Upload
brett-wright
View
225
Download
6
Tags:
Embed Size (px)
Citation preview
CaseCase
A 25-year-old woman A 25-year-old woman A 4-m history of A 4-m history of abdominal abdominal painpain in the left lower quadrant in the left lower quadrant and and bloody diarrheabloody diarrhea
CaseCase
Stool Examination: WBC Stool Examination: WBC + ,RBC +++ ,RBC ++
MicrobiologicMicrobiologic cultures of stools : cultures of stools : negativenegative
ColonoscopyColonoscopy
ColonoscopyColonoscopy
Continuous ulcers begin in the Continuous ulcers begin in the
rectumrectum
Colonoscopy biopsyColonoscopy biopsy
PathologyPathology
(H/E, 4x) (H/E, 10x)
crypt
abscesses
Ulcerative Ulcerative Colitis Colitis
Yan Chen Yan Chen 陈焰 陈焰 Second Affiliated Second Affiliated
Hospital Hospital
ConceptConcept Idiopathic Idiopathic IInflammatory nflammatory BBowel owel
DDiseaseisease
(( IBD) IBD)
Ulcerative colitis(UC)Ulcerative colitis(UC)
Crohn’sCrohn’s disease (CD)disease (CD)
IBD IBD 有关内容有关内容
Learning ObjectivesLearning Objectives
• Understand the current theories of IBD pathogenesis
• Understand the clinical presentation, and management of ulcerative colitis and Crohn’s disease
• Understand the fundamental differences between ulcerative colitis and Crohn’s
commendatory websites commendatory websites and booksand books
commendatory websitescommendatory websites http://content.nejm.org/http://content.nejm.org/ http://www.ccfa.orghttp://www.ccfa.org http://www.gastrolab.net/show.htmlhttp://www.gastrolab.net/show.html http://www-medlib.med.utah.edu/WebPath/TUTORIAL/http://www-medlib.med.utah.edu/WebPath/TUTORIAL/
IBD/IBD.htmlIBD/IBD.html commendatory bookscommendatory books
Harrison’s principles of internal medicine Harrison’s principles of internal medicine
1515thth Edition Edition
Goldman: Cecil Medicine, 23rd ed Chapter Goldman: Cecil Medicine, 23rd ed Chapter 144 144
Ulcerative Colitis (UC)Ulcerative Colitis (UC) Concept Concept EtiologyEtiology PathologyPathology Clinical presentationClinical presentation Diagnosis and differential Diagnosis and differential
diagnosis diagnosis ComplicationsComplications TreatmentTreatment
ConceptConcept Ulcerative ColitisUlcerative Colitis
An idiopathic An idiopathic
inflammatory disorderinflammatory disorder
involving primarily the involving primarily the
mucosa and submucosamucosa and submucosa
of the colonof the colon
especially the rectumespecially the rectum
often with mucosal often with mucosal
erosions and ulcerserosions and ulcers
ConceptConcept
colitis confined colitis confined rectum rectum (proctitis) (proctitis) rectum and sigmoid colon rectum and sigmoid colon
(proctosigmoiditis)(proctosigmoiditis) splenic flexure splenic flexure (left sided (left sided
colitis)colitis) colitis up to colitis up to
the hepatic flexure the hepatic flexure (extensive (extensive colitis)colitis)
the whole colon the whole colon (pancolitis)(pancolitis)
ConceptConcept
Ulcerative Colitis (UC)Ulcerative Colitis (UC) Concept Concept Etiology Etiology PathologyPathology Clinical presentationClinical presentation Diagnosis and differential Diagnosis and differential
diagnosis diagnosis ComplicationsComplications TreatmentTreatment
Etiologic Theories in IBD
Mucosal Immune Mucosal Immune SystemSystem
(Immuno-regulatory (Immuno-regulatory Defect)Defect)
Environmental Environmental TriggersTriggers
(Lumenal Bacteria, (Lumenal Bacteria, Infection)Infection)
Genetic Genetic PredispositionPredisposition IBD
Ulcerative Colitis (UC)Ulcerative Colitis (UC) Concept Concept EtiologyEtiology PathologyPathology Clinical presentationClinical presentation Diagnosis and differential Diagnosis and differential
diagnosis diagnosis ComplicationsComplications TreatmentTreatment
PathologyPathology Tends to begin in the rectum Tends to begin in the rectum
and be continuous and be continuous Limited inflammation Limited inflammation
Mucosa and submucosaMucosa and submucosa Crypt abscessCrypt abscess
PathologyPathology Tends to be Tends to be
continuous continuous along the along the mucosal mucosal surface;surface;
Tends to begin Tends to begin in the in the rectum.rectum.
