy and optimization of each step of therapy and considerable judgment about each outcomeconsiderable judgment about each outcome Skillful application of medical therapy makes all Skillful application of medical therapy makes all
the difference in outcomesthe difference in outcomes
Surgery for IBDSurgery for IBDGeneral ConceptsGeneral Concepts
Majority will need surgery 78 over Majority will need surgery 78 over twenty yearstwenty years
Surgery generally indicated for Surgery generally indicated for complicationscomplications of disease of disease
Surgery must be directed at area of Surgery must be directed at area of bowel responsible for complicationbowel responsible for complication
Indications for SurgeryIndications for Surgery Intestinal obstruction (most Intestinal obstruction (most
common)common) Intractabilitysteroid Intractabilitysteroid
dependencedependence Non-healing fistulaAbscessNon-healing fistulaAbscess Toxic megacolonFree Toxic megacolonFree
perforationperforation Uncontrollable GI bleedingUncontrollable GI bleeding Severe perianal diseaseSevere perianal disease CancerCancer Growth retardation Growth retardation
(children)(children) Severe uncontrollable Severe uncontrollable
extraintestinal extraintestinal manifestationsmanifestations
Management of IBDSummary
The goals of therapy are Relieve symptoms Prevent relapse Correct nutritional deficiencies Control inflammation Prevent complications especially colon cancer
Treatment depends on 1048707 Type of disease 1048707 Site of disease 1048707 Disease severity
Treatment may include drugs nutrition supplements surgery or a combination of these options
Criteria for Indeterminate Criteria for Indeterminate ColitisColitis
No evidence of No evidence of small bowel small bowel involvement involvement fistula or fistula or perianal diseaseperianal disease
Absence of Absence of diagnostic diagnostic criteria for CD criteria for CD or UC by or UC by microscopymicroscopy
Differential Diagnosis of Differential Diagnosis of Chronic Diarrhea and Weight Chronic Diarrhea and Weight
LossLoss Colonic diseasesColonic diseases
IBDIBD NeoplasiaNeoplasia Ischemic bowelIschemic bowel
PancreaticPancreatic Chronic pancreatitisChronic pancreatitis CancerCancer Cystic fibrosisCystic fibrosis
EnteropathicEnteropathic Celiac diseaseCeliac disease Tropical sprueTropical sprue LymphomaLymphoma Mesenteric ischemiaMesenteric ischemia Whipplersquos diseaseWhipplersquos disease
HormonaldrugsHormonaldrugs VipomaVipoma ZESZES Medullary CA of Medullary CA of
thyroidthyroid NSAIDS useNSAIDS use
Educational ObjectivesEducational Objectives Definitions and spectrum of inflammatory Definitions and spectrum of inflammatory
bowel disease (IBD)bowel disease (IBD) Epidemiology of IBDEpidemiology of IBD Etiopathogenesis of IBDEtiopathogenesis of IBD Clinical manifestations of ulcerative colitis Clinical manifestations of ulcerative colitis
(UC)(UC) Clinical manifestations of Crohnrsquos disease Clinical manifestations of Crohnrsquos disease
(CD)(CD) Distinguishing features between UC and CDDistinguishing features between UC and CD Diagnostic approach to IBDDiagnostic approach to IBD Medical management of IBDMedical management of IBD Indications for and role of surgeryIndications for and role of surgery
Diagnostic Approach to Diagnostic Approach to Patients with Suspected Patients with Suspected
IBDIBD HistoryhelliphelliphistoryhelliphelliphistoryHistoryhelliphelliphistoryhelliphelliphistory Clinical examClinical exam Laboratory testsLaboratory tests Radiological imagingRadiological imaging EndoscopyEndoscopy Special serological testingSpecial serological testing Genetic testingGenetic testing
Diagnosis-LAB Blood test
CD Mild anemia mild leukocytosis elevated ESR elevated CRP positive ASCA
UC Anemia hypokalemia hypoalbuminemia elevated ESR elevated LFTs positive p-ANCA
Stool analysis Many WBCs and or RBCs No ova or parasites
What are the Serological What are the Serological Markers in IBDMarkers in IBD
pANCA (perinuclear staining pattern)pANCA (perinuclear staining pattern) Loss of perinuclear pattern after Loss of perinuclear pattern after
DNAaseDNAase Differentiate from the ldquoother pANCAsrdquoDifferentiate from the ldquoother pANCAsrdquo
Antibody against myeloperoxidaseAntibody against myeloperoxidase Antibody against cathepsin G elastase lysozyme Antibody against cathepsin G elastase lysozyme
and lactoferrinand lactoferrin ASCA (anti-ASCA (anti-Saccharomyces cerevisiaeSaccharomyces cerevisiae))
Both IgG and IgABoth IgG and IgA Recognize mannose in the cell wall Recognize mannose in the cell wall
mannan of mannan of Saccharomyces cerevisiaeSaccharomyces cerevisiae
Why Use Serological Why Use Serological Markers in Clinical Markers in Clinical
PracticePractice Differentiate IBD from functional bowel Differentiate IBD from functional bowel
disordersdisorders Accurately diagnose Crohnrsquos or UC in a patient Accurately diagnose Crohnrsquos or UC in a patient
withwith Severe colitisSevere colitis Indeterminate colitisIndeterminate colitis
Predict disease course or complications in IBDPredict disease course or complications in IBD CD phenotypeCD phenotype Severity of diseaseSeverity of disease Risk of pouchitisRisk of pouchitis
SummarySummary
pANCA and ASCA are specific for UC pANCA and ASCA are specific for UC and CD respectivelyand CD respectively
Neither pANCA nor ASCA are sensitive Neither pANCA nor ASCA are sensitive enough to exclude IBDenough to exclude IBD
In patients with IC available In patients with IC available serological markers do not accurately serological markers do not accurately predict the subsequent disease coursepredict the subsequent disease course
Antibody profiles can predict disease Antibody profiles can predict disease behavior in IBDbehavior in IBD
Diagnostic ApproachDiagnostic ApproachEndoscopyEndoscopy
Endoscopy useful forEndoscopy useful for Initial diagnosisInitial diagnosis Assessment of severityAssessment of severity Tissue diagnosisTissue diagnosis FU during treatmentFU during treatment Assessment of disease exacerbationAssessment of disease exacerbation Surveillance for risk of cancerSurveillance for risk of cancer Treatment of certain complications (eg Treatment of certain complications (eg
strictures)strictures)
Crohnrsquos DiseaseCrohnrsquos DiseaseEndoscopic FeaturesEndoscopic Features
Asymmetric patchy inflammationAsymmetric patchy inflammation Skip lesionsSkip lesions Rectal sparingRectal sparing Ulcerations-deepserpiginousUlcerations-deepserpiginous Cobblestoning-commonCobblestoning-common Pseudopolyps-rarePseudopolyps-rare BiopsyBiopsy
Erosions and normal mucosaErosions and normal mucosa Granulomas in 15 to 35 of specimensGranulomas in 15 to 35 of specimens
Ulcerative ColitisUlcerative ColitisEndoscopic FeaturesEndoscopic Features
Diffuse involvementDiffuse involvement Rectum always diseasedRectum always diseased Superficial ulcerationsSuperficial ulcerations FriabilitybleedingFriabilitybleeding Flatteningdisappearance of haustral Flatteningdisappearance of haustral
foldsfolds PseudopolypsPseudopolyps No cobblestoningNo cobblestoning Bx No granulomasBx No granulomas
Imaging for Crohn Imaging for Crohn DiseaseDisease
Traditional TechniquesTraditional Techniques Abdominal RadiographsAbdominal Radiographs
Barium UGI Barium UGI
Barium small bowel follow throughBarium small bowel follow through
Barium EnteroclysisBarium Enteroclysis
Barium EnemaBarium Enema
Imaging for Crohn Disease Imaging for Crohn Disease Newer TechniquesNewer Techniques
CTCT
CT EnteroclysisCT Enteroclysis
CT EnterographyCT Enterography
Magnetic ResonanceMagnetic Resonance
UltrasoundUltrasound
Nuclear MedicineNuclear Medicine
Imaging for Crohns DiseaseImaging for Crohns Disease SummarySummary
Useful Newer TechniquesUseful Newer Techniques evolvingevolving CT EnterographyCT Enterography
Comprehensive evaluation of all bowel amp solid organsComprehensive evaluation of all bowel amp solid organs
Magnetic ResonanceMagnetic Resonance
Useful for ano-rectal diseaseUseful for ano-rectal disease
Real-time MR has potential for detection of stricturesReal-time MR has potential for detection of strictures
Traditional imaging techniques still of value in Traditional imaging techniques still of value in selected cases selected cases
The Capsule (WCE)The Capsule (WCE)
WCEWCE
bull Diameter 11mm Length 26mmDiameter 11mm Length 26mmbull Optical dome Intestinal illumination Optical dome Intestinal illumination
by white light emitting diodes (LEDrsquos)by white light emitting diodes (LEDrsquos)bull LensLensbull Complementary metal-oxide silicone Complementary metal-oxide silicone
imager (color camera chip)imager (color camera chip)bull TransmitterTransmitterbull Two batteries (silver oxide)Two batteries (silver oxide)
GE Junction Duodenum
Jejunum Ileocecal Valve
Educational ObjectivesEducational Objectives Definitions and spectrum of inflammatory Definitions and spectrum of inflammatory
bowel disease (IBD)bowel disease (IBD) Epidemiology of IBDEpidemiology of IBD Etiopathogenesis of IBDEtiopathogenesis of IBD Clinical manifestations of ulcerative colitis Clinical manifestations of ulcerative colitis
(UC)(UC) Clinical manifestations of Crohnrsquos disease Clinical manifestations of Crohnrsquos disease
(CD)(CD) Distinguishing features between UC and CDDistinguishing features between UC and CD Diagnostic approach to IBDDiagnostic approach to IBD Complications of IBDComplications of IBD IBD managementIBD management
IBD-ComplicationsIBD-Complications GI BleedingGI Bleeding Toxic megacolonToxic megacolon PerforationPerforation Thromboembolic phenomenaThromboembolic phenomena FistulasfissuresFistulasfissures AbscessAbscess StricturesobstructionStricturesobstruction MalabsorptionmalnutritionMalabsorptionmalnutrition CancerCancer
Best Protection
Surveillance colonoscopySurveillance colonoscopy
Procto-colectomy (for UC)Procto-colectomy (for UC)
Descending Colon Descending Colon StrictureStricture
Colonic StricturesColonic Strictures
Consider nonsurgical management Consider nonsurgical management ifif Endoscopically accessibleEndoscopically accessible Multiple prior resectionsMultiple prior resections Shorter strictures (less than 5 cm)Shorter strictures (less than 5 cm) Steroid injection if significant Steroid injection if significant
inflammationinflammation
Fistula DefinitionA communication between two epithelial-lined organsLifetime risk of fistula in CD30
Perianal FistulaPerianal Fistula
Pretreatment 2 Weeks
10 Weeks 18 weeks
Educational ObjectivesEducational Objectives Definitions and spectrum of inflammatory Definitions and spectrum of inflammatory
bowel disease (IBD)bowel disease (IBD) Epidemiology of IBDEpidemiology of IBD Etiopathogenesis of IBDEtiopathogenesis of IBD Clinical manifestations of ulcerative colitis Clinical manifestations of ulcerative colitis
(UC)(UC) Clinical manifestations of Crohnrsquos disease Clinical manifestations of Crohnrsquos disease
(CD)(CD) Distinguishing features between UC and CDDistinguishing features between UC and CD Diagnostic approach to IBDDiagnostic approach to IBD Complications of IBDComplications of IBD IBD managementIBD management
Goals of Therapy for IBDGoals of Therapy for IBD
Inducing remissionInducing remission Maintaining remissionMaintaining remission Restoring and maintaining nutritionRestoring and maintaining nutrition Maintaining patientrsquos quality of lifeMaintaining patientrsquos quality of life Prevention of complicationsPrevention of complications Surgical intervention (selection of Surgical intervention (selection of
optimal time for surgery)optimal time for surgery)
Inductive TherapiesInductive Therapies
For UCFor UC AminosalicylatesAminosalicylates CorticosteroidsCorticosteroids CyclosporinCyclosporin
For CDFor CD AminosalicylatesAminosalicylates CorticosteroidsCorticosteroids AntibioticsAntibiotics Anti-TNFAnti-TNF
Maintenance TherapiesMaintenance Therapies
ImmunosupressorsImmunosupressors AzathioprineAzathioprine 6-MP6-MP MethotrexateMethotrexate
AminosalicylatesAminosalicylates Anti-TNFAnti-TNF
NOT NOT corticosteroidscorticosteroids
IBD ManagementIBD ManagementSummarySummary
There is no ldquoone size fits allrdquo to IBD therapyThere is no ldquoone size fits allrdquo to IBD therapy Therapy and decision making are tailored to the Therapy and decision making are tailored to the
individualindividual
Algorithms are based upon available evidenceAlgorithms are based upon available evidence Evidence is in constant fluxEvidence is in constant flux
Success of algorithms depends upon Success of algorithms depends upon optimization of each step of therapy and optimization of each step of therapy and considerable judgment about each outcomeconsiderable judgment about each outcome Skillful application of medical therapy makes all Skillful application of medical therapy makes all
the difference in outcomesthe difference in outcomes
Surgery for IBDSurgery for IBDGeneral ConceptsGeneral Concepts
Majority will need surgery 78 over Majority will need surgery 78 over twenty yearstwenty years
Surgery generally indicated for Surgery generally indicated for complicationscomplications of disease of disease
Surgery must be directed at area of Surgery must be directed at area of bowel responsible for complicationbowel responsible for complication
Indications for SurgeryIndications for Surgery Intestinal obstruction (most Intestinal obstruction (most
common)common) Intractabilitysteroid Intractabilitysteroid
dependencedependence Non-healing fistulaAbscessNon-healing fistulaAbscess Toxic megacolonFree Toxic megacolonFree
perforationperforation Uncontrollable GI bleedingUncontrollable GI bleeding Severe perianal diseaseSevere perianal disease CancerCancer Growth retardation Growth retardation
(children)(children) Severe uncontrollable Severe uncontrollable
extraintestinal extraintestinal manifestationsmanifestations
Management of IBDSummary
The goals of therapy are Relieve symptoms Prevent relapse Correct nutritional deficiencies Control inflammation Prevent complications especially colon cancer
Treatment depends on 1048707 Type of disease 1048707 Site of disease 1048707 Disease severity
Treatment may include drugs nutrition supplements surgery or a combination of these options
Differential Diagnosis of Differential Diagnosis of Chronic Diarrhea and Weight Chronic Diarrhea and Weight
LossLoss Colonic diseasesColonic diseases
IBDIBD NeoplasiaNeoplasia Ischemic bowelIschemic bowel
PancreaticPancreatic Chronic pancreatitisChronic pancreatitis CancerCancer Cystic fibrosisCystic fibrosis
EnteropathicEnteropathic Celiac diseaseCeliac disease Tropical sprueTropical sprue LymphomaLymphoma Mesenteric ischemiaMesenteric ischemia Whipplersquos diseaseWhipplersquos disease
HormonaldrugsHormonaldrugs VipomaVipoma ZESZES Medullary CA of Medullary CA of
thyroidthyroid NSAIDS useNSAIDS use
Educational ObjectivesEducational Objectives Definitions and spectrum of inflammatory Definitions and spectrum of inflammatory
bowel disease (IBD)bowel disease (IBD) Epidemiology of IBDEpidemiology of IBD Etiopathogenesis of IBDEtiopathogenesis of IBD Clinical manifestations of ulcerative colitis Clinical manifestations of ulcerative colitis
(UC)(UC) Clinical manifestations of Crohnrsquos disease Clinical manifestations of Crohnrsquos disease
(CD)(CD) Distinguishing features between UC and CDDistinguishing features between UC and CD Diagnostic approach to IBDDiagnostic approach to IBD Medical management of IBDMedical management of IBD Indications for and role of surgeryIndications for and role of surgery
Diagnostic Approach to Diagnostic Approach to Patients with Suspected Patients with Suspected
IBDIBD HistoryhelliphelliphistoryhelliphelliphistoryHistoryhelliphelliphistoryhelliphelliphistory Clinical examClinical exam Laboratory testsLaboratory tests Radiological imagingRadiological imaging EndoscopyEndoscopy Special serological testingSpecial serological testing Genetic testingGenetic testing
Diagnosis-LAB Blood test
CD Mild anemia mild leukocytosis elevated ESR elevated CRP positive ASCA
UC Anemia hypokalemia hypoalbuminemia elevated ESR elevated LFTs positive p-ANCA
Stool analysis Many WBCs and or RBCs No ova or parasites
What are the Serological What are the Serological Markers in IBDMarkers in IBD
pANCA (perinuclear staining pattern)pANCA (perinuclear staining pattern) Loss of perinuclear pattern after Loss of perinuclear pattern after
DNAaseDNAase Differentiate from the ldquoother pANCAsrdquoDifferentiate from the ldquoother pANCAsrdquo
Antibody against myeloperoxidaseAntibody against myeloperoxidase Antibody against cathepsin G elastase lysozyme Antibody against cathepsin G elastase lysozyme
and lactoferrinand lactoferrin ASCA (anti-ASCA (anti-Saccharomyces cerevisiaeSaccharomyces cerevisiae))
Both IgG and IgABoth IgG and IgA Recognize mannose in the cell wall Recognize mannose in the cell wall
mannan of mannan of Saccharomyces cerevisiaeSaccharomyces cerevisiae
Why Use Serological Why Use Serological Markers in Clinical Markers in Clinical
PracticePractice Differentiate IBD from functional bowel Differentiate IBD from functional bowel
disordersdisorders Accurately diagnose Crohnrsquos or UC in a patient Accurately diagnose Crohnrsquos or UC in a patient
withwith Severe colitisSevere colitis Indeterminate colitisIndeterminate colitis
Predict disease course or complications in IBDPredict disease course or complications in IBD CD phenotypeCD phenotype Severity of diseaseSeverity of disease Risk of pouchitisRisk of pouchitis
SummarySummary
pANCA and ASCA are specific for UC pANCA and ASCA are specific for UC and CD respectivelyand CD respectively
Neither pANCA nor ASCA are sensitive Neither pANCA nor ASCA are sensitive enough to exclude IBDenough to exclude IBD
In patients with IC available In patients with IC available serological markers do not accurately serological markers do not accurately predict the subsequent disease coursepredict the subsequent disease course
Antibody profiles can predict disease Antibody profiles can predict disease behavior in IBDbehavior in IBD
Diagnostic ApproachDiagnostic ApproachEndoscopyEndoscopy
Endoscopy useful forEndoscopy useful for Initial diagnosisInitial diagnosis Assessment of severityAssessment of severity Tissue diagnosisTissue diagnosis FU during treatmentFU during treatment Assessment of disease exacerbationAssessment of disease exacerbation Surveillance for risk of cancerSurveillance for risk of cancer Treatment of certain complications (eg Treatment of certain complications (eg
strictures)strictures)
Crohnrsquos DiseaseCrohnrsquos DiseaseEndoscopic FeaturesEndoscopic Features
Asymmetric patchy inflammationAsymmetric patchy inflammation Skip lesionsSkip lesions Rectal sparingRectal sparing Ulcerations-deepserpiginousUlcerations-deepserpiginous Cobblestoning-commonCobblestoning-common Pseudopolyps-rarePseudopolyps-rare BiopsyBiopsy
Erosions and normal mucosaErosions and normal mucosa Granulomas in 15 to 35 of specimensGranulomas in 15 to 35 of specimens
Ulcerative ColitisUlcerative ColitisEndoscopic FeaturesEndoscopic Features
Diffuse involvementDiffuse involvement Rectum always diseasedRectum always diseased Superficial ulcerationsSuperficial ulcerations FriabilitybleedingFriabilitybleeding Flatteningdisappearance of haustral Flatteningdisappearance of haustral
foldsfolds PseudopolypsPseudopolyps No cobblestoningNo cobblestoning Bx No granulomasBx No granulomas
Imaging for Crohn Imaging for Crohn DiseaseDisease
Traditional TechniquesTraditional Techniques Abdominal RadiographsAbdominal Radiographs
Barium UGI Barium UGI
Barium small bowel follow throughBarium small bowel follow through
Barium EnteroclysisBarium Enteroclysis
Barium EnemaBarium Enema
Imaging for Crohn Disease Imaging for Crohn Disease Newer TechniquesNewer Techniques
CTCT
CT EnteroclysisCT Enteroclysis
CT EnterographyCT Enterography
Magnetic ResonanceMagnetic Resonance
UltrasoundUltrasound
Nuclear MedicineNuclear Medicine
Imaging for Crohns DiseaseImaging for Crohns Disease SummarySummary
Useful Newer TechniquesUseful Newer Techniques evolvingevolving CT EnterographyCT Enterography
Comprehensive evaluation of all bowel amp solid organsComprehensive evaluation of all bowel amp solid organs
Magnetic ResonanceMagnetic Resonance
Useful for ano-rectal diseaseUseful for ano-rectal disease
Real-time MR has potential for detection of stricturesReal-time MR has potential for detection of strictures
Traditional imaging techniques still of value in Traditional imaging techniques still of value in selected cases selected cases
The Capsule (WCE)The Capsule (WCE)
WCEWCE
bull Diameter 11mm Length 26mmDiameter 11mm Length 26mmbull Optical dome Intestinal illumination Optical dome Intestinal illumination
by white light emitting diodes (LEDrsquos)by white light emitting diodes (LEDrsquos)bull LensLensbull Complementary metal-oxide silicone Complementary metal-oxide silicone
imager (color camera chip)imager (color camera chip)bull TransmitterTransmitterbull Two batteries (silver oxide)Two batteries (silver oxide)
GE Junction Duodenum
Jejunum Ileocecal Valve
Educational ObjectivesEducational Objectives Definitions and spectrum of inflammatory Definitions and spectrum of inflammatory
bowel disease (IBD)bowel disease (IBD) Epidemiology of IBDEpidemiology of IBD Etiopathogenesis of IBDEtiopathogenesis of IBD Clinical manifestations of ulcerative colitis Clinical manifestations of ulcerative colitis
(UC)(UC) Clinical manifestations of Crohnrsquos disease Clinical manifestations of Crohnrsquos disease
(CD)(CD) Distinguishing features between UC and CDDistinguishing features between UC and CD Diagnostic approach to IBDDiagnostic approach to IBD Complications of IBDComplications of IBD IBD managementIBD management
IBD-ComplicationsIBD-Complications GI BleedingGI Bleeding Toxic megacolonToxic megacolon PerforationPerforation Thromboembolic phenomenaThromboembolic phenomena FistulasfissuresFistulasfissures AbscessAbscess StricturesobstructionStricturesobstruction MalabsorptionmalnutritionMalabsorptionmalnutrition CancerCancer
Best Protection
Surveillance colonoscopySurveillance colonoscopy
Procto-colectomy (for UC)Procto-colectomy (for UC)
Descending Colon Descending Colon StrictureStricture
Colonic StricturesColonic Strictures
Consider nonsurgical management Consider nonsurgical management ifif Endoscopically accessibleEndoscopically accessible Multiple prior resectionsMultiple prior resections Shorter strictures (less than 5 cm)Shorter strictures (less than 5 cm) Steroid injection if significant Steroid injection if significant
inflammationinflammation
Fistula DefinitionA communication between two epithelial-lined organsLifetime risk of fistula in CD30
Perianal FistulaPerianal Fistula
Pretreatment 2 Weeks
10 Weeks 18 weeks
Educational ObjectivesEducational Objectives Definitions and spectrum of inflammatory Definitions and spectrum of inflammatory
bowel disease (IBD)bowel disease (IBD) Epidemiology of IBDEpidemiology of IBD Etiopathogenesis of IBDEtiopathogenesis of IBD Clinical manifestations of ulcerative colitis Clinical manifestations of ulcerative colitis
(UC)(UC) Clinical manifestations of Crohnrsquos disease Clinical manifestations of Crohnrsquos disease
(CD)(CD) Distinguishing features between UC and CDDistinguishing features between UC and CD Diagnostic approach to IBDDiagnostic approach to IBD Complications of IBDComplications of IBD IBD managementIBD management
Goals of Therapy for IBDGoals of Therapy for IBD
Inducing remissionInducing remission Maintaining remissionMaintaining remission Restoring and maintaining nutritionRestoring and maintaining nutrition Maintaining patientrsquos quality of lifeMaintaining patientrsquos quality of life Prevention of complicationsPrevention of complications Surgical intervention (selection of Surgical intervention (selection of
optimal time for surgery)optimal time for surgery)
Inductive TherapiesInductive Therapies
For UCFor UC AminosalicylatesAminosalicylates CorticosteroidsCorticosteroids CyclosporinCyclosporin
For CDFor CD AminosalicylatesAminosalicylates CorticosteroidsCorticosteroids AntibioticsAntibiotics Anti-TNFAnti-TNF
Maintenance TherapiesMaintenance Therapies
ImmunosupressorsImmunosupressors AzathioprineAzathioprine 6-MP6-MP MethotrexateMethotrexate
AminosalicylatesAminosalicylates Anti-TNFAnti-TNF
NOT NOT corticosteroidscorticosteroids
IBD ManagementIBD ManagementSummarySummary
There is no ldquoone size fits allrdquo to IBD therapyThere is no ldquoone size fits allrdquo to IBD therapy Therapy and decision making are tailored to the Therapy and decision making are tailored to the
individualindividual
Algorithms are based upon available evidenceAlgorithms are based upon available evidence Evidence is in constant fluxEvidence is in constant flux
