Inflammatory Bowel Diseases PDF

# Inflammatory bowel diseases ## Crohn's Disease ### GENERAL CONSIDERATIONS - 30% of cases involve the small bowel only mostly (ileitis). - 50% of all cases involve the small bowel and colon (ileococolitis). - In 20% of cases, the colon alone is affected. - 30% of patients have associated perianal d...

# Inflammatory bowel diseases ## Crohn's Disease ### GENERAL CONSIDERATIONS - 30% of cases involve the small bowel only mostly (ileitis). - 50% of all cases involve the small bowel and colon (ileococolitis). - In 20% of cases, the colon alone is affected. - 30% of patients have associated perianal disease. - Less than 5% of patients have symptomatic involvement of the upper intestinal tract. - Crohn's disease is a transmural process that can result in mucosal inflammation and ulceration, stricturing, fistula development, and abscess formation. - Cigarette smoking is strongly associated with the development of Crohn's disease, resistance to medical therapy, and early disease relapse. ## Symptoms and Signs - Malaise, weight loss, and loss of energy. - In patients with ileitis or ileocalitis, there may be diarrhea (usually) non bloody and intermittent. - In patients with colitis involving the rectum or left colon, there may be bloody diarrhea and fecal urgency, which may mimic the symptoms of ulcerative colitis. - Cramping or steady right lower quadrant or periumbilical pain is common. ## Physical examination - Focal tenderness, usually in the right lower quadrant. - Apalpable, tender mass that represents thickened or matted loops of inflamed intestine in the lower abdomen. - Intestinal obstruction due to narrowing of the small bowel may occur as a result of inflammation, spasm, or fibrotic stenosis. - Penetrating disease and fistulae: Penetration through the bowel can result in an intra-abdominal or retroperitoneal phlegmon or abscess manifested by: - Fevers, chills, a tender abdominal mass, and leukocytosis. ## Extraintestinal manifestations: - Arthralgias, arthritis. - Iritis or uveitis. - Pyoderma gangrenosum or erythema nodosum. - Oral aphthous lesions are common. - Gallstones. - Nephrolithiasis with urate or calcium oxalate stones may occur. ## Laboratory values - CBC: Anemia (Iron deficiency or vitamin B12 Malabsorption) and Leukocytosis - Hypoalbuminemia - ↑↑ ESR or C-reactive protein - Fecal lactoferrin or calprotectin levels. - Stool specimens are sent for examination for routine pathogens, ova and parasites, leukocytes, fat, and C difficile toxin. ## Special Diagnostic Studies: - Colonoscopy. - CT or MR Enterography or small bowel follow-through. - Capsule endoscopy. ## COMPLICATIONS - Abscess - Obstruction - Abdominal and Rectovaginal Fistulas - Carcinoma - Hemorrhage - Malabsorption ## TREATMENT OF ACTIVE DISEASE ### A. Nutrition #### 1. Diet: - Patients should eat a well-balanced diet with as few restrictions as possible. - Eating smaller but more frequent meals. - Patients with diarrhea (drink fluids to avoid dehydration). - Certain foods worsen symptoms, especially fried or greasy foods, because lactose intolerance is common. - Patients with obstructive symptoms should be placed on a low-roughage diet, ie, no raw fruits or vegetables, popcorn, nuts, etc. - Resection of more than 100 cm of terminal ileum results in fat malabsorption for which a low-fat diet is recommended. - Parenteral vitamin B12 (100 mcg intramuscularly per month) commonly is needed for patients with previous ileal resection or extensive terminal ileal disease. #### 2. Enteral therapy: - Supplemental enteral therapy via nasogastric tube may be required for children and adolescents with poor intake and growth retardation. #### 3. Total parenteral nutrition: - TPN is used short term in patients with active disease and progressive weight loss or those awaiting surgery. # Ulcerative Colitis ## ESSENTIALS OF DIAGNOSIS - Bloody diarrhea. - Lower abdominal cramps and fecal urgency. - Anemia, low serum albumin. - Negative stool cultures. - Sigmoidoscopy is the key to diagnosis. ## CLINICAL FINDINGS ### 1. Symptoms and Signs - Bloody diarrhea is the hallmark (patients should be asked about stool frequency, the presence and amount of rectal bleeding). - Lower abdominal cramps, tenesmus and fecal urgency. ### A. Physical examination - Should focus on the patient's volume status as determined by orthostatic blood pressure and pulse measurements and by nutritional status. - On abdominal examination, the clinician should look for tenderness and evidence of peritoneal inflammation. - Red blood may be present on digital rectal examination. ### B. Laboratory Findings - The degree of anemia, sedimentation rate, and serum albumin reflects disease severity. ### C. Endoscopy #### 1. DISEASE SEVERITY - Patients with mild disease - Have a gradual onset of infrequent diarrhea (less than four movements per day) with intermittent rectal bleeding and mucus. - Stools may be formed or loose in consistency. - Because of rectal inflammation, there is fecal urgency and tenesmus. - Left lower quadrant cramps relieved by defecation are common, but there is no significant abdominal tenderness. #### 2. Patients with moderate disease - Have more severe diarrhea with frequent bleeding. - Abdominal pain and tenderness may be present but are not severe. - There may be mild fever, anemia, and hypoalbuminemia. #### 3. Severe disease - Patients with severe disease have more than six bloody bowel movements per day, resulting in severe anemia, hypovolemia, and impaired nutrition with hypoalbuminemia. - Abdominal pain and tenderness are present. - "Fulminant colitis" is a subset of severe disease characterized by rapidly worsening symptoms with signs of toxicity, ## General measures: - Discontinue all oral intake for 24-48 hours or until the patient demonstrates clinical improvement. - TPN is indicated only in patients with poor nutritional status or if feedings cannot be reinstituted within 7-10 days. - All opioid or anticholinergic agents should be discontinued. - Restore circulating volume with fluids, correct electrolyte abnormalities, and consider transfusion for significant anemia. - Abdominal examinations should be repeated to look for evidence of worsening distention or pain. - A plain abdominal radiograph should be ordered on admission to look for evidence of colonic dilation. - Send stools for bacterial culture, *C difficile* toxin assay, and examination for ova and parasites. - CMV superinfection should be considered in patients receiving long-term immunosuppressive therapy who are unresponsive to corticosteroid therapy. - Due to a high risk of venous thromboembolic disease, prophylaxis should be administered. - Surgical consultation should be sought for all patients with severe disease. ## 1- Corticosteroid therapy: ## 2- Anti-TNF therapies: - A single infusion of infliximab, 5 mg/kg ## 3- Cyclosporine: ## 4- Surgical therapy: - Patients with severe disease who do not improve after corticosteroid, infliximab, or cyclosporine ## COMPLICATIONS: - Endoscopic or histologic inflammation in the ileal pouch ("pouchitis") develops in over 40% of patients, resulting in increased stool frequency, fecal urgency, cramping, and bleeding.