PathologyPathology Tends to begin in the rectum Tends to begin in the rectum
and be continuous and be continuous Limited inflammation Limited inflammation
Mucosa and submucosaMucosa and submucosa Crypt abscessCrypt abscess
Normal colonNormal colon
Ulcerative colitisUlcerative colitis
PathologyPathology Tends to begin in the rectum Tends to begin in the rectum
and be continuous and be continuous Limited inflammation Limited inflammation
Mucosa and submucosaMucosa and submucosa Crypt abscess: Crypt abscess:
Characteristic finding Characteristic finding
Characteristic finding Characteristic finding Crypt Crypt
abscessabscess
PathologyPathology Tends to begin in the rectum Tends to begin in the rectum
and be continuous and be continuous Limited inflammation Limited inflammation
Mucosa and submucosaMucosa and submucosa Crypt abscessCrypt abscess
Ulcerative Colitis (UC)Ulcerative Colitis (UC) Concept Concept EtiologyEtiology PathologyPathology Clinical presentation Clinical presentation Diagnosis and differential Diagnosis and differential
diagnosis diagnosis ComplicationsComplications TreatmentTreatment
Clinical presentation Clinical presentation
variablevariable
Bloody diarrhea Bloody diarrhea hallmark hallmark
Abdominal painAbdominal pain
Fecal urgencyFecal urgency
Tenesmus Tenesmus
U CU C Mild Moderate SevereMild Moderate Severe
Bowel movementsBowel movements <4/d 4-6/d >6/d <4/d 4-6/d >6/dBlood in stoolBlood in stool Small Moderate Severe Small Moderate SevereFever Fever None <37.5 >37.5℃ ℃ None <37.5 >37.5℃ ℃Tachycardia Tachycardia None <90 >90 None <90 >90Anemia Anemia Mild Moderate Severe Mild Moderate SevereESR ESR <30mm >30mm <30mm >30mmEndoscopicEndoscopic Erythema Marked Erythema Spontaneous Erythema Marked Erythema Spontaneous appearance appearance contract bleeding bleeding, contract bleeding bleeding, ulcerations ulcerations
extraintestinal extraintestinal manifestationmanifestation
Erythema Erythema nodosumnodosum
Pyoderma gangrenosumPyoderma gangrenosum
EpisclerEpiscler
itisitis
Ulcerative Colitis (UC)Ulcerative Colitis (UC) Concept Concept EtiologyEtiology PathologyPathology Clinical presentationClinical presentation Diagnosis and differential Diagnosis and differential
diagnosisdiagnosis Complications Complications TreatmentTreatment
DiagnosisDiagnosis
Essentials of DiagnosisEssentials of Diagnosis Bloody diarrheaBloody diarrhea Lower abdominal pain and Lower abdominal pain and
fecal urgencyfecal urgency Anemia,low serum albuminAnemia,low serum albumin Negative stool cultures Negative stool cultures Colonoscopy Colonoscopy is key to is key to
diagnosisdiagnosis Imaging is helpful sometimes Imaging is helpful sometimes
Laboratory findingLaboratory finding Negative stool culturesNegative stool cultures
Anemia, ESR,CRPAnemia, ESR,CRP
low serum albuminlow serum albumin
p-ANCA: 70% positivep-ANCA: 70% positive
Negative stool culturesNegative stool cultures
Very importantVery important
ImagingImaging
Plain abdominalPlain abdominal
Barium enemas Barium enemas
Plain abdominalPlain abdominal
Severe patients Severe patients
colonic dilation colonic dilation
Toxic megacolonToxic megacolon
DiagnosisDiagnosis
Essentials of DiagnosisEssentials of Diagnosis Bloody diarrheaBloody diarrhea Lower abdominal pain and Lower abdominal pain and
fecal urgencyfecal urgency Anemia,low serum albuminAnemia,low serum albumin Negative stool cultures Negative stool cultures Colonoscopy Colonoscopy is key to is key to
diagnosisdiagnosis Imaging is helpful sometimes Imaging is helpful sometimes
Concept Concept EtiologyEtiology PathologyPathology Clinical presentationClinical presentation Diagnosis andDiagnosis and
differential diagnosis differential diagnosis Complications Complications Treatment Treatment
Differential diagnosisDifferential diagnosis
Infectious diseaseInfectious disease :: ameba, ameba, dysentery…dysentery…
CDCDColon cancer Colon cancer IBSIBSTubTubIschemic colitisIschemic colitis
amebiasis amebiasis
HE stain PAS : trophozoite
amebiasisamebiasis
amebiasis
amebiasis
colonscopy
Ulcerative ColitisUlcerative Colitis Crohn Disease Crohn Disease
Colon onlyColon only involved involved Pan-intestinalPan-intestinal
Continuous Continuous inflammation inflammation extending proximally extending proximally from from rectumrectum
Skip-Skip-lesions with lesions with intervening normal intervening normal mucosamucosa
Inflammation in Inflammation in mucosa and mucosa and submucosasubmucosa only only
TransmuralTransmural inflammationinflammation
No granulomas, No granulomas, crypt crypt abscessabscess
Non-caseating Non-caseating granulomasgranulomas
pANCA positivepANCA positive pASCA negetivepASCA negetive