Success of algorithms depends upon Success of algorithms depends upon optimization of each step of therapy and optimization of each step of therapy and considerable judgment about each outcomeconsiderable judgment about each outcome Skillful application of medical therapy makes all Skillful application of medical therapy makes all
the difference in outcomesthe difference in outcomes
Surgery for IBDSurgery for IBDGeneral ConceptsGeneral Concepts
Majority will need surgery 78 over Majority will need surgery 78 over twenty yearstwenty years
Surgery generally indicated for Surgery generally indicated for complicationscomplications of disease of disease
Surgery must be directed at area of Surgery must be directed at area of bowel responsible for complicationbowel responsible for complication
Indications for SurgeryIndications for Surgery Intestinal obstruction (most Intestinal obstruction (most
common)common) Intractabilitysteroid Intractabilitysteroid
dependencedependence Non-healing fistulaAbscessNon-healing fistulaAbscess Toxic megacolonFree Toxic megacolonFree
perforationperforation Uncontrollable GI bleedingUncontrollable GI bleeding Severe perianal diseaseSevere perianal disease CancerCancer Growth retardation Growth retardation
(children)(children) Severe uncontrollable Severe uncontrollable
extraintestinal extraintestinal manifestationsmanifestations
Management of IBDSummary
The goals of therapy are Relieve symptoms Prevent relapse Correct nutritional deficiencies Control inflammation Prevent complications especially colon cancer
Treatment depends on 1048707 Type of disease 1048707 Site of disease 1048707 Disease severity
Treatment may include drugs nutrition supplements surgery or a combination of these options
Educational ObjectivesEducational Objectives Definitions and spectrum of inflammatory Definitions and spectrum of inflammatory
bowel disease (IBD)bowel disease (IBD) Epidemiology of IBDEpidemiology of IBD Etiopathogenesis of IBDEtiopathogenesis of IBD Clinical manifestations of ulcerative colitis Clinical manifestations of ulcerative colitis
(UC)(UC) Clinical manifestations of Crohnrsquos disease Clinical manifestations of Crohnrsquos disease
(CD)(CD) Distinguishing features between UC and CDDistinguishing features between UC and CD Diagnostic approach to IBDDiagnostic approach to IBD Medical management of IBDMedical management of IBD Indications for and role of surgeryIndications for and role of surgery
Diagnostic Approach to Diagnostic Approach to Patients with Suspected Patients with Suspected
IBDIBD HistoryhelliphelliphistoryhelliphelliphistoryHistoryhelliphelliphistoryhelliphelliphistory Clinical examClinical exam Laboratory testsLaboratory tests Radiological imagingRadiological imaging EndoscopyEndoscopy Special serological testingSpecial serological testing Genetic testingGenetic testing
Diagnosis-LAB Blood test
CD Mild anemia mild leukocytosis elevated ESR elevated CRP positive ASCA
UC Anemia hypokalemia hypoalbuminemia elevated ESR elevated LFTs positive p-ANCA
Stool analysis Many WBCs and or RBCs No ova or parasites
What are the Serological What are the Serological Markers in IBDMarkers in IBD
pANCA (perinuclear staining pattern)pANCA (perinuclear staining pattern) Loss of perinuclear pattern after Loss of perinuclear pattern after
DNAaseDNAase Differentiate from the ldquoother pANCAsrdquoDifferentiate from the ldquoother pANCAsrdquo
Antibody against myeloperoxidaseAntibody against myeloperoxidase Antibody against cathepsin G elastase lysozyme Antibody against cathepsin G elastase lysozyme
and lactoferrinand lactoferrin ASCA (anti-ASCA (anti-Saccharomyces cerevisiaeSaccharomyces cerevisiae))
Both IgG and IgABoth IgG and IgA Recognize mannose in the cell wall Recognize mannose in the cell wall
mannan of mannan of Saccharomyces cerevisiaeSaccharomyces cerevisiae
Why Use Serological Why Use Serological Markers in Clinical Markers in Clinical
PracticePractice Differentiate IBD from functional bowel Differentiate IBD from functional bowel
disordersdisorders Accurately diagnose Crohnrsquos or UC in a patient Accurately diagnose Crohnrsquos or UC in a patient
withwith Severe colitisSevere colitis Indeterminate colitisIndeterminate colitis
Predict disease course or complications in IBDPredict disease course or complications in IBD CD phenotypeCD phenotype Severity of diseaseSeverity of disease Risk of pouchitisRisk of pouchitis
SummarySummary
pANCA and ASCA are specific for UC pANCA and ASCA are specific for UC and CD respectivelyand CD respectively
Neither pANCA nor ASCA are sensitive Neither pANCA nor ASCA are sensitive enough to exclude IBDenough to exclude IBD
In patients with IC available In patients with IC available serological markers do not accurately serological markers do not accurately predict the subsequent disease coursepredict the subsequent disease course
Antibody profiles can predict disease Antibody profiles can predict disease behavior in IBDbehavior in IBD
Diagnostic ApproachDiagnostic ApproachEndoscopyEndoscopy
Endoscopy useful forEndoscopy useful for Initial diagnosisInitial diagnosis Assessment of severityAssessment of severity Tissue diagnosisTissue diagnosis FU during treatmentFU during treatment Assessment of disease exacerbationAssessment of disease exacerbation Surveillance for risk of cancerSurveillance for risk of cancer Treatment of certain complications (eg Treatment of certain complications (eg
strictures)strictures)
Crohnrsquos DiseaseCrohnrsquos DiseaseEndoscopic FeaturesEndoscopic Features
Asymmetric patchy inflammationAsymmetric patchy inflammation Skip lesionsSkip lesions Rectal sparingRectal sparing Ulcerations-deepserpiginousUlcerations-deepserpiginous Cobblestoning-commonCobblestoning-common Pseudopolyps-rarePseudopolyps-rare BiopsyBiopsy
Erosions and normal mucosaErosions and normal mucosa Granulomas in 15 to 35 of specimensGranulomas in 15 to 35 of specimens
Ulcerative ColitisUlcerative ColitisEndoscopic FeaturesEndoscopic Features
Diffuse involvementDiffuse involvement Rectum always diseasedRectum always diseased Superficial ulcerationsSuperficial ulcerations FriabilitybleedingFriabilitybleeding Flatteningdisappearance of haustral Flatteningdisappearance of haustral
foldsfolds PseudopolypsPseudopolyps No cobblestoningNo cobblestoning Bx No granulomasBx No granulomas
Imaging for Crohn Imaging for Crohn DiseaseDisease
Traditional TechniquesTraditional Techniques Abdominal RadiographsAbdominal Radiographs
Barium UGI Barium UGI
Barium small bowel follow throughBarium small bowel follow through
Barium EnteroclysisBarium Enteroclysis
Barium EnemaBarium Enema
Imaging for Crohn Disease Imaging for Crohn Disease Newer TechniquesNewer Techniques
CTCT
CT EnteroclysisCT Enteroclysis
CT EnterographyCT Enterography
Magnetic ResonanceMagnetic Resonance
UltrasoundUltrasound
Nuclear MedicineNuclear Medicine
Imaging for Crohns DiseaseImaging for Crohns Disease SummarySummary
Useful Newer TechniquesUseful Newer Techniques evolvingevolving CT EnterographyCT Enterography
Comprehensive evaluation of all bowel amp solid organsComprehensive evaluation of all bowel amp solid organs
Magnetic ResonanceMagnetic Resonance
Useful for ano-rectal diseaseUseful for ano-rectal disease
Real-time MR has potential for detection of stricturesReal-time MR has potential for detection of strictures
Traditional imaging techniques still of value in Traditional imaging techniques still of value in selected cases selected cases
The Capsule (WCE)The Capsule (WCE)
WCEWCE
bull Diameter 11mm Length 26mmDiameter 11mm Length 26mmbull Optical dome Intestinal illumination Optical dome Intestinal illumination
by white light emitting diodes (LEDrsquos)by white light emitting diodes (LEDrsquos)bull LensLensbull Complementary metal-oxide silicone Complementary metal-oxide silicone
imager (color camera chip)imager (color camera chip)bull TransmitterTransmitterbull Two batteries (silver oxide)Two batteries (silver oxide)
GE Junction Duodenum
Jejunum Ileocecal Valve
Educational ObjectivesEducational Objectives Definitions and spectrum of inflammatory Definitions and spectrum of inflammatory
bowel disease (IBD)bowel disease (IBD) Epidemiology of IBDEpidemiology of IBD Etiopathogenesis of IBDEtiopathogenesis of IBD Clinical manifestations of ulcerative colitis Clinical manifestations of ulcerative colitis
(UC)(UC) Clinical manifestations of Crohnrsquos disease Clinical manifestations of Crohnrsquos disease
(CD)(CD) Distinguishing features between UC and CDDistinguishing features between UC and CD Diagnostic approach to IBDDiagnostic approach to IBD Complications of IBDComplications of IBD IBD managementIBD management
IBD-ComplicationsIBD-Complications GI BleedingGI Bleeding Toxic megacolonToxic megacolon PerforationPerforation Thromboembolic phenomenaThromboembolic phenomena FistulasfissuresFistulasfissures AbscessAbscess StricturesobstructionStricturesobstruction MalabsorptionmalnutritionMalabsorptionmalnutrition CancerCancer
Best Protection
Surveillance colonoscopySurveillance colonoscopy
Procto-colectomy (for UC)Procto-colectomy (for UC)
Descending Colon Descending Colon StrictureStricture
Colonic StricturesColonic Strictures
Consider nonsurgical management Consider nonsurgical management ifif Endoscopically accessibleEndoscopically accessible Multiple prior resectionsMultiple prior resections Shorter strictures (less than 5 cm)Shorter strictures (less than 5 cm) Steroid injection if significant Steroid injection if significant
inflammationinflammation
Fistula DefinitionA communication between two epithelial-lined organsLifetime risk of fistula in CD30
Perianal FistulaPerianal Fistula
Pretreatment 2 Weeks
10 Weeks 18 weeks
Educational ObjectivesEducational Objectives Definitions and spectrum of inflammatory Definitions and spectrum of inflammatory
bowel disease (IBD)bowel disease (IBD) Epidemiology of IBDEpidemiology of IBD Etiopathogenesis of IBDEtiopathogenesis of IBD Clinical manifestations of ulcerative colitis Clinical manifestations of ulcerative colitis
(UC)(UC) Clinical manifestations of Crohnrsquos disease Clinical manifestations of Crohnrsquos disease
(CD)(CD) Distinguishing features between UC and CDDistinguishing features between UC and CD Diagnostic approach to IBDDiagnostic approach to IBD Complications of IBDComplications of IBD IBD managementIBD management
Goals of Therapy for IBDGoals of Therapy for IBD
Inducing remissionInducing remission Maintaining remissionMaintaining remission Restoring and maintaining nutritionRestoring and maintaining nutrition Maintaining patientrsquos quality of lifeMaintaining patientrsquos quality of life Prevention of complicationsPrevention of complications Surgical intervention (selection of Surgical intervention (selection of
optimal time for surgery)optimal time for surgery)
Inductive TherapiesInductive Therapies
For UCFor UC AminosalicylatesAminosalicylates CorticosteroidsCorticosteroids CyclosporinCyclosporin
For CDFor CD AminosalicylatesAminosalicylates CorticosteroidsCorticosteroids AntibioticsAntibiotics Anti-TNFAnti-TNF
Maintenance TherapiesMaintenance Therapies
ImmunosupressorsImmunosupressors AzathioprineAzathioprine 6-MP6-MP MethotrexateMethotrexate
AminosalicylatesAminosalicylates Anti-TNFAnti-TNF
NOT NOT corticosteroidscorticosteroids
IBD ManagementIBD ManagementSummarySummary
There is no ldquoone size fits allrdquo to IBD therapyThere is no ldquoone size fits allrdquo to IBD therapy Therapy and decision making are tailored to the Therapy and decision making are tailored to the
individualindividual
Algorithms are based upon available evidenceAlgorithms are based upon available evidence Evidence is in constant fluxEvidence is in constant flux
Success of algorithms depends upon Success of algorithms depends upon optimization of each step of therapy and optimization of each step of therapy and considerable judgment about each outcomeconsiderable judgment about each outcome Skillful application of medical therapy makes all Skillful application of medical therapy makes all
the difference in outcomesthe difference in outcomes
Surgery for IBDSurgery for IBDGeneral ConceptsGeneral Concepts
Majority will need surgery 78 over Majority will need surgery 78 over twenty yearstwenty years
Surgery generally indicated for Surgery generally indicated for complicationscomplications of disease of disease
Surgery must be directed at area of Surgery must be directed at area of bowel responsible for complicationbowel responsible for complication
Indications for SurgeryIndications for Surgery Intestinal obstruction (most Intestinal obstruction (most
common)common) Intractabilitysteroid Intractabilitysteroid
dependencedependence Non-healing fistulaAbscessNon-healing fistulaAbscess Toxic megacolonFree Toxic megacolonFree
perforationperforation Uncontrollable GI bleedingUncontrollable GI bleeding Severe perianal diseaseSevere perianal disease CancerCancer Growth retardation Growth retardation
(children)(children) Severe uncontrollable Severe uncontrollable
extraintestinal extraintestinal manifestationsmanifestations
Management of IBDSummary
The goals of therapy are Relieve symptoms Prevent relapse Correct nutritional deficiencies Control inflammation Prevent complications especially colon cancer
Treatment depends on 1048707 Type of disease 1048707 Site of disease 1048707 Disease severity
Treatment may include drugs nutrition supplements surgery or a combination of these options
Diagnostic Approach to Diagnostic Approach to Patients with Suspected Patients with Suspected
IBDIBD HistoryhelliphelliphistoryhelliphelliphistoryHistoryhelliphelliphistoryhelliphelliphistory Clinical examClinical exam Laboratory testsLaboratory tests Radiological imagingRadiological imaging EndoscopyEndoscopy Special serological testingSpecial serological testing Genetic testingGenetic testing
Diagnosis-LAB Blood test
CD Mild anemia mild leukocytosis elevated ESR elevated CRP positive ASCA
UC Anemia hypokalemia hypoalbuminemia elevated ESR elevated LFTs positive p-ANCA
Stool analysis Many WBCs and or RBCs No ova or parasites
What are the Serological What are the Serological Markers in IBDMarkers in IBD
pANCA (perinuclear staining pattern)pANCA (perinuclear staining pattern) Loss of perinuclear pattern after Loss of perinuclear pattern after
DNAaseDNAase Differentiate from the ldquoother pANCAsrdquoDifferentiate from the ldquoother pANCAsrdquo
Antibody against myeloperoxidaseAntibody against myeloperoxidase Antibody against cathepsin G elastase lysozyme Antibody against cathepsin G elastase lysozyme
and lactoferrinand lactoferrin ASCA (anti-ASCA (anti-Saccharomyces cerevisiaeSaccharomyces cerevisiae))
Both IgG and IgABoth IgG and IgA Recognize mannose in the cell wall Recognize mannose in the cell wall
mannan of mannan of Saccharomyces cerevisiaeSaccharomyces cerevisiae
Why Use Serological Why Use Serological Markers in Clinical Markers in Clinical
PracticePractice Differentiate IBD from functional bowel Differentiate IBD from functional bowel
disordersdisorders Accurately diagnose Crohnrsquos or UC in a patient Accurately diagnose Crohnrsquos or UC in a patient
withwith Severe colitisSevere colitis Indeterminate colitisIndeterminate colitis
Predict disease course or complications in IBDPredict disease course or complications in IBD CD phenotypeCD phenotype Severity of diseaseSeverity of disease Risk of pouchitisRisk of pouchitis
SummarySummary
pANCA and ASCA are specific for UC pANCA and ASCA are specific for UC and CD respectivelyand CD respectively
Neither pANCA nor ASCA are sensitive Neither pANCA nor ASCA are sensitive enough to exclude IBDenough to exclude IBD
In patients with IC available In patients with IC available serological markers do not accurately serological markers do not accurately predict the subsequent disease coursepredict the subsequent disease course
Antibody profiles can predict disease Antibody profiles can predict disease behavior in IBDbehavior in IBD
Diagnostic ApproachDiagnostic ApproachEndoscopyEndoscopy
Endoscopy useful forEndoscopy useful for Initial diagnosisInitial diagnosis Assessment of severityAssessment of severity Tissue diagnosisTissue diagnosis FU during treatmentFU during treatment Assessment of disease exacerbationAssessment of disease exacerbation Surveillance for risk of cancerSurveillance for risk of cancer Treatment of certain complications (eg Treatment of certain complications (eg
strictures)strictures)
Crohnrsquos DiseaseCrohnrsquos DiseaseEndoscopic FeaturesEndoscopic Features
Asymmetric patchy inflammationAsymmetric patchy inflammation Skip lesionsSkip lesions Rectal sparingRectal sparing Ulcerations-deepserpiginousUlcerations-deepserpiginous Cobblestoning-commonCobblestoning-common Pseudopolyps-rarePseudopolyps-rare BiopsyBiopsy
Erosions and normal mucosaErosions and normal mucosa Granulomas in 15 to 35 of specimensGranulomas in 15 to 35 of specimens
Ulcerative ColitisUlcerative ColitisEndoscopic FeaturesEndoscopic Features
Diffuse involvementDiffuse involvement Rectum always diseasedRectum always diseased Superficial ulcerationsSuperficial ulcerations FriabilitybleedingFriabilitybleeding Flatteningdisappearance of haustral Flatteningdisappearance of haustral
foldsfolds PseudopolypsPseudopolyps No cobblestoningNo cobblestoning Bx No granulomasBx No granulomas
Imaging for Crohn Imaging for Crohn DiseaseDisease
Traditional TechniquesTraditional Techniques Abdominal RadiographsAbdominal Radiographs
Barium UGI Barium UGI
Barium small bowel follow throughBarium small bowel follow through
Barium EnteroclysisBarium Enteroclysis
Barium EnemaBarium Enema
Imaging for Crohn Disease Imaging for Crohn Disease Newer TechniquesNewer Techniques
CTCT
CT EnteroclysisCT Enteroclysis
CT EnterographyCT Enterography
Magnetic ResonanceMagnetic Resonance
UltrasoundUltrasound
Nuclear MedicineNuclear Medicine
Imaging for Crohns DiseaseImaging for Crohns Disease SummarySummary
Useful Newer TechniquesUseful Newer Techniques evolvingevolving CT EnterographyCT Enterography
Comprehensive evaluation of all bowel amp solid organsComprehensive evaluation of all bowel amp solid organs
Magnetic ResonanceMagnetic Resonance
Useful for ano-rectal diseaseUseful for ano-rectal disease
Real-time MR has potential for detection of stricturesReal-time MR has potential for detection of strictures
Traditional imaging techniques still of value in Traditional imaging techniques still of value in selected cases selected cases
The Capsule (WCE)The Capsule (WCE)
WCEWCE
bull Diameter 11mm Length 26mmDiameter 11mm Length 26mmbull Optical dome Intestinal illumination Optical dome Intestinal illumination
by white light emitting diodes (LEDrsquos)by white light emitting diodes (LEDrsquos)bull LensLensbull Complementary metal-oxide silicone Complementary metal-oxide silicone
imager (color camera chip)imager (color camera chip)bull TransmitterTransmitterbull Two batteries (silver oxide)Two batteries (silver oxide)
GE Junction Duodenum
Jejunum Ileocecal Valve
Educational ObjectivesEducational Objectives Definitions and spectrum of inflammatory Definitions and spectrum of inflammatory
bowel disease (IBD)bowel disease (IBD) Epidemiology of IBDEpidemiology of IBD Etiopathogenesis of IBDEtiopathogenesis of IBD Clinical manifestations of ulcerative colitis Clinical manifestations of ulcerative colitis
(UC)(UC) Clinical manifestations of Crohnrsquos disease Clinical manifestations of Crohnrsquos disease
(CD)(CD) Distinguishing features between UC and CDDistinguishing features between UC and CD Diagnostic approach to IBDDiagnostic approach to IBD Complications of IBDComplications of IBD IBD managementIBD management
IBD-ComplicationsIBD-Complications GI BleedingGI Bleeding Toxic megacolonToxic megacolon PerforationPerforation Thromboembolic phenomenaThromboembolic phenomena FistulasfissuresFistulasfissures AbscessAbscess StricturesobstructionStricturesobstruction MalabsorptionmalnutritionMalabsorptionmalnutrition CancerCancer
Best Protection
Surveillance colonoscopySurveillance colonoscopy
Procto-colectomy (for UC)Procto-colectomy (for UC)
Descending Colon Descending Colon StrictureStricture
Colonic StricturesColonic Strictures
Consider nonsurgical management Consider nonsurgical management ifif Endoscopically accessibleEndoscopically accessible Multiple prior resectionsMultiple prior resections Shorter strictures (less than 5 cm)Shorter strictures (less than 5 cm) Steroid injection if significant Steroid injection if significant
inflammationinflammation
Fistula DefinitionA communication between two epithelial-lined organsLifetime risk of fistula in CD30
Perianal FistulaPerianal Fistula
Pretreatment 2 Weeks
10 Weeks 18 weeks
Educational ObjectivesEducational Objectives Definitions and spectrum of inflammatory Definitions and spectrum of inflammatory
bowel disease (IBD)bowel disease (IBD) Epidemiology of IBDEpidemiology of IBD Etiopathogenesis of IBDEtiopathogenesis of IBD Clinical manifestations of ulcerative colitis Clinical manifestations of ulcerative colitis
(UC)(UC) Clinical manifestations of Crohnrsquos disease Clinical manifestations of Crohnrsquos disease
(CD)(CD) Distinguishing features between UC and CDDistinguishing features between UC and CD Diagnostic approach to IBDDiagnostic approach to IBD Complications of IBDComplications of IBD IBD managementIBD management
Goals of Therapy for IBDGoals of Therapy for IBD
Inducing remissionInducing remission Maintaining remissionMaintaining remission Restoring and maintaining nutritionRestoring and maintaining nutrition Maintaining patientrsquos quality of lifeMaintaining patientrsquos quality of life Prevention of complicationsPrevention of complications Surgical intervention (selection of Surgical intervention (selection of
optimal time for surgery)optimal time for surgery)
Inductive TherapiesInductive Therapies
For UCFor UC AminosalicylatesAminosalicylates CorticosteroidsCorticosteroids CyclosporinCyclosporin
For CDFor CD AminosalicylatesAminosalicylates CorticosteroidsCorticosteroids AntibioticsAntibiotics Anti-TNFAnti-TNF
Maintenance TherapiesMaintenance Therapies
ImmunosupressorsImmunosupressors AzathioprineAzathioprine 6-MP6-MP MethotrexateMethotrexate
AminosalicylatesAminosalicylates Anti-TNFAnti-TNF
NOT NOT corticosteroidscorticosteroids
IBD ManagementIBD ManagementSummarySummary
There is no ldquoone size fits allrdquo to IBD therapyThere is no ldquoone size fits allrdquo to IBD therapy Therapy and decision making are tailored to the Therapy and decision making are tailored to the
individualindividual
Algorithms are based upon available evidenceAlgorithms are based upon available evidence Evidence is in constant fluxEvidence is in constant flux
Success of algorithms depends upon Success of algorithms depends upon optimization of each step of therapy and optimization of each step of therapy and considerable judgment about each outcomeconsiderable judgment about each outcome Skillful application of medical therapy makes all Skillful application of medical therapy makes all
the difference in outcomesthe difference in outcomes
Surgery for IBDSurgery for IBDGeneral ConceptsGeneral Concepts
Majority will need surgery 78 over Majority will need surgery 78 over twenty yearstwenty years
Surgery generally indicated for Surgery generally indicated for complicationscomplications of disease of disease
Surgery must be directed at area of Surgery must be directed at area of bowel responsible for complicationbowel responsible for complication
Indications for SurgeryIndications for Surgery Intestinal obstruction (most Intestinal obstruction (most
common)common) Intractabilitysteroid Intractabilitysteroid
dependencedependence Non-healing fistulaAbscessNon-healing fistulaAbscess Toxic megacolonFree Toxic megacolonFree
perforationperforation Uncontrollable GI bleedingUncontrollable GI bleeding Severe perianal diseaseSevere perianal disease CancerCancer Growth retardation Growth retardation
(children)(children) Severe uncontrollable Severe uncontrollable
extraintestinal extraintestinal manifestationsmanifestations
Management of IBDSummary
The goals of therapy are Relieve symptoms Prevent relapse Correct nutritional deficiencies Control inflammation Prevent complications especially colon cancer
Treatment depends on 1048707 Type of disease 1048707 Site of disease 1048707 Disease severity
Treatment may include drugs nutrition supplements surgery or a combination of these options
Diagnosis-LAB Blood test
CD Mild anemia mild leukocytosis elevated ESR elevated CRP positive ASCA
UC Anemia hypokalemia hypoalbuminemia elevated ESR elevated LFTs positive p-ANCA
Stool analysis Many WBCs and or RBCs No ova or parasites
What are the Serological What are the Serological Markers in IBDMarkers in IBD
