Inflammatory Bowel Disease PDF

AfraTafreeh.com Inflammatory Bowel Disease Jason Ryan, MD, MPH Inflammatory Bowel Disease Two chronic autoimmune bowel diseases Crohn’s disease Ulcerative colitis Both have relapsing, remitting course Patients have “flares” AfraTafreeh.com Increased medica...

AfraTafreeh.com Inflammatory Bowel Disease Jason Ryan, MD, MPH Inflammatory Bowel Disease Two chronic autoimmune bowel diseases Crohn’s disease Ulcerative colitis Both have relapsing, remitting course Patients have “flares” AfraTafreeh.com Increased medication requirements  AfraTafreeh.com Inflammatory Bowel Disease Similar symptoms both disorders Recurrent episodes Abdominal pain Bloody diarrhea Inflammatory Bowel Disease Slight female predominance in most studies Age of onset usually 15 to 40 years Some studies suggest second spike in 50 to 80 year olds More common among whites More common amongAfraTafreeh.com Jewish populations Classic presentation White woman in 30s Jewish descent  AfraTafreeh.com Bloody Diarrhea Many causes other than IBD especially infection Typical studies sent when considering IBD Stool cultures (Salmonella, Shigella, Campylobacter, Yersinia) Testing for E. coli O157:H7 Other stool studies (C. diff, Ova and parasites) Ulcerative Colitis Pathologic Features Ulcers form in intestinal tract Inflammation of mucosa and sometimes submucosa Importantly NOT full thickness inflammation AfraTafreeh.com Goran tek-en/Wikipedia  AfraTafreeh.com Ulcerative Colitis Pathologic Features Always starts in rectum → works upward Always has rectal involvement Left lower quadrant pain is common Never involves small intestine “Colitis” Wikipedia/Public Domain Ulcerative Colitis Gross Morphology Pseudopolyps (healing of ulcers) AfraTafreeh.com Ed Uthman, MD.  AfraTafreeh.com Ulcerative Colitis Gross Morphology Loss of haustra (lead pipe appearance on X-ray/CT) Common findings and pseudolesions at computed tomography colonography. Colégio Brasileiro de Radiologia e Diagnóstico por Imagem. Giuseppe D'Ippolito et al. Used with permission. Ulcerative Colitis Microscopy Crypt abscesses PMN infiltration of crypts AfraTafreeh.com KGH/Wikipedia KGH/Wikipedia  AfraTafreeh.com Ulcerative Colitis Extra-intestinal Features Pyoderma gangrenosum Deep, necrotic skin ulceration Primary sclerosing cholangitis Ankylosing spondylitis Inflammation of spine Uveitis Inflammation of middle layer eye Crohnie/Public Domain Toxic Megacolon Rare complication of UC (also infectious colitis) Cessation of colonic contractions Evidence that nitric oxide inhibits smooth muscle tone Leads to intestinal dilation → rapid distention occurs Wall thins → prone toAfraTafreeh.com rupture Can cause perforation  AfraTafreeh.com Toxic Megacolon Presentation Abdominal pain Distention Fever Diarrhea Shock Hellerhoff/Wikipedia Ulcerative Colitis Adenocarcinoma Significant risk in UC Risk based on two key factors Duration of disease (>10 years before most cancers form) Extent of disease (more disease = more risk) Involvement into right colon = more disease AfraTafreeh.com “Right sided colitis” or “pancolitis” are risk factors Screening colonoscopy recommended Multiple biopsies taken Colectomy sometimes required  AfraTafreeh.com Antibody Tests p-ANCA Antibody seen in vasculitis syndromes Churg-Strauss and Microscopic Polyangiitis Also seen in ulcerative colitis Anti-saccharomyces cerevisiae antibodies (ASCA) Saccharomyces cerevisiae: type of yeast Elevated antibody levels seen in Crohn’s Both tests suggested to distinguish forms of IBD Not reliable for routine clinical use Crohn’s Disease Pathologic Features Granulomatous inflammation Entire wall affected (“transmural”) Any portion of the GI tract can be affected “Mouth to anus” Oral ulcers can be seenAfraTafreeh.com  AfraTafreeh.com Crohn’s Disease Pathologic Features Terminal ileum is common location Malabsorption Vitamin deficiencies (B12) Malabsorption of bile salts May have non-bloody diarrhea due to malabsorption May have right lower quadrant pain Often spares the rectum Often “skips” sections Crohn’s Disease Pathologic Features Terminal ileum is common location Malabsorption Vitamin deficiencies (B12) Malabsorption of bile salts May have non-bloodyAfraTafreeh.com diarrhea due to malabsorption May have right lower quadrant pain Often spares the rectum Often “skips” sections  AfraTafreeh.com Crohn’s Disease Pathologic Features RicHard-59/Wikipedia Crohn’s Disease Microscopy Non-caseating granulomas AfraTafreeh.com Nephron /Wikipedia  AfraTafreeh.com Crohn’s Disease Gross Morphology Cobblestone mucosa Public Domain/Wikipedia Crohn’s Disease Gross Morphology Fistulas Peri-anal Abdominal Bladder (“enterovesical fistula”) AfraTafreeh.com  AfraTafreeh.com Crohn’s Disease Gross Morphology Creeping fat Transmural inflammation heals Condensed fibrous tissue pulls fat around bowel wall Can wrap around bowel Strictures Healing leads to fibrous tissue Dense fibrous tissue narrows lumen “String sign” Adenocarcinoma Risk only when colon involved When colon involved, surveillance colonoscopy AfraTafreeh.com  AfraTafreeh.com Crohn’s Disease Extra-intestinal Features Migratory polyarthritis Most common extra-intestinal manifestation Arthritis of large joints (knees, hips) Erythema nodosum Inflammation of fat tissue under skin James Heilman, MD Crohn’s Disease Extra-intestinal Features Kidney stones Calcium oxalate stones High oxalate levels seen in Crohn’s Fat malabsorption → Fat binds to calcium Oxalate free to be absorbed in the gut AfraTafreeh.com Ankylosing spondylitis Uveitis  AfraTafreeh.com Immunology T-cells: major contributor both disorders Ulcerative colitis Th2 mediated disorder No granulomas Crohn’s disease Th1 mediated disorder Granulomatous disease Smoking Improves outcomes in UC Worsens outcomes in Crohn’s AfraTafreeh.com Pixabay/Public Domain  AfraTafreeh.com IBD Treatments Corticosteroids Azathioprine Methotrexate 6-MP Infliximab/adalimumab Sulfasalazine 5-ASA Sulfasalazine Not active until reaches colon Perfect for UC! Acetylsalicylic acid (aspirin) Sulfasalazine AfraTafreeh.com Colonic Bacteria Sulfapyridine 5-aminosalicylic acid (5-ASA)  AfraTafreeh.com Sulfasalazine Side Effects GI upset (nausea, vomiting) Sulfonamide hypersensitivity Oligospermia in men Mechanism unclear Reversible with drug cessation Problem for men trying to conceive on therapy Gilberto Santa Rosa/Wikipedia 5-ASA Mesalamine Many side effects of sulfasalazine due to sulfa sulfasalazine - sulfa moiety = 5-ASA Less side effects BUT absorbed in jejunum Less delivery to colon AfraTafreeh.com Modified 5-ASA compounds resist absorption Coating or delayed release capsules Asacol, Pentasa 5-aminosalicylic acid (5-ASA)