Inflammatory Bowel Disease

Inflammatory Bowel Disease (IBD) Ulcerative colitis and Crohn's disease

• Chronic inflammatory diseases of the gastrointestinal tract

• No single finding is diagnostic for these diseases

• Epidemiological, clinical, laboratory, imaging and pathological characteristics

• Some patients have a clinical picture that falls between the two diseases

Case

• 23 y old female with 6 weeks diarrhea• Liquid stools no blood• Bowel movement at night• Colicky abdominal pain• Fever to 38°C• Loss of appetite• Weight loss 6 kilograms

Case

• Red painful nodules on the lower leg

• Painful knee and wrist joints

• Previous history of a perianal abcess

• Smokes 20 cigarettes a day for 5 years

• Brother with Crohn’s disease

Questions

1. Does the patient have inflammatory bowel disease?

2. How do we diagnose it?

3. How do we treat the patient?

Differential DiagnosisSmall Intestine

• Infections • Malabsorption• Lymphoma• Ulcerative jejenoileitis• Tuberculosis• NSAID enteropathy• Ischemic bowel

– etiology– epidemiological, – clinical, – laboratory, – imaging– pathology

Differential DiagnosisColon

• Infection• Pseudomembranous

colitis• Radiation colitis• Ischemic colitis• Microscopic colitis

– etiology– epidemiological– clinical– laboratory– imaging– pathology

Diagnosis – Building the Picture

Epidemiology

Clinical

Laboratory

Imaging

Pathology

Response to treatment

IBD

Epidemiology IBD

Epidemiology

• 23 y old

• Female

• Jewish

• Smoker

• Brother with Crohn’s

Cause(s) of IBD

• Genetic• Infection• Immunological

Genetic Influence

GEOGRAPHICAL PREVALENCE OF IBD

Epidemiology

Clinical

IBD

Symptoms

• Diarrhea ± mucus, blood• Abdominal pain• Fever• Loss of appetite• Weight loss• Tiredness and weakness

Symptoms (continued)

• Joint pains, arthritis

• Mouth ulcers

• Skin rash – erythema nodosum

• Perianal abscesses and fistuli

• Eye inflammation

Epidemiology

Clinical

Laboratory

IBD

Laboratory

• Infection – stool microscopy and culture

• Malabsorption – stool fat (>6g/day)

• Inflammation – – Erythrocyte sedimentation rate, CRP– Anemia: iron deficiency, Vit B12 deficiency,

anemia of chronic disease,

• Nutrition – low albumin

p-ANCA and ASCA in IBD

Epidemiology

Clinical

Laboratory

Imaging

IBD

IBD and Imaging

• Is there inflammation in the digestive tract?– If not – are there any other relevant processes

• What is the distribution of the inflammation?

• What are the characteristics of the inflammation?

• Take biopsies during imaging?

Small Intestine and Colon • Duodenum (60 cm long)

– shortest and widest; • Jejunum (2.5 m long)

– most of digestion & absorption• Ileum (longest at 3.5 m)

– water and electrolyte absorption– ends at ileocecal valve

• Colon (1.5 m long)– water and electrolyte absorption

Differences Between UC and Crohn’s Disease

Characteristic Features of Ulcerative Colitis

Crohn’s DiseaseAnatomic Distribution

Crohn’s DiseaseConsequences of Transmural

Inflammation

• Inflammatory masses• Fistuli• Intestinal obstruction• Perforation

Ulcerative Colitis-Imaging Modalities

Colon:

• Plain abdominal X-ray

• Colonoscopy

• Barium enema

• (CT)

Ulcerative Colitis

Colon:• Plain

abdominal X-ray

• Colonoscopy• Barium enema• (CT)

Normal Barium Enema

Colon:• Plain abdominal X-ray• Colonoscopy• Barium enema• (CT)

Ulcerative Colitis

BENIGN STRICTURE

Ulcerative Colitis

Colon:• Plain abdominal X-

ray• Colonoscopy• Barium enema• (CT)

Crohn’s Disease Imaging modalities

• Barium studies– Small bowel follow through and enteroclysis– Barium enema

• Endoscopy– Ileoscopy at colonoscopy– Upper GI endoscopy and enteroscopy

• CT• Ultrasound• Isotope scan• Capsule endoscopy

X-ray Appearance of Crohn’s Disease

• Barium studies– Small bowel follow through

and enteroclysis– Barium enema

• Endoscopy– Ileoscopy at colonoscopy– Upper GI endoscopy and

enteroscopy• CT• Ultrasound• Isotope scan• Capsule endoscopy

Mesenteric Involvement

Jejenitis

Gastro-duodenitis

Crohn’s Colitis

Early Crohn’s Disease-Terminal Ileum

• Barium studies– Small bowel follow through and

enteroclysis– Barium enema

• Endoscopy– Ileoscopy and colonoscopy– Upper GI endoscopy and

enteroscopy• CT• Ultrasound• Isotope scan• Capsule endoscopy

Crohn’s Colitis

Crohn’s Disease

UC

Crohn’s Disease - Enteroscopy• Barium studies

– Small bowel follow through and enteroclysis

– Barium enema• Endoscopy

– Ileoscopy at colonoscopy– Upper GI endoscopy and

enteroscopy• CT• Ultrasound• Isotope scan• Capsule endoscopy

Crohn’s Disease

• Small bowel follow through and enteroclysis – barium

• Ileoscopy at colonoscopy• Upper GI endoscopy and

enteroscopy• CT• Ultrasound• Isotope scan• Capsule endoscopy

Crohn’s Disease - CT

Crohn’s Disease

• Small bowel follow through and enteroclysis – barium

• Ileoscopy at colonoscopy• Upper GI endoscopy and

enteroscopy• CT• Ultrasound• Isotope scan• Capsule endoscopy

Video Capsule Endoscopy in IBD

• 17 patients with suspected CD not diagnosable by conventional methods

• Iron deficiency anemia (9), abdominal pain (8), diarrhea (7), weight loss (3)

• 12 (70.6%) patients diagnosed as Crohn’s

• Mean duration of symptoms 7.4 years

Fireman et al

Epidemiology

Clinical

Laboratory

Imaging

Pathology

IBD

Differences Between UC and Crohn’s Disease

Ulcerative colitis and Crohn’s disease

UC• Mucosal disease

Crohn’s Disease• Transmural

inflammation

Crohn’s Disease-Serosal View

Removed Colon

UC Crohn’s

Distinguishing Features of Crohn’s Disease

Colorectal Cancer and IBD

RISK OF COLORECTAL CANCER

FACTORS MODIFYING RISK OF COLITIS-ASSOCIATED

CANCER

COLONOSCOPIC SURVEILLANCE FOR

DYSPLASIA

Extraintestinal Manifestations

Erythema nodosumAphthous ulcer

Iritis

Crohn’s Perianal Disease

PERIPHERAL ARTHRITIS

Osteopenia

Skin LesionsErythema Nodosum Pyoderma Gangrenosum

SCLEROSING CHOLANGITIS

Primary Sclerosing Cholangitis

Sclerosing Cholangitis- MR Cholangiography (MRCP)

IBD in Kibbutzim Crohn’s Disease UC

25.5/100,000 in 1987 to

65.1/100,000 in 1997

121/100,000 in 1987 to

167/100,000 in 1997