pANCA (perinuclear staining pattern)pANCA (perinuclear staining pattern) Loss of perinuclear pattern after Loss of perinuclear pattern after
DNAaseDNAase Differentiate from the ldquoother pANCAsrdquoDifferentiate from the ldquoother pANCAsrdquo
Antibody against myeloperoxidaseAntibody against myeloperoxidase Antibody against cathepsin G elastase lysozyme Antibody against cathepsin G elastase lysozyme
and lactoferrinand lactoferrin ASCA (anti-ASCA (anti-Saccharomyces cerevisiaeSaccharomyces cerevisiae))
Both IgG and IgABoth IgG and IgA Recognize mannose in the cell wall Recognize mannose in the cell wall
mannan of mannan of Saccharomyces cerevisiaeSaccharomyces cerevisiae
Why Use Serological Why Use Serological Markers in Clinical Markers in Clinical
PracticePractice Differentiate IBD from functional bowel Differentiate IBD from functional bowel
disordersdisorders Accurately diagnose Crohnrsquos or UC in a patient Accurately diagnose Crohnrsquos or UC in a patient
withwith Severe colitisSevere colitis Indeterminate colitisIndeterminate colitis
Predict disease course or complications in IBDPredict disease course or complications in IBD CD phenotypeCD phenotype Severity of diseaseSeverity of disease Risk of pouchitisRisk of pouchitis
SummarySummary
pANCA and ASCA are specific for UC pANCA and ASCA are specific for UC and CD respectivelyand CD respectively
Neither pANCA nor ASCA are sensitive Neither pANCA nor ASCA are sensitive enough to exclude IBDenough to exclude IBD
In patients with IC available In patients with IC available serological markers do not accurately serological markers do not accurately predict the subsequent disease coursepredict the subsequent disease course
Antibody profiles can predict disease Antibody profiles can predict disease behavior in IBDbehavior in IBD
Diagnostic ApproachDiagnostic ApproachEndoscopyEndoscopy
Endoscopy useful forEndoscopy useful for Initial diagnosisInitial diagnosis Assessment of severityAssessment of severity Tissue diagnosisTissue diagnosis FU during treatmentFU during treatment Assessment of disease exacerbationAssessment of disease exacerbation Surveillance for risk of cancerSurveillance for risk of cancer Treatment of certain complications (eg Treatment of certain complications (eg
strictures)strictures)
Crohnrsquos DiseaseCrohnrsquos DiseaseEndoscopic FeaturesEndoscopic Features
Asymmetric patchy inflammationAsymmetric patchy inflammation Skip lesionsSkip lesions Rectal sparingRectal sparing Ulcerations-deepserpiginousUlcerations-deepserpiginous Cobblestoning-commonCobblestoning-common Pseudopolyps-rarePseudopolyps-rare BiopsyBiopsy
Erosions and normal mucosaErosions and normal mucosa Granulomas in 15 to 35 of specimensGranulomas in 15 to 35 of specimens
Ulcerative ColitisUlcerative ColitisEndoscopic FeaturesEndoscopic Features
Diffuse involvementDiffuse involvement Rectum always diseasedRectum always diseased Superficial ulcerationsSuperficial ulcerations FriabilitybleedingFriabilitybleeding Flatteningdisappearance of haustral Flatteningdisappearance of haustral
foldsfolds PseudopolypsPseudopolyps No cobblestoningNo cobblestoning Bx No granulomasBx No granulomas
Imaging for Crohn Imaging for Crohn DiseaseDisease
Traditional TechniquesTraditional Techniques Abdominal RadiographsAbdominal Radiographs
Barium UGI Barium UGI
Barium small bowel follow throughBarium small bowel follow through
Barium EnteroclysisBarium Enteroclysis
Barium EnemaBarium Enema
Imaging for Crohn Disease Imaging for Crohn Disease Newer TechniquesNewer Techniques
CTCT
CT EnteroclysisCT Enteroclysis
CT EnterographyCT Enterography
Magnetic ResonanceMagnetic Resonance
UltrasoundUltrasound
Nuclear MedicineNuclear Medicine
Imaging for Crohns DiseaseImaging for Crohns Disease SummarySummary
Useful Newer TechniquesUseful Newer Techniques evolvingevolving CT EnterographyCT Enterography
Comprehensive evaluation of all bowel amp solid organsComprehensive evaluation of all bowel amp solid organs
Magnetic ResonanceMagnetic Resonance
Useful for ano-rectal diseaseUseful for ano-rectal disease
Real-time MR has potential for detection of stricturesReal-time MR has potential for detection of strictures
Traditional imaging techniques still of value in Traditional imaging techniques still of value in selected cases selected cases
The Capsule (WCE)The Capsule (WCE)
WCEWCE
bull Diameter 11mm Length 26mmDiameter 11mm Length 26mmbull Optical dome Intestinal illumination Optical dome Intestinal illumination
by white light emitting diodes (LEDrsquos)by white light emitting diodes (LEDrsquos)bull LensLensbull Complementary metal-oxide silicone Complementary metal-oxide silicone
imager (color camera chip)imager (color camera chip)bull TransmitterTransmitterbull Two batteries (silver oxide)Two batteries (silver oxide)
GE Junction Duodenum
Jejunum Ileocecal Valve
Educational ObjectivesEducational Objectives Definitions and spectrum of inflammatory Definitions and spectrum of inflammatory
bowel disease (IBD)bowel disease (IBD) Epidemiology of IBDEpidemiology of IBD Etiopathogenesis of IBDEtiopathogenesis of IBD Clinical manifestations of ulcerative colitis Clinical manifestations of ulcerative colitis
(UC)(UC) Clinical manifestations of Crohnrsquos disease Clinical manifestations of Crohnrsquos disease
(CD)(CD) Distinguishing features between UC and CDDistinguishing features between UC and CD Diagnostic approach to IBDDiagnostic approach to IBD Complications of IBDComplications of IBD IBD managementIBD management
IBD-ComplicationsIBD-Complications GI BleedingGI Bleeding Toxic megacolonToxic megacolon PerforationPerforation Thromboembolic phenomenaThromboembolic phenomena FistulasfissuresFistulasfissures AbscessAbscess StricturesobstructionStricturesobstruction MalabsorptionmalnutritionMalabsorptionmalnutrition CancerCancer
Best Protection
Surveillance colonoscopySurveillance colonoscopy
Procto-colectomy (for UC)Procto-colectomy (for UC)
Descending Colon Descending Colon StrictureStricture
Colonic StricturesColonic Strictures
Consider nonsurgical management Consider nonsurgical management ifif Endoscopically accessibleEndoscopically accessible Multiple prior resectionsMultiple prior resections Shorter strictures (less than 5 cm)Shorter strictures (less than 5 cm) Steroid injection if significant Steroid injection if significant
inflammationinflammation
Fistula DefinitionA communication between two epithelial-lined organsLifetime risk of fistula in CD30
Perianal FistulaPerianal Fistula
Pretreatment 2 Weeks
10 Weeks 18 weeks
Educational ObjectivesEducational Objectives Definitions and spectrum of inflammatory Definitions and spectrum of inflammatory
bowel disease (IBD)bowel disease (IBD) Epidemiology of IBDEpidemiology of IBD Etiopathogenesis of IBDEtiopathogenesis of IBD Clinical manifestations of ulcerative colitis Clinical manifestations of ulcerative colitis
(UC)(UC) Clinical manifestations of Crohnrsquos disease Clinical manifestations of Crohnrsquos disease
(CD)(CD) Distinguishing features between UC and CDDistinguishing features between UC and CD Diagnostic approach to IBDDiagnostic approach to IBD Complications of IBDComplications of IBD IBD managementIBD management
Goals of Therapy for IBDGoals of Therapy for IBD
Inducing remissionInducing remission Maintaining remissionMaintaining remission Restoring and maintaining nutritionRestoring and maintaining nutrition Maintaining patientrsquos quality of lifeMaintaining patientrsquos quality of life Prevention of complicationsPrevention of complications Surgical intervention (selection of Surgical intervention (selection of
optimal time for surgery)optimal time for surgery)
Inductive TherapiesInductive Therapies
For UCFor UC AminosalicylatesAminosalicylates CorticosteroidsCorticosteroids CyclosporinCyclosporin
For CDFor CD AminosalicylatesAminosalicylates CorticosteroidsCorticosteroids AntibioticsAntibiotics Anti-TNFAnti-TNF
Maintenance TherapiesMaintenance Therapies
ImmunosupressorsImmunosupressors AzathioprineAzathioprine 6-MP6-MP MethotrexateMethotrexate
AminosalicylatesAminosalicylates Anti-TNFAnti-TNF
NOT NOT corticosteroidscorticosteroids
IBD ManagementIBD ManagementSummarySummary
There is no ldquoone size fits allrdquo to IBD therapyThere is no ldquoone size fits allrdquo to IBD therapy Therapy and decision making are tailored to the Therapy and decision making are tailored to the
individualindividual
Algorithms are based upon available evidenceAlgorithms are based upon available evidence Evidence is in constant fluxEvidence is in constant flux
Success of algorithms depends upon Success of algorithms depends upon optimization of each step of therapy and optimization of each step of therapy and considerable judgment about each outcomeconsiderable judgment about each outcome Skillful application of medical therapy makes all Skillful application of medical therapy makes all
the difference in outcomesthe difference in outcomes
Surgery for IBDSurgery for IBDGeneral ConceptsGeneral Concepts
Majority will need surgery 78 over Majority will need surgery 78 over twenty yearstwenty years
Surgery generally indicated for Surgery generally indicated for complicationscomplications of disease of disease
Surgery must be directed at area of Surgery must be directed at area of bowel responsible for complicationbowel responsible for complication
Indications for SurgeryIndications for Surgery Intestinal obstruction (most Intestinal obstruction (most
common)common) Intractabilitysteroid Intractabilitysteroid
dependencedependence Non-healing fistulaAbscessNon-healing fistulaAbscess Toxic megacolonFree Toxic megacolonFree
perforationperforation Uncontrollable GI bleedingUncontrollable GI bleeding Severe perianal diseaseSevere perianal disease CancerCancer Growth retardation Growth retardation
(children)(children) Severe uncontrollable Severe uncontrollable
extraintestinal extraintestinal manifestationsmanifestations
Management of IBDSummary
The goals of therapy are Relieve symptoms Prevent relapse Correct nutritional deficiencies Control inflammation Prevent complications especially colon cancer
Treatment depends on 1048707 Type of disease 1048707 Site of disease 1048707 Disease severity
Treatment may include drugs nutrition supplements surgery or a combination of these options
What are the Serological What are the Serological Markers in IBDMarkers in IBD
pANCA (perinuclear staining pattern)pANCA (perinuclear staining pattern) Loss of perinuclear pattern after Loss of perinuclear pattern after
DNAaseDNAase Differentiate from the ldquoother pANCAsrdquoDifferentiate from the ldquoother pANCAsrdquo
Antibody against myeloperoxidaseAntibody against myeloperoxidase Antibody against cathepsin G elastase lysozyme Antibody against cathepsin G elastase lysozyme
and lactoferrinand lactoferrin ASCA (anti-ASCA (anti-Saccharomyces cerevisiaeSaccharomyces cerevisiae))
Both IgG and IgABoth IgG and IgA Recognize mannose in the cell wall Recognize mannose in the cell wall
mannan of mannan of Saccharomyces cerevisiaeSaccharomyces cerevisiae
Why Use Serological Why Use Serological Markers in Clinical Markers in Clinical
PracticePractice Differentiate IBD from functional bowel Differentiate IBD from functional bowel
disordersdisorders Accurately diagnose Crohnrsquos or UC in a patient Accurately diagnose Crohnrsquos or UC in a patient
withwith Severe colitisSevere colitis Indeterminate colitisIndeterminate colitis
Predict disease course or complications in IBDPredict disease course or complications in IBD CD phenotypeCD phenotype Severity of diseaseSeverity of disease Risk of pouchitisRisk of pouchitis
SummarySummary
pANCA and ASCA are specific for UC pANCA and ASCA are specific for UC and CD respectivelyand CD respectively
Neither pANCA nor ASCA are sensitive Neither pANCA nor ASCA are sensitive enough to exclude IBDenough to exclude IBD
In patients with IC available In patients with IC available serological markers do not accurately serological markers do not accurately predict the subsequent disease coursepredict the subsequent disease course
Antibody profiles can predict disease Antibody profiles can predict disease behavior in IBDbehavior in IBD
Diagnostic ApproachDiagnostic ApproachEndoscopyEndoscopy
Endoscopy useful forEndoscopy useful for Initial diagnosisInitial diagnosis Assessment of severityAssessment of severity Tissue diagnosisTissue diagnosis FU during treatmentFU during treatment Assessment of disease exacerbationAssessment of disease exacerbation Surveillance for risk of cancerSurveillance for risk of cancer Treatment of certain complications (eg Treatment of certain complications (eg
strictures)strictures)
Crohnrsquos DiseaseCrohnrsquos DiseaseEndoscopic FeaturesEndoscopic Features
Asymmetric patchy inflammationAsymmetric patchy inflammation Skip lesionsSkip lesions Rectal sparingRectal sparing Ulcerations-deepserpiginousUlcerations-deepserpiginous Cobblestoning-commonCobblestoning-common Pseudopolyps-rarePseudopolyps-rare BiopsyBiopsy
Erosions and normal mucosaErosions and normal mucosa Granulomas in 15 to 35 of specimensGranulomas in 15 to 35 of specimens
Ulcerative ColitisUlcerative ColitisEndoscopic FeaturesEndoscopic Features
Diffuse involvementDiffuse involvement Rectum always diseasedRectum always diseased Superficial ulcerationsSuperficial ulcerations FriabilitybleedingFriabilitybleeding Flatteningdisappearance of haustral Flatteningdisappearance of haustral
foldsfolds PseudopolypsPseudopolyps No cobblestoningNo cobblestoning Bx No granulomasBx No granulomas
Imaging for Crohn Imaging for Crohn DiseaseDisease
Traditional TechniquesTraditional Techniques Abdominal RadiographsAbdominal Radiographs
Barium UGI Barium UGI
Barium small bowel follow throughBarium small bowel follow through
Barium EnteroclysisBarium Enteroclysis
Barium EnemaBarium Enema
Imaging for Crohn Disease Imaging for Crohn Disease Newer TechniquesNewer Techniques
CTCT
CT EnteroclysisCT Enteroclysis
CT EnterographyCT Enterography
Magnetic ResonanceMagnetic Resonance
UltrasoundUltrasound
Nuclear MedicineNuclear Medicine
Imaging for Crohns DiseaseImaging for Crohns Disease SummarySummary
Useful Newer TechniquesUseful Newer Techniques evolvingevolving CT EnterographyCT Enterography
Comprehensive evaluation of all bowel amp solid organsComprehensive evaluation of all bowel amp solid organs
Magnetic ResonanceMagnetic Resonance
Useful for ano-rectal diseaseUseful for ano-rectal disease
Real-time MR has potential for detection of stricturesReal-time MR has potential for detection of strictures
Traditional imaging techniques still of value in Traditional imaging techniques still of value in selected cases selected cases
The Capsule (WCE)The Capsule (WCE)
WCEWCE
bull Diameter 11mm Length 26mmDiameter 11mm Length 26mmbull Optical dome Intestinal illumination Optical dome Intestinal illumination
by white light emitting diodes (LEDrsquos)by white light emitting diodes (LEDrsquos)bull LensLensbull Complementary metal-oxide silicone Complementary metal-oxide silicone
imager (color camera chip)imager (color camera chip)bull TransmitterTransmitterbull Two batteries (silver oxide)Two batteries (silver oxide)
GE Junction Duodenum
Jejunum Ileocecal Valve
Educational ObjectivesEducational Objectives Definitions and spectrum of inflammatory Definitions and spectrum of inflammatory
bowel disease (IBD)bowel disease (IBD) Epidemiology of IBDEpidemiology of IBD Etiopathogenesis of IBDEtiopathogenesis of IBD Clinical manifestations of ulcerative colitis Clinical manifestations of ulcerative colitis
(UC)(UC) Clinical manifestations of Crohnrsquos disease Clinical manifestations of Crohnrsquos disease
(CD)(CD) Distinguishing features between UC and CDDistinguishing features between UC and CD Diagnostic approach to IBDDiagnostic approach to IBD Complications of IBDComplications of IBD IBD managementIBD management
IBD-ComplicationsIBD-Complications GI BleedingGI Bleeding Toxic megacolonToxic megacolon PerforationPerforation Thromboembolic phenomenaThromboembolic phenomena FistulasfissuresFistulasfissures AbscessAbscess StricturesobstructionStricturesobstruction MalabsorptionmalnutritionMalabsorptionmalnutrition CancerCancer
Best Protection
Surveillance colonoscopySurveillance colonoscopy
Procto-colectomy (for UC)Procto-colectomy (for UC)
Descending Colon Descending Colon StrictureStricture
Colonic StricturesColonic Strictures
Consider nonsurgical management Consider nonsurgical management ifif Endoscopically accessibleEndoscopically accessible Multiple prior resectionsMultiple prior resections Shorter strictures (less than 5 cm)Shorter strictures (less than 5 cm) Steroid injection if significant Steroid injection if significant
inflammationinflammation
Fistula DefinitionA communication between two epithelial-lined organsLifetime risk of fistula in CD30
Perianal FistulaPerianal Fistula
Pretreatment 2 Weeks
10 Weeks 18 weeks
Educational ObjectivesEducational Objectives Definitions and spectrum of inflammatory Definitions and spectrum of inflammatory
bowel disease (IBD)bowel disease (IBD) Epidemiology of IBDEpidemiology of IBD Etiopathogenesis of IBDEtiopathogenesis of IBD Clinical manifestations of ulcerative colitis Clinical manifestations of ulcerative colitis
(UC)(UC) Clinical manifestations of Crohnrsquos disease Clinical manifestations of Crohnrsquos disease
(CD)(CD) Distinguishing features between UC and CDDistinguishing features between UC and CD Diagnostic approach to IBDDiagnostic approach to IBD Complications of IBDComplications of IBD IBD managementIBD management
Goals of Therapy for IBDGoals of Therapy for IBD
Inducing remissionInducing remission Maintaining remissionMaintaining remission Restoring and maintaining nutritionRestoring and maintaining nutrition Maintaining patientrsquos quality of lifeMaintaining patientrsquos quality of life Prevention of complicationsPrevention of complications Surgical intervention (selection of Surgical intervention (selection of
optimal time for surgery)optimal time for surgery)
Inductive TherapiesInductive Therapies
For UCFor UC AminosalicylatesAminosalicylates CorticosteroidsCorticosteroids CyclosporinCyclosporin
For CDFor CD AminosalicylatesAminosalicylates CorticosteroidsCorticosteroids AntibioticsAntibiotics Anti-TNFAnti-TNF
Maintenance TherapiesMaintenance Therapies
ImmunosupressorsImmunosupressors AzathioprineAzathioprine 6-MP6-MP MethotrexateMethotrexate
AminosalicylatesAminosalicylates Anti-TNFAnti-TNF
NOT NOT corticosteroidscorticosteroids
IBD ManagementIBD ManagementSummarySummary
There is no ldquoone size fits allrdquo to IBD therapyThere is no ldquoone size fits allrdquo to IBD therapy Therapy and decision making are tailored to the Therapy and decision making are tailored to the
individualindividual
Algorithms are based upon available evidenceAlgorithms are based upon available evidence Evidence is in constant fluxEvidence is in constant flux
Success of algorithms depends upon Success of algorithms depends upon optimization of each step of therapy and optimization of each step of therapy and considerable judgment about each outcomeconsiderable judgment about each outcome Skillful application of medical therapy makes all Skillful application of medical therapy makes all
the difference in outcomesthe difference in outcomes
Surgery for IBDSurgery for IBDGeneral ConceptsGeneral Concepts
Majority will need surgery 78 over Majority will need surgery 78 over twenty yearstwenty years
Surgery generally indicated for Surgery generally indicated for complicationscomplications of disease of disease
Surgery must be directed at area of Surgery must be directed at area of bowel responsible for complicationbowel responsible for complication
Indications for SurgeryIndications for Surgery Intestinal obstruction (most Intestinal obstruction (most
common)common) Intractabilitysteroid Intractabilitysteroid
dependencedependence Non-healing fistulaAbscessNon-healing fistulaAbscess Toxic megacolonFree Toxic megacolonFree
perforationperforation Uncontrollable GI bleedingUncontrollable GI bleeding Severe perianal diseaseSevere perianal disease CancerCancer Growth retardation Growth retardation
(children)(children) Severe uncontrollable Severe uncontrollable
extraintestinal extraintestinal manifestationsmanifestations
Management of IBDSummary
The goals of therapy are Relieve symptoms Prevent relapse Correct nutritional deficiencies Control inflammation Prevent complications especially colon cancer
Treatment depends on 1048707 Type of disease 1048707 Site of disease 1048707 Disease severity
Treatment may include drugs nutrition supplements surgery or a combination of these options
Why Use Serological Why Use Serological Markers in Clinical Markers in Clinical
PracticePractice Differentiate IBD from functional bowel Differentiate IBD from functional bowel
disordersdisorders Accurately diagnose Crohnrsquos or UC in a patient Accurately diagnose Crohnrsquos or UC in a patient
withwith Severe colitisSevere colitis Indeterminate colitisIndeterminate colitis
Predict disease course or complications in IBDPredict disease course or complications in IBD CD phenotypeCD phenotype Severity of diseaseSeverity of disease Risk of pouchitisRisk of pouchitis
SummarySummary
pANCA and ASCA are specific for UC pANCA and ASCA are specific for UC and CD respectivelyand CD respectively
Neither pANCA nor ASCA are sensitive Neither pANCA nor ASCA are sensitive enough to exclude IBDenough to exclude IBD
In patients with IC available In patients with IC available serological markers do not accurately serological markers do not accurately predict the subsequent disease coursepredict the subsequent disease course
Antibody profiles can predict disease Antibody profiles can predict disease behavior in IBDbehavior in IBD
Diagnostic ApproachDiagnostic ApproachEndoscopyEndoscopy
Endoscopy useful forEndoscopy useful for Initial diagnosisInitial diagnosis Assessment of severityAssessment of severity Tissue diagnosisTissue diagnosis FU during treatmentFU during treatment Assessment of disease exacerbationAssessment of disease exacerbation Surveillance for risk of cancerSurveillance for risk of cancer Treatment of certain complications (eg Treatment of certain complications (eg
strictures)strictures)
Crohnrsquos DiseaseCrohnrsquos DiseaseEndoscopic FeaturesEndoscopic Features
Asymmetric patchy inflammationAsymmetric patchy inflammation Skip lesionsSkip lesions Rectal sparingRectal sparing Ulcerations-deepserpiginousUlcerations-deepserpiginous Cobblestoning-commonCobblestoning-common Pseudopolyps-rarePseudopolyps-rare BiopsyBiopsy
Erosions and normal mucosaErosions and normal mucosa Granulomas in 15 to 35 of specimensGranulomas in 15 to 35 of specimens
Ulcerative ColitisUlcerative ColitisEndoscopic FeaturesEndoscopic Features
Diffuse involvementDiffuse involvement Rectum always diseasedRectum always diseased Superficial ulcerationsSuperficial ulcerations FriabilitybleedingFriabilitybleeding Flatteningdisappearance of haustral Flatteningdisappearance of haustral
foldsfolds PseudopolypsPseudopolyps No cobblestoningNo cobblestoning Bx No granulomasBx No granulomas
Imaging for Crohn Imaging for Crohn DiseaseDisease
Traditional TechniquesTraditional Techniques Abdominal RadiographsAbdominal Radiographs
Barium UGI Barium UGI
Barium small bowel follow throughBarium small bowel follow through
Barium EnteroclysisBarium Enteroclysis
Barium EnemaBarium Enema
Imaging for Crohn Disease Imaging for Crohn Disease Newer TechniquesNewer Techniques
CTCT
CT EnteroclysisCT Enteroclysis
CT EnterographyCT Enterography
Magnetic ResonanceMagnetic Resonance
UltrasoundUltrasound
Nuclear MedicineNuclear Medicine
Imaging for Crohns DiseaseImaging for Crohns Disease SummarySummary
Useful Newer TechniquesUseful Newer Techniques evolvingevolving CT EnterographyCT Enterography
Comprehensive evaluation of all bowel amp solid organsComprehensive evaluation of all bowel amp solid organs
Magnetic ResonanceMagnetic Resonance
Useful for ano-rectal diseaseUseful for ano-rectal disease
Real-time MR has potential for detection of stricturesReal-time MR has potential for detection of strictures
Traditional imaging techniques still of value in Traditional imaging techniques still of value in selected cases selected cases
The Capsule (WCE)The Capsule (WCE)
WCEWCE
bull Diameter 11mm Length 26mmDiameter 11mm Length 26mmbull Optical dome Intestinal illumination Optical dome Intestinal illumination
by white light emitting diodes (LEDrsquos)by white light emitting diodes (LEDrsquos)bull LensLensbull Complementary metal-oxide silicone Complementary metal-oxide silicone
imager (color camera chip)imager (color camera chip)bull TransmitterTransmitterbull Two batteries (silver oxide)Two batteries (silver oxide)
GE Junction Duodenum
Jejunum Ileocecal Valve
Educational ObjectivesEducational Objectives Definitions and spectrum of inflammatory Definitions and spectrum of inflammatory
