1

Review

Ashraf M. AbdelKaderGeneral surgery Lecturer

Faculty of medicine

Banha University

2014

IBD

Definition ,Epidemiology ,Etiology and Pathology .

Diagnosis and Activity Assessment :

1. Clinical .

2. Radiological .

3. Endoscopic .

4. Histological .

Treatment of active IBD

(IBD)

It is an idiopathic inflammatory intestinal disease resulting from

an inappropriate immune activation to host intestinal

microflora.

Types of IBD are

Ulcerative colitis

Crohn’s disease

Indeterminate colitis

GEOGRAPHICAL PREVALENCE OF IBD

Europe NA

Ulcerative Colitis Crohn’s Disease

Age-Specific Incidence of IBD *

Incidence in both CD and UC have 2 peaks

( in 3 rd and 6 th decades ).

10

0

2

4

6

8

0 20 40 60 80

10

0

2

4

6

8

0 20 40 60 80

Age (yrs) Age (yrs)

Current Etiologic Hypothesis for IBD

One model of IBD pathogenesis. Aspects of both CD and UC.

Comparison of the distribution patterns, ulcers and wall thickenings of CD and UC.

Pathological Features That Differ between CD and UC

Artwork is reproduced, with permission, from the Johns Hopkins Gastroenterology and Hepatology Resource Center,www.hopkins-gi.org,copyright 2006, Johns Hopkins University, all rights reserved.

CD: Gross Appearance

UC: Gross Appearance

THERE IS NO ONE SINGLE TEST

TO DX IBD

Diagnosis and Assessment

of Activity in IBD

Clinical

diagnosis

and

Assessment of IBD Activity

Clinical presentation of IBD

A- symptoms:- diarrhea

- rectal bleeding

- tenesmus

- passage of mucus

- abdominal pain

- other symptoms: anorexia,

nausea, vomiting, fever,

and weight loss

B- Signs

Examination findings in CD

Loss of weight

General ill health

Aphthous ulceration of mouth, glossitis angular stomatitis

Abdominal tenderness and RIF mass

Perianal skin tags, fissures, fistulae

Examination findings in UC

Hydration & volume status determined by B.P

Pulse rate

High temperature

Abdominal: Tenderness & evidence

of peritoneal inflammation

Presence of blood on DRE

Clinical findings That Differ between CD and UC

CD UC

Defecation Often porridge like

,sometimes steatorrhea

Often mucus-like and

with blood

Tenesmus Less common More common

Fever Common Indicates severe

disease

Fistulae Common Seldom

Weight loss Often More seldom

Malignant

potential

With colonic

involvement

Yes

Toxic megacolon No Yes

after surgery Recurrence is common No recurrence

Artwork is reproduced, with permission, from the Johns Hopkins Gastroenterology and Hepatology Resource Center,

www.hopkins-gi.org,copyright 2006, Johns Hopkins University, all rights reserved.

Complication of UC

Haemorrhage

Perforation

Toxic megacolon (transverse colon with a diameter of

more than 5 cm to 6cm with loss of haustration

Cancer: with active colitis of more than eight year

Complication of CD

Strictures with intestinal obstruction

Abscesses

Fistulas

Cancer: Risk related to the severity and duration of the disease.

watering-can perineum secondary to severe perianal Crohn disease.

Clinical Assessment of Activity in IBD

A-Ulcerative colitis Clinical Activity Index(UCCAI)

B-Crohn's Disease clinical Activity Indices:

I - Harvey-Bradshaw index

II - Crohn's Disease Activity Index

Criteria Mild Disease

Severe Disease Fulminant Disease

Stools < 4/day > 6/day > 10/day

Blood in stool Intermittent Frequent Continuous

Temperature Normal > 37.5°C > 37.5°C

Pulse Normal > 90 beats/min > 90 beats/min

Hemoglobin Normal < 75% of normal Transfusion required

ESR ≤30 mm/hr > 30 mm/hr > 30 mm/hr

Colonic features on radiography

_ Air, edematous wall, thumbprinting

Dilatation

Clinical signs _ Abdominal tenderness

Abdominal distention and tenderness

A-Ulcerative colitis Clinical Activity Index.Criteria for Evaluating Severity of Ulcerative Colitis

B-Crohn's Disease clinical Activity Indices

I - Harvey-Bradshaw index

A-general well-being (0 = very well, 1 = slightly below

average, 2 = poor, 3 = very poor, 4 = terrible)

B- abdominal pain (0 = none, 1 = mild, 2 = moderate, 3 =

severe) .

