IBD - SAWA '06 Summarizing Group

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IBD - SAWA '06 Summarizing Group Powered By Docstoc
					Inflammatory Bowel
      Disease
              4th year MS
               2009-2010

           Khaled Jadallah, MD
      Assistant Professor of Medicine
 Gastroenterology, Hepatology & Nutrition
          Educational Objectives
   Definitions and spectrum of inflammatory bowel
    disease (IBD)
   Epidemiology of IBD
   Etiopathogenesis of IBD
   Clinical manifestations of ulcerative colitis (UC)
   Clinical manifestations of Crohn’s disease (CD)
   Distinguishing features between UC and CD
   Diagnostic approach to IBD
   Complications of IBD
   IBD management
       Inflammatory Bowel Disease
IBD include a group of chronic relapsing disorders that
cause inflammation or ulceration in the small and/or
large intestines. IBD is classified as:

 Ulcerative colitis (UC)- causes ulceration and
inflammation of the mucosa of the colon and rectum

 Crohn's 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
          Educational Objectives
   Definitions and spectrum of inflammatory bowel
    disease (IBD)
   Epidemiology of IBD
   Etiopathogenesis of IBD
   Clinical manifestations of ulcerative colitis (UC)
   Clinical manifestations of Crohn’s disease (CD)
   Distinguishing features between UC and CD
   Diagnostic approach to IBD
   Complications of IBD
   IBD management
           Epidemiology of IBD
                     Ulcerative colitis Crohn’s disease
Incidence (US)       11/100 000         7/100 000
Age of onset         15-30 & 60-80      15-30 & 60-80
Male:female ratio          1:1              1,1-1,8:1
Smoking              May prevent       May cause disease
                     disease
Oral contraceptiveNo increased risk Relative risk 1,9
Appendectomy      Not protective    Protective
Monozygotic twins 8% concordance 67% concordance
High

Medium

Low
          Educational Objectives
   Definitions and spectrum of inflammatory bowel
    disease (IBD)
   Epidemiology of IBD
   Etiopathogenesis of IBD
   Clinical manifestations of ulcerative colitis (UC)
   Clinical manifestations of Crohn’s disease (CD)
   Distinguishing features between UC and CD
   Diagnostic approach to IBD
   Complications of IBD
   IBD management
Nature          Nurture

         IBD
Genes          Environment
          Educational Objectives
   Definitions and spectrum of inflammatory bowel
    disease (IBD)
   Epidemiology of IBD
   Etiopathogenesis of IBD
   Clinical manifestations of ulcerative colitis (UC)
   Clinical manifestations of Crohn’s disease (CD)
   Distinguishing features between UC and CD
   Diagnostic approach to IBD
   Complications of IBD
   IBD management
    Ulcerative Colitis – clinical presentation
   Patients with proctitis usually pass fresh blood or blood-
    stained mucus either mixed with stool or streaked onto the
    surface of normal or hard stool; tenesmus is a feature

   When the disease extends beyond the rectum, blood is
    usually mixed with stool or grossly bloody diarrhea may be
    noted

   When the disease is severe, patients pass a liquid stool
    containing blood, pus, fecal matter

   Other symptoms in moderate to severe disease include:
    anorexia, nausea, vomitting, fever, abdominal pain, weight
    loss
Ulcerative colitis – macroscopic features

  Mucosa is :
- erythematous, has a granular surface that looks like a sand paper

  In more severe diseases:
- hemorrhagic, edematous and ulcerated

   In fulminant disease a toxic colitis or a toxic megacolon may
    develop ( wall becomes very thin and mucosa is severely
    ulcerated)
                 UC
Disease Distribution at Presentation




           37%
                      46%

              17%
           UC – disease severity
              MILD          MODERATE SEVERE

BOWEL         < 4 per day   4-6 per day   >6 per day
MOVEMENTS

BLOOD IN      small         moderate      Severe
STOOL

FEVER         none          <37,5°C       > 37,5°C

TACHYCARDIA   none          <90 mean      >90 mean
                            pulse         pulse
             UC – disease severity
                   MILD             MODERATE                 SEVERE