bowel disease (IBD)bowel disease (IBD) Epidemiology of IBDEpidemiology of IBD Etiopathogenesis of IBDEtiopathogenesis of IBD Clinical manifestations of ulcerative colitis Clinical manifestations of ulcerative colitis
(UC)(UC) Clinical manifestations of Crohnrsquos disease Clinical manifestations of Crohnrsquos disease
(CD)(CD) Distinguishing features between UC and CDDistinguishing features between UC and CD Diagnostic approach to IBDDiagnostic approach to IBD Complications of IBDComplications of IBD IBD managementIBD management
IBD-ComplicationsIBD-Complications GI BleedingGI Bleeding Toxic megacolonToxic megacolon PerforationPerforation Thromboembolic phenomenaThromboembolic phenomena FistulasfissuresFistulasfissures AbscessAbscess StricturesobstructionStricturesobstruction MalabsorptionmalnutritionMalabsorptionmalnutrition CancerCancer
Best Protection
Surveillance colonoscopySurveillance colonoscopy
Procto-colectomy (for UC)Procto-colectomy (for UC)
Descending Colon Descending Colon StrictureStricture
Colonic StricturesColonic Strictures
Consider nonsurgical management Consider nonsurgical management ifif Endoscopically accessibleEndoscopically accessible Multiple prior resectionsMultiple prior resections Shorter strictures (less than 5 cm)Shorter strictures (less than 5 cm) Steroid injection if significant Steroid injection if significant
inflammationinflammation
Fistula DefinitionA communication between two epithelial-lined organsLifetime risk of fistula in CD30
Perianal FistulaPerianal Fistula
Pretreatment 2 Weeks
10 Weeks 18 weeks
Educational ObjectivesEducational Objectives Definitions and spectrum of inflammatory Definitions and spectrum of inflammatory
bowel disease (IBD)bowel disease (IBD) Epidemiology of IBDEpidemiology of IBD Etiopathogenesis of IBDEtiopathogenesis of IBD Clinical manifestations of ulcerative colitis Clinical manifestations of ulcerative colitis
(UC)(UC) Clinical manifestations of Crohnrsquos disease Clinical manifestations of Crohnrsquos disease
(CD)(CD) Distinguishing features between UC and CDDistinguishing features between UC and CD Diagnostic approach to IBDDiagnostic approach to IBD Complications of IBDComplications of IBD IBD managementIBD management
Goals of Therapy for IBDGoals of Therapy for IBD
Inducing remissionInducing remission Maintaining remissionMaintaining remission Restoring and maintaining nutritionRestoring and maintaining nutrition Maintaining patientrsquos quality of lifeMaintaining patientrsquos quality of life Prevention of complicationsPrevention of complications Surgical intervention (selection of Surgical intervention (selection of
optimal time for surgery)optimal time for surgery)
Inductive TherapiesInductive Therapies
For UCFor UC AminosalicylatesAminosalicylates CorticosteroidsCorticosteroids CyclosporinCyclosporin
For CDFor CD AminosalicylatesAminosalicylates CorticosteroidsCorticosteroids AntibioticsAntibiotics Anti-TNFAnti-TNF
Maintenance TherapiesMaintenance Therapies
ImmunosupressorsImmunosupressors AzathioprineAzathioprine 6-MP6-MP MethotrexateMethotrexate
AminosalicylatesAminosalicylates Anti-TNFAnti-TNF
NOT NOT corticosteroidscorticosteroids
IBD ManagementIBD ManagementSummarySummary
There is no ldquoone size fits allrdquo to IBD therapyThere is no ldquoone size fits allrdquo to IBD therapy Therapy and decision making are tailored to the Therapy and decision making are tailored to the
individualindividual
Algorithms are based upon available evidenceAlgorithms are based upon available evidence Evidence is in constant fluxEvidence is in constant flux
Success of algorithms depends upon Success of algorithms depends upon optimization of each step of therapy and optimization of each step of therapy and considerable judgment about each outcomeconsiderable judgment about each outcome Skillful application of medical therapy makes all Skillful application of medical therapy makes all
the difference in outcomesthe difference in outcomes
Surgery for IBDSurgery for IBDGeneral ConceptsGeneral Concepts
Majority will need surgery 78 over Majority will need surgery 78 over twenty yearstwenty years
Surgery generally indicated for Surgery generally indicated for complicationscomplications of disease of disease
Surgery must be directed at area of Surgery must be directed at area of bowel responsible for complicationbowel responsible for complication
Indications for SurgeryIndications for Surgery Intestinal obstruction (most Intestinal obstruction (most
common)common) Intractabilitysteroid Intractabilitysteroid
dependencedependence Non-healing fistulaAbscessNon-healing fistulaAbscess Toxic megacolonFree Toxic megacolonFree
perforationperforation Uncontrollable GI bleedingUncontrollable GI bleeding Severe perianal diseaseSevere perianal disease CancerCancer Growth retardation Growth retardation
(children)(children) Severe uncontrollable Severe uncontrollable
extraintestinal extraintestinal manifestationsmanifestations
Management of IBDSummary
The goals of therapy are Relieve symptoms Prevent relapse Correct nutritional deficiencies Control inflammation Prevent complications especially colon cancer
Treatment depends on 1048707 Type of disease 1048707 Site of disease 1048707 Disease severity
Treatment may include drugs nutrition supplements surgery or a combination of these options
SummarySummary
pANCA and ASCA are specific for UC pANCA and ASCA are specific for UC and CD respectivelyand CD respectively
Neither pANCA nor ASCA are sensitive Neither pANCA nor ASCA are sensitive enough to exclude IBDenough to exclude IBD
In patients with IC available In patients with IC available serological markers do not accurately serological markers do not accurately predict the subsequent disease coursepredict the subsequent disease course
Antibody profiles can predict disease Antibody profiles can predict disease behavior in IBDbehavior in IBD
Diagnostic ApproachDiagnostic ApproachEndoscopyEndoscopy
Endoscopy useful forEndoscopy useful for Initial diagnosisInitial diagnosis Assessment of severityAssessment of severity Tissue diagnosisTissue diagnosis FU during treatmentFU during treatment Assessment of disease exacerbationAssessment of disease exacerbation Surveillance for risk of cancerSurveillance for risk of cancer Treatment of certain complications (eg Treatment of certain complications (eg
strictures)strictures)
Crohnrsquos DiseaseCrohnrsquos DiseaseEndoscopic FeaturesEndoscopic Features
Asymmetric patchy inflammationAsymmetric patchy inflammation Skip lesionsSkip lesions Rectal sparingRectal sparing Ulcerations-deepserpiginousUlcerations-deepserpiginous Cobblestoning-commonCobblestoning-common Pseudopolyps-rarePseudopolyps-rare BiopsyBiopsy
Erosions and normal mucosaErosions and normal mucosa Granulomas in 15 to 35 of specimensGranulomas in 15 to 35 of specimens
Ulcerative ColitisUlcerative ColitisEndoscopic FeaturesEndoscopic Features
Diffuse involvementDiffuse involvement Rectum always diseasedRectum always diseased Superficial ulcerationsSuperficial ulcerations FriabilitybleedingFriabilitybleeding Flatteningdisappearance of haustral Flatteningdisappearance of haustral
foldsfolds PseudopolypsPseudopolyps No cobblestoningNo cobblestoning Bx No granulomasBx No granulomas
Imaging for Crohn Imaging for Crohn DiseaseDisease
Traditional TechniquesTraditional Techniques Abdominal RadiographsAbdominal Radiographs
Barium UGI Barium UGI
Barium small bowel follow throughBarium small bowel follow through
Barium EnteroclysisBarium Enteroclysis
Barium EnemaBarium Enema
Imaging for Crohn Disease Imaging for Crohn Disease Newer TechniquesNewer Techniques
CTCT
CT EnteroclysisCT Enteroclysis
CT EnterographyCT Enterography
Magnetic ResonanceMagnetic Resonance
UltrasoundUltrasound
Nuclear MedicineNuclear Medicine
Imaging for Crohns DiseaseImaging for Crohns Disease SummarySummary
Useful Newer TechniquesUseful Newer Techniques evolvingevolving CT EnterographyCT Enterography
Comprehensive evaluation of all bowel amp solid organsComprehensive evaluation of all bowel amp solid organs
Magnetic ResonanceMagnetic Resonance
Useful for ano-rectal diseaseUseful for ano-rectal disease
Real-time MR has potential for detection of stricturesReal-time MR has potential for detection of strictures
Traditional imaging techniques still of value in Traditional imaging techniques still of value in selected cases selected cases
The Capsule (WCE)The Capsule (WCE)
WCEWCE
bull Diameter 11mm Length 26mmDiameter 11mm Length 26mmbull Optical dome Intestinal illumination Optical dome Intestinal illumination
by white light emitting diodes (LEDrsquos)by white light emitting diodes (LEDrsquos)bull LensLensbull Complementary metal-oxide silicone Complementary metal-oxide silicone
imager (color camera chip)imager (color camera chip)bull TransmitterTransmitterbull Two batteries (silver oxide)Two batteries (silver oxide)
GE Junction Duodenum
Jejunum Ileocecal Valve
Educational ObjectivesEducational Objectives Definitions and spectrum of inflammatory Definitions and spectrum of inflammatory
bowel disease (IBD)bowel disease (IBD) Epidemiology of IBDEpidemiology of IBD Etiopathogenesis of IBDEtiopathogenesis of IBD Clinical manifestations of ulcerative colitis Clinical manifestations of ulcerative colitis
(UC)(UC) Clinical manifestations of Crohnrsquos disease Clinical manifestations of Crohnrsquos disease
(CD)(CD) Distinguishing features between UC and CDDistinguishing features between UC and CD Diagnostic approach to IBDDiagnostic approach to IBD Complications of IBDComplications of IBD IBD managementIBD management
IBD-ComplicationsIBD-Complications GI BleedingGI Bleeding Toxic megacolonToxic megacolon PerforationPerforation Thromboembolic phenomenaThromboembolic phenomena FistulasfissuresFistulasfissures AbscessAbscess StricturesobstructionStricturesobstruction MalabsorptionmalnutritionMalabsorptionmalnutrition CancerCancer
Best Protection
Surveillance colonoscopySurveillance colonoscopy
Procto-colectomy (for UC)Procto-colectomy (for UC)
Descending Colon Descending Colon StrictureStricture
Colonic StricturesColonic Strictures
Consider nonsurgical management Consider nonsurgical management ifif Endoscopically accessibleEndoscopically accessible Multiple prior resectionsMultiple prior resections Shorter strictures (less than 5 cm)Shorter strictures (less than 5 cm) Steroid injection if significant Steroid injection if significant
inflammationinflammation
Fistula DefinitionA communication between two epithelial-lined organsLifetime risk of fistula in CD30
Perianal FistulaPerianal Fistula
Pretreatment 2 Weeks
10 Weeks 18 weeks
Educational ObjectivesEducational Objectives Definitions and spectrum of inflammatory Definitions and spectrum of inflammatory
bowel disease (IBD)bowel disease (IBD) Epidemiology of IBDEpidemiology of IBD Etiopathogenesis of IBDEtiopathogenesis of IBD Clinical manifestations of ulcerative colitis Clinical manifestations of ulcerative colitis
(UC)(UC) Clinical manifestations of Crohnrsquos disease Clinical manifestations of Crohnrsquos disease
(CD)(CD) Distinguishing features between UC and CDDistinguishing features between UC and CD Diagnostic approach to IBDDiagnostic approach to IBD Complications of IBDComplications of IBD IBD managementIBD management
Goals of Therapy for IBDGoals of Therapy for IBD
Inducing remissionInducing remission Maintaining remissionMaintaining remission Restoring and maintaining nutritionRestoring and maintaining nutrition Maintaining patientrsquos quality of lifeMaintaining patientrsquos quality of life Prevention of complicationsPrevention of complications Surgical intervention (selection of Surgical intervention (selection of
optimal time for surgery)optimal time for surgery)
Inductive TherapiesInductive Therapies
For UCFor UC AminosalicylatesAminosalicylates CorticosteroidsCorticosteroids CyclosporinCyclosporin
For CDFor CD AminosalicylatesAminosalicylates CorticosteroidsCorticosteroids AntibioticsAntibiotics Anti-TNFAnti-TNF
Maintenance TherapiesMaintenance Therapies
ImmunosupressorsImmunosupressors AzathioprineAzathioprine 6-MP6-MP MethotrexateMethotrexate
AminosalicylatesAminosalicylates Anti-TNFAnti-TNF
NOT NOT corticosteroidscorticosteroids
IBD ManagementIBD ManagementSummarySummary
There is no ldquoone size fits allrdquo to IBD therapyThere is no ldquoone size fits allrdquo to IBD therapy Therapy and decision making are tailored to the Therapy and decision making are tailored to the
individualindividual
Algorithms are based upon available evidenceAlgorithms are based upon available evidence Evidence is in constant fluxEvidence is in constant flux
Success of algorithms depends upon Success of algorithms depends upon optimization of each step of therapy and optimization of each step of therapy and considerable judgment about each outcomeconsiderable judgment about each outcome Skillful application of medical therapy makes all Skillful application of medical therapy makes all
the difference in outcomesthe difference in outcomes
Surgery for IBDSurgery for IBDGeneral ConceptsGeneral Concepts
Majority will need surgery 78 over Majority will need surgery 78 over twenty yearstwenty years
Surgery generally indicated for Surgery generally indicated for complicationscomplications of disease of disease
Surgery must be directed at area of Surgery must be directed at area of bowel responsible for complicationbowel responsible for complication
Indications for SurgeryIndications for Surgery Intestinal obstruction (most Intestinal obstruction (most
common)common) Intractabilitysteroid Intractabilitysteroid
dependencedependence Non-healing fistulaAbscessNon-healing fistulaAbscess Toxic megacolonFree Toxic megacolonFree
perforationperforation Uncontrollable GI bleedingUncontrollable GI bleeding Severe perianal diseaseSevere perianal disease CancerCancer Growth retardation Growth retardation
(children)(children) Severe uncontrollable Severe uncontrollable
extraintestinal extraintestinal manifestationsmanifestations
Management of IBDSummary
The goals of therapy are Relieve symptoms Prevent relapse Correct nutritional deficiencies Control inflammation Prevent complications especially colon cancer
Treatment depends on 1048707 Type of disease 1048707 Site of disease 1048707 Disease severity
Treatment may include drugs nutrition supplements surgery or a combination of these options
Diagnostic ApproachDiagnostic ApproachEndoscopyEndoscopy
Endoscopy useful forEndoscopy useful for Initial diagnosisInitial diagnosis Assessment of severityAssessment of severity Tissue diagnosisTissue diagnosis FU during treatmentFU during treatment Assessment of disease exacerbationAssessment of disease exacerbation Surveillance for risk of cancerSurveillance for risk of cancer Treatment of certain complications (eg Treatment of certain complications (eg
strictures)strictures)
Crohnrsquos DiseaseCrohnrsquos DiseaseEndoscopic FeaturesEndoscopic Features
Asymmetric patchy inflammationAsymmetric patchy inflammation Skip lesionsSkip lesions Rectal sparingRectal sparing Ulcerations-deepserpiginousUlcerations-deepserpiginous Cobblestoning-commonCobblestoning-common Pseudopolyps-rarePseudopolyps-rare BiopsyBiopsy
Erosions and normal mucosaErosions and normal mucosa Granulomas in 15 to 35 of specimensGranulomas in 15 to 35 of specimens
Ulcerative ColitisUlcerative ColitisEndoscopic FeaturesEndoscopic Features
Diffuse involvementDiffuse involvement Rectum always diseasedRectum always diseased Superficial ulcerationsSuperficial ulcerations FriabilitybleedingFriabilitybleeding Flatteningdisappearance of haustral Flatteningdisappearance of haustral
foldsfolds PseudopolypsPseudopolyps No cobblestoningNo cobblestoning Bx No granulomasBx No granulomas
Imaging for Crohn Imaging for Crohn DiseaseDisease
Traditional TechniquesTraditional Techniques Abdominal RadiographsAbdominal Radiographs
Barium UGI Barium UGI
Barium small bowel follow throughBarium small bowel follow through
Barium EnteroclysisBarium Enteroclysis
Barium EnemaBarium Enema
Imaging for Crohn Disease Imaging for Crohn Disease Newer TechniquesNewer Techniques
CTCT
CT EnteroclysisCT Enteroclysis
CT EnterographyCT Enterography
Magnetic ResonanceMagnetic Resonance
UltrasoundUltrasound
Nuclear MedicineNuclear Medicine
Imaging for Crohns DiseaseImaging for Crohns Disease SummarySummary
Useful Newer TechniquesUseful Newer Techniques evolvingevolving CT EnterographyCT Enterography
Comprehensive evaluation of all bowel amp solid organsComprehensive evaluation of all bowel amp solid organs
Magnetic ResonanceMagnetic Resonance
Useful for ano-rectal diseaseUseful for ano-rectal disease
Real-time MR has potential for detection of stricturesReal-time MR has potential for detection of strictures
Traditional imaging techniques still of value in Traditional imaging techniques still of value in selected cases selected cases
The Capsule (WCE)The Capsule (WCE)
WCEWCE
bull Diameter 11mm Length 26mmDiameter 11mm Length 26mmbull Optical dome Intestinal illumination Optical dome Intestinal illumination
by white light emitting diodes (LEDrsquos)by white light emitting diodes (LEDrsquos)bull LensLensbull Complementary metal-oxide silicone Complementary metal-oxide silicone
imager (color camera chip)imager (color camera chip)bull TransmitterTransmitterbull Two batteries (silver oxide)Two batteries (silver oxide)
GE Junction Duodenum
Jejunum Ileocecal Valve
Educational ObjectivesEducational Objectives Definitions and spectrum of inflammatory Definitions and spectrum of inflammatory
bowel disease (IBD)bowel disease (IBD) Epidemiology of IBDEpidemiology of IBD Etiopathogenesis of IBDEtiopathogenesis of IBD Clinical manifestations of ulcerative colitis Clinical manifestations of ulcerative colitis
(UC)(UC) Clinical manifestations of Crohnrsquos disease Clinical manifestations of Crohnrsquos disease
(CD)(CD) Distinguishing features between UC and CDDistinguishing features between UC and CD Diagnostic approach to IBDDiagnostic approach to IBD Complications of IBDComplications of IBD IBD managementIBD management
IBD-ComplicationsIBD-Complications GI BleedingGI Bleeding Toxic megacolonToxic megacolon PerforationPerforation Thromboembolic phenomenaThromboembolic phenomena FistulasfissuresFistulasfissures AbscessAbscess StricturesobstructionStricturesobstruction MalabsorptionmalnutritionMalabsorptionmalnutrition CancerCancer
Best Protection
Surveillance colonoscopySurveillance colonoscopy
Procto-colectomy (for UC)Procto-colectomy (for UC)
Descending Colon Descending Colon StrictureStricture
Colonic StricturesColonic Strictures
Consider nonsurgical management Consider nonsurgical management ifif Endoscopically accessibleEndoscopically accessible Multiple prior resectionsMultiple prior resections Shorter strictures (less than 5 cm)Shorter strictures (less than 5 cm) Steroid injection if significant Steroid injection if significant
inflammationinflammation
Fistula DefinitionA communication between two epithelial-lined organsLifetime risk of fistula in CD30
Perianal FistulaPerianal Fistula
Pretreatment 2 Weeks
10 Weeks 18 weeks
Educational ObjectivesEducational Objectives Definitions and spectrum of inflammatory Definitions and spectrum of inflammatory
bowel disease (IBD)bowel disease (IBD) Epidemiology of IBDEpidemiology of IBD Etiopathogenesis of IBDEtiopathogenesis of IBD Clinical manifestations of ulcerative colitis Clinical manifestations of ulcerative colitis
(UC)(UC) Clinical manifestations of Crohnrsquos disease Clinical manifestations of Crohnrsquos disease
(CD)(CD) Distinguishing features between UC and CDDistinguishing features between UC and CD Diagnostic approach to IBDDiagnostic approach to IBD Complications of IBDComplications of IBD IBD managementIBD management
Goals of Therapy for IBDGoals of Therapy for IBD
Inducing remissionInducing remission Maintaining remissionMaintaining remission Restoring and maintaining nutritionRestoring and maintaining nutrition Maintaining patientrsquos quality of lifeMaintaining patientrsquos quality of life Prevention of complicationsPrevention of complications Surgical intervention (selection of Surgical intervention (selection of
optimal time for surgery)optimal time for surgery)
Inductive TherapiesInductive Therapies
For UCFor UC AminosalicylatesAminosalicylates CorticosteroidsCorticosteroids CyclosporinCyclosporin
For CDFor CD AminosalicylatesAminosalicylates CorticosteroidsCorticosteroids AntibioticsAntibiotics Anti-TNFAnti-TNF
Maintenance TherapiesMaintenance Therapies
ImmunosupressorsImmunosupressors AzathioprineAzathioprine 6-MP6-MP MethotrexateMethotrexate
AminosalicylatesAminosalicylates Anti-TNFAnti-TNF
NOT NOT corticosteroidscorticosteroids
IBD ManagementIBD ManagementSummarySummary
There is no ldquoone size fits allrdquo to IBD therapyThere is no ldquoone size fits allrdquo to IBD therapy Therapy and decision making are tailored to the Therapy and decision making are tailored to the
individualindividual
Algorithms are based upon available evidenceAlgorithms are based upon available evidence Evidence is in constant fluxEvidence is in constant flux
Success of algorithms depends upon Success of algorithms depends upon optimization of each step of therapy and optimization of each step of therapy and considerable judgment about each outcomeconsiderable judgment about each outcome Skillful application of medical therapy makes all Skillful application of medical therapy makes all
the difference in outcomesthe difference in outcomes
Surgery for IBDSurgery for IBDGeneral ConceptsGeneral Concepts
Majority will need surgery 78 over Majority will need surgery 78 over twenty yearstwenty years
Surgery generally indicated for Surgery generally indicated for complicationscomplications of disease of disease
Surgery must be directed at area of Surgery must be directed at area of bowel responsible for complicationbowel responsible for complication
Indications for SurgeryIndications for Surgery Intestinal obstruction (most Intestinal obstruction (most
common)common) Intractabilitysteroid Intractabilitysteroid
dependencedependence Non-healing fistulaAbscessNon-healing fistulaAbscess Toxic megacolonFree Toxic megacolonFree
perforationperforation Uncontrollable GI bleedingUncontrollable GI bleeding Severe perianal diseaseSevere perianal disease CancerCancer Growth retardation Growth retardation
(children)(children) Severe uncontrollable Severe uncontrollable
extraintestinal extraintestinal manifestationsmanifestations
Management of IBDSummary
The goals of therapy are Relieve symptoms Prevent relapse Correct nutritional deficiencies Control inflammation Prevent complications especially colon cancer
Treatment depends on 1048707 Type of disease 1048707 Site of disease 1048707 Disease severity
Treatment may include drugs nutrition supplements surgery or a combination of these options
Crohnrsquos DiseaseCrohnrsquos DiseaseEndoscopic FeaturesEndoscopic Features
Asymmetric patchy inflammationAsymmetric patchy inflammation Skip lesionsSkip lesions Rectal sparingRectal sparing Ulcerations-deepserpiginousUlcerations-deepserpiginous Cobblestoning-commonCobblestoning-common Pseudopolyps-rarePseudopolyps-rare BiopsyBiopsy
Erosions and normal mucosaErosions and normal mucosa Granulomas in 15 to 35 of specimensGranulomas in 15 to 35 of specimens
Ulcerative ColitisUlcerative ColitisEndoscopic FeaturesEndoscopic Features
Diffuse involvementDiffuse involvement Rectum always diseasedRectum always diseased Superficial ulcerationsSuperficial ulcerations FriabilitybleedingFriabilitybleeding Flatteningdisappearance of haustral Flatteningdisappearance of haustral
foldsfolds PseudopolypsPseudopolyps No cobblestoningNo cobblestoning Bx No granulomasBx No granulomas
Imaging for Crohn Imaging for Crohn DiseaseDisease
Traditional TechniquesTraditional Techniques Abdominal RadiographsAbdominal Radiographs
Barium UGI Barium UGI
Barium small bowel follow throughBarium small bowel follow through
Barium EnteroclysisBarium Enteroclysis
Barium EnemaBarium Enema
Imaging for Crohn Disease Imaging for Crohn Disease Newer TechniquesNewer Techniques
CTCT
CT EnteroclysisCT Enteroclysis
CT EnterographyCT Enterography
Magnetic ResonanceMagnetic Resonance
UltrasoundUltrasound
Nuclear MedicineNuclear Medicine
Imaging for Crohns DiseaseImaging for Crohns Disease SummarySummary
Useful Newer TechniquesUseful Newer Techniques evolvingevolving CT EnterographyCT Enterography
Comprehensive evaluation of all bowel amp solid organsComprehensive evaluation of all bowel amp solid organs
Magnetic ResonanceMagnetic Resonance
Useful for ano-rectal diseaseUseful for ano-rectal disease
Real-time MR has potential for detection of stricturesReal-time MR has potential for detection of strictures
Traditional imaging techniques still of value in Traditional imaging techniques still of value in selected cases selected cases
