Definitions

DefinitionsDefinitions

UCUC Inflammation confined Inflammation confined

to mucosato mucosa Starting in rectumStarting in rectum

May involve entire May involve entire coloncolon

Crypt abscessCrypt abscess RareRare

Rectal sparingRectal sparing DiscontinuousDiscontinuous Only proctitisOnly proctitis

Crohn’sCrohn’s Superficial ulcer to Superficial ulcer to

submucosa, submucosa, muscularis and serosamuscularis and serosa Transmural Transmural

inflammationinflammation Any portion of the Any portion of the

alimentary tractalimentary tract Mouth to anusMouth to anus

FistulasFistulas GranulomasGranulomas

Only a minority of Only a minority of patientspatients

Epidemiology & Genetics Epidemiology & Genetics - IBD- IBD

M=FM=F Increased riskIncreased risk

Turners, Hermansky-Pudlak, GSD type 1B, Turners, Hermansky-Pudlak, GSD type 1B, Leukocyte adhesionLeukocyte adhesion

First degree relativeFirst degree relative Single greatest risk factor (30 to 100 times)Single greatest risk factor (30 to 100 times)

Multiple genetic lociMultiple genetic loci pANCA pANCA

70% UC70% UC ASCAASCA

50-60%CD50-60%CD

PathogenesisPathogenesis

Cause unknownCause unknown Abnormalities in gastrointestinal Abnormalities in gastrointestinal

immunoregulationimmunoregulation Cytokines, arachidonic acid Cytokines, arachidonic acid

metabolites, reactive oxygen metabolites, reactive oxygen intermediates and growth factorsintermediates and growth factors

DiarrheaDiarrhea

Factors increase electrolyte secretionFactors increase electrolyte secretion Increased fluid lossIncreased fluid loss

Loss of bile salts from terminal ileumLoss of bile salts from terminal ileum MalabsorptionMalabsorption Bacterial overgrowthBacterial overgrowth CDCD

Exudation of serum proteins and bloodExudation of serum proteins and blood PLEPLE CDCD

Intestinal ManifestationsIntestinal Manifestations

UCUC Bloody diarrheaBloody diarrhea Proctitis Proctitis

May have formed May have formed stoolstool

Pain with Pain with defecationdefecation

BothBoth Nausea and/or vomitingNausea and/or vomiting FeverFever

*Know the clinical manifestations and distinguish*Know the clinical manifestations and distinguish

Crohn’sCrohn’s DiarrheaDiarrhea

50%50% Occasionally bloodyOccasionally bloody

Abdominal painAbdominal pain More severeMore severe

Perirectal Perirectal inflammationinflammation 25%25% Fissure and/or fistulaFissure and/or fistula

Aphthous ulcersAphthous ulcers

*Understand that chronic perianal *Understand that chronic perianal lesions or recurrent aphthous lesions or recurrent aphthous ulcers can be an early sign of CDulcers can be an early sign of CD

Intestinal ManifestationsIntestinal Manifestations

Extraintestinal Extraintestinal ManifestationsManifestations

25-35%25-35%

Directly related to disease activityDirectly related to disease activity Unrelated to disease activityUnrelated to disease activity Result from the presence of diseased Result from the presence of diseased

bowelbowel Arise from therapyArise from therapy


Growth FailureGrowth Failure 20-30% CD20-30% CD

MultifactorialMultifactorial Chronic undernutrition, steroids,Chronic undernutrition, steroids,

cytokinescytokines 10% UC10% UC

Prolonged steroidsProlonged steroids Don’t forget delayed pubertyDon’t forget delayed puberty *May be a presenting sign*May be a presenting sign

*Know the reasons for growth failure in patients with IBD*Know the reasons for growth failure in patients with IBD*Know that pts with CD may have GF secondary to *Know that pts with CD may have GF secondary to

decreased caloric intakedecreased caloric intake

ArthritisArthritis PeripheralPeripheral

10%10% Larger jointsLarger joints Related to active colonic diseaseRelated to active colonic disease

AxialAxial Ankylosing spondylitis/SacroiliitisAnkylosing spondylitis/Sacroiliitis Rare in childrenRare in children

*Recognize that arthritis may occur in patients with IBD*Recognize that arthritis may occur in patients with IBD


SkinSkin Pyoderma Pyoderma

gangrenosgangrenosumum

Erythema Erythema nodosumnodosum


LiverLiver SteatosisSteatosis Elevated enzymesElevated enzymes Chronic hepatitisChronic hepatitis Sclerosing cholangitisSclerosing cholangitis CholelithiasisCholelithiasis Acalculous cholecystitisAcalculous cholecystitis Budd-Chiari SyndromeBudd-Chiari Syndrome


