Case A 25-year-old woman A 25-year-old woman A 4-m history of abdominal pain in the left lower...

CaseCase

A 25-year-old woman A 25-year-old woman A 4-m history of A 4-m history of abdominal abdominal painpain in the left lower quadrant in the left lower quadrant and and bloody diarrheabloody diarrhea

CaseCase

Stool Examination: WBC Stool Examination: WBC + ,RBC +++ ,RBC ++

MicrobiologicMicrobiologic cultures of stools : cultures of stools : negativenegative

ColonoscopyColonoscopy

ColonoscopyColonoscopy

Continuous ulcers begin in the Continuous ulcers begin in the

rectumrectum

Colonoscopy biopsyColonoscopy biopsy

PathologyPathology

(H/E, 4x) (H/E, 10x)

crypt

abscesses

Ulcerative Ulcerative Colitis Colitis

Yan Chen Yan Chen 陈焰陈焰 Second Affiliated Second Affiliated

Hospital Hospital

ConceptConcept Idiopathic Idiopathic IInflammatory nflammatory BBowel owel

DDiseaseisease

(( IBD) IBD)

Ulcerative colitis(UC)Ulcerative colitis(UC)

Crohn’sCrohn’s disease (CD)disease (CD)

IBD IBD 有关内容有关内容

Learning ObjectivesLearning Objectives

• Understand the current theories of IBD pathogenesis

• Understand the clinical presentation, and management of ulcerative colitis and Crohn’s disease

• Understand the fundamental differences between ulcerative colitis and Crohn’s

commendatory websites commendatory websites and booksand books

commendatory websitescommendatory websites http://content.nejm.org/http://content.nejm.org/ http://www.ccfa.orghttp://www.ccfa.org http://www.gastrolab.net/show.htmlhttp://www.gastrolab.net/show.html http://www-medlib.med.utah.edu/WebPath/TUTORIAL/http://www-medlib.med.utah.edu/WebPath/TUTORIAL/

IBD/IBD.htmlIBD/IBD.html commendatory bookscommendatory books

Harrison’s principles of internal medicine Harrison’s principles of internal medicine

1515thth Edition Edition

Goldman: Cecil Medicine, 23rd ed Chapter Goldman: Cecil Medicine, 23rd ed Chapter 144 144

Ulcerative Colitis (UC)Ulcerative Colitis (UC) Concept Concept EtiologyEtiology PathologyPathology Clinical presentationClinical presentation Diagnosis and differential Diagnosis and differential

diagnosis diagnosis ComplicationsComplications TreatmentTreatment

ConceptConcept Ulcerative ColitisUlcerative Colitis

An idiopathic An idiopathic

inflammatory disorderinflammatory disorder

involving primarily the involving primarily the

mucosa and submucosamucosa and submucosa

of the colonof the colon

especially the rectumespecially the rectum

often with mucosal often with mucosal

erosions and ulcerserosions and ulcers

ConceptConcept

colitis confined colitis confined rectum rectum (proctitis) (proctitis) rectum and sigmoid colon rectum and sigmoid colon

(proctosigmoiditis)(proctosigmoiditis) splenic flexure splenic flexure (left sided (left sided

colitis)colitis) colitis up to colitis up to

the hepatic flexure the hepatic flexure (extensive (extensive colitis)colitis)

the whole colon the whole colon (pancolitis)(pancolitis)

ConceptConcept

Ulcerative Colitis (UC)Ulcerative Colitis (UC) Concept Concept Etiology Etiology PathologyPathology Clinical presentationClinical presentation Diagnosis and differential Diagnosis and differential


Etiologic Theories in IBD

Mucosal Immune Mucosal Immune SystemSystem

(Immuno-regulatory (Immuno-regulatory Defect)Defect)

Environmental Environmental TriggersTriggers

(Lumenal Bacteria, (Lumenal Bacteria, Infection)Infection)

Genetic Genetic PredispositionPredisposition IBD

PathologyPathology Tends to begin in the rectum Tends to begin in the rectum

and be continuous and be continuous Limited inflammation Limited inflammation

Mucosa and submucosaMucosa and submucosa Crypt abscessCrypt abscess

PathologyPathology Tends to be Tends to be

continuous continuous along the along the mucosal mucosal surface;surface;

Tends to begin Tends to begin in the in the rectum.rectum.