ANEMIA
               mild                 >75%                   <75%

ESR
               <30mm                                       >30mm

ENDOSCOPIC     Erythema,            Marked erythema,       Spontaneous
APPEARANCE     decreased vascular   coarse granularity,    bleeding, ulceration
               pattern, fine        contact bleeding, no
               granularity          ulceration
          Educational Objectives
   Definitions and spectrum of inflammatory bowel
    disease (IBD)
   Epidemiology of IBD
   Etiopathogenesis of IBD
   Clinical manifestations of ulcerative colitis (UC)
   Clinical manifestations of Crohn’s disease (CD)
   Distinguishing features between UC and CD
   Diagnostic approach to IBD
   Complications of IBD
   IBD management
          CD: Clinical Features
   Abdominal pain, often postprandial
   Diarrhea, usually watery
   Rectal bleeding
   Weight loss
   Right lower quadrant pain/palpable mass
   Fever
   Growth retardation in children
   Perirectal fistula
    Crohn’s disease – macroscopic features
   Can affect any part of GI tract from the mouth to the anus

   30-40% of patients have small bowel disease alone

   40-55% of patients have both small and large intestines disease

   15-25% of patients have colitis alone

   In 75% of patients with small intestinal disease the terminal
    ileum in involved in 90%
                     Crohn’s Disease:
                   Anatomic Distribution




                       Small bowel
                       alone
                       (33%)




                           Ileocolic
                           (45%)
Frequency of involvement
                                           Colon alone
                           Least           (20%)
Most
    Crohn’s disease – macroscopic features


   CD is a transmural process

   CD is segmental with skip areas in the midst of
    diseased intestine

   In one third of patients with CD perirectal
    fistulas, fissures, abscesses, anal stenosis are
    present
    Crohn’s disease – macroscopic features


   Active CD is characterized by focal
    inflammation and formation of fistula tracts

   The bowel wall thickens and becomes narrowed
    and fibrotic, leading to chronic, recurrent bowel
    obstruction
         Crohn’s Disease Activity Index
                    (CDAI)

   Incorporates 8 variables:
       1. liquid or very soft stools /day
       2. Abdominal pain & cramping
       3. Extraintestinal manifestations
       4. Complications
       5. Abdominal mass
       6. Use of anti diarrheal medications anti-
       7. Hematocrit
       8. Body weight
    Crohn’s Disease Red Flags
 Onset after stopping smoking
 Bleeding only

 Diverticulosis

 Atherosclerosis

 Prolapse
Extraintestinal Manifestations
            of IBD
 Skin
     Erythema nodosum
     Pyoderma gangrenosum
 Joints
     Peripheral arthritis
     Sacroileitis
     Ankylosing spondylitis
 Eye
     Uveitis
     Episcleritis
     Iritis
 Hepatobiliary complications
     Gallstones
     PSC
 Renal complications
     Nephrolithiasis
     Recurrent UTIs
          Educational Objectives
   Definitions and spectrum of inflammatory bowel
    disease (IBD)
   Epidemiology of IBD
   Etiopathogenesis of IBD
   Clinical manifestations of ulcerative colitis (UC)
   Clinical manifestations of Crohn’s disease (CD)
   Distinguishing features between UC and CD
   Diagnostic approach to IBD
   Medical management of IBD
   Indications for and role of surgery
              Symptoms of IBD
                  UC vs CD
     Feature            UC               CD
Fever             Uncommon         Common
Rectal bleeding   Common           < ½ of patients
Abdominal         May be present   Common
tenderness
Abdominal mass    Uncommon         Common
Abdominal pain    Uncommon         Very common
Weight loss       Uncommon         Common
Tenesmus          Very common      Uncommon
                   UC vs CD
    Complications/Response to Treatment
                      UC          CD
Fistulas              No           Yes

Small intestine       No        Frequently
obstruction
Colonic              Rarely     Frequently
obstruction
Response to           No           Yes
antibiotic
Recurrence after      No           Yes
surgery
                  UC vs CD
         Different endoscopic features
                      UC              CD

