Pathology and Management of Inflammatory Bowel Disease
Brian Wells, MS-3, MSM, MPH
St. George’s University School of Medicine
I have finally come to the conclusion that a good set of bowels is worth more to a man than any quantity of brains.
- Josh Billings (4/20/1818 – 10/14/1885)
© 2010 Brian Wells
IBD
Informative
Beneficial
Deployable
Inflammatory Bowel Disease
© 2010 Brian Wells
Today’s Goals
Mathematical Description of Transmural Involvement
(+) Informative
(-) Beneficial
(-) Deployable
© 2010 Brian Wells
Infammatory Bowel Disease
Ulcerative Colitis
Crohn’s Disease
(Leśniowski-Crohn’s Diease in Poland)
© 2010 Brian Wells
Infammatory Bowel Disease
© 2010 Brian Wells
Crohn’s Disease - How did we get here?
Giovanni Battista Morgagni2/25/1682 – 12/6/1771
First description: 1769
Burrill B. Crohn, MD6/13/1884 – 7/29/1983
1932 - “Regional ilitius” thought due to Mycobacterium paratuberculosis
Similar to Johne’s Disease
Thomas Kennedy Dalziel 1861–1924
Chronic interstial enteritis. Br Med J 1913; 2: 1068–1070
Antoni Leśniowski1/28/1867–4/4/1940Annals of the Warsaw Medical Association 1903-1905 – “a chronic inflammatory process in the wall of the gut.”
© 2010 Brian Wells
Epidemiology
Ulcerative Colitis Crohn’s Disease
Incidence (per 100,000) 10 (0.5–24.5) 5.8 (0.1-16)
Prevalence (per 100,000) 229 (=) 133 (↑)
At-risk population High in Jewish, low in African-American, +FHx in 20%
High in Jewish, low in African-American, ~equal in Caucasian and AA
Sex Male > Female (slightly) Female > Male (slightly)
Distribution Bimodal: 20-35, 50-65 Bimodal: 25-40, 50-65
Factors More common with ex-smokers and nonsmokers
More common with smokers
*Centers for Disease Control and Prevention
U.S. Population estimate (July 2009): 307,006,550
Overall prevalence (2006): 396/100,000 persons
Total estimated cases (July 2009): ~1.2-1.4 M cases
*Lakatos PL. Recent trends in the epidemiology of inflammatory bowel diseases: up or down?World J Gastroenterol 2006;12(38):6102–08.
© 2010 Brian Wells
Comparative Summary
Ulcerative Colitis Crohn’s Disease
Type of Involvement Diffuse, No skip areas Skip areas
Depth of Involvement Mucosa & submucosa Transmural
Rectal Involvement 95% 50%
Perianal disease - +
Fistulas - +
© 2010 Brian Wells
Comparative Summary
Ulcerative Colitis Crohn’s Disease
Ileal involvement - +
Aphthous ulcers & linear ulcers
- +
Cobblestone appearance - +
Ulceration Fine, superficial Deep with submucosal extension
P-ANCA 70% Occasional
© 2010 Brian Wells
Comparative Summary
Ulcerative Colitis Crohn’s Disease
Anti-saccharomyces Occasional >50%
Risk of colon CA ++ +
Granulomas - Non-caseating
Extraintestinal manifestations
Arthritis, iritis, erythema nodosum, pyoderma gangrenosum
© 2010 Brian Wells
Comparative Summary
Ulcerative Colitis Crohn’s Disease
Medical Treatment Ulcerative proctitis5-ASA suppositoriesConsider adding: rectal steroid enema, steroid foam, 5-ASA enemas
Ulcerative colitisOral 5-ASA and/or rectal 5-ASA enemas or steroid foamFor severe disease consider adding enema or IV steroids, or TNF-α inhibitors
Mild to moderate diseaseOral 5-ASA or sulfasalazine. Consider adding: antibiotics flagyl +/- cipro
SevereIV steroids, immunosuppressive drugs, TNF-α inhibitors
FistulasTNF-α inhibitors
© 2010 Brian Wells
© 2010 Brian Wells
Horton K M et al. Radiographics 2000;20:399-418
©2000 by Radiological Society of North America
Contrast-enhanced CT scan shows minimal diffuse thickening of the sigmoid colon with minimal inflammatory stranding.
Ulcerative colitis in a 27-year-old man
© 2010 Brian Wells
Horton K M et al. Radiographics 2000;20:399-418
©2000 by Radiological Society of North America
CT scan obtained with oral contrast material shows moderate thickening of the terminal ileum (curved arrow) and cecum (straight arrow) with adjacent inflammatory changes in the pericolic fat.
Crohn’s Disease
Medical Management
• Drug selection– 5-ASA– Sulfasalazine, mesalamine– Steroids– TNF-α inhibitors
• Dosing• Role of technology
© 2010 Brian Wells
Surgical Management
• 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
© 2010 Brian Wells
*Current Surgical Therapy 9th Edition
Surgical Management
• Surgical alternatives for ulcerative colitis
Emergency Operation Elective Operation±Subtotal colectomy with end ileostomy
Panproctocolectomy withpermanent end ileostomy (simple and curative)
Panproctocolectomy with permanent end ileostomy
Subtotal colectomy with ileorectalAnastomosis (rarely performed)
Proctocolectomy with continentileostomy (Kock pouch) - Rarely performedPanproctocolectomy with IPAAwith or without diverting ileostomy (CI in Crohn’s disease)
± Standard procedure*Construction of a pouch is avoided in the emergency setting
© 2010 Brian Wells
Surgical Management
• Indications for surgery in Crohn’s DiseaseUrgent 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
Most patients with Crohn's disease ultimately require one or more operations in their lifetime. Operative indications are the same no matter where the disease manifests itself.
© 2010 Brian Wells
Thank you!
Any questions?
© 2010 Brian Wells
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