The Capsule (WCE)The Capsule (WCE)
WCEWCE
bull Diameter 11mm Length 26mmDiameter 11mm Length 26mmbull Optical dome Intestinal illumination Optical dome Intestinal illumination
by white light emitting diodes (LEDrsquos)by white light emitting diodes (LEDrsquos)bull LensLensbull Complementary metal-oxide silicone Complementary metal-oxide silicone
imager (color camera chip)imager (color camera chip)bull TransmitterTransmitterbull Two batteries (silver oxide)Two batteries (silver oxide)
GE Junction Duodenum
Jejunum Ileocecal Valve
Educational ObjectivesEducational Objectives Definitions and spectrum of inflammatory Definitions and spectrum of inflammatory
bowel disease (IBD)bowel disease (IBD) Epidemiology of IBDEpidemiology of IBD Etiopathogenesis of IBDEtiopathogenesis of IBD Clinical manifestations of ulcerative colitis Clinical manifestations of ulcerative colitis
(UC)(UC) Clinical manifestations of Crohnrsquos disease Clinical manifestations of Crohnrsquos disease
(CD)(CD) Distinguishing features between UC and CDDistinguishing features between UC and CD Diagnostic approach to IBDDiagnostic approach to IBD Complications of IBDComplications of IBD IBD managementIBD management
IBD-ComplicationsIBD-Complications GI BleedingGI Bleeding Toxic megacolonToxic megacolon PerforationPerforation Thromboembolic phenomenaThromboembolic phenomena FistulasfissuresFistulasfissures AbscessAbscess StricturesobstructionStricturesobstruction MalabsorptionmalnutritionMalabsorptionmalnutrition CancerCancer
Best Protection
Surveillance colonoscopySurveillance colonoscopy
Procto-colectomy (for UC)Procto-colectomy (for UC)
Descending Colon Descending Colon StrictureStricture
Colonic StricturesColonic Strictures
Consider nonsurgical management Consider nonsurgical management ifif Endoscopically accessibleEndoscopically accessible Multiple prior resectionsMultiple prior resections Shorter strictures (less than 5 cm)Shorter strictures (less than 5 cm) Steroid injection if significant Steroid injection if significant
inflammationinflammation
Fistula DefinitionA communication between two epithelial-lined organsLifetime risk of fistula in CD30
Perianal FistulaPerianal Fistula
Pretreatment 2 Weeks
10 Weeks 18 weeks
Educational ObjectivesEducational Objectives Definitions and spectrum of inflammatory Definitions and spectrum of inflammatory
bowel disease (IBD)bowel disease (IBD) Epidemiology of IBDEpidemiology of IBD Etiopathogenesis of IBDEtiopathogenesis of IBD Clinical manifestations of ulcerative colitis Clinical manifestations of ulcerative colitis
(UC)(UC) Clinical manifestations of Crohnrsquos disease Clinical manifestations of Crohnrsquos disease
(CD)(CD) Distinguishing features between UC and CDDistinguishing features between UC and CD Diagnostic approach to IBDDiagnostic approach to IBD Complications of IBDComplications of IBD IBD managementIBD management
Goals of Therapy for IBDGoals of Therapy for IBD
Inducing remissionInducing remission Maintaining remissionMaintaining remission Restoring and maintaining nutritionRestoring and maintaining nutrition Maintaining patientrsquos quality of lifeMaintaining patientrsquos quality of life Prevention of complicationsPrevention of complications Surgical intervention (selection of Surgical intervention (selection of
optimal time for surgery)optimal time for surgery)
Inductive TherapiesInductive Therapies
For UCFor UC AminosalicylatesAminosalicylates CorticosteroidsCorticosteroids CyclosporinCyclosporin
For CDFor CD AminosalicylatesAminosalicylates CorticosteroidsCorticosteroids AntibioticsAntibiotics Anti-TNFAnti-TNF
Maintenance TherapiesMaintenance Therapies
ImmunosupressorsImmunosupressors AzathioprineAzathioprine 6-MP6-MP MethotrexateMethotrexate
AminosalicylatesAminosalicylates Anti-TNFAnti-TNF
NOT NOT corticosteroidscorticosteroids
IBD ManagementIBD ManagementSummarySummary
There is no ldquoone size fits allrdquo to IBD therapyThere is no ldquoone size fits allrdquo to IBD therapy Therapy and decision making are tailored to the Therapy and decision making are tailored to the
individualindividual
Algorithms are based upon available evidenceAlgorithms are based upon available evidence Evidence is in constant fluxEvidence is in constant flux
Success of algorithms depends upon Success of algorithms depends upon optimization of each step of therapy and optimization of each step of therapy and considerable judgment about each outcomeconsiderable judgment about each outcome Skillful application of medical therapy makes all Skillful application of medical therapy makes all
the difference in outcomesthe difference in outcomes
Surgery for IBDSurgery for IBDGeneral ConceptsGeneral Concepts
Majority will need surgery 78 over Majority will need surgery 78 over twenty yearstwenty years
Surgery generally indicated for Surgery generally indicated for complicationscomplications of disease of disease
Surgery must be directed at area of Surgery must be directed at area of bowel responsible for complicationbowel responsible for complication
Indications for SurgeryIndications for Surgery Intestinal obstruction (most Intestinal obstruction (most
common)common) Intractabilitysteroid Intractabilitysteroid
dependencedependence Non-healing fistulaAbscessNon-healing fistulaAbscess Toxic megacolonFree Toxic megacolonFree
perforationperforation Uncontrollable GI bleedingUncontrollable GI bleeding Severe perianal diseaseSevere perianal disease CancerCancer Growth retardation Growth retardation
(children)(children) Severe uncontrollable Severe uncontrollable
extraintestinal extraintestinal manifestationsmanifestations
Management of IBDSummary
The goals of therapy are Relieve symptoms Prevent relapse Correct nutritional deficiencies Control inflammation Prevent complications especially colon cancer
Treatment depends on 1048707 Type of disease 1048707 Site of disease 1048707 Disease severity
Treatment may include drugs nutrition supplements surgery or a combination of these options
Ulcerative ColitisUlcerative ColitisEndoscopic FeaturesEndoscopic Features
Diffuse involvementDiffuse involvement Rectum always diseasedRectum always diseased Superficial ulcerationsSuperficial ulcerations FriabilitybleedingFriabilitybleeding Flatteningdisappearance of haustral Flatteningdisappearance of haustral
foldsfolds PseudopolypsPseudopolyps No cobblestoningNo cobblestoning Bx No granulomasBx No granulomas
Imaging for Crohn Imaging for Crohn DiseaseDisease
Traditional TechniquesTraditional Techniques Abdominal RadiographsAbdominal Radiographs
Barium UGI Barium UGI
Barium small bowel follow throughBarium small bowel follow through
Barium EnteroclysisBarium Enteroclysis
Barium EnemaBarium Enema
Imaging for Crohn Disease Imaging for Crohn Disease Newer TechniquesNewer Techniques
CTCT
CT EnteroclysisCT Enteroclysis
CT EnterographyCT Enterography
Magnetic ResonanceMagnetic Resonance
UltrasoundUltrasound
Nuclear MedicineNuclear Medicine
Imaging for Crohns DiseaseImaging for Crohns Disease SummarySummary
Useful Newer TechniquesUseful Newer Techniques evolvingevolving CT EnterographyCT Enterography
Comprehensive evaluation of all bowel amp solid organsComprehensive evaluation of all bowel amp solid organs
Magnetic ResonanceMagnetic Resonance
Useful for ano-rectal diseaseUseful for ano-rectal disease
Real-time MR has potential for detection of stricturesReal-time MR has potential for detection of strictures
Traditional imaging techniques still of value in Traditional imaging techniques still of value in selected cases selected cases
The Capsule (WCE)The Capsule (WCE)
WCEWCE
bull Diameter 11mm Length 26mmDiameter 11mm Length 26mmbull Optical dome Intestinal illumination Optical dome Intestinal illumination
by white light emitting diodes (LEDrsquos)by white light emitting diodes (LEDrsquos)bull LensLensbull Complementary metal-oxide silicone Complementary metal-oxide silicone
imager (color camera chip)imager (color camera chip)bull TransmitterTransmitterbull Two batteries (silver oxide)Two batteries (silver oxide)
GE Junction Duodenum
Jejunum Ileocecal Valve
Educational ObjectivesEducational Objectives Definitions and spectrum of inflammatory Definitions and spectrum of inflammatory
bowel disease (IBD)bowel disease (IBD) Epidemiology of IBDEpidemiology of IBD Etiopathogenesis of IBDEtiopathogenesis of IBD Clinical manifestations of ulcerative colitis Clinical manifestations of ulcerative colitis
(UC)(UC) Clinical manifestations of Crohnrsquos disease Clinical manifestations of Crohnrsquos disease
(CD)(CD) Distinguishing features between UC and CDDistinguishing features between UC and CD Diagnostic approach to IBDDiagnostic approach to IBD Complications of IBDComplications of IBD IBD managementIBD management
IBD-ComplicationsIBD-Complications GI BleedingGI Bleeding Toxic megacolonToxic megacolon PerforationPerforation Thromboembolic phenomenaThromboembolic phenomena FistulasfissuresFistulasfissures AbscessAbscess StricturesobstructionStricturesobstruction MalabsorptionmalnutritionMalabsorptionmalnutrition CancerCancer
Best Protection
Surveillance colonoscopySurveillance colonoscopy
Procto-colectomy (for UC)Procto-colectomy (for UC)
Descending Colon Descending Colon StrictureStricture
Colonic StricturesColonic Strictures
Consider nonsurgical management Consider nonsurgical management ifif Endoscopically accessibleEndoscopically accessible Multiple prior resectionsMultiple prior resections Shorter strictures (less than 5 cm)Shorter strictures (less than 5 cm) Steroid injection if significant Steroid injection if significant
inflammationinflammation
Fistula DefinitionA communication between two epithelial-lined organsLifetime risk of fistula in CD30
Perianal FistulaPerianal Fistula
Pretreatment 2 Weeks
10 Weeks 18 weeks
Educational ObjectivesEducational Objectives Definitions and spectrum of inflammatory Definitions and spectrum of inflammatory
bowel disease (IBD)bowel disease (IBD) Epidemiology of IBDEpidemiology of IBD Etiopathogenesis of IBDEtiopathogenesis of IBD Clinical manifestations of ulcerative colitis Clinical manifestations of ulcerative colitis
(UC)(UC) Clinical manifestations of Crohnrsquos disease Clinical manifestations of Crohnrsquos disease
(CD)(CD) Distinguishing features between UC and CDDistinguishing features between UC and CD Diagnostic approach to IBDDiagnostic approach to IBD Complications of IBDComplications of IBD IBD managementIBD management
Goals of Therapy for IBDGoals of Therapy for IBD
Inducing remissionInducing remission Maintaining remissionMaintaining remission Restoring and maintaining nutritionRestoring and maintaining nutrition Maintaining patientrsquos quality of lifeMaintaining patientrsquos quality of life Prevention of complicationsPrevention of complications Surgical intervention (selection of Surgical intervention (selection of
optimal time for surgery)optimal time for surgery)
Inductive TherapiesInductive Therapies
For UCFor UC AminosalicylatesAminosalicylates CorticosteroidsCorticosteroids CyclosporinCyclosporin
For CDFor CD AminosalicylatesAminosalicylates CorticosteroidsCorticosteroids AntibioticsAntibiotics Anti-TNFAnti-TNF
Maintenance TherapiesMaintenance Therapies
ImmunosupressorsImmunosupressors AzathioprineAzathioprine 6-MP6-MP MethotrexateMethotrexate
AminosalicylatesAminosalicylates Anti-TNFAnti-TNF
NOT NOT corticosteroidscorticosteroids
IBD ManagementIBD ManagementSummarySummary
There is no ldquoone size fits allrdquo to IBD therapyThere is no ldquoone size fits allrdquo to IBD therapy Therapy and decision making are tailored to the Therapy and decision making are tailored to the
individualindividual
Algorithms are based upon available evidenceAlgorithms are based upon available evidence Evidence is in constant fluxEvidence is in constant flux
Success of algorithms depends upon Success of algorithms depends upon optimization of each step of therapy and optimization of each step of therapy and considerable judgment about each outcomeconsiderable judgment about each outcome Skillful application of medical therapy makes all Skillful application of medical therapy makes all
the difference in outcomesthe difference in outcomes
Surgery for IBDSurgery for IBDGeneral ConceptsGeneral Concepts
Majority will need surgery 78 over Majority will need surgery 78 over twenty yearstwenty years
Surgery generally indicated for Surgery generally indicated for complicationscomplications of disease of disease
Surgery must be directed at area of Surgery must be directed at area of bowel responsible for complicationbowel responsible for complication
Indications for SurgeryIndications for Surgery Intestinal obstruction (most Intestinal obstruction (most
common)common) Intractabilitysteroid Intractabilitysteroid
dependencedependence Non-healing fistulaAbscessNon-healing fistulaAbscess Toxic megacolonFree Toxic megacolonFree
perforationperforation Uncontrollable GI bleedingUncontrollable GI bleeding Severe perianal diseaseSevere perianal disease CancerCancer Growth retardation Growth retardation
(children)(children) Severe uncontrollable Severe uncontrollable
extraintestinal extraintestinal manifestationsmanifestations
Management of IBDSummary
The goals of therapy are Relieve symptoms Prevent relapse Correct nutritional deficiencies Control inflammation Prevent complications especially colon cancer
Treatment depends on 1048707 Type of disease 1048707 Site of disease 1048707 Disease severity
Treatment may include drugs nutrition supplements surgery or a combination of these options
Imaging for Crohn Imaging for Crohn DiseaseDisease
Traditional TechniquesTraditional Techniques Abdominal RadiographsAbdominal Radiographs
Barium UGI Barium UGI
Barium small bowel follow throughBarium small bowel follow through
Barium EnteroclysisBarium Enteroclysis
Barium EnemaBarium Enema
Imaging for Crohn Disease Imaging for Crohn Disease Newer TechniquesNewer Techniques
CTCT
CT EnteroclysisCT Enteroclysis
CT EnterographyCT Enterography
Magnetic ResonanceMagnetic Resonance
UltrasoundUltrasound
Nuclear MedicineNuclear Medicine
Imaging for Crohns DiseaseImaging for Crohns Disease SummarySummary
Useful Newer TechniquesUseful Newer Techniques evolvingevolving CT EnterographyCT Enterography
Comprehensive evaluation of all bowel amp solid organsComprehensive evaluation of all bowel amp solid organs
Magnetic ResonanceMagnetic Resonance
Useful for ano-rectal diseaseUseful for ano-rectal disease
Real-time MR has potential for detection of stricturesReal-time MR has potential for detection of strictures
Traditional imaging techniques still of value in Traditional imaging techniques still of value in selected cases selected cases
The Capsule (WCE)The Capsule (WCE)
WCEWCE
bull Diameter 11mm Length 26mmDiameter 11mm Length 26mmbull Optical dome Intestinal illumination Optical dome Intestinal illumination
by white light emitting diodes (LEDrsquos)by white light emitting diodes (LEDrsquos)bull LensLensbull Complementary metal-oxide silicone Complementary metal-oxide silicone
imager (color camera chip)imager (color camera chip)bull TransmitterTransmitterbull Two batteries (silver oxide)Two batteries (silver oxide)
GE Junction Duodenum
Jejunum Ileocecal Valve
Educational ObjectivesEducational Objectives Definitions and spectrum of inflammatory Definitions and spectrum of inflammatory
bowel disease (IBD)bowel disease (IBD) Epidemiology of IBDEpidemiology of IBD Etiopathogenesis of IBDEtiopathogenesis of IBD Clinical manifestations of ulcerative colitis Clinical manifestations of ulcerative colitis
(UC)(UC) Clinical manifestations of Crohnrsquos disease Clinical manifestations of Crohnrsquos disease
(CD)(CD) Distinguishing features between UC and CDDistinguishing features between UC and CD Diagnostic approach to IBDDiagnostic approach to IBD Complications of IBDComplications of IBD IBD managementIBD management
IBD-ComplicationsIBD-Complications GI BleedingGI Bleeding Toxic megacolonToxic megacolon PerforationPerforation Thromboembolic phenomenaThromboembolic phenomena FistulasfissuresFistulasfissures AbscessAbscess StricturesobstructionStricturesobstruction MalabsorptionmalnutritionMalabsorptionmalnutrition CancerCancer
Best Protection
Surveillance colonoscopySurveillance colonoscopy
Procto-colectomy (for UC)Procto-colectomy (for UC)
Descending Colon Descending Colon StrictureStricture
Colonic StricturesColonic Strictures
Consider nonsurgical management Consider nonsurgical management ifif Endoscopically accessibleEndoscopically accessible Multiple prior resectionsMultiple prior resections Shorter strictures (less than 5 cm)Shorter strictures (less than 5 cm) Steroid injection if significant Steroid injection if significant
inflammationinflammation
Fistula DefinitionA communication between two epithelial-lined organsLifetime risk of fistula in CD30
Perianal FistulaPerianal Fistula
Pretreatment 2 Weeks
10 Weeks 18 weeks
Educational ObjectivesEducational Objectives Definitions and spectrum of inflammatory Definitions and spectrum of inflammatory
bowel disease (IBD)bowel disease (IBD) Epidemiology of IBDEpidemiology of IBD Etiopathogenesis of IBDEtiopathogenesis of IBD Clinical manifestations of ulcerative colitis Clinical manifestations of ulcerative colitis
(UC)(UC) Clinical manifestations of Crohnrsquos disease Clinical manifestations of Crohnrsquos disease
(CD)(CD) Distinguishing features between UC and CDDistinguishing features between UC and CD Diagnostic approach to IBDDiagnostic approach to IBD Complications of IBDComplications of IBD IBD managementIBD management
Goals of Therapy for IBDGoals of Therapy for IBD
Inducing remissionInducing remission Maintaining remissionMaintaining remission Restoring and maintaining nutritionRestoring and maintaining nutrition Maintaining patientrsquos quality of lifeMaintaining patientrsquos quality of life Prevention of complicationsPrevention of complications Surgical intervention (selection of Surgical intervention (selection of
optimal time for surgery)optimal time for surgery)
Inductive TherapiesInductive Therapies
For UCFor UC AminosalicylatesAminosalicylates CorticosteroidsCorticosteroids CyclosporinCyclosporin
For CDFor CD AminosalicylatesAminosalicylates CorticosteroidsCorticosteroids AntibioticsAntibiotics Anti-TNFAnti-TNF
Maintenance TherapiesMaintenance Therapies
ImmunosupressorsImmunosupressors AzathioprineAzathioprine 6-MP6-MP MethotrexateMethotrexate
AminosalicylatesAminosalicylates Anti-TNFAnti-TNF
NOT NOT corticosteroidscorticosteroids
IBD ManagementIBD ManagementSummarySummary
There is no ldquoone size fits allrdquo to IBD therapyThere is no ldquoone size fits allrdquo to IBD therapy Therapy and decision making are tailored to the Therapy and decision making are tailored to the
individualindividual
Algorithms are based upon available evidenceAlgorithms are based upon available evidence Evidence is in constant fluxEvidence is in constant flux
Success of algorithms depends upon Success of algorithms depends upon optimization of each step of therapy and optimization of each step of therapy and considerable judgment about each outcomeconsiderable judgment about each outcome Skillful application of medical therapy makes all Skillful application of medical therapy makes all
the difference in outcomesthe difference in outcomes
Surgery for IBDSurgery for IBDGeneral ConceptsGeneral Concepts
Majority will need surgery 78 over Majority will need surgery 78 over twenty yearstwenty years
Surgery generally indicated for Surgery generally indicated for complicationscomplications of disease of disease
Surgery must be directed at area of Surgery must be directed at area of bowel responsible for complicationbowel responsible for complication
Indications for SurgeryIndications for Surgery Intestinal obstruction (most Intestinal obstruction (most
common)common) Intractabilitysteroid Intractabilitysteroid
dependencedependence Non-healing fistulaAbscessNon-healing fistulaAbscess Toxic megacolonFree Toxic megacolonFree
perforationperforation Uncontrollable GI bleedingUncontrollable GI bleeding Severe perianal diseaseSevere perianal disease CancerCancer Growth retardation Growth retardation
(children)(children) Severe uncontrollable Severe uncontrollable
extraintestinal extraintestinal manifestationsmanifestations
Management of IBDSummary
The goals of therapy are Relieve symptoms Prevent relapse Correct nutritional deficiencies Control inflammation Prevent complications especially colon cancer
Treatment depends on 1048707 Type of disease 1048707 Site of disease 1048707 Disease severity
Treatment may include drugs nutrition supplements surgery or a combination of these options
Imaging for Crohn Disease Imaging for Crohn Disease Newer TechniquesNewer Techniques
CTCT
CT EnteroclysisCT Enteroclysis
CT EnterographyCT Enterography
Magnetic ResonanceMagnetic Resonance
UltrasoundUltrasound
Nuclear MedicineNuclear Medicine
Imaging for Crohns DiseaseImaging for Crohns Disease SummarySummary
Useful Newer TechniquesUseful Newer Techniques evolvingevolving CT EnterographyCT Enterography
Comprehensive evaluation of all bowel amp solid organsComprehensive evaluation of all bowel amp solid organs
Magnetic ResonanceMagnetic Resonance
Useful for ano-rectal diseaseUseful for ano-rectal disease
Real-time MR has potential for detection of stricturesReal-time MR has potential for detection of strictures
Traditional imaging techniques still of value in Traditional imaging techniques still of value in selected cases selected cases
The Capsule (WCE)The Capsule (WCE)
WCEWCE
bull Diameter 11mm Length 26mmDiameter 11mm Length 26mmbull Optical dome Intestinal illumination Optical dome Intestinal illumination
by white light emitting diodes (LEDrsquos)by white light emitting diodes (LEDrsquos)bull LensLensbull Complementary metal-oxide silicone Complementary metal-oxide silicone
imager (color camera chip)imager (color camera chip)bull TransmitterTransmitterbull Two batteries (silver oxide)Two batteries (silver oxide)
GE Junction Duodenum
Jejunum Ileocecal Valve
Educational ObjectivesEducational Objectives Definitions and spectrum of inflammatory Definitions and spectrum of inflammatory
bowel disease (IBD)bowel disease (IBD) Epidemiology of IBDEpidemiology of IBD Etiopathogenesis of IBDEtiopathogenesis of IBD Clinical manifestations of ulcerative colitis Clinical manifestations of ulcerative colitis
(UC)(UC) Clinical manifestations of Crohnrsquos disease Clinical manifestations of Crohnrsquos disease
(CD)(CD) Distinguishing features between UC and CDDistinguishing features between UC and CD Diagnostic approach to IBDDiagnostic approach to IBD Complications of IBDComplications of IBD IBD managementIBD management
IBD-ComplicationsIBD-Complications GI BleedingGI Bleeding Toxic megacolonToxic megacolon PerforationPerforation Thromboembolic phenomenaThromboembolic phenomena FistulasfissuresFistulasfissures AbscessAbscess StricturesobstructionStricturesobstruction MalabsorptionmalnutritionMalabsorptionmalnutrition CancerCancer
Best Protection
Surveillance colonoscopySurveillance colonoscopy
Procto-colectomy (for UC)Procto-colectomy (for UC)
Descending Colon Descending Colon StrictureStricture
Colonic StricturesColonic Strictures
Consider nonsurgical management Consider nonsurgical management ifif Endoscopically accessibleEndoscopically accessible Multiple prior resectionsMultiple prior resections Shorter strictures (less than 5 cm)Shorter strictures (less than 5 cm) Steroid injection if significant Steroid injection if significant
inflammationinflammation
Fistula DefinitionA communication between two epithelial-lined organsLifetime risk of fistula in CD30
Perianal FistulaPerianal Fistula
Pretreatment 2 Weeks
10 Weeks 18 weeks
Educational ObjectivesEducational Objectives Definitions and spectrum of inflammatory Definitions and spectrum of inflammatory
bowel disease (IBD)bowel disease (IBD) Epidemiology of IBDEpidemiology of IBD Etiopathogenesis of IBDEtiopathogenesis of IBD Clinical manifestations of ulcerative colitis Clinical manifestations of ulcerative colitis
(UC)(UC) Clinical manifestations of Crohnrsquos disease Clinical manifestations of Crohnrsquos disease
(CD)(CD) Distinguishing features between UC and CDDistinguishing features between UC and CD Diagnostic approach to IBDDiagnostic approach to IBD Complications of IBDComplications of IBD IBD managementIBD management
Goals of Therapy for IBDGoals of Therapy for IBD
Inducing remissionInducing remission Maintaining remissionMaintaining remission Restoring and maintaining nutritionRestoring and maintaining nutrition Maintaining patientrsquos quality of lifeMaintaining patientrsquos quality of life Prevention of complicationsPrevention of complications Surgical intervention (selection of Surgical intervention (selection of