C- number of liquid stools per day.

D- abdominal mass (0 = none, 1 = dubious, 2 = definite, 3 =

tender) .

E- Complications, with one point for each.

-----------------------------------------------------------------------------

A score of less than 5 represent clinical remission.

II - Crohn's Disease Activity Index(CDAI)

Clinical or laboratory variable Weighting factor

Number of liquid or soft stools each day for seven days x 2

Abdominal pain (graded from 0-3 on severity) each day for seven

days

x 5

General well-being, subjectively assessed from 0 (well) to 4

(terrible) each day for seven days

x 7

Presence of complications* x 20

Taking Lomotil or opiates for diarrhea x 30

Presence of an abdominal mass (0 as none, 2 as questionable, 5 as

definite)

x 10

Hematocrit of <0.47 in men and <0.42 in women x 6

Percentage deviation from standard weight x 1

Crohn's Disease Activity Index.

Remission of CD below 150.

Severe CD greater than 450

Laboratory testsfor

diagnosis

and

Assessment of IBD Activity

A-Routine blood work

CBC: HB, WBCS and platelets.

Nutritional evaluation:

Vitamin B12 , iron studies, folate & other nutritional

markers

B - Serological Markers

ESR

In UC, the correlation between ESR and disease activity is good.

In CD, the ESR appears to be a less accurate measure of disease

activity.

CRP

CRP is a valuable marker to detect the activity of IBD Can be

used as a marker to treatment response

Orosomucoid :

The levels of circulating orosomucoid correlate with

disease activity of IBD.

C-Serologic Markers Antibodies

1-Anti-neutrophil cytoplasmic antibodies (ANCAs)

2-Antibodies to outer membrane porin (Anti-OmpC).

3-Anticarbohydrate antibodies: antilaminaribioside

carbohydrate IgG (ALCA).

D-Fecal Biomarkers

Fecal calprotectin

Measured in stool by ELISA

sensitive marker of inflammation

Fecal lactoferrin

Measured in stool by ELISA

Sensitive marker of inflammation

Fecal S100A12:

Detectable in serum and stool

But the fecal assay is more sensitive and specific for

IBD

Radiological

Diagnosis

and

Assessment of IBD activity

Barium enema

Endoscopic Ultrasound Abdominal Ultrasonography

Abdominal Ultrasonography

Mural enhancement Comb sign

Computed tomography

Intestinal stricture with

prestenotic dilatation.

Magnetic resonance enterography with gadolinium contrast in

CD. shows mural hyperenhancement, mural thickening, and the comb

sign (engorged perienteric vasculature) involving the terminal ileum.

(signs of active disease ).

VI - Wireless capsule endoscopy

(WCE)

VII-Double balloon enteroscopy

VIII-Nuclear Medicine

Tc-99m (WBC) imaging is superior to contrast

radiology for assessing the extent and activity of

inflammatory bowel disease. can be used to accurately

distinguish CD from UC .

More recently PET/CT and PET-MRI has been

combined with CT enterography or enteroclysis

techniques to further improve localization and reduce

false positives

PET-MRI of patient with cecal active inflammation

Endoscopy for Diagnosis

and Assessment of IBD activity

Endoscopic Features of IBDUlcerative colitis

Edema

Erythema/Loss of vascularity

Friability

Erosions

Mucopurulent exudate

Spontaneous bleeding

Ulceration

45

Endoscopic Features of IBDCrohn’s Disease

Patchy edema, erythema

(Discontinuous)

Apthous ulcerations

Coalescing ulcerations

Cobblestoning

Longitudinal “bear claw” ulcers

46

2- Endoscopic Indices of IBD Activity

A-Endoscopic assessment of disease activity in the UC

I - The Mayo Score.

II- The Baron Score

III - The Ulcerative Colitis Endoscopic Index of Severity (UCEIS).

B - Endoscopic assessment of disease activity in the CD

I - Crohn’s Disease Endoscopic Index of Severity (CDEIS).

II - Endoscopic Crohn’s Disease Index (SES-CD).

III - Rutgeerts’ score .

