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.