optimal time for surgery)optimal time for surgery)
Inductive TherapiesInductive Therapies
For UCFor UC AminosalicylatesAminosalicylates CorticosteroidsCorticosteroids CyclosporinCyclosporin
For CDFor CD AminosalicylatesAminosalicylates CorticosteroidsCorticosteroids AntibioticsAntibiotics Anti-TNFAnti-TNF
Maintenance TherapiesMaintenance Therapies
ImmunosupressorsImmunosupressors AzathioprineAzathioprine 6-MP6-MP MethotrexateMethotrexate
AminosalicylatesAminosalicylates Anti-TNFAnti-TNF
NOT NOT corticosteroidscorticosteroids
IBD ManagementIBD ManagementSummarySummary
There is no ldquoone size fits allrdquo to IBD therapyThere is no ldquoone size fits allrdquo to IBD therapy Therapy and decision making are tailored to the Therapy and decision making are tailored to the
individualindividual
Algorithms are based upon available evidenceAlgorithms are based upon available evidence Evidence is in constant fluxEvidence is in constant flux
Success of algorithms depends upon Success of algorithms depends upon optimization of each step of therapy and optimization of each step of therapy and considerable judgment about each outcomeconsiderable judgment about each outcome Skillful application of medical therapy makes all Skillful application of medical therapy makes all
the difference in outcomesthe difference in outcomes
Surgery for IBDSurgery for IBDGeneral ConceptsGeneral Concepts
Majority will need surgery 78 over Majority will need surgery 78 over twenty yearstwenty years
Surgery generally indicated for Surgery generally indicated for complicationscomplications of disease of disease
Surgery must be directed at area of Surgery must be directed at area of bowel responsible for complicationbowel responsible for complication
Indications for SurgeryIndications for Surgery Intestinal obstruction (most Intestinal obstruction (most
common)common) Intractabilitysteroid Intractabilitysteroid
dependencedependence Non-healing fistulaAbscessNon-healing fistulaAbscess Toxic megacolonFree Toxic megacolonFree
perforationperforation Uncontrollable GI bleedingUncontrollable GI bleeding Severe perianal diseaseSevere perianal disease CancerCancer Growth retardation Growth retardation
(children)(children) Severe uncontrollable Severe uncontrollable
extraintestinal extraintestinal manifestationsmanifestations
Management of IBDSummary
The goals of therapy are Relieve symptoms Prevent relapse Correct nutritional deficiencies Control inflammation Prevent complications especially colon cancer
Treatment depends on 1048707 Type of disease 1048707 Site of disease 1048707 Disease severity
Treatment may include drugs nutrition supplements surgery or a combination of these options
Imaging for Crohns DiseaseImaging for Crohns Disease SummarySummary
Useful Newer TechniquesUseful Newer Techniques evolvingevolving CT EnterographyCT Enterography
Comprehensive evaluation of all bowel amp solid organsComprehensive evaluation of all bowel amp solid organs
Magnetic ResonanceMagnetic Resonance
Useful for ano-rectal diseaseUseful for ano-rectal disease
Real-time MR has potential for detection of stricturesReal-time MR has potential for detection of strictures
Traditional imaging techniques still of value in Traditional imaging techniques still of value in selected cases selected cases
The Capsule (WCE)The Capsule (WCE)
WCEWCE
bull Diameter 11mm Length 26mmDiameter 11mm Length 26mmbull Optical dome Intestinal illumination Optical dome Intestinal illumination
by white light emitting diodes (LEDrsquos)by white light emitting diodes (LEDrsquos)bull LensLensbull Complementary metal-oxide silicone Complementary metal-oxide silicone
imager (color camera chip)imager (color camera chip)bull TransmitterTransmitterbull Two batteries (silver oxide)Two batteries (silver oxide)
GE Junction Duodenum
Jejunum Ileocecal Valve
Educational ObjectivesEducational Objectives Definitions and spectrum of inflammatory Definitions and spectrum of inflammatory
bowel disease (IBD)bowel disease (IBD) Epidemiology of IBDEpidemiology of IBD Etiopathogenesis of IBDEtiopathogenesis of IBD Clinical manifestations of ulcerative colitis Clinical manifestations of ulcerative colitis
(UC)(UC) Clinical manifestations of Crohnrsquos disease Clinical manifestations of Crohnrsquos disease
(CD)(CD) Distinguishing features between UC and CDDistinguishing features between UC and CD Diagnostic approach to IBDDiagnostic approach to IBD Complications of IBDComplications of IBD IBD managementIBD management
IBD-ComplicationsIBD-Complications GI BleedingGI Bleeding Toxic megacolonToxic megacolon PerforationPerforation Thromboembolic phenomenaThromboembolic phenomena FistulasfissuresFistulasfissures AbscessAbscess StricturesobstructionStricturesobstruction MalabsorptionmalnutritionMalabsorptionmalnutrition CancerCancer
Best Protection
Surveillance colonoscopySurveillance colonoscopy
Procto-colectomy (for UC)Procto-colectomy (for UC)
Descending Colon Descending Colon StrictureStricture
Colonic StricturesColonic Strictures
Consider nonsurgical management Consider nonsurgical management ifif Endoscopically accessibleEndoscopically accessible Multiple prior resectionsMultiple prior resections Shorter strictures (less than 5 cm)Shorter strictures (less than 5 cm) Steroid injection if significant Steroid injection if significant
inflammationinflammation
Fistula DefinitionA communication between two epithelial-lined organsLifetime risk of fistula in CD30
Perianal FistulaPerianal Fistula
Pretreatment 2 Weeks
10 Weeks 18 weeks
Educational ObjectivesEducational Objectives Definitions and spectrum of inflammatory Definitions and spectrum of inflammatory
bowel disease (IBD)bowel disease (IBD) Epidemiology of IBDEpidemiology of IBD Etiopathogenesis of IBDEtiopathogenesis of IBD Clinical manifestations of ulcerative colitis Clinical manifestations of ulcerative colitis
(UC)(UC) Clinical manifestations of Crohnrsquos disease Clinical manifestations of Crohnrsquos disease
(CD)(CD) Distinguishing features between UC and CDDistinguishing features between UC and CD Diagnostic approach to IBDDiagnostic approach to IBD Complications of IBDComplications of IBD IBD managementIBD management
Goals of Therapy for IBDGoals of Therapy for IBD
Inducing remissionInducing remission Maintaining remissionMaintaining remission Restoring and maintaining nutritionRestoring and maintaining nutrition Maintaining patientrsquos quality of lifeMaintaining patientrsquos quality of life Prevention of complicationsPrevention of complications Surgical intervention (selection of Surgical intervention (selection of
optimal time for surgery)optimal time for surgery)
Inductive TherapiesInductive Therapies
For UCFor UC AminosalicylatesAminosalicylates CorticosteroidsCorticosteroids CyclosporinCyclosporin
For CDFor CD AminosalicylatesAminosalicylates CorticosteroidsCorticosteroids AntibioticsAntibiotics Anti-TNFAnti-TNF
Maintenance TherapiesMaintenance Therapies
ImmunosupressorsImmunosupressors AzathioprineAzathioprine 6-MP6-MP MethotrexateMethotrexate
AminosalicylatesAminosalicylates Anti-TNFAnti-TNF
NOT NOT corticosteroidscorticosteroids
IBD ManagementIBD ManagementSummarySummary
There is no ldquoone size fits allrdquo to IBD therapyThere is no ldquoone size fits allrdquo to IBD therapy Therapy and decision making are tailored to the Therapy and decision making are tailored to the
individualindividual
Algorithms are based upon available evidenceAlgorithms are based upon available evidence Evidence is in constant fluxEvidence is in constant flux
Success of algorithms depends upon Success of algorithms depends upon optimization of each step of therapy and optimization of each step of therapy and considerable judgment about each outcomeconsiderable judgment about each outcome Skillful application of medical therapy makes all Skillful application of medical therapy makes all
the difference in outcomesthe difference in outcomes
Surgery for IBDSurgery for IBDGeneral ConceptsGeneral Concepts
Majority will need surgery 78 over Majority will need surgery 78 over twenty yearstwenty years
Surgery generally indicated for Surgery generally indicated for complicationscomplications of disease of disease
Surgery must be directed at area of Surgery must be directed at area of bowel responsible for complicationbowel responsible for complication
Indications for SurgeryIndications for Surgery Intestinal obstruction (most Intestinal obstruction (most
common)common) Intractabilitysteroid Intractabilitysteroid
dependencedependence Non-healing fistulaAbscessNon-healing fistulaAbscess Toxic megacolonFree Toxic megacolonFree
perforationperforation Uncontrollable GI bleedingUncontrollable GI bleeding Severe perianal diseaseSevere perianal disease CancerCancer Growth retardation Growth retardation
(children)(children) Severe uncontrollable Severe uncontrollable
extraintestinal extraintestinal manifestationsmanifestations
Management of IBDSummary
The goals of therapy are Relieve symptoms Prevent relapse Correct nutritional deficiencies Control inflammation Prevent complications especially colon cancer
Treatment depends on 1048707 Type of disease 1048707 Site of disease 1048707 Disease severity
Treatment may include drugs nutrition supplements surgery or a combination of these options
The Capsule (WCE)The Capsule (WCE)
WCEWCE
bull Diameter 11mm Length 26mmDiameter 11mm Length 26mmbull Optical dome Intestinal illumination Optical dome Intestinal illumination
by white light emitting diodes (LEDrsquos)by white light emitting diodes (LEDrsquos)bull LensLensbull Complementary metal-oxide silicone Complementary metal-oxide silicone
imager (color camera chip)imager (color camera chip)bull TransmitterTransmitterbull Two batteries (silver oxide)Two batteries (silver oxide)
GE Junction Duodenum
Jejunum Ileocecal Valve
Educational ObjectivesEducational Objectives Definitions and spectrum of inflammatory Definitions and spectrum of inflammatory
bowel disease (IBD)bowel disease (IBD) Epidemiology of IBDEpidemiology of IBD Etiopathogenesis of IBDEtiopathogenesis of IBD Clinical manifestations of ulcerative colitis Clinical manifestations of ulcerative colitis
(UC)(UC) Clinical manifestations of Crohnrsquos disease Clinical manifestations of Crohnrsquos disease
(CD)(CD) Distinguishing features between UC and CDDistinguishing features between UC and CD Diagnostic approach to IBDDiagnostic approach to IBD Complications of IBDComplications of IBD IBD managementIBD management
IBD-ComplicationsIBD-Complications GI BleedingGI Bleeding Toxic megacolonToxic megacolon PerforationPerforation Thromboembolic phenomenaThromboembolic phenomena FistulasfissuresFistulasfissures AbscessAbscess StricturesobstructionStricturesobstruction MalabsorptionmalnutritionMalabsorptionmalnutrition CancerCancer
Best Protection
Surveillance colonoscopySurveillance colonoscopy
Procto-colectomy (for UC)Procto-colectomy (for UC)
Descending Colon Descending Colon StrictureStricture
Colonic StricturesColonic Strictures
Consider nonsurgical management Consider nonsurgical management ifif Endoscopically accessibleEndoscopically accessible Multiple prior resectionsMultiple prior resections Shorter strictures (less than 5 cm)Shorter strictures (less than 5 cm) Steroid injection if significant Steroid injection if significant
inflammationinflammation
Fistula DefinitionA communication between two epithelial-lined organsLifetime risk of fistula in CD30
Perianal FistulaPerianal Fistula
Pretreatment 2 Weeks
10 Weeks 18 weeks
Educational ObjectivesEducational Objectives Definitions and spectrum of inflammatory Definitions and spectrum of inflammatory
bowel disease (IBD)bowel disease (IBD) Epidemiology of IBDEpidemiology of IBD Etiopathogenesis of IBDEtiopathogenesis of IBD Clinical manifestations of ulcerative colitis Clinical manifestations of ulcerative colitis
(UC)(UC) Clinical manifestations of Crohnrsquos disease Clinical manifestations of Crohnrsquos disease
(CD)(CD) Distinguishing features between UC and CDDistinguishing features between UC and CD Diagnostic approach to IBDDiagnostic approach to IBD Complications of IBDComplications of IBD IBD managementIBD management
Goals of Therapy for IBDGoals of Therapy for IBD
Inducing remissionInducing remission Maintaining remissionMaintaining remission Restoring and maintaining nutritionRestoring and maintaining nutrition Maintaining patientrsquos quality of lifeMaintaining patientrsquos quality of life Prevention of complicationsPrevention of complications Surgical intervention (selection of Surgical intervention (selection of
optimal time for surgery)optimal time for surgery)
Inductive TherapiesInductive Therapies
For UCFor UC AminosalicylatesAminosalicylates CorticosteroidsCorticosteroids CyclosporinCyclosporin
For CDFor CD AminosalicylatesAminosalicylates CorticosteroidsCorticosteroids AntibioticsAntibiotics Anti-TNFAnti-TNF
Maintenance TherapiesMaintenance Therapies
ImmunosupressorsImmunosupressors AzathioprineAzathioprine 6-MP6-MP MethotrexateMethotrexate
AminosalicylatesAminosalicylates Anti-TNFAnti-TNF
NOT NOT corticosteroidscorticosteroids
IBD ManagementIBD ManagementSummarySummary
There is no ldquoone size fits allrdquo to IBD therapyThere is no ldquoone size fits allrdquo to IBD therapy Therapy and decision making are tailored to the Therapy and decision making are tailored to the
individualindividual
Algorithms are based upon available evidenceAlgorithms are based upon available evidence Evidence is in constant fluxEvidence is in constant flux
Success of algorithms depends upon Success of algorithms depends upon optimization of each step of therapy and optimization of each step of therapy and considerable judgment about each outcomeconsiderable judgment about each outcome Skillful application of medical therapy makes all Skillful application of medical therapy makes all
the difference in outcomesthe difference in outcomes
Surgery for IBDSurgery for IBDGeneral ConceptsGeneral Concepts
Majority will need surgery 78 over Majority will need surgery 78 over twenty yearstwenty years
Surgery generally indicated for Surgery generally indicated for complicationscomplications of disease of disease
Surgery must be directed at area of Surgery must be directed at area of bowel responsible for complicationbowel responsible for complication
Indications for SurgeryIndications for Surgery Intestinal obstruction (most Intestinal obstruction (most
common)common) Intractabilitysteroid Intractabilitysteroid
dependencedependence Non-healing fistulaAbscessNon-healing fistulaAbscess Toxic megacolonFree Toxic megacolonFree
perforationperforation Uncontrollable GI bleedingUncontrollable GI bleeding Severe perianal diseaseSevere perianal disease CancerCancer Growth retardation Growth retardation
(children)(children) Severe uncontrollable Severe uncontrollable
extraintestinal extraintestinal manifestationsmanifestations
Management of IBDSummary
The goals of therapy are Relieve symptoms Prevent relapse Correct nutritional deficiencies Control inflammation Prevent complications especially colon cancer
Treatment depends on 1048707 Type of disease 1048707 Site of disease 1048707 Disease severity
Treatment may include drugs nutrition supplements surgery or a combination of these options
WCEWCE
bull Diameter 11mm Length 26mmDiameter 11mm Length 26mmbull Optical dome Intestinal illumination Optical dome Intestinal illumination
by white light emitting diodes (LEDrsquos)by white light emitting diodes (LEDrsquos)bull LensLensbull Complementary metal-oxide silicone Complementary metal-oxide silicone
imager (color camera chip)imager (color camera chip)bull TransmitterTransmitterbull Two batteries (silver oxide)Two batteries (silver oxide)
GE Junction Duodenum
Jejunum Ileocecal Valve
Educational ObjectivesEducational Objectives Definitions and spectrum of inflammatory Definitions and spectrum of inflammatory
bowel disease (IBD)bowel disease (IBD) Epidemiology of IBDEpidemiology of IBD Etiopathogenesis of IBDEtiopathogenesis of IBD Clinical manifestations of ulcerative colitis Clinical manifestations of ulcerative colitis
(UC)(UC) Clinical manifestations of Crohnrsquos disease Clinical manifestations of Crohnrsquos disease
(CD)(CD) Distinguishing features between UC and CDDistinguishing features between UC and CD Diagnostic approach to IBDDiagnostic approach to IBD Complications of IBDComplications of IBD IBD managementIBD management
IBD-ComplicationsIBD-Complications GI BleedingGI Bleeding Toxic megacolonToxic megacolon PerforationPerforation Thromboembolic phenomenaThromboembolic phenomena FistulasfissuresFistulasfissures AbscessAbscess StricturesobstructionStricturesobstruction MalabsorptionmalnutritionMalabsorptionmalnutrition CancerCancer
Best Protection
Surveillance colonoscopySurveillance colonoscopy
Procto-colectomy (for UC)Procto-colectomy (for UC)
Descending Colon Descending Colon StrictureStricture
Colonic StricturesColonic Strictures
Consider nonsurgical management Consider nonsurgical management ifif Endoscopically accessibleEndoscopically accessible Multiple prior resectionsMultiple prior resections Shorter strictures (less than 5 cm)Shorter strictures (less than 5 cm) Steroid injection if significant Steroid injection if significant
inflammationinflammation
Fistula DefinitionA communication between two epithelial-lined organsLifetime risk of fistula in CD30
Perianal FistulaPerianal Fistula
Pretreatment 2 Weeks
10 Weeks 18 weeks
Educational ObjectivesEducational Objectives Definitions and spectrum of inflammatory Definitions and spectrum of inflammatory
bowel disease (IBD)bowel disease (IBD) Epidemiology of IBDEpidemiology of IBD Etiopathogenesis of IBDEtiopathogenesis of IBD Clinical manifestations of ulcerative colitis Clinical manifestations of ulcerative colitis
(UC)(UC) Clinical manifestations of Crohnrsquos disease Clinical manifestations of Crohnrsquos disease
(CD)(CD) Distinguishing features between UC and CDDistinguishing features between UC and CD Diagnostic approach to IBDDiagnostic approach to IBD Complications of IBDComplications of IBD IBD managementIBD management
Goals of Therapy for IBDGoals of Therapy for IBD
Inducing remissionInducing remission Maintaining remissionMaintaining remission Restoring and maintaining nutritionRestoring and maintaining nutrition Maintaining patientrsquos quality of lifeMaintaining patientrsquos quality of life Prevention of complicationsPrevention of complications Surgical intervention (selection of Surgical intervention (selection of
optimal time for surgery)optimal time for surgery)
Inductive TherapiesInductive Therapies
For UCFor UC AminosalicylatesAminosalicylates CorticosteroidsCorticosteroids CyclosporinCyclosporin
For CDFor CD AminosalicylatesAminosalicylates CorticosteroidsCorticosteroids AntibioticsAntibiotics Anti-TNFAnti-TNF
Maintenance TherapiesMaintenance Therapies
ImmunosupressorsImmunosupressors AzathioprineAzathioprine 6-MP6-MP MethotrexateMethotrexate
AminosalicylatesAminosalicylates Anti-TNFAnti-TNF
NOT NOT corticosteroidscorticosteroids
IBD ManagementIBD ManagementSummarySummary
There is no ldquoone size fits allrdquo to IBD therapyThere is no ldquoone size fits allrdquo to IBD therapy Therapy and decision making are tailored to the Therapy and decision making are tailored to the
individualindividual
Algorithms are based upon available evidenceAlgorithms are based upon available evidence Evidence is in constant fluxEvidence is in constant flux
Success of algorithms depends upon Success of algorithms depends upon optimization of each step of therapy and optimization of each step of therapy and considerable judgment about each outcomeconsiderable judgment about each outcome Skillful application of medical therapy makes all Skillful application of medical therapy makes all
the difference in outcomesthe difference in outcomes
Surgery for IBDSurgery for IBDGeneral ConceptsGeneral Concepts
Majority will need surgery 78 over Majority will need surgery 78 over twenty yearstwenty years
Surgery generally indicated for Surgery generally indicated for complicationscomplications of disease of disease
Surgery must be directed at area of Surgery must be directed at area of bowel responsible for complicationbowel responsible for complication
Indications for SurgeryIndications for Surgery Intestinal obstruction (most Intestinal obstruction (most
common)common) Intractabilitysteroid Intractabilitysteroid
dependencedependence Non-healing fistulaAbscessNon-healing fistulaAbscess Toxic megacolonFree Toxic megacolonFree
perforationperforation Uncontrollable GI bleedingUncontrollable GI bleeding Severe perianal diseaseSevere perianal disease CancerCancer Growth retardation Growth retardation
(children)(children) Severe uncontrollable Severe uncontrollable
extraintestinal extraintestinal manifestationsmanifestations
Management of IBDSummary
The goals of therapy are Relieve symptoms Prevent relapse Correct nutritional deficiencies Control inflammation Prevent complications especially colon cancer
Treatment depends on 1048707 Type of disease 1048707 Site of disease 1048707 Disease severity
Treatment may include drugs nutrition supplements surgery or a combination of these options
GE Junction Duodenum
Jejunum Ileocecal Valve
Educational ObjectivesEducational Objectives Definitions and spectrum of inflammatory Definitions and spectrum of inflammatory
bowel disease (IBD)bowel disease (IBD) Epidemiology of IBDEpidemiology of IBD Etiopathogenesis of IBDEtiopathogenesis of IBD Clinical manifestations of ulcerative colitis Clinical manifestations of ulcerative colitis
(UC)(UC) Clinical manifestations of Crohnrsquos disease Clinical manifestations of Crohnrsquos disease
(CD)(CD) Distinguishing features between UC and CDDistinguishing features between UC and CD Diagnostic approach to IBDDiagnostic approach to IBD Complications of IBDComplications of IBD IBD managementIBD management
IBD-ComplicationsIBD-Complications GI BleedingGI Bleeding Toxic megacolonToxic megacolon PerforationPerforation Thromboembolic phenomenaThromboembolic phenomena FistulasfissuresFistulasfissures AbscessAbscess StricturesobstructionStricturesobstruction MalabsorptionmalnutritionMalabsorptionmalnutrition CancerCancer
Best Protection
Surveillance colonoscopySurveillance colonoscopy
Procto-colectomy (for UC)Procto-colectomy (for UC)
Descending Colon Descending Colon StrictureStricture
Colonic StricturesColonic Strictures
Consider nonsurgical management Consider nonsurgical management ifif Endoscopically accessibleEndoscopically accessible Multiple prior resectionsMultiple prior resections Shorter strictures (less than 5 cm)Shorter strictures (less than 5 cm) Steroid injection if significant Steroid injection if significant
inflammationinflammation
Fistula DefinitionA communication between two epithelial-lined organsLifetime risk of fistula in CD30
Perianal FistulaPerianal Fistula
Pretreatment 2 Weeks
10 Weeks 18 weeks
Educational ObjectivesEducational Objectives Definitions and spectrum of inflammatory Definitions and spectrum of inflammatory
bowel disease (IBD)bowel disease (IBD) Epidemiology of IBDEpidemiology of IBD Etiopathogenesis of IBDEtiopathogenesis of IBD Clinical manifestations of ulcerative colitis Clinical manifestations of ulcerative colitis
(UC)(UC) Clinical manifestations of Crohnrsquos disease Clinical manifestations of Crohnrsquos disease
(CD)(CD) Distinguishing features between UC and CDDistinguishing features between UC and CD Diagnostic approach to IBDDiagnostic approach to IBD Complications of IBDComplications of IBD IBD managementIBD management
Goals of Therapy for IBDGoals of Therapy for IBD
Inducing remissionInducing remission Maintaining remissionMaintaining remission Restoring and maintaining nutritionRestoring and maintaining nutrition Maintaining patientrsquos quality of lifeMaintaining patientrsquos quality of life Prevention of complicationsPrevention of complications Surgical intervention (selection of Surgical intervention (selection of
optimal time for surgery)optimal time for surgery)
Inductive TherapiesInductive Therapies
For UCFor UC AminosalicylatesAminosalicylates CorticosteroidsCorticosteroids CyclosporinCyclosporin
For CDFor CD AminosalicylatesAminosalicylates CorticosteroidsCorticosteroids AntibioticsAntibiotics Anti-TNFAnti-TNF
Maintenance TherapiesMaintenance Therapies
ImmunosupressorsImmunosupressors AzathioprineAzathioprine 6-MP6-MP MethotrexateMethotrexate
AminosalicylatesAminosalicylates Anti-TNFAnti-TNF
NOT NOT corticosteroidscorticosteroids
IBD ManagementIBD ManagementSummarySummary
There is no ldquoone size fits allrdquo to IBD therapyThere is no ldquoone size fits allrdquo to IBD therapy Therapy and decision making are tailored to the Therapy and decision making are tailored to the
individualindividual