Bleeding is commonBleeding is common Bleeding is Bleeding is uncommonuncommon
Fistulae are rareFistulae are rare Fistulae Fistulae are common are common
UC CDUC CD
Colon only, proximally Colon only, proximally
from rectumfrom rectum
Pan-Pan-intestinal, intestinal, Skip-Skip-lesionslesions
UC CDUC CD
mucosa and mucosa and
submucosasubmucosa
TransmuralTransmural
crypt abscesscrypt abscess
granulomagranuloma
ss
CDCD
FistulaeFistulae
Ulcerative Colitis (UC)Ulcerative Colitis (UC) Concept Concept EtiologyEtiology PathologyPathology Clinical presentationClinical presentation Diagnosis and differential Diagnosis and differential
diagnosis diagnosis Complications Complications TreatmentTreatment
Complications Complications
Toxic megacolonToxic megacolon
Bleeding Bleeding
PerforationPerforation
Risk of colon cancerRisk of colon cancer
Toxic megacolonToxic megacolon < 2% of cases < 2% of cases
particularly severe particularly severe UC UC
Defined as a Defined as a severe severe episodeepisode of colitis of colitis with segmental or with segmental or total total dilationdilation of the of the colon (colonic colon (colonic dilation of > 5cm)dilation of > 5cm)
Mortality rate : Mortality rate : 20%20%
Toxic megacolonToxic megacolon
An acute An acute transmural fulminanttransmural fulminant colitis with the neurogenic loss of colitis with the neurogenic loss of motor tone.motor tone.
The rapid development of colonic The rapid development of colonic dilatation dilatation due to damage to the due to damage to the entire wallentire wall of the colon associated of the colon associated with neuromuscular degeneration. with neuromuscular degeneration.
Toxic megacolonToxic megacolon
Diagnosis Diagnosis Clinical findingsClinical findings
Symptoms Symptoms Signs Signs
Laboratory finding Laboratory finding abdominal plainabdominal plain
Clinical findingsClinical findings SymptomsSymptoms
Abdominal pain Abdominal pain Abdominal distention Abdominal distention Fever Fever Rapid heart rate Rapid heart rate Dehydration Dehydration
Signs Signs Abdominal tendernessAbdominal tenderness May be signs of May be signs of
septic shock septic shock Possible loss of bowel Possible loss of bowel
soundssounds
Lab findingLab finding
Elevated white blood cell Elevated white blood cell Low potassium level Low potassium level Abdominal plainAbdominal plain shows colonic shows colonic
dilationdilation
Toxic megacolonToxic megacolon
CausesCausesLower potassium level Lower potassium level Barium enemaBarium enemaAnticholinergicsAnticholinergicsDrugs used for pain reliefDrugs used for pain relief
Case 1Case 1
A 72-year-old woman A 72-year-old woman Vomiting Vomiting Abdominal distentionAbdominal distention History of hypertension and History of hypertension and
ulcerative colitisulcerative colitis
Case 1Case 1
supineerect
Toxic megacolonToxic megacolon
CauseCause
Toxic megacolonToxic megacolon
CauseCause
Lower potassium level after Lower potassium level after taking diuretics for taking diuretics for hypertensionhypertension
Case 2Case 2
a 44-year-old man a 44-year-old man Long history of ulcerative Long history of ulcerative
colitiscolitis Double-contrast barium enemaDouble-contrast barium enema
Case 2Case 2
Double-contrast barium enemaDouble-contrast barium enema
Case 2Case 2 2 days later
Toxic megacolonToxic megacolon
CausesCausesLower potassium level Lower potassium level Barium enemaBarium enemaAnticholinergicsAnticholinergicsDrugs used for pain reliefDrugs used for pain relief
Complications Complications
Toxic megacolonToxic megacolon
Bleeding Bleeding
PerforationPerforation
Risk of colon cancerRisk of colon cancer
Cumulative Risk of CRC in Cumulative Risk of CRC in UCUC
0.5-1.0% per year after 10 years of disease0.5-1.0% per year after 10 years of disease
Eaden et al. Eaden et al. GutGut 48:526, 2001 48:526, 2001
TreatmentTreatment
Dependent on the extent of Dependent on the extent of colonic involvement and severity colonic involvement and severity of illnessof illness
2 objectives2 objectives Inducing remissionInducing remission (periods of time (periods of time
that are symptom-free) that are symptom-free) Maintaining remissionMaintaining remission (preventing (preventing
flare-ups of disease) flare-ups of disease)
Sulfasalazine (SASP)Sulfasalazine (SASP) Made up ofMade up of
5-aminosalicylic acid (5-ASA): 5-aminosalicylic acid (5-ASA): functionally active moiety of SASPfunctionally active moiety of SASP
sulfur molecule: related to the sulfur molecule: related to the side effectsside effects
Newer 5-ASA drugs avoid the Newer 5-ASA drugs avoid the side effects side effects
Any other questions?Any other questions?
陈焰 陈焰 1375711865313757118653