A - Endoscopic assessment of disease activity in

the ulcerative colitis.

score Endoscopic Findings Disease

severity

0 Normal mucosa , Mucosal healing or

inactive UC

Inactive

1 Mild friability, reduced vascular pattern, and

mucosal erythema

Mild disease

2 Friability, erosions, complete loss of

vascular pattern, and significant erythema

Moderate

disease

3 Ulceration and spontaneous bleeding Sever disease

I - The Mayo Score

II-The Baron Score

Endoscopic activity is defined as a Baron Score of >1

score Endoscopic findings

0 Normal mucosa with no bleeding and normal

vascular pattern present throughout the colon

1 Abnormal mucosa that is not expressly hemorrhagic

2 Bleeding with light intervention with an instrument

of the mucosa but no spontaneous bleeding

3 Spontaneous bleeding before the instrument is

introduced.

III-The Ulcerative Colitis Endoscopic Index of Severity

(UCEIS) (It is a newer scoring system)

Score Endoscopic findings (vascular pattern)

1 normal vascular pattern

2 partial loss of pattern

3 complete obliteration of vascular pattern

Score Endoscopic findings (Bleeding)

1 none

2 mucosal bleeding

3 mild colonic luminal bleeding

4 moderate or severe luminal bleeding

Score Endoscopic findings (Erosions and ulcers )

1 none

2 erosions

3 superficial ulcerations

4 deep ulcers

B - Endoscopic assessment of disease activity in the CD

I - Crohn’s Disease Endoscopic Index of Severity (CDEIS)

Rectum Sigmoid and left colon Transverse colon Right colon Ileum

Total

Deep ulcerations (12 if present) Total 1

Superficial ulcerations (12 if present) Total 2

Surface involved by disease (cm) Total 3

Surface involved by ulcerations (cm) Total 4

Total 1 + Total 2 + Total 3 + Total 4 = Total A

Number of segments totally or partially explored n

Total A ⁄ n = Total B

If an ulcerated stenosis is present anywhere add 3 = C

If a non-ulcerated stenosis is present anywhere add 3= D

Total B + C + D = CDEIS

II - Rutgeerts’ score Grade Endoscopic findings

i0 No lesions in the distal ileum

i1 ≤ 5 apthous lesions

i2 >5 apthous lesions with normal mucosa between the

lesions, or skip areas of larger lesions or lesions

confined to ileocolonic anastomosis

i3 Diffuse apthous ileitis with diffusely inflamed mucosa

i4 Diffuse inflammation with already larger ulcers,

nodules, and ⁄ or narrowing

Rutgeerts’ score is the gold standard for

Endoscopical post-surgical recurrence evaluation

Histological Examination

for

Assessment of IBD activity

Grade 0 Structural (architectural change) Subgrades : 0.0 No

abnormality 0.1 Mild abnormality 0.2 Mild or

moderate diffuse ormultifocal abnormalities 0.3 Severe

diffuse or multifocal abnormalities

Grade 1 Chronic inflammatory infiltrate Subgrades 1.0 No increase

1.1 Mild but unequivocal increase 1.2 Moderate increase

1.3 Marked increase

Grade 2 Lamina propria neutrophils and eosinophils

2A Eosinophils 2B Neutrophils

Grade 3 Neutrophils in epithelium

Grade 4 Crypt destruction

Grade 5 Erosion or ulceration.

A - Histological Assessment of activity in UCHistologic scoring system for the assessment of severity in UC.

B - Histological Assessment of activity in CD

Histologic findings Score

Epithelial damage 0-2

Architectural changes 0-2

Mononuclear infiltrate in LP 0-2

PMN infiltrate in epithelium 0-3

Erosion / ulcers 0-1

Granulomas 0-1

Proportion of biopsies affected 0-3

Pointes of histologic assessment of disease activity in CD

Fig. 14:UC. Mucosal atrophy with loss

of crypts. Neutrophils are still present

in the lumen and wall of one of the

crypts indicating persistent activity.

(H&E x10).

Fig.15: CD Stomach. Gastric mucosal

biopsy containing two characteristic

granulomas. (H&E x10).

Ischemic colitis

Intestinal tuberculosis

Radiation-induced colitis

Arteriovenous malformations

NSAID enteropathy

Behcet disease

Colorectal malignancy

AIDS

Celiac disease

Microscopic colitis

Irritable bowel syndrome

Lactose intolerance

Functional diarrhea

Gastrointestinal infections

Behcet disease

Colorectal malignancy

Principles For Treatment

of active IBD

One size does not fit all.