Algorithms are based upon available evidenceAlgorithms are based upon available evidence Evidence is in constant fluxEvidence is in constant flux
Success of algorithms depends upon Success of algorithms depends upon optimization of each step of therapy and optimization of each step of therapy and considerable judgment about each outcomeconsiderable judgment about each outcome Skillful application of medical therapy makes all Skillful application of medical therapy makes all
the difference in outcomesthe difference in outcomes
Surgery for IBDSurgery for IBDGeneral ConceptsGeneral Concepts
Majority will need surgery 78 over Majority will need surgery 78 over twenty yearstwenty years
Surgery generally indicated for Surgery generally indicated for complicationscomplications of disease of disease
Surgery must be directed at area of Surgery must be directed at area of bowel responsible for complicationbowel responsible for complication
Indications for SurgeryIndications for Surgery Intestinal obstruction (most Intestinal obstruction (most
common)common) Intractabilitysteroid Intractabilitysteroid
dependencedependence Non-healing fistulaAbscessNon-healing fistulaAbscess Toxic megacolonFree Toxic megacolonFree
perforationperforation Uncontrollable GI bleedingUncontrollable GI bleeding Severe perianal diseaseSevere perianal disease CancerCancer Growth retardation Growth retardation
(children)(children) Severe uncontrollable Severe uncontrollable
extraintestinal extraintestinal manifestationsmanifestations
Management of IBDSummary
The goals of therapy are Relieve symptoms Prevent relapse Correct nutritional deficiencies Control inflammation Prevent complications especially colon cancer
Treatment depends on 1048707 Type of disease 1048707 Site of disease 1048707 Disease severity
Treatment may include drugs nutrition supplements surgery or a combination of these options
Educational ObjectivesEducational Objectives Definitions and spectrum of inflammatory Definitions and spectrum of inflammatory
bowel disease (IBD)bowel disease (IBD) Epidemiology of IBDEpidemiology of IBD Etiopathogenesis of IBDEtiopathogenesis of IBD Clinical manifestations of ulcerative colitis Clinical manifestations of ulcerative colitis
(UC)(UC) Clinical manifestations of Crohnrsquos disease Clinical manifestations of Crohnrsquos disease
(CD)(CD) Distinguishing features between UC and CDDistinguishing features between UC and CD Diagnostic approach to IBDDiagnostic approach to IBD Complications of IBDComplications of IBD IBD managementIBD management
IBD-ComplicationsIBD-Complications GI BleedingGI Bleeding Toxic megacolonToxic megacolon PerforationPerforation Thromboembolic phenomenaThromboembolic phenomena FistulasfissuresFistulasfissures AbscessAbscess StricturesobstructionStricturesobstruction MalabsorptionmalnutritionMalabsorptionmalnutrition CancerCancer
Best Protection
Surveillance colonoscopySurveillance colonoscopy
Procto-colectomy (for UC)Procto-colectomy (for UC)
Descending Colon Descending Colon StrictureStricture
Colonic StricturesColonic Strictures
Consider nonsurgical management Consider nonsurgical management ifif Endoscopically accessibleEndoscopically accessible Multiple prior resectionsMultiple prior resections Shorter strictures (less than 5 cm)Shorter strictures (less than 5 cm) Steroid injection if significant Steroid injection if significant
inflammationinflammation
Fistula DefinitionA communication between two epithelial-lined organsLifetime risk of fistula in CD30
Perianal FistulaPerianal Fistula
Pretreatment 2 Weeks
10 Weeks 18 weeks
Educational ObjectivesEducational Objectives Definitions and spectrum of inflammatory Definitions and spectrum of inflammatory
bowel disease (IBD)bowel disease (IBD) Epidemiology of IBDEpidemiology of IBD Etiopathogenesis of IBDEtiopathogenesis of IBD Clinical manifestations of ulcerative colitis Clinical manifestations of ulcerative colitis
(UC)(UC) Clinical manifestations of Crohnrsquos disease Clinical manifestations of Crohnrsquos disease
(CD)(CD) Distinguishing features between UC and CDDistinguishing features between UC and CD Diagnostic approach to IBDDiagnostic approach to IBD Complications of IBDComplications of IBD IBD managementIBD management
Goals of Therapy for IBDGoals of Therapy for IBD
Inducing remissionInducing remission Maintaining remissionMaintaining remission Restoring and maintaining nutritionRestoring and maintaining nutrition Maintaining patientrsquos quality of lifeMaintaining patientrsquos quality of life Prevention of complicationsPrevention of complications Surgical intervention (selection of Surgical intervention (selection of
optimal time for surgery)optimal time for surgery)
Inductive TherapiesInductive Therapies
For UCFor UC AminosalicylatesAminosalicylates CorticosteroidsCorticosteroids CyclosporinCyclosporin
For CDFor CD AminosalicylatesAminosalicylates CorticosteroidsCorticosteroids AntibioticsAntibiotics Anti-TNFAnti-TNF
Maintenance TherapiesMaintenance Therapies
ImmunosupressorsImmunosupressors AzathioprineAzathioprine 6-MP6-MP MethotrexateMethotrexate
AminosalicylatesAminosalicylates Anti-TNFAnti-TNF
NOT NOT corticosteroidscorticosteroids
IBD ManagementIBD ManagementSummarySummary
There is no ldquoone size fits allrdquo to IBD therapyThere is no ldquoone size fits allrdquo to IBD therapy Therapy and decision making are tailored to the Therapy and decision making are tailored to the
individualindividual
Algorithms are based upon available evidenceAlgorithms are based upon available evidence Evidence is in constant fluxEvidence is in constant flux
Success of algorithms depends upon Success of algorithms depends upon optimization of each step of therapy and optimization of each step of therapy and considerable judgment about each outcomeconsiderable judgment about each outcome Skillful application of medical therapy makes all Skillful application of medical therapy makes all
the difference in outcomesthe difference in outcomes
Surgery for IBDSurgery for IBDGeneral ConceptsGeneral Concepts
Majority will need surgery 78 over Majority will need surgery 78 over twenty yearstwenty years
Surgery generally indicated for Surgery generally indicated for complicationscomplications of disease of disease
Surgery must be directed at area of Surgery must be directed at area of bowel responsible for complicationbowel responsible for complication
Indications for SurgeryIndications for Surgery Intestinal obstruction (most Intestinal obstruction (most
common)common) Intractabilitysteroid Intractabilitysteroid
dependencedependence Non-healing fistulaAbscessNon-healing fistulaAbscess Toxic megacolonFree Toxic megacolonFree
perforationperforation Uncontrollable GI bleedingUncontrollable GI bleeding Severe perianal diseaseSevere perianal disease CancerCancer Growth retardation Growth retardation
(children)(children) Severe uncontrollable Severe uncontrollable
extraintestinal extraintestinal manifestationsmanifestations
Management of IBDSummary
The goals of therapy are Relieve symptoms Prevent relapse Correct nutritional deficiencies Control inflammation Prevent complications especially colon cancer
Treatment depends on 1048707 Type of disease 1048707 Site of disease 1048707 Disease severity
Treatment may include drugs nutrition supplements surgery or a combination of these options
IBD-ComplicationsIBD-Complications GI BleedingGI Bleeding Toxic megacolonToxic megacolon PerforationPerforation Thromboembolic phenomenaThromboembolic phenomena FistulasfissuresFistulasfissures AbscessAbscess StricturesobstructionStricturesobstruction MalabsorptionmalnutritionMalabsorptionmalnutrition CancerCancer
Best Protection
Surveillance colonoscopySurveillance colonoscopy
Procto-colectomy (for UC)Procto-colectomy (for UC)
Descending Colon Descending Colon StrictureStricture
Colonic StricturesColonic Strictures
Consider nonsurgical management Consider nonsurgical management ifif Endoscopically accessibleEndoscopically accessible Multiple prior resectionsMultiple prior resections Shorter strictures (less than 5 cm)Shorter strictures (less than 5 cm) Steroid injection if significant Steroid injection if significant
inflammationinflammation
Fistula DefinitionA communication between two epithelial-lined organsLifetime risk of fistula in CD30
Perianal FistulaPerianal Fistula
Pretreatment 2 Weeks
10 Weeks 18 weeks
Educational ObjectivesEducational Objectives Definitions and spectrum of inflammatory Definitions and spectrum of inflammatory
bowel disease (IBD)bowel disease (IBD) Epidemiology of IBDEpidemiology of IBD Etiopathogenesis of IBDEtiopathogenesis of IBD Clinical manifestations of ulcerative colitis Clinical manifestations of ulcerative colitis
(UC)(UC) Clinical manifestations of Crohnrsquos disease Clinical manifestations of Crohnrsquos disease
(CD)(CD) Distinguishing features between UC and CDDistinguishing features between UC and CD Diagnostic approach to IBDDiagnostic approach to IBD Complications of IBDComplications of IBD IBD managementIBD management
Goals of Therapy for IBDGoals of Therapy for IBD
Inducing remissionInducing remission Maintaining remissionMaintaining remission Restoring and maintaining nutritionRestoring and maintaining nutrition Maintaining patientrsquos quality of lifeMaintaining patientrsquos quality of life Prevention of complicationsPrevention of complications Surgical intervention (selection of Surgical intervention (selection of
optimal time for surgery)optimal time for surgery)
Inductive TherapiesInductive Therapies
For UCFor UC AminosalicylatesAminosalicylates CorticosteroidsCorticosteroids CyclosporinCyclosporin
For CDFor CD AminosalicylatesAminosalicylates CorticosteroidsCorticosteroids AntibioticsAntibiotics Anti-TNFAnti-TNF
Maintenance TherapiesMaintenance Therapies
ImmunosupressorsImmunosupressors AzathioprineAzathioprine 6-MP6-MP MethotrexateMethotrexate
AminosalicylatesAminosalicylates Anti-TNFAnti-TNF
NOT NOT corticosteroidscorticosteroids
IBD ManagementIBD ManagementSummarySummary
There is no ldquoone size fits allrdquo to IBD therapyThere is no ldquoone size fits allrdquo to IBD therapy Therapy and decision making are tailored to the Therapy and decision making are tailored to the
individualindividual
Algorithms are based upon available evidenceAlgorithms are based upon available evidence Evidence is in constant fluxEvidence is in constant flux
Success of algorithms depends upon Success of algorithms depends upon optimization of each step of therapy and optimization of each step of therapy and considerable judgment about each outcomeconsiderable judgment about each outcome Skillful application of medical therapy makes all Skillful application of medical therapy makes all
the difference in outcomesthe difference in outcomes
Surgery for IBDSurgery for IBDGeneral ConceptsGeneral Concepts
Majority will need surgery 78 over Majority will need surgery 78 over twenty yearstwenty years
Surgery generally indicated for Surgery generally indicated for complicationscomplications of disease of disease
Surgery must be directed at area of Surgery must be directed at area of bowel responsible for complicationbowel responsible for complication
Indications for SurgeryIndications for Surgery Intestinal obstruction (most Intestinal obstruction (most
common)common) Intractabilitysteroid Intractabilitysteroid
dependencedependence Non-healing fistulaAbscessNon-healing fistulaAbscess Toxic megacolonFree Toxic megacolonFree
perforationperforation Uncontrollable GI bleedingUncontrollable GI bleeding Severe perianal diseaseSevere perianal disease CancerCancer Growth retardation Growth retardation
(children)(children) Severe uncontrollable Severe uncontrollable
extraintestinal extraintestinal manifestationsmanifestations
Management of IBDSummary
The goals of therapy are Relieve symptoms Prevent relapse Correct nutritional deficiencies Control inflammation Prevent complications especially colon cancer
Treatment depends on 1048707 Type of disease 1048707 Site of disease 1048707 Disease severity
Treatment may include drugs nutrition supplements surgery or a combination of these options
Best Protection
Surveillance colonoscopySurveillance colonoscopy
Procto-colectomy (for UC)Procto-colectomy (for UC)
Descending Colon Descending Colon StrictureStricture
Colonic StricturesColonic Strictures
Consider nonsurgical management Consider nonsurgical management ifif Endoscopically accessibleEndoscopically accessible Multiple prior resectionsMultiple prior resections Shorter strictures (less than 5 cm)Shorter strictures (less than 5 cm) Steroid injection if significant Steroid injection if significant
inflammationinflammation
Fistula DefinitionA communication between two epithelial-lined organsLifetime risk of fistula in CD30
Perianal FistulaPerianal Fistula
Pretreatment 2 Weeks
10 Weeks 18 weeks
Educational ObjectivesEducational Objectives Definitions and spectrum of inflammatory Definitions and spectrum of inflammatory
bowel disease (IBD)bowel disease (IBD) Epidemiology of IBDEpidemiology of IBD Etiopathogenesis of IBDEtiopathogenesis of IBD Clinical manifestations of ulcerative colitis Clinical manifestations of ulcerative colitis
(UC)(UC) Clinical manifestations of Crohnrsquos disease Clinical manifestations of Crohnrsquos disease
(CD)(CD) Distinguishing features between UC and CDDistinguishing features between UC and CD Diagnostic approach to IBDDiagnostic approach to IBD Complications of IBDComplications of IBD IBD managementIBD management
Goals of Therapy for IBDGoals of Therapy for IBD
Inducing remissionInducing remission Maintaining remissionMaintaining remission Restoring and maintaining nutritionRestoring and maintaining nutrition Maintaining patientrsquos quality of lifeMaintaining patientrsquos quality of life Prevention of complicationsPrevention of complications Surgical intervention (selection of Surgical intervention (selection of
optimal time for surgery)optimal time for surgery)
Inductive TherapiesInductive Therapies
For UCFor UC AminosalicylatesAminosalicylates CorticosteroidsCorticosteroids CyclosporinCyclosporin
For CDFor CD AminosalicylatesAminosalicylates CorticosteroidsCorticosteroids AntibioticsAntibiotics Anti-TNFAnti-TNF
Maintenance TherapiesMaintenance Therapies
ImmunosupressorsImmunosupressors AzathioprineAzathioprine 6-MP6-MP MethotrexateMethotrexate
AminosalicylatesAminosalicylates Anti-TNFAnti-TNF
NOT NOT corticosteroidscorticosteroids
IBD ManagementIBD ManagementSummarySummary
There is no ldquoone size fits allrdquo to IBD therapyThere is no ldquoone size fits allrdquo to IBD therapy Therapy and decision making are tailored to the Therapy and decision making are tailored to the
individualindividual
Algorithms are based upon available evidenceAlgorithms are based upon available evidence Evidence is in constant fluxEvidence is in constant flux
Success of algorithms depends upon Success of algorithms depends upon optimization of each step of therapy and optimization of each step of therapy and considerable judgment about each outcomeconsiderable judgment about each outcome Skillful application of medical therapy makes all Skillful application of medical therapy makes all
the difference in outcomesthe difference in outcomes
Surgery for IBDSurgery for IBDGeneral ConceptsGeneral Concepts
Majority will need surgery 78 over Majority will need surgery 78 over twenty yearstwenty years
Surgery generally indicated for Surgery generally indicated for complicationscomplications of disease of disease
Surgery must be directed at area of Surgery must be directed at area of bowel responsible for complicationbowel responsible for complication
Indications for SurgeryIndications for Surgery Intestinal obstruction (most Intestinal obstruction (most
common)common) Intractabilitysteroid Intractabilitysteroid
dependencedependence Non-healing fistulaAbscessNon-healing fistulaAbscess Toxic megacolonFree Toxic megacolonFree
perforationperforation Uncontrollable GI bleedingUncontrollable GI bleeding Severe perianal diseaseSevere perianal disease CancerCancer Growth retardation Growth retardation
(children)(children) Severe uncontrollable Severe uncontrollable
extraintestinal extraintestinal manifestationsmanifestations
Management of IBDSummary
The goals of therapy are Relieve symptoms Prevent relapse Correct nutritional deficiencies Control inflammation Prevent complications especially colon cancer
Treatment depends on 1048707 Type of disease 1048707 Site of disease 1048707 Disease severity
Treatment may include drugs nutrition supplements surgery or a combination of these options
Descending Colon Descending Colon StrictureStricture
Colonic StricturesColonic Strictures
Consider nonsurgical management Consider nonsurgical management ifif Endoscopically accessibleEndoscopically accessible Multiple prior resectionsMultiple prior resections Shorter strictures (less than 5 cm)Shorter strictures (less than 5 cm) Steroid injection if significant Steroid injection if significant
inflammationinflammation
Fistula DefinitionA communication between two epithelial-lined organsLifetime risk of fistula in CD30
Perianal FistulaPerianal Fistula
Pretreatment 2 Weeks
10 Weeks 18 weeks
Educational ObjectivesEducational Objectives Definitions and spectrum of inflammatory Definitions and spectrum of inflammatory
bowel disease (IBD)bowel disease (IBD) Epidemiology of IBDEpidemiology of IBD Etiopathogenesis of IBDEtiopathogenesis of IBD Clinical manifestations of ulcerative colitis Clinical manifestations of ulcerative colitis
(UC)(UC) Clinical manifestations of Crohnrsquos disease Clinical manifestations of Crohnrsquos disease
(CD)(CD) Distinguishing features between UC and CDDistinguishing features between UC and CD Diagnostic approach to IBDDiagnostic approach to IBD Complications of IBDComplications of IBD IBD managementIBD management
Goals of Therapy for IBDGoals of Therapy for IBD
Inducing remissionInducing remission Maintaining remissionMaintaining remission Restoring and maintaining nutritionRestoring and maintaining nutrition Maintaining patientrsquos quality of lifeMaintaining patientrsquos quality of life Prevention of complicationsPrevention of complications Surgical intervention (selection of Surgical intervention (selection of
optimal time for surgery)optimal time for surgery)
Inductive TherapiesInductive Therapies
For UCFor UC AminosalicylatesAminosalicylates CorticosteroidsCorticosteroids CyclosporinCyclosporin
For CDFor CD AminosalicylatesAminosalicylates CorticosteroidsCorticosteroids AntibioticsAntibiotics Anti-TNFAnti-TNF
Maintenance TherapiesMaintenance Therapies
ImmunosupressorsImmunosupressors AzathioprineAzathioprine 6-MP6-MP MethotrexateMethotrexate
AminosalicylatesAminosalicylates Anti-TNFAnti-TNF
NOT NOT corticosteroidscorticosteroids
IBD ManagementIBD ManagementSummarySummary
There is no ldquoone size fits allrdquo to IBD therapyThere is no ldquoone size fits allrdquo to IBD therapy Therapy and decision making are tailored to the Therapy and decision making are tailored to the
individualindividual
Algorithms are based upon available evidenceAlgorithms are based upon available evidence Evidence is in constant fluxEvidence is in constant flux
Success of algorithms depends upon Success of algorithms depends upon optimization of each step of therapy and optimization of each step of therapy and considerable judgment about each outcomeconsiderable judgment about each outcome Skillful application of medical therapy makes all Skillful application of medical therapy makes all
the difference in outcomesthe difference in outcomes
Surgery for IBDSurgery for IBDGeneral ConceptsGeneral Concepts
Majority will need surgery 78 over Majority will need surgery 78 over twenty yearstwenty years
Surgery generally indicated for Surgery generally indicated for complicationscomplications of disease of disease
Surgery must be directed at area of Surgery must be directed at area of bowel responsible for complicationbowel responsible for complication
Indications for SurgeryIndications for Surgery Intestinal obstruction (most Intestinal obstruction (most
common)common) Intractabilitysteroid Intractabilitysteroid
dependencedependence Non-healing fistulaAbscessNon-healing fistulaAbscess Toxic megacolonFree Toxic megacolonFree
perforationperforation Uncontrollable GI bleedingUncontrollable GI bleeding Severe perianal diseaseSevere perianal disease CancerCancer Growth retardation Growth retardation
(children)(children) Severe uncontrollable Severe uncontrollable
extraintestinal extraintestinal manifestationsmanifestations
Management of IBDSummary
The goals of therapy are Relieve symptoms Prevent relapse Correct nutritional deficiencies Control inflammation Prevent complications especially colon cancer
Treatment depends on 1048707 Type of disease 1048707 Site of disease 1048707 Disease severity
Treatment may include drugs nutrition supplements surgery or a combination of these options
Colonic StricturesColonic Strictures
Consider nonsurgical management Consider nonsurgical management ifif Endoscopically accessibleEndoscopically accessible Multiple prior resectionsMultiple prior resections Shorter strictures (less than 5 cm)Shorter strictures (less than 5 cm) Steroid injection if significant Steroid injection if significant
inflammationinflammation
Fistula DefinitionA communication between two epithelial-lined organsLifetime risk of fistula in CD30
Perianal FistulaPerianal Fistula
Pretreatment 2 Weeks
10 Weeks 18 weeks
Educational ObjectivesEducational Objectives Definitions and spectrum of inflammatory Definitions and spectrum of inflammatory
bowel disease (IBD)bowel disease (IBD) Epidemiology of IBDEpidemiology of IBD Etiopathogenesis of IBDEtiopathogenesis of IBD Clinical manifestations of ulcerative colitis Clinical manifestations of ulcerative colitis
(UC)(UC) Clinical manifestations of Crohnrsquos disease Clinical manifestations of Crohnrsquos disease
(CD)(CD) Distinguishing features between UC and CDDistinguishing features between UC and CD Diagnostic approach to IBDDiagnostic approach to IBD Complications of IBDComplications of IBD IBD managementIBD management
Goals of Therapy for IBDGoals of Therapy for IBD
Inducing remissionInducing remission Maintaining remissionMaintaining remission Restoring and maintaining nutritionRestoring and maintaining nutrition Maintaining patientrsquos quality of lifeMaintaining patientrsquos quality of life Prevention of complicationsPrevention of complications Surgical intervention (selection of Surgical intervention (selection of
optimal time for surgery)optimal time for surgery)
Inductive TherapiesInductive Therapies
For UCFor UC AminosalicylatesAminosalicylates CorticosteroidsCorticosteroids CyclosporinCyclosporin
For CDFor CD AminosalicylatesAminosalicylates CorticosteroidsCorticosteroids AntibioticsAntibiotics Anti-TNFAnti-TNF
Maintenance TherapiesMaintenance Therapies
ImmunosupressorsImmunosupressors AzathioprineAzathioprine 6-MP6-MP MethotrexateMethotrexate
AminosalicylatesAminosalicylates Anti-TNFAnti-TNF
NOT NOT corticosteroidscorticosteroids
IBD ManagementIBD ManagementSummarySummary
There is no ldquoone size fits allrdquo to IBD therapyThere is no ldquoone size fits allrdquo to IBD therapy Therapy and decision making are tailored to the Therapy and decision making are tailored to the
individualindividual
Algorithms are based upon available evidenceAlgorithms are based upon available evidence Evidence is in constant fluxEvidence is in constant flux
Success of algorithms depends upon Success of algorithms depends upon optimization of each step of therapy and optimization of each step of therapy and considerable judgment about each outcomeconsiderable judgment about each outcome Skillful application of medical therapy makes all Skillful application of medical therapy makes all
the difference in outcomesthe difference in outcomes
Surgery for IBDSurgery for IBDGeneral ConceptsGeneral Concepts
Majority will need surgery 78 over Majority will need surgery 78 over twenty yearstwenty years
Surgery generally indicated for Surgery generally indicated for complicationscomplications of disease of disease
Surgery must be directed at area of Surgery must be directed at area of bowel responsible for complicationbowel responsible for complication
Indications for SurgeryIndications for Surgery Intestinal obstruction (most Intestinal obstruction (most
common)common) Intractabilitysteroid Intractabilitysteroid
dependencedependence Non-healing fistulaAbscessNon-healing fistulaAbscess Toxic megacolonFree Toxic megacolonFree
perforationperforation Uncontrollable GI bleedingUncontrollable GI bleeding Severe perianal diseaseSevere perianal disease CancerCancer Growth retardation Growth retardation
(children)(children) Severe uncontrollable Severe uncontrollable
extraintestinal extraintestinal manifestationsmanifestations