Normal colonNormal colon

Ulcerative colitisUlcerative colitis



Mucosa and submucosaMucosa and submucosa Crypt abscess: Crypt abscess:

Characteristic finding Characteristic finding

Characteristic finding Characteristic finding Crypt Crypt

abscessabscess

Ulcerative Colitis (UC)Ulcerative Colitis (UC) Concept Concept EtiologyEtiology PathologyPathology Clinical presentation Clinical presentation Diagnosis and differential Diagnosis and differential


Clinical presentation Clinical presentation

variablevariable

Bloody diarrhea Bloody diarrhea hallmark hallmark

Abdominal painAbdominal pain

Fecal urgencyFecal urgency

Tenesmus Tenesmus

U CU C Mild Moderate SevereMild Moderate Severe

Bowel movementsBowel movements <4/d 4-6/d >6/d <4/d 4-6/d >6/dBlood in stoolBlood in stool Small Moderate Severe Small Moderate SevereFever Fever None <37.5 >37.5℃ ℃ None <37.5 >37.5℃ ℃Tachycardia Tachycardia None <90 >90 None <90 >90Anemia Anemia Mild Moderate Severe Mild Moderate SevereESR ESR <30mm >30mm <30mm >30mmEndoscopicEndoscopic Erythema Marked Erythema Spontaneous Erythema Marked Erythema Spontaneous appearance appearance contract bleeding bleeding, contract bleeding bleeding, ulcerations ulcerations

extraintestinal extraintestinal manifestationmanifestation

Erythema Erythema nodosumnodosum

Pyoderma gangrenosumPyoderma gangrenosum

EpisclerEpiscler

itisitis


diagnosisdiagnosis Complications Complications TreatmentTreatment

DiagnosisDiagnosis

Essentials of DiagnosisEssentials of Diagnosis Bloody diarrheaBloody diarrhea Lower abdominal pain and Lower abdominal pain and

fecal urgencyfecal urgency Anemia,low serum albuminAnemia,low serum albumin Negative stool cultures Negative stool cultures Colonoscopy Colonoscopy is key to is key to

diagnosisdiagnosis Imaging is helpful sometimes Imaging is helpful sometimes

Laboratory findingLaboratory finding Negative stool culturesNegative stool cultures

Anemia, ESR,CRPAnemia, ESR,CRP

low serum albuminlow serum albumin

p-ANCA: 70% positivep-ANCA: 70% positive

Negative stool culturesNegative stool cultures

Very importantVery important

ImagingImaging

Plain abdominalPlain abdominal

Barium enemas Barium enemas

Plain abdominalPlain abdominal

Severe patients Severe patients

colonic dilation colonic dilation

Toxic megacolonToxic megacolon

DiagnosisDiagnosis

Essentials of DiagnosisEssentials of Diagnosis Bloody diarrheaBloody diarrhea Lower abdominal pain and Lower abdominal pain and

fecal urgencyfecal urgency Anemia,low serum albuminAnemia,low serum albumin Negative stool cultures Negative stool cultures Colonoscopy Colonoscopy is key to is key to

diagnosisdiagnosis Imaging is helpful sometimes Imaging is helpful sometimes

Concept Concept EtiologyEtiology PathologyPathology Clinical presentationClinical presentation Diagnosis andDiagnosis and

differential diagnosis differential diagnosis Complications Complications Treatment Treatment

Differential diagnosisDifferential diagnosis

Infectious diseaseInfectious disease ：： ameba, ameba, dysentery…dysentery…

CDCDColon cancer Colon cancer IBSIBSTubTubIschemic colitisIschemic colitis

amebiasis amebiasis

HE stain PAS ： trophozoite

amebiasisamebiasis

amebiasis

amebiasis

colonscopy

Ulcerative ColitisUlcerative Colitis Crohn Disease Crohn Disease

Colon onlyColon only involved involved Pan-intestinalPan-intestinal

Continuous Continuous inflammation inflammation extending proximally extending proximally from from rectumrectum

Skip-Skip-lesions with lesions with intervening normal intervening normal mucosamucosa

Inflammation in Inflammation in mucosa and mucosa and submucosasubmucosa only only