Rectal sparing       Rarely       Frequently

Continuous            Yes         Occasionally
disease
„Cobblestoning”       No              Yes

Granuloma on          No          Occasionally
biopsy
    Criteria for Indeterminate Colitis
   No evidence of small
    bowel involvement,
    fistula, or perianal
    disease

   Absence of diagnostic
    criteria for CD or UC
    by microscopy
        Differential Diagnosis of Chronic
           Diarrhea and Weight Loss
   Colonic diseases              Enteropathic
       IBD                           Celiac disease
       Neoplasia                     Tropical sprue
       Ischemic bowel                Lymphoma
   Pancreatic                        Mesenteric ischemia
       Chronic pancreatitis          Whipple’s disease
       Cancer                    Hormonal/drugs
       Cystic fibrosis               Vipoma
                                      ZES
                                      Medullary CA of thyroid
                                      NSAIDS use
          Educational Objectives
   Definitions and spectrum of inflammatory bowel
    disease (IBD)
   Epidemiology of IBD
   Etiopathogenesis of IBD
   Clinical manifestations of ulcerative colitis (UC)
   Clinical manifestations of Crohn’s disease (CD)
   Distinguishing features between UC and CD
   Diagnostic approach to IBD
   Medical management of IBD
   Indications for and role of surgery
    Diagnostic Approach to Patients
         with Suspected IBD
   History……history……history
   Clinical exam
   Laboratory tests
   Radiological imaging
   Endoscopy
   Special serological testing
   Genetic 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 Markers in
                    IBD?
   pANCA (perinuclear staining pattern)
      Loss of perinuclear pattern after DNAase
      Differentiate from the “other pANCAs”
        Antibody against myeloperoxidase
        Antibody against cathepsin G, elastase, lysozyme, and
         lactoferrin
   ASCA (anti-Saccharomyces cerevisiae)
     Both IgG and IgA
     Recognize mannose in the cell wall mannan
      of Saccharomyces cerevisiae
     Why Use Serological Markers in
          Clinical Practice?
   Differentiate IBD from functional bowel disorders
   Accurately diagnose Crohn’s or UC in a patient with:
     Severe colitis
     Indeterminate colitis
   Predict disease course or complications in IBD
     CD  phenotype
     Severity of disease

     Risk of pouchitis
                     Summary
   pANCA and ASCA are specific for UC and CD
    respectively
   Neither pANCA nor ASCA are sensitive enough to
    exclude IBD
   In patients with IC, available serological markers do
    not accurately predict the subsequent disease course
   Antibody profiles can predict disease behavior in
    IBD
             Diagnostic Approach
                      Endoscopy
   Endoscopy useful for
     Initial diagnosis
     Assessment of severity

     Tissue diagnosis

     F/U during treatment

     Assessment of disease exacerbation

     Surveillance for risk of cancer

     Treatment of certain complications (e.g. strictures)
                 Crohn’s Disease
               Endoscopic Features
   Asymmetric patchy inflammation
   Skip lesions
   Rectal sparing
   Ulcerations-deep/serpiginous
   Cobblestoning-common
   Pseudopolyps-rare
   Biopsy
       Erosions and normal mucosa
       Granulomas in 15 to 35% of specimens
             Ulcerative Colitis
            Endoscopic Features
   Diffuse involvement
   Rectum always diseased
   Superficial ulcerations
   Friability/bleeding
   Flattening/disappearance of haustral folds
   Pseudopolyps
   No cobblestoning
   Bx: No granulomas
      Imaging for Crohn Disease
             Traditional Techniques
   Abdominal Radiographs
   Barium UGI
   Barium small bowel follow through
   Barium Enteroclysis
   Barium Enema
         Imaging for Crohn Disease
                 Newer Techniques

   CT
   CT Enteroclysis
   CT Enterography
   Magnetic Resonance
   Ultrasound
   Nuclear Medicine
                  Imaging for Crohns Disease
                                   Summary
   Useful Newer Techniques evolving
        CT Enterography
             Comprehensive evaluation of all bowel & solid organs