Risks vs benefits.

TREATMENTTreatment for IBD may include:

DIETARY CHANGES LIFESTYLE CHANGES

DRUG THERAPY SURGERY

Dietary Changes

Eating :

Low-fat foods.

Smaller, more

frequent meals.

Avoiding :

foods high in

undigestible fiber.

Refined sugars .

LIFESTYLE CHANGES.

Taking rest No smoking

Stress reductionDoing exercise

Acute Management of Active IBD

Treatment

General Care

Proper resuscitation.

Hospitalization.

Bowel rest to reduces the volume of diarrhea.

Blood products should be administered to treat

significant anemia or coagulopathy.

Pain relievers. Acetaminophen.

Iron supplements.

Nutrition(TPN).

Avoid (Narcotics, antidiarrheal agents and

anticholinergic ) can precipitate toxic dilation of the

colon.

Drug Therapies1- 5-Aminosalicylates (5-ASA)

2- Glucocorticoids (steroids)

3- Antibiotics

4- Immunosuppressants

Thiopurines

Azathioprine

6-mercaptopurin

Methotrexate

Cyclosporine

5- Biological Therapy

Infliximab

Oral•Varies by agent: may be released in the distal/terminal ileum, or colon1

Distribution of 5-ASA Preparations

Suppositories• Reach the upper rectum2,5

(15-20 cm beyond the anal verge)

Liquid Enemas• May reach the splenic flexure2-4

• Do not frequently concentrate in the rectum3

1. Sandborn WJ, et al. Aliment Pharmacol Ther. 2003;17:29-42; 2. Regueiro M, et al. Inflamm Bowel Dis. 2006;12:972–978; 3. Van Bodegraven AA, et al. Aliment Pharmacol Ther. 1996; 10:327-332; 4. Chapman NJ, et al. Mayo Clin Proc. 1992;62:245-248; 5. Williams CN, et al. Dig Dis Sci. 1987;32:71S-75S.

1- 5-ASA; Sulfasalazine (Supp. , enemas or Oral)

2 - Hydrocortisone or Methylprednisolone (IV , Oral or enema)

Fast symptom relief

40 to 60 mg/day in a continuous I.V. infusion

5 to 10 days

Not advised for prolonged use (120 day max)

Does not improve long term surgery rates

3 - Ciprofloxacin +/- Metronidazole

Effectiveness arguable but often seen used anyway

4 - IV Cyclosporine 2-4 mg/kg

Effective for induction of remission but not long-term maintenance

Patients who did not respond to I.V. steroid

If no improvement within 4 to 5 days or if complete remission is not achieved by 10 to 14 days, surgical treatment is advised. (32)

5 - Infliximab is currently approved for use in IBD

Induction- 3 separate infusions of 5 mg/kg for

moderate to severe IBD at weeks 0, 2, and 6

Maintenance- infusions every 8 weeks

Step up vs Top Down

74

Surgical

Management of

IBD

Indications for surgery in ulcerative colitis

Urgent Surgery Elective Surgery

Ongoing hemorrhage Failure of medical therapy

Toxic megacolon Intolerable side effect of

medical therapy

Colonic perforation Development of dysplasia

Fulminant ulcerative colitis Carcinoma

Colonic stricture

Growth retardation in

children

*Current Surgical Therapy 9th Edition

Artwork is reproduced, with permission, from the Johns Hopkins Gastroenterology and Hepatology Resource Center, www.hopkins-gi.org,copyright 2006, Johns Hopkins University, all rights reserved.

Artwork is reproduced, with permission, from the Johns Hopkins Gastroenterology and Hepatology Resource Center, www.hopkins-gi.org,copyright 2006, Johns Hopkins University, all rights reserved.

Surgical Management

Indications for surgery in Crohn’s Disease

Urgent Surgery Elective Surgery

Perforation Stricture

Abscess Fistula

Uncontrollable

hemorrhage

Malignancy

Toxic megacolon Malnutrition

Bowel obstruction Poorly controlled despite

management

Extra-intestinal manifestations

*Medical Management of the Surgical Patient: A Textbook of Perioperative Medicine*ASCRS – American Society of Colon and Rectal Surgeons

Surgical treatment

Artwork is reproduced, with permission, from the Johns Hopkins Gastroenterology and Hepatology Resource Center, www.hopkins-gi.org,copyright 2006, Johns Hopkins University, all rights reserved.

Thank You