TransmuralTransmural inflammationinflammation

No granulomas, No granulomas, crypt crypt abscessabscess

Non-caseating Non-caseating granulomasgranulomas

pANCA positivepANCA positive pASCA negetivepASCA negetive

Bleeding is commonBleeding is common Bleeding is Bleeding is uncommonuncommon

Fistulae are rareFistulae are rare Fistulae Fistulae are common are common

UC CDUC CD

Colon only, proximally Colon only, proximally

from rectumfrom rectum

Pan-Pan-intestinal, intestinal, Skip-Skip-lesionslesions

UC CDUC CD

mucosa and mucosa and

submucosasubmucosa

TransmuralTransmural

crypt abscesscrypt abscess

granulomagranuloma

ss

CDCD

FistulaeFistulae


diagnosis diagnosis Complications Complications TreatmentTreatment

Complications Complications


Bleeding Bleeding

PerforationPerforation

Risk of colon cancerRisk of colon cancer

Toxic megacolonToxic megacolon < 2% of cases < 2% of cases

particularly severe particularly severe UC UC

Defined as a Defined as a severe severe episodeepisode of colitis of colitis with segmental or with segmental or total total dilationdilation of the of the colon (colonic colon (colonic dilation of > 5cm)dilation of > 5cm)

Mortality rate : Mortality rate : 20%20%


An acute An acute transmural fulminanttransmural fulminant colitis with the neurogenic loss of colitis with the neurogenic loss of motor tone.motor tone.

The rapid development of colonic The rapid development of colonic dilatation dilatation due to damage to the due to damage to the entire wallentire wall of the colon associated of the colon associated with neuromuscular degeneration. with neuromuscular degeneration.


Diagnosis Diagnosis Clinical findingsClinical findings

Symptoms Symptoms Signs Signs

Laboratory finding Laboratory finding abdominal plainabdominal plain

Clinical findingsClinical findings SymptomsSymptoms

Abdominal pain Abdominal pain Abdominal distention Abdominal distention Fever Fever Rapid heart rate Rapid heart rate Dehydration Dehydration

Signs Signs Abdominal tendernessAbdominal tenderness May be signs of May be signs of

septic shock septic shock Possible loss of bowel Possible loss of bowel

soundssounds

Lab findingLab finding

Elevated white blood cell Elevated white blood cell Low potassium level Low potassium level Abdominal plainAbdominal plain shows colonic shows colonic

dilationdilation


CausesCausesLower potassium level Lower potassium level Barium enemaBarium enemaAnticholinergicsAnticholinergicsDrugs used for pain reliefDrugs used for pain relief

Case 1Case 1

A 72-year-old woman A 72-year-old woman Vomiting Vomiting Abdominal distentionAbdominal distention History of hypertension and History of hypertension and

ulcerative colitisulcerative colitis

Case 1Case 1

supineerect


CauseCause


CauseCause

Lower potassium level after Lower potassium level after taking diuretics for taking diuretics for hypertensionhypertension

Case 2Case 2

a 44-year-old man a 44-year-old man Long history of ulcerative Long history of ulcerative

colitiscolitis Double-contrast barium enemaDouble-contrast barium enema

Case 2Case 2

Double-contrast barium enemaDouble-contrast barium enema

Case 2Case 2 2 days later


CausesCausesLower potassium level Lower potassium level Barium enemaBarium enemaAnticholinergicsAnticholinergicsDrugs used for pain reliefDrugs used for pain relief

Complications Complications


Bleeding Bleeding

PerforationPerforation

Risk of colon cancerRisk of colon cancer

Cumulative Risk of CRC in Cumulative Risk of CRC in UCUC

0.5-1.0% per year after 10 years of disease0.5-1.0% per year after 10 years of disease

Eaden et al. Eaden et al. GutGut 48:526, 2001 48:526, 2001

TreatmentTreatment

Dependent on the extent of Dependent on the extent of colonic involvement and severity colonic involvement and severity of illnessof illness

2 objectives2 objectives Inducing remissionInducing remission (periods of time (periods of time

that are symptom-free) that are symptom-free) Maintaining remissionMaintaining remission (preventing (preventing

flare-ups of disease) flare-ups of disease)

Sulfasalazine (SASP)Sulfasalazine (SASP) Made up ofMade up of

5-aminosalicylic acid (5-ASA): 5-aminosalicylic acid (5-ASA): functionally active moiety of SASPfunctionally active moiety of SASP

sulfur molecule: related to the sulfur molecule: related to the side effectsside effects

Newer 5-ASA drugs avoid the Newer 5-ASA drugs avoid the side effects side effects

Any other questions?Any other questions?

陈焰陈焰 1375711865313757118653

[email protected][email protected]

Case A 25-year-old woman A 25-year-old woman A 4-m history of abdominal pain in the left lower...

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