Management of IBDSummary
The goals of therapy are Relieve symptoms Prevent relapse Correct nutritional deficiencies Control inflammation Prevent complications especially colon cancer
Treatment depends on 1048707 Type of disease 1048707 Site of disease 1048707 Disease severity
Treatment may include drugs nutrition supplements surgery or a combination of these options
Fistula DefinitionA communication between two epithelial-lined organsLifetime risk of fistula in CD30
Perianal FistulaPerianal Fistula
Pretreatment 2 Weeks
10 Weeks 18 weeks
Educational ObjectivesEducational Objectives Definitions and spectrum of inflammatory Definitions and spectrum of inflammatory
bowel disease (IBD)bowel disease (IBD) Epidemiology of IBDEpidemiology of IBD Etiopathogenesis of IBDEtiopathogenesis of IBD Clinical manifestations of ulcerative colitis Clinical manifestations of ulcerative colitis
(UC)(UC) Clinical manifestations of Crohnrsquos disease Clinical manifestations of Crohnrsquos disease
(CD)(CD) Distinguishing features between UC and CDDistinguishing features between UC and CD Diagnostic approach to IBDDiagnostic approach to IBD Complications of IBDComplications of IBD IBD managementIBD management
Goals of Therapy for IBDGoals of Therapy for IBD
Inducing remissionInducing remission Maintaining remissionMaintaining remission Restoring and maintaining nutritionRestoring and maintaining nutrition Maintaining patientrsquos quality of lifeMaintaining patientrsquos quality of life Prevention of complicationsPrevention of complications Surgical intervention (selection of Surgical intervention (selection of
optimal time for surgery)optimal time for surgery)
Inductive TherapiesInductive Therapies
For UCFor UC AminosalicylatesAminosalicylates CorticosteroidsCorticosteroids CyclosporinCyclosporin
For CDFor CD AminosalicylatesAminosalicylates CorticosteroidsCorticosteroids AntibioticsAntibiotics Anti-TNFAnti-TNF
Maintenance TherapiesMaintenance Therapies
ImmunosupressorsImmunosupressors AzathioprineAzathioprine 6-MP6-MP MethotrexateMethotrexate
AminosalicylatesAminosalicylates Anti-TNFAnti-TNF
NOT NOT corticosteroidscorticosteroids
IBD ManagementIBD ManagementSummarySummary
There is no ldquoone size fits allrdquo to IBD therapyThere is no ldquoone size fits allrdquo to IBD therapy Therapy and decision making are tailored to the Therapy and decision making are tailored to the
individualindividual
Algorithms are based upon available evidenceAlgorithms are based upon available evidence Evidence is in constant fluxEvidence is in constant flux
Success of algorithms depends upon Success of algorithms depends upon optimization of each step of therapy and optimization of each step of therapy and considerable judgment about each outcomeconsiderable judgment about each outcome Skillful application of medical therapy makes all Skillful application of medical therapy makes all
the difference in outcomesthe difference in outcomes
Surgery for IBDSurgery for IBDGeneral ConceptsGeneral Concepts
Majority will need surgery 78 over Majority will need surgery 78 over twenty yearstwenty years
Surgery generally indicated for Surgery generally indicated for complicationscomplications of disease of disease
Surgery must be directed at area of Surgery must be directed at area of bowel responsible for complicationbowel responsible for complication
Indications for SurgeryIndications for Surgery Intestinal obstruction (most Intestinal obstruction (most
common)common) Intractabilitysteroid Intractabilitysteroid
dependencedependence Non-healing fistulaAbscessNon-healing fistulaAbscess Toxic megacolonFree Toxic megacolonFree
perforationperforation Uncontrollable GI bleedingUncontrollable GI bleeding Severe perianal diseaseSevere perianal disease CancerCancer Growth retardation Growth retardation
(children)(children) Severe uncontrollable Severe uncontrollable
extraintestinal extraintestinal manifestationsmanifestations
Management of IBDSummary
The goals of therapy are Relieve symptoms Prevent relapse Correct nutritional deficiencies Control inflammation Prevent complications especially colon cancer
Treatment depends on 1048707 Type of disease 1048707 Site of disease 1048707 Disease severity
Treatment may include drugs nutrition supplements surgery or a combination of these options
Perianal FistulaPerianal Fistula
Pretreatment 2 Weeks
10 Weeks 18 weeks
Educational ObjectivesEducational Objectives Definitions and spectrum of inflammatory Definitions and spectrum of inflammatory
bowel disease (IBD)bowel disease (IBD) Epidemiology of IBDEpidemiology of IBD Etiopathogenesis of IBDEtiopathogenesis of IBD Clinical manifestations of ulcerative colitis Clinical manifestations of ulcerative colitis
(UC)(UC) Clinical manifestations of Crohnrsquos disease Clinical manifestations of Crohnrsquos disease
(CD)(CD) Distinguishing features between UC and CDDistinguishing features between UC and CD Diagnostic approach to IBDDiagnostic approach to IBD Complications of IBDComplications of IBD IBD managementIBD management
Goals of Therapy for IBDGoals of Therapy for IBD
Inducing remissionInducing remission Maintaining remissionMaintaining remission Restoring and maintaining nutritionRestoring and maintaining nutrition Maintaining patientrsquos quality of lifeMaintaining patientrsquos quality of life Prevention of complicationsPrevention of complications Surgical intervention (selection of Surgical intervention (selection of
optimal time for surgery)optimal time for surgery)
Inductive TherapiesInductive Therapies
For UCFor UC AminosalicylatesAminosalicylates CorticosteroidsCorticosteroids CyclosporinCyclosporin
For CDFor CD AminosalicylatesAminosalicylates CorticosteroidsCorticosteroids AntibioticsAntibiotics Anti-TNFAnti-TNF
Maintenance TherapiesMaintenance Therapies
ImmunosupressorsImmunosupressors AzathioprineAzathioprine 6-MP6-MP MethotrexateMethotrexate
AminosalicylatesAminosalicylates Anti-TNFAnti-TNF
NOT NOT corticosteroidscorticosteroids
IBD ManagementIBD ManagementSummarySummary
There is no ldquoone size fits allrdquo to IBD therapyThere is no ldquoone size fits allrdquo to IBD therapy Therapy and decision making are tailored to the Therapy and decision making are tailored to the
individualindividual
Algorithms are based upon available evidenceAlgorithms are based upon available evidence Evidence is in constant fluxEvidence is in constant flux
Success of algorithms depends upon Success of algorithms depends upon optimization of each step of therapy and optimization of each step of therapy and considerable judgment about each outcomeconsiderable judgment about each outcome Skillful application of medical therapy makes all Skillful application of medical therapy makes all
the difference in outcomesthe difference in outcomes
Surgery for IBDSurgery for IBDGeneral ConceptsGeneral Concepts
Majority will need surgery 78 over Majority will need surgery 78 over twenty yearstwenty years
Surgery generally indicated for Surgery generally indicated for complicationscomplications of disease of disease
Surgery must be directed at area of Surgery must be directed at area of bowel responsible for complicationbowel responsible for complication
Indications for SurgeryIndications for Surgery Intestinal obstruction (most Intestinal obstruction (most
common)common) Intractabilitysteroid Intractabilitysteroid
dependencedependence Non-healing fistulaAbscessNon-healing fistulaAbscess Toxic megacolonFree Toxic megacolonFree
perforationperforation Uncontrollable GI bleedingUncontrollable GI bleeding Severe perianal diseaseSevere perianal disease CancerCancer Growth retardation Growth retardation
(children)(children) Severe uncontrollable Severe uncontrollable
extraintestinal extraintestinal manifestationsmanifestations
Management of IBDSummary
The goals of therapy are Relieve symptoms Prevent relapse Correct nutritional deficiencies Control inflammation Prevent complications especially colon cancer
Treatment depends on 1048707 Type of disease 1048707 Site of disease 1048707 Disease severity
Treatment may include drugs nutrition supplements surgery or a combination of these options
Educational ObjectivesEducational Objectives Definitions and spectrum of inflammatory Definitions and spectrum of inflammatory
bowel disease (IBD)bowel disease (IBD) Epidemiology of IBDEpidemiology of IBD Etiopathogenesis of IBDEtiopathogenesis of IBD Clinical manifestations of ulcerative colitis Clinical manifestations of ulcerative colitis
(UC)(UC) Clinical manifestations of Crohnrsquos disease Clinical manifestations of Crohnrsquos disease
(CD)(CD) Distinguishing features between UC and CDDistinguishing features between UC and CD Diagnostic approach to IBDDiagnostic approach to IBD Complications of IBDComplications of IBD IBD managementIBD management
Goals of Therapy for IBDGoals of Therapy for IBD
Inducing remissionInducing remission Maintaining remissionMaintaining remission Restoring and maintaining nutritionRestoring and maintaining nutrition Maintaining patientrsquos quality of lifeMaintaining patientrsquos quality of life Prevention of complicationsPrevention of complications Surgical intervention (selection of Surgical intervention (selection of
optimal time for surgery)optimal time for surgery)
Inductive TherapiesInductive Therapies
For UCFor UC AminosalicylatesAminosalicylates CorticosteroidsCorticosteroids CyclosporinCyclosporin
For CDFor CD AminosalicylatesAminosalicylates CorticosteroidsCorticosteroids AntibioticsAntibiotics Anti-TNFAnti-TNF
Maintenance TherapiesMaintenance Therapies
ImmunosupressorsImmunosupressors AzathioprineAzathioprine 6-MP6-MP MethotrexateMethotrexate
AminosalicylatesAminosalicylates Anti-TNFAnti-TNF
NOT NOT corticosteroidscorticosteroids
IBD ManagementIBD ManagementSummarySummary
There is no ldquoone size fits allrdquo to IBD therapyThere is no ldquoone size fits allrdquo to IBD therapy Therapy and decision making are tailored to the Therapy and decision making are tailored to the
individualindividual
Algorithms are based upon available evidenceAlgorithms are based upon available evidence Evidence is in constant fluxEvidence is in constant flux
Success of algorithms depends upon Success of algorithms depends upon optimization of each step of therapy and optimization of each step of therapy and considerable judgment about each outcomeconsiderable judgment about each outcome Skillful application of medical therapy makes all Skillful application of medical therapy makes all
the difference in outcomesthe difference in outcomes
Surgery for IBDSurgery for IBDGeneral ConceptsGeneral Concepts
Majority will need surgery 78 over Majority will need surgery 78 over twenty yearstwenty years
Surgery generally indicated for Surgery generally indicated for complicationscomplications of disease of disease
Surgery must be directed at area of Surgery must be directed at area of bowel responsible for complicationbowel responsible for complication
Indications for SurgeryIndications for Surgery Intestinal obstruction (most Intestinal obstruction (most
common)common) Intractabilitysteroid Intractabilitysteroid
dependencedependence Non-healing fistulaAbscessNon-healing fistulaAbscess Toxic megacolonFree Toxic megacolonFree
perforationperforation Uncontrollable GI bleedingUncontrollable GI bleeding Severe perianal diseaseSevere perianal disease CancerCancer Growth retardation Growth retardation
(children)(children) Severe uncontrollable Severe uncontrollable
extraintestinal extraintestinal manifestationsmanifestations
Management of IBDSummary
The goals of therapy are Relieve symptoms Prevent relapse Correct nutritional deficiencies Control inflammation Prevent complications especially colon cancer
Treatment depends on 1048707 Type of disease 1048707 Site of disease 1048707 Disease severity
Treatment may include drugs nutrition supplements surgery or a combination of these options
Goals of Therapy for IBDGoals of Therapy for IBD
Inducing remissionInducing remission Maintaining remissionMaintaining remission Restoring and maintaining nutritionRestoring and maintaining nutrition Maintaining patientrsquos quality of lifeMaintaining patientrsquos quality of life Prevention of complicationsPrevention of complications Surgical intervention (selection of Surgical intervention (selection of
optimal time for surgery)optimal time for surgery)
Inductive TherapiesInductive Therapies
For UCFor UC AminosalicylatesAminosalicylates CorticosteroidsCorticosteroids CyclosporinCyclosporin
For CDFor CD AminosalicylatesAminosalicylates CorticosteroidsCorticosteroids AntibioticsAntibiotics Anti-TNFAnti-TNF
Maintenance TherapiesMaintenance Therapies
ImmunosupressorsImmunosupressors AzathioprineAzathioprine 6-MP6-MP MethotrexateMethotrexate
AminosalicylatesAminosalicylates Anti-TNFAnti-TNF
NOT NOT corticosteroidscorticosteroids
IBD ManagementIBD ManagementSummarySummary
There is no ldquoone size fits allrdquo to IBD therapyThere is no ldquoone size fits allrdquo to IBD therapy Therapy and decision making are tailored to the Therapy and decision making are tailored to the
individualindividual
Algorithms are based upon available evidenceAlgorithms are based upon available evidence Evidence is in constant fluxEvidence is in constant flux
Success of algorithms depends upon Success of algorithms depends upon optimization of each step of therapy and optimization of each step of therapy and considerable judgment about each outcomeconsiderable judgment about each outcome Skillful application of medical therapy makes all Skillful application of medical therapy makes all
the difference in outcomesthe difference in outcomes
Surgery for IBDSurgery for IBDGeneral ConceptsGeneral Concepts
Majority will need surgery 78 over Majority will need surgery 78 over twenty yearstwenty years
Surgery generally indicated for Surgery generally indicated for complicationscomplications of disease of disease
Surgery must be directed at area of Surgery must be directed at area of bowel responsible for complicationbowel responsible for complication
Indications for SurgeryIndications for Surgery Intestinal obstruction (most Intestinal obstruction (most
common)common) Intractabilitysteroid Intractabilitysteroid
dependencedependence Non-healing fistulaAbscessNon-healing fistulaAbscess Toxic megacolonFree Toxic megacolonFree
perforationperforation Uncontrollable GI bleedingUncontrollable GI bleeding Severe perianal diseaseSevere perianal disease CancerCancer Growth retardation Growth retardation
(children)(children) Severe uncontrollable Severe uncontrollable
extraintestinal extraintestinal manifestationsmanifestations
Management of IBDSummary
The goals of therapy are Relieve symptoms Prevent relapse Correct nutritional deficiencies Control inflammation Prevent complications especially colon cancer
Treatment depends on 1048707 Type of disease 1048707 Site of disease 1048707 Disease severity
Treatment may include drugs nutrition supplements surgery or a combination of these options
Inductive TherapiesInductive Therapies
For UCFor UC AminosalicylatesAminosalicylates CorticosteroidsCorticosteroids CyclosporinCyclosporin
For CDFor CD AminosalicylatesAminosalicylates CorticosteroidsCorticosteroids AntibioticsAntibiotics Anti-TNFAnti-TNF
Maintenance TherapiesMaintenance Therapies
ImmunosupressorsImmunosupressors AzathioprineAzathioprine 6-MP6-MP MethotrexateMethotrexate
AminosalicylatesAminosalicylates Anti-TNFAnti-TNF
NOT NOT corticosteroidscorticosteroids
IBD ManagementIBD ManagementSummarySummary
There is no ldquoone size fits allrdquo to IBD therapyThere is no ldquoone size fits allrdquo to IBD therapy Therapy and decision making are tailored to the Therapy and decision making are tailored to the
individualindividual
Algorithms are based upon available evidenceAlgorithms are based upon available evidence Evidence is in constant fluxEvidence is in constant flux
Success of algorithms depends upon Success of algorithms depends upon optimization of each step of therapy and optimization of each step of therapy and considerable judgment about each outcomeconsiderable judgment about each outcome Skillful application of medical therapy makes all Skillful application of medical therapy makes all
the difference in outcomesthe difference in outcomes
Surgery for IBDSurgery for IBDGeneral ConceptsGeneral Concepts
Majority will need surgery 78 over Majority will need surgery 78 over twenty yearstwenty years
Surgery generally indicated for Surgery generally indicated for complicationscomplications of disease of disease
Surgery must be directed at area of Surgery must be directed at area of bowel responsible for complicationbowel responsible for complication
Indications for SurgeryIndications for Surgery Intestinal obstruction (most Intestinal obstruction (most
common)common) Intractabilitysteroid Intractabilitysteroid
dependencedependence Non-healing fistulaAbscessNon-healing fistulaAbscess Toxic megacolonFree Toxic megacolonFree
perforationperforation Uncontrollable GI bleedingUncontrollable GI bleeding Severe perianal diseaseSevere perianal disease CancerCancer Growth retardation Growth retardation
(children)(children) Severe uncontrollable Severe uncontrollable
extraintestinal extraintestinal manifestationsmanifestations
Management of IBDSummary
The goals of therapy are Relieve symptoms Prevent relapse Correct nutritional deficiencies Control inflammation Prevent complications especially colon cancer
Treatment depends on 1048707 Type of disease 1048707 Site of disease 1048707 Disease severity
Treatment may include drugs nutrition supplements surgery or a combination of these options
Maintenance TherapiesMaintenance Therapies
ImmunosupressorsImmunosupressors AzathioprineAzathioprine 6-MP6-MP MethotrexateMethotrexate
AminosalicylatesAminosalicylates Anti-TNFAnti-TNF
NOT NOT corticosteroidscorticosteroids
IBD ManagementIBD ManagementSummarySummary
There is no ldquoone size fits allrdquo to IBD therapyThere is no ldquoone size fits allrdquo to IBD therapy Therapy and decision making are tailored to the Therapy and decision making are tailored to the
individualindividual
Algorithms are based upon available evidenceAlgorithms are based upon available evidence Evidence is in constant fluxEvidence is in constant flux
Success of algorithms depends upon Success of algorithms depends upon optimization of each step of therapy and optimization of each step of therapy and considerable judgment about each outcomeconsiderable judgment about each outcome Skillful application of medical therapy makes all Skillful application of medical therapy makes all
the difference in outcomesthe difference in outcomes
Surgery for IBDSurgery for IBDGeneral ConceptsGeneral Concepts
Majority will need surgery 78 over Majority will need surgery 78 over twenty yearstwenty years
Surgery generally indicated for Surgery generally indicated for complicationscomplications of disease of disease
Surgery must be directed at area of Surgery must be directed at area of bowel responsible for complicationbowel responsible for complication
Indications for SurgeryIndications for Surgery Intestinal obstruction (most Intestinal obstruction (most
common)common) Intractabilitysteroid Intractabilitysteroid
dependencedependence Non-healing fistulaAbscessNon-healing fistulaAbscess Toxic megacolonFree Toxic megacolonFree
perforationperforation Uncontrollable GI bleedingUncontrollable GI bleeding Severe perianal diseaseSevere perianal disease CancerCancer Growth retardation Growth retardation
(children)(children) Severe uncontrollable Severe uncontrollable
extraintestinal extraintestinal manifestationsmanifestations
Management of IBDSummary
The goals of therapy are Relieve symptoms Prevent relapse Correct nutritional deficiencies Control inflammation Prevent complications especially colon cancer
Treatment depends on 1048707 Type of disease 1048707 Site of disease 1048707 Disease severity
Treatment may include drugs nutrition supplements surgery or a combination of these options
IBD ManagementIBD ManagementSummarySummary
There is no ldquoone size fits allrdquo to IBD therapyThere is no ldquoone size fits allrdquo to IBD therapy Therapy and decision making are tailored to the Therapy and decision making are tailored to the
individualindividual
Algorithms are based upon available evidenceAlgorithms are based upon available evidence Evidence is in constant fluxEvidence is in constant flux
Success of algorithms depends upon Success of algorithms depends upon optimization of each step of therapy and optimization of each step of therapy and considerable judgment about each outcomeconsiderable judgment about each outcome Skillful application of medical therapy makes all Skillful application of medical therapy makes all
the difference in outcomesthe difference in outcomes
Surgery for IBDSurgery for IBDGeneral ConceptsGeneral Concepts
Majority will need surgery 78 over Majority will need surgery 78 over twenty yearstwenty years
Surgery generally indicated for Surgery generally indicated for complicationscomplications of disease of disease
Surgery must be directed at area of Surgery must be directed at area of bowel responsible for complicationbowel responsible for complication
Indications for SurgeryIndications for Surgery Intestinal obstruction (most Intestinal obstruction (most
common)common) Intractabilitysteroid Intractabilitysteroid
dependencedependence Non-healing fistulaAbscessNon-healing fistulaAbscess Toxic megacolonFree Toxic megacolonFree
perforationperforation Uncontrollable GI bleedingUncontrollable GI bleeding Severe perianal diseaseSevere perianal disease CancerCancer Growth retardation Growth retardation
(children)(children) Severe uncontrollable Severe uncontrollable
extraintestinal extraintestinal manifestationsmanifestations
Management of IBDSummary
The goals of therapy are Relieve symptoms Prevent relapse Correct nutritional deficiencies Control inflammation Prevent complications especially colon cancer
Treatment depends on 1048707 Type of disease 1048707 Site of disease 1048707 Disease severity
Treatment may include drugs nutrition supplements surgery or a combination of these options
Surgery for IBDSurgery for IBDGeneral ConceptsGeneral Concepts
Majority will need surgery 78 over Majority will need surgery 78 over twenty yearstwenty years
Surgery generally indicated for Surgery generally indicated for complicationscomplications of disease of disease
Surgery must be directed at area of Surgery must be directed at area of bowel responsible for complicationbowel responsible for complication
Indications for SurgeryIndications for Surgery Intestinal obstruction (most Intestinal obstruction (most
common)common) Intractabilitysteroid Intractabilitysteroid
dependencedependence Non-healing fistulaAbscessNon-healing fistulaAbscess Toxic megacolonFree Toxic megacolonFree
perforationperforation Uncontrollable GI bleedingUncontrollable GI bleeding Severe perianal diseaseSevere perianal disease CancerCancer Growth retardation Growth retardation
(children)(children) Severe uncontrollable Severe uncontrollable
extraintestinal extraintestinal manifestationsmanifestations
Management of IBDSummary
The goals of therapy are Relieve symptoms Prevent relapse Correct nutritional deficiencies Control inflammation Prevent complications especially colon cancer
Treatment depends on 1048707 Type of disease 1048707 Site of disease 1048707 Disease severity
Treatment may include drugs nutrition supplements surgery or a combination of these options
Indications for SurgeryIndications for Surgery Intestinal obstruction (most Intestinal obstruction (most
common)common) Intractabilitysteroid Intractabilitysteroid
dependencedependence Non-healing fistulaAbscessNon-healing fistulaAbscess Toxic megacolonFree Toxic megacolonFree
perforationperforation Uncontrollable GI bleedingUncontrollable GI bleeding Severe perianal diseaseSevere perianal disease CancerCancer Growth retardation Growth retardation
(children)(children) Severe uncontrollable Severe uncontrollable
extraintestinal extraintestinal manifestationsmanifestations
Management of IBDSummary
The goals of therapy are Relieve symptoms Prevent relapse Correct nutritional deficiencies Control inflammation Prevent complications especially colon cancer
Treatment depends on 1048707 Type of disease 1048707 Site of disease 1048707 Disease severity
Treatment may include drugs nutrition supplements surgery or a combination of these options
Management of IBDSummary
The goals of therapy are Relieve symptoms Prevent relapse Correct nutritional deficiencies Control inflammation Prevent complications especially colon cancer
Treatment depends on 1048707 Type of disease 1048707 Site of disease 1048707 Disease severity
Treatment may include drugs nutrition supplements surgery or a combination of these options
