Clinical feature and diagnosis of ibd

8/7/2019 Clinical feature and diagnosis of ibd

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Vikash kumar


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How IBD is Diagnosedy Clinica l history y Physica l examinationy Laboratory testsy Endoscopy (Gastroscopy/ Colonoscopy)y X-ray f indingsy Tissue biopsy (patho logy)


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Ulcerative Colitis clinical presentationy Patients with proctitis usually pass fresh blood or

blood-stained

mucus either mixed with stool orstreaked onto the surface of normal or hard stool;tenesmus is a feature

y When the disease extends beyond the rectum, bloodis usually mixed with stool or grossl

y bloody diarrheamay be noted

y

When the disease is severe, patients pass a liquid stoolcontaining blood, pus, fecal matter

y Other symptoms in moderate to severe diseaseinclude: anorexia, nausea, vomitting, fever,abdominal pain, weight loss


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y Typica lly, UC will begin between th e ages of 15-35 but can occur at any age, occasiona lly bef ore the age of 5and even af ter th e age of 85. Cigarette smoking can decrease th e risk of developing ulcerati ve colitis.A noth er interesting influence, also prot ective against the developm ent of UC is an appendectomy . Pati ents who have had an appendectomy bef ore th e age of 21,

because of an inflammatory prob lem, (such as appendicitis) have as much as a 60% lower incid enceto develop ulcerati ve colitis. W hy an appendectomy is prot ective, is not known. It does not, however, prot ect against th e developm ent of Crohn s disease.


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Ulc erative Co litis

Left-sided ColitisProctitis Total Colitis

The small intestine is not involved.


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U CDisease Distribution at Presentation

46%37%

17%


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Symp to m s of Ulc erative Co litis

y Symptoms depend on extent and severity of

inflammationy R ectal bleeding and urgency to ev acuat ey Diarrh eay A bdomina l crampingy Extraint estina l (systemic) symptoms

y Joint pain/s wellingy Ey e inflammationy Skin lesions


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Ulc erative Co litis

Coloni c Comp lic ations

Perforation

Stricture

Blee ing

Cancer


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U C disease severit yMILDMILD MODERATEMODERATE SEVERESEVERE

BOWEL BOWEL

MOVEMENTS MOVEMENTS < 4 per day < 4 per day 44--6 per day 6 per day >6 per day >6 per day

BLOOD I OOL BLOOD I OOL smallsmall moderatemoderate SevereSevere

F EVER F EVER nonenone 37,5 C C

TACHYCAR D I ATACHYCAR D I A n on en on e 90 mea n 90 mean ulseulse

90 mea n 90 mea n ulseulse


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U C disease severit yMILDMILD MODERATEMODERATE SEVERESEVERE

ANEMIA ANEMIA

mi ldmi ld >75%>75%


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Comm on Symp to m s of Crohn s Disease

y Diarrh eay A bdomina l pain and tend ernessy

Loss of app etit e and weight y Fevery Fatigu ey R ecta l bleeding and ana l ulcersy S tunt ed growth in children


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C rohn s Disease:C rohn s Disease:Anatomic DistributionAnatomic Distribution

Small bowelSmall bowelalonealone(33%)(33%)

IleocolicIleocolic(45%)(45%)

C olon aloneC olon alone(20%)(20%)

Frequency of involvementFrequency of involvement

MostMost LeastLeast


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Crohn s Disease:

Clinic a l Features

PeritonitisMesenteric Abscess


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Crohn s Disease:

Clinic a l Features

Internal Fistulae


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Peri-Anal Fistulaeand/or Abscesses

External Fistula(via appendectomy incision)

Crohn s Disease:

Clinic a l Features


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Fistula

Skin Ta

Abscess

Fissure

Crohn s Disease:

Periana l Prob le m s


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Perforation

Stricture

Cancer

Fistula

Abscess

Crohn s Disease:

Intestina l Comp lic ations


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IBD: Extra-intestina l ManifestationsSkinEye

ones and JointsKidneyLiver/

Gall ladder


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E xtraintestinalManifestations of IBD

SkinErythema nodosumPyoderma gangr enosum

JointsPeriph eral arthritisS

acroi leitisA nky losing spondy litisEy e

UveitisEpiscleritisIritis

Hepatobi liary comp licationsGallston esPSC

R enal comp licationsNephro lithiasis

R ecurr ent UTIs


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IBD:

Skin Lesions

Erythema nodosum

Pyoderma

an renosum


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Symp to m s of IBDU C vs CD

FeatureFeature U CU C CDCD

F everF ever Uncommo nUncommo n Commo nCommo n

Rectal bleed ing Rectal bleed ing Commo nCommo n < o f pat ients< o f pat ients

Abd omi nalAbd omi naltendernesstenderness

May be presentMay be present Commo nCommo n

Abd omi nal m assAbd omi nal m ass Uncommo nUncommo n Commo nCommo n

Abd omi nal pa inAbd omi nal pa in Uncommo nUncommo n Very commo nVery c ommo n

Weight lo ssWeight lo ss Uncommo nUncommo n Commo nCommo n

Tenes m usTenes m us Very c ommo nVery c ommo n Unc ommo nUnc ommo n


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Colonos c opy in IBDy Diagnosis of IBD (UC v s. CD)

y Allows v isualization of large int estin e

and ileumy Allows biopsi es to examin e colon tissu e

y Determin es activ ity of diseasey Important f or pre-canc er sur veillance

in UC and CD


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Ulcerative colitis macroscopic features

y Mucosa is :

- eryth ematous, has a granu lar sur f ace that looks like a sand pap er

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

y In fulminant disease a toxic colitis or a toxic megacolon may develop ( wall becomes very thin and mucosa is severely ulcerated)


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Ulc erative Co litis:

Colonos c opy App earan c e

MildNormal Severe


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y The name ulcerative colitis suggests that the lining of thecolon is covered with ulcers, but ulcers are typically seen onlyin severe colitis. The normal lining of the colon or mucosa isslightly pink in appearance, like the inside of the lining of your cheek, with a delicate lace-like pattern of small blood vessels.Small ridges or folds are also spaced throughout the colon. Thelining of the colon in mild ulcerative colitis is redder thannormal ( erythematous ) without the delicate pattern of bloodvessels. This indicates inflammation is present in the tissue.The lining can also be friable, meaning that the surface canbleed or ooze a small amount of blood when stroked gentlywith a cotton swab. This common abnormality seen in UC canexplain why some patients may observe some bleeding or evensevere bleeding as their stools become more formed, whichcauses them to rub more firmly against the lining of the colon.


