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INFLAMMATORY BOWEL DISEASE(IBD)
“Upper & Lower GI Diseases” Lecture of Gastroentero-Hepatology System, FKUH
Centre of Gastroentero-Hepatology, Wahidin Sudirohusodo Hospital TeachingInternal Medicine, Faculty of Medicine, Hasanuddin University
Level of competent : 3A
Introduction DEFINITION a chronic
inflammation of the intestine that is marked by remission & relapses and distills clinically into ulcerative colitis (UC) and Crohn’s disease (CD).
CD, initially described in 1932 by Drs Burrill Crohn, Gordon Oppenheimer, and Leon Ginzburg, is an idiopathic transmural chronic inflammatory disorder affecting any part of the gastrointestinal tract.
UC, have been described by Drs Wilks and Moxon in 1875; is a diffuse mucosal inflammation limited to the colon.
EpidemiologyCrohn’s disease (CD) : Incidence rates were
generally lower and were broadly similar for men and women, with rates for both sexes declining with increasing age
Ulcerative colitis (UC) : Incidence rates for men
remaining fairly constant with increasing age, whereas for women decreased.
Typicallypresent at a relative young age, often in adolescence
The median age of diagnosis CD and UC is the third and fourth decade of life, respectively
Female predominance in CD and male predominance in UC
Pathogenesis Three major contributory
factors: genetic susceptibility, environmental triggers, and immune activation
Dysregulated mucosal immune respone to antigenic components of the normal commensal microbiota that reside within the intestine in a genetically susceptible host
Modifying enviromental factors (e.g tobacco, OCPs, appendectomy)
Mucosal
immune
respons
Commensal
Microbial Antigen
Genetics(e.g.
chromosomes 5 and 16)
Regulation of
immune response
?
Regulation of
barrier & bacteria?
Clinical symptom
s
Tissue injury
Th1,Th2 or Th17
mediated inflammat
ory response
T Regulator
y response
General symptoms Chronic diarrhea Abdominal pain &
cramping Blood in stool Reduced appetite Weight loss Fever
Distiguishing Features of UC & CDULCERATIVE COLITIS CROHN’S DISEASE
Pain crampy, lower abdominal, relived by bowel movement
Pain constant, often in right lower quadrant (RLQ), not relieved by bowel movement
Bloody stool Stool usually not grossly bloody
No abdominal mass Abdominal mass, often in RLQ
Affect only colon May affect small & large bowel, occasionally esophagus & stomatch
Mucosal disease (granulomas are not a feature)
Transmural disease (granulomas found in a minority patients)
Continuous from rectum May be discontinous (skip area)
DIAGNOSIS
Anamnesis : sign & simptoms Onset & course of
symptoms Growth retardation &
failure to develop sexual maturity
Physical examination : Often thin & undernourished,
anemia, tachycardia, low grade fever, mild-moderate abdominal tenderness (UC), a tender mass in RLQ
Toxic megacolon or abscess : Abdominal distention, rebound tenderness, absence of bowel sound & high fever
Extraintestinal manifestation may be evident : hepatobiliary, dermatologic, oral, occular, musculoskeletal, hematologic
Diagnostic studies
Laboratory : CBC, urinalysis, serum chemistery,
serologic: ANCA (Antineutrophil cytoplasmic Antibodies), ASCA (Ab Saccharomyces cerevisiae)
Stool examination Endoscopy LGI + mucosal
biopsy
Plain abdomen, CT abdomen, CT enterography-colonography
Pil cam imaging Barium enema shold not be
performed
COMPLICATIONS Perforation, abscess,
fistula, obstruction Anemia, osteoporosis Life-threatening
hemorrhage (rare) Toxic megacolon Colorectal cancer
DIFFERENTIAL DIAGNOSIS Bacterial colitis
(campylobacter, shigella, salmonella, E.coli)
Clostridium difficile-associated colitis
Parasitic colitis (amebiasis)
Ischemic colitis Radiation colitis
Sexual transmitted colitis (CMV, herpes)
Crohn’s disease look-alikes (lymphoma, yersinia, tuberculosis)
GI malignancy Irritable Bowel
Syndrome (IBS)
GENERAL PRINCIPAL OF THERAPY
Dependent on several distinct factors : disease location (eg, ileocecal vs colonic or proctitis vs pancolitis), severity (mild, moderate, or severe), and complications.
Should be individualized based on the patient’s prior symptomatic response and tolerance to specific medical therapies.
Therapy is sequential to treat acute disease and then to maintain remission.
TREATMENT Diet and nutrition Drugs :
5-Aminosalicylates : sulfasalazine 1-4g/day twice daily, mesalamine 2-4g/day 3-4times daily, olsalazine 1-3g/day twice daily Steroids oral-iv in CD : budesonide 9mg/d, prednisone/ methylprednisolone 40-60mg/d Antibiotics : ciprofloxacin 500mg twice daily, metronidazole 1-1.5g/d (in CD with perianal disease)Immunomodulators : azatioprine2-2.5mg/kg/d or mercaptopurine 1-1.5mg/kg/d, methotrexate 15-25mg im once daily (inchronic active & steroid dependent)Anti-Tumor Necrosis Factor (TNF) : Infliximab 5mg/kg at week 0,2,6
Surgery : due to complication
Prognosis
75% have to surgery 25% can managed
using medical therapy (UC)
Risk for CRC 8-10 years later
References Avunduk C. Inflammatory Bowel Disease. In Manual of Gastroenterology diagnosis & therapy. 4th Edition.
Lippincott Williams & Willkins. 2009;pp244-263.
Blumberg RS. Inflammatory Bowel Disease : Imunologic considerations. In Current diagnosis & treatment Gastroenterology, Hepatology & Endoscopy. Ed by Greenberger NJ, Blumberg RS, Burakoff R. Lange McGraw-Hill companies, 2009,pp11-21.
Burakoff R, Hande S. Inflammatory Bowel Disease : Medical considerations. In Current diagnosis & treatment Gastroenterology, Hepatology & Endoscopy. Ed by Greenberger NJ, Blumberg RS, Burakoff R. Lange McGraw-Hill companies. 2009;pp22-33.
Inflammatory Bowel Disease. MIMS Gastroenterology Indonesia. 2nd Edition. CMP Medica. 2009/2010.
Lower Gastrointestinal Tract Inflammatory bowel disease. In Atlas of Gastrointestinal Endoscopy and Related Pathology . Ed by Klaus Schiller F.R. Cockel R,. Hunt RH. Blackwell Science Ltd, 2002; pp 270-289.
Paradowski TJ, Ciorba M. Inflammatory Bowel Disease. In The Washington Manual Gastroenterology Subspeciality Consult. 2nd Edition. Ed by Gyawali CP, Henderson KE, De Fer TM. Lippincott Williams & Willkins. 2008;pp127-139.
Riegler G, de Leone A. IBD: Epidemiology and Risk Factors. In Inflammatory Bowel Disease and Familial Adenomatous Polyposis, Clinical Management and Patients’ Quality of Life. Ed by Delaini GG. Springer-Verlag Italy. 2006
Shanahan F. Ulcerative colitis. In Clinical Gastroenterology and Hepatology. Ed by Weinstein WM, Hawkey CJ, Bosch J et al. Elsevier Mosby. 2005; pp.343-358.
Vermeire S, Rutgeerts P. Crohn’s Disease. In Clinical Gastroenterology and Hepatology. Ed by Weinstein WM, Hawkey CJ, Bosch J et al. Elsevier Mosby. 2005; pp.359-376.