        Magnetic Resonance
             Useful for ano-rectal disease
             Real-time MR has potential for detection of strictures


   Traditional imaging techniques still of value in selected cases
The Capsule (WCE)
                       WCE
•   Diameter 11mm: Length 26mm
•   Optical dome: Intestinal illumination by white
    light emitting diodes (LED’s)
•   Lens
•   Complementary metal-oxide silicone imager
    (color camera chip)
•   Transmitter
•   Two batteries (silver oxide)
GE Junction         Duodenum




   Jejunum    Ileocecal Valve
          Educational Objectives
   Definitions and spectrum of inflammatory bowel
    disease (IBD)
   Epidemiology of IBD
   Etiopathogenesis of IBD
   Clinical manifestations of ulcerative colitis (UC)
   Clinical manifestations of Crohn’s disease (CD)
   Distinguishing features between UC and CD
   Diagnostic approach to IBD
   Complications of IBD
   IBD management
            IBD-Complications
   GI Bleeding
   Toxic megacolon
   Perforation
   Thromboembolic phenomena
   Fistulas/fissures
   Abscess
   Strictures/obstruction
   Malabsorption/malnutrition
   Cancer
             Best Protection
   Surveillance colonoscopy

   Procto-colectomy (for UC)
Descending Colon Stricture
              Colonic Strictures
   Consider nonsurgical management if:
     Endoscopically accessible
     Multiple prior resections

     Shorter strictures (less than 5 cm)

     Steroid injection if significant inflammation
             Fistula: Definition
A communication between two epithelial-lined organs.
Lifetime risk of fistula in CD:30%
Perianal Fistula


Pretreatment       2 Weeks




 10 Weeks          18 weeks
          Educational Objectives
   Definitions and spectrum of inflammatory bowel
    disease (IBD)
   Epidemiology of IBD
   Etiopathogenesis of IBD
   Clinical manifestations of ulcerative colitis (UC)
   Clinical manifestations of Crohn’s disease (CD)
   Distinguishing features between UC and CD
   Diagnostic approach to IBD
   Complications of IBD
   IBD management
        Goals of Therapy for IBD
   Inducing remission
   Maintaining remission
   Restoring and maintaining nutrition
   Maintaining patient’s quality of life
   Prevention of complications
   Surgical intervention (selection of optimal time
    for surgery)
                 Inductive Therapies

   For UC
       Aminosalicylates
       Corticosteroids
       Cyclosporin
   For CD
       Aminosalicylates
       Corticosteroids
       Antibiotics
       Anti-TNF
         Maintenance Therapies
   Immunosupressors
     Azathioprine
     6-MP

     Methotrexate

   Aminosalicylates
   Anti-TNF
             NOT corticosteroids
                   IBD Management
                      Summary
   There is no “one size fits all” to IBD therapy
       Therapy and decision making are tailored to the individual
   Algorithms are based upon available evidence
       Evidence is in constant flux
   Success of algorithms depends upon optimization of
    each step of therapy and considerable judgment about
    each outcome
       Skillful application of medical therapy makes all the
        difference in outcomes
                Surgery for IBD
                   General Concepts

   Majority will need surgery: 78% over twenty
    years
   Surgery generally indicated for complications of
    disease
   Surgery must be directed at area of bowel
    responsible for complication
            Indications for Surgery
   Intestinal obstruction (most
    common)
   Intractability/steroid dependence
   Non-healing fistula/Abscess
   Toxic megacolon/Free
    perforation
   Uncontrollable GI bleeding
   Severe perianal disease
   Cancer
   Growth retardation (children)
   Severe uncontrollable
    extraintestinal manifestations
                  Management of IBD
                                Summary

   The goals of therapy are
       Relieve symptoms
       Prevent relapse
       Correct nutritional deficiencies
       Control inflammation
       Prevent complications, especially colon cancer
   Treatment depends on
       ���� Type of disease
       ���� Site of disease
       ���� Disease severity
   Treatment may include drugs , nutrition supplements ,
    surgery or a combination of these options

				
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