PancreasPancreas PancreatitisPancreatitis

BoneBone OsteopeniaOsteopenia Aseptic NecrosisAseptic Necrosis

EyeEye UveitisUveitis EpiscleritisEpiscleritis KeratitisKeratitis


UrologicUrologic NephrolithiasisNephrolithiasis Obstructive hydronephrosisObstructive hydronephrosis Enterovesical fistulaEnterovesical fistula NephritisNephritis Amyloidosis Amyloidosis


HematologicHematologic AnemiaAnemia

IronIron FolateFolate B12B12 AutoimmuneAutoimmune

ThrombocytosisThrombocytosis ThrombocytopeniaThrombocytopenia

HypercoaguableHypercoaguable


DiagnosisDiagnosis No substitute for H&PNo substitute for H&P LabsLabs

AnemiaAnemia Most due to iron deficiencyMost due to iron deficiency

ThrombocytosisThrombocytosis ESR – 80% CD, 40% UCESR – 80% CD, 40% UC CRPCRP

Sensitive for active diseaseSensitive for active disease Low albuminLow albumin

Protein loss and malnutritionProtein loss and malnutrition Elevated liver enzymesElevated liver enzymes pANCA, ASCApANCA, ASCA

DiagnosisDiagnosis RadiographsRadiographs

UGI with SBFTUGI with SBFT CDCD

EndoscopyEndoscopy GrossGross MicroscopicMicroscopic

ComplicationsComplications CTCT

Abscess Abscess

*Plan the initial evaluation of a patient with suspected IBD*Plan the initial evaluation of a patient with suspected IBD

Admit?Admit?

Severe ColitisSevere Colitis FeverFever HypoalbumnemiaHypoalbumnemia Anemia Anemia >5 bloody stools/day>5 bloody stools/day

Bowel rest, TPN, IV Bowel rest, TPN, IV steroids and careful steroids and careful monitoringmonitoring

ManagementManagement

PharmacologicPharmacologic AminosalicylatesAminosalicylates

Mesalamine, sulfasalazineMesalamine, sulfasalazine Mild colonic inflammationMild colonic inflammation

CorticosteroidsCorticosteroids Prednisone, budesonidePrednisone, budesonide Moderate to severe symptomsModerate to severe symptoms

>5 bloody stools/day, fever, hypoalbuminemia, >5 bloody stools/day, fever, hypoalbuminemia, anemiaanemia

Goal is to decrease symptoms then change to Goal is to decrease symptoms then change to maintenance therapymaintenance therapy


PharmacologicPharmacologic ImmunomodulatorsImmunomodulators

Azathioprine, 6-MP, methotrexateAzathioprine, 6-MP, methotrexate Steroid dependant or refractorySteroid dependant or refractory Maintenance Maintenance

BiologicsBiologics InfliximabInfliximab Steroid dependant or refractorySteroid dependant or refractory MaintenanceMaintenance


PharmacologicPharmacologic AntibioticsAntibiotics

Metronidazole, ciprofloxacinMetronidazole, ciprofloxacin Perirectal fistula, abscessPerirectal fistula, abscess

ProbioticsProbiotics Lactobacillus GG, Saccharomyces boulardiiLactobacillus GG, Saccharomyces boulardii Adjunctive therapyAdjunctive therapy


Nutrition TherapyNutrition Therapy PrimaryPrimary AdjunctiveAdjunctive Important for Important for

RemissionRemission Chronic undernutritionChronic undernutrition Growth failureGrowth failure


Surgical TherapySurgical Therapy Uncontrolled GI bleedingUncontrolled GI bleeding Bowel perforationBowel perforation ObstructionObstruction Unacceptable medication toxicityUnacceptable medication toxicity Intractability Intractability Growth failureGrowth failure Some perirectal diseaseSome perirectal disease CancerCancer

PrognosisPrognosis

UCUC 70% remission in 3 months70% remission in 3 months 50% remission for 1 year50% remission for 1 year 10-26% colectomy within 5 years10-26% colectomy within 5 years 70% likelihood of severe disease if 70% likelihood of severe disease if

proctitis presentproctitis present

PrognosisPrognosis

CDCD 1% will not have at least one relapse1% will not have at least one relapse IleocolitisIleocolitis

Responds poorly to medical therapyResponds poorly to medical therapy Greater need for surgeryGreater need for surgery

70% will have surgery within 10-20 70% will have surgery within 10-20 years of diagnosisyears of diagnosis

CancerCancer Colitis >10 y and extentColitis >10 y and extent Sclerosing cholangitisSclerosing cholangitis

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