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y Sometimes inflammation can be present with little or no redness or other abnormalities seen. Examination

of biopsies under the microscope can be a moredefinitive indication of what is happening in the liningof the intestine. In more severe colitis, the colon mayhave ulcerations, may be swollen ( edematous ) and the

surface may be covered with thick substance, acombination of mucous and pus, that drips off of theinflamed surface (called an exudate ). In long standingsevere colitis the colon begins to loose its ridges and

other features (sometimes called featureless or havinga lead-pipe appearance).


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y The appearance of Crohns, when seen through ascope, can have several features which are characteristic

of Crohns. However, it may also look like UC, so muchso that it can be impossible in some cases to distinguishthe two diseases endoscopically. The classic appearanceof Crohns includes definite ulcerations with normal,healthy-appearing intestinal lining in the surrounding

tissue. Typically there are long, linear ulcerations(sometimes called bear claw ulcerations because it looksas if a bear was scrounging around in the intestinesscraping deeply as he moves along his way). Cobble-stoning is a characteristic finding, with deep ulcerationscriss-crossing, leaving nubs of normal tissue (thecobblestones).

y


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y Crohn's can also cause the development of a tightstricture, a narrowed, fibrotic area, which might not allow

the scope to pass through. These strictures develop over along period of time, usually years, and result from chronicinflammation and the bodys attempt to heal. Slow gradualscarring can continue to tighten over years. Also, as

mentioned, Crohns can have a diseased area followed byan abrupt change to normal and then a diseased segment.Detecting a small fistula by colonoscopy can be difficult,though larger fistula can be occasionally seen. Theyappear through the scope as a nub of inflamed tissue and acentral opening.


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Crohn s Disease:

Colonos c op ic App earan c e

Cobb l toneD i r e te Ul e r tri t r e( rr ow in g)


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Diagnosis-LABy Blood test

y CD: Mild anemia, mild leukocytosis, elev ated ESR, elev ated CRP, positi ve A S CA

y UC: A nemia, hypoka lemia, hypoa lbumin emia, elev ated ESR, elev ated LFTs, positi ve p-A NCA

y Stool analysisy

Many WBCs and /or R BCsy No ov a or parasit es


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W hat are the Sero logi c a l Mar kers in IBD?y pA NCA (perinuc lear staining patt ern)

y Loss of perinuc lear patt ern af ter DNA asey

Differentiat e f rom th e oth er pA NCA sy A ntibody against my eloperoxidasey A ntibody against cath epsin G, elastas e, lysozyme, and

lacto ferriny A S CA (anti- Saccharomyces cerevisiae )

y Both IgG and IgA y R ecogniz e mannos e in th e cell wall

mannan of Saccharomyces cerevisiae


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W hy U se Sero logi c a l Mar kers in C linic a l

Pra c tic e?y Differentiat e IBD f rom f unctiona l bowel disord ersy A ccurat ely diagnos e Crohn s orUC in a pati ent with :

y S evere colitisy Ind eterminat e colitis

y Predict disease cours e or comp lications in IBDy CD phenotyp ey S everity of diseasey Risk of pouchitis


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Summ ar yy pA NCA and A SCA are specif ic f or UC and CD

respectively y

Neith er pA NCA nor A S CA are sensiti ve enough to exclude IBDy In pati ents with IC, av ailable serological

mark ers do not accurat ely predict th e

subs equent disease cours ey A ntibody prof iles can predict disease behav ior

in IBD


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Diagnosti c App roa c hEndos c opy

y Endoscopy usef ul f ory Initia l diagnosisy

A ssessment of severity y Tissue diagnosisy F/U during treatm enty A ssessment of disease exacerbationy S ur veillance f or risk of cancery Treatm ent of certain comp lications (e.g. strictur es)


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Im aging for Crohn DiseaseTraditiona l Tec hniques

y A bdomina l Radiographsy Barium UGIy Barium small bowel f ollow throughy Barium Enteroclysis

y Barium Enema


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Im aging for Crohn DiseaseNewer Te c hniques

y CT

y CT Enteroclysisy CT Enterography y Magnetic R esonanc ey Ultrasoundy Nuclear Medicin e


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Im aging for Crohns Disease

Summ ar yy U seful Newer Techniques evolving

y C

TE

nterography y C omprehensive evaluation of all bowel & solid organs

y Magnetic Resonancey U seful for ano-rectal disease

y R eal-tim e MR has pot entia l f or detection of strictur es

y Traditiona l imaging techni ques still of v alue in selected cases


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The C apsule (W CE )The C apsule (W CE )


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W CEDiameter 11mm : Length 26mmO ptica l dom e: Intestina l illumination by white light

emitting diod es (LED s)LensComp lementary metal-oxide silicone imager (color camera chip)

Transmitt erTwo batt eries (silver oxide)


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GE Junction Duod enum

Jejunum Ileocecal Valve


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Clinical feature and diagnosis of ibd

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