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BOALA INFLAMATORIE INTESTINALA

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  • BOALA INFLAMATORIEINTESTINALA

  • dr cora pop BIIBOALA INFLAMATORIE INTESTINALA

    Dou entiti distincte

    Colita ulcerativ (CU) Boala Crohn (BC)

  • dr cora pop BIIBOALA INFLAMATORIE INTESTINALACU inflamaie cronic a mucoasei i submucoasei colonice

    BC inflamaia celor 4 straturi ale mucoasei -mai ales ileon i/sau colon proximal

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  • dr cora pop BIIBOALA INFLAMATORIE INTESTINALA etiologie

    Nu a fost identificat un agent cauzalAsociate cu un rspuns imun exagerat al mucoasei tractului gastrointestinalSusceptibilitatea geneticNOD2

  • dr cora pop BIIBOALA INFLAMATORIE INTESTINALA Fiziopatologie La indivizii predispusi genetic, rspuns inflamator iniiat de factori necontrolai de mecanismele homeostatice

    Infecii bacteriene i virale Fumatul

  • dr cora pop BIIBOALA INFLAMATORIE INTESTINALA Fiziopatologie

  • dr cora pop BIIBOALA INFLAMATORIE INTESTINALA Fiziopatologie

  • dr cora pop BIICOLITA ULCERATIVCea mai frecvent cauz de diaree cu snge, mucus i puroiAfecteaz rectul > 95%Se extinde proximal la colon n proporii variate

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    25% exclusiv rect, 50% partea stinga a colonului, 25% pancolit

  • dr cora pop BIICOLITA ULCERATIV Epidemiologie:

    Inciden bimodal decadele 3 i 6-7Mai frecvent la brbai cu 20%Mai frecvent n zone urbaneRedus cu 50% la fumtori Risc de 15 ori mai mare la rudele de gradul I

  • dr cora pop BIICOLITA ULCERATIV Anatomie patologicModificrile inflamatorii se opresc la valva ileocecalExtensie continuUlceraii superficiale rar trec de muscularUlcere longitudinale de-a lungul teniaei coli (1/5)Polipi inflamatori

  • dr cora pop BIICOLITA ULCERATIV Anatomie patologicInfiltrat cu plasmocite i neutrofile n lamina propria i n glande abcese cripticeDepleia celulelor caliciformen exacerbri repetate mucoasa se distruge pe toat grosimea absena glandelor, fibroz

  • dr cora pop BIICOLITA ULCERATIVmanifestari clinice

    RECTIT - scaune formate (1-2/ zi), evacuare intermitent de mucus sangvinolent -constipatie/scibale -tenesme,urgen

  • dr cora pop BIICOLITA ULCERATIVmanifestari cliniceSIGMOIDIT/ COLIT STNG/ PANCOLIT -diaree sangvinolent -rectoragii + mucus -tenesme -incontinen -crampe hipogastrice

    Forme severe febr, anorexie,scadere ponderela,grea,manifestarile anemiei,manifestarile hipoalbuminemiei

  • dr cora pop BIICOLITA ULCERATIV

    EXAMEN FIZICCaexieFebrHipocratismSensibilitate la palparea colonicStare general alterataMeteorism (megacolon toxic)Boal perirectal mai rar ca n BC

  • dr cora pop BIICOLITA ULCERATIV Stadializare (Truelove)FORMA DE BOALAUoar < 4 scaune/zi ,fr toxicitate

    Moderat 4 scaune/zi ,cu toxicitate minim

    Sever 6 scaune/zi, i/sau toxicitate

    Toxicitate: febr, tahicardie, anemie, VSH crescuta

  • dr cora pop BIICOLITA ULCERATIV investigatii de laboratorLeucocitozVSH TrombocitozPCR crescutAnemie hipocroma microcitara/posthemoragicahipopotasemieAc pANCA crescui (75% cazuri)

  • dr cora pop BIICOLITA ULCERATIV Endoscopia Colit ncepnd cu rectul circumferenial pn la mucoas normalGranularitate, friabilitate, ulceraiiPierderea pattern-ului vascularPolipi i stricturi n canalul anal sau la 8-9 cm deasupra

  • dr cora pop BIICOLITA ULCERATIV EndoscopiaBeneficiile endoscopieiDiagnosticul de CU Diagnosticul diferential cu BCExtensia si severitatea boliiRaspunsul la tratamentUrmarire pentru displazie

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  • dr cora pop BIICOLITA ULCERATIV EndoscopiaBiopsiaInfiltrat inflamator limitat la mucoas, abcese i distorsiuni criptice, scderea numrului celulelor caliciforme, ulceraii epiteliale, dezorganizarea arhitecturii normale glande atrofiate, ramificate

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  • dr cora pop BIICOLITA ULCERATIV Radiologie RADIOGRAFIA ABDOMINAL SIMPLMegacolon toxic perforaie polipi vizibili pe fondul aerului din colonul transvers

  • dr cora pop BIICOLITA ULCERATIV RadiologieIRIGOGRAFIA

    Complicaii locale, extinderea boliiCI la p. cu colon dilatat sau n stare grav normal n stadiile precoce sau afectarea rectalCresterea spatiului dintre rect si sacru- cronicitate

  • dr cora pop BIICOLITA ULCERATIV RadiologieIRIGOGRAFIAn stadii avansate pierderea haustraiilorcolon tubular distorsiunea mucoasei colon scurtat polipi inflamatori ulceraii ileit retrograd staz fecal

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  • dr cora pop BIICOLITA ULCERATIV Complicaii localeHEMORAGIA

    Brusc masivNecesit transfuzii de snge, colectomie de urgen

  • dr cora pop BIICOLITA ULCERATIV Complicaii localePOLIPI INFLAMATORIDetectai radiologic i endoscopicNu se transf malignProtruzii polipoide ale mucoasei, edem, hiperplazia epitelial, esut de granulaieDiagnostic diferenial cu adenomul/ neoplazia

  • dr cora pop BIICOLITA ULCERATIV Complicaii localeSTRICTURILEPancolit 10% cazuriHipertrofia musculaturii; unice, localizate sau multiple, difuzeDiagnostic radiologic i endoscopicCel mai frecvent n rectTest cu propantelin i.v.

  • dr cora pop BIICOLITA ULCERATIV Complicaii localeDILATAIA TOXIC1-2% din cazuriForme severeColectomie de urgenDin cauza scderii capacitii de contracie; segment adinamic colonul transvers se destinde i perforeazCauze depleia de K, anticolinergice, opiacee, sulfat de bariu

  • dr cora pop BIICOLITA ULCERATIV Complicaii localeDILATAIA TOXIC

    Clinic stare general alterat, febr, leucocitoz, abdomen destins, numr sczut al scaunelor;Rx. -dilataie > 6 cm diametru colonului transvers Tratament - colectomie dup transfuzii sangvine i plasm; - antibioterapie intestinal

  • dr cora pop BIICOLITA ULCERATIV Complicaii localePERFORAIAn acutizri peretele subire perforeaz Peritonit generalizat fecala fatala in 75%n spaiul retroperitoneal sau perirectal fistuleRadiologic aer sub diafragmSe instaleaz insidios (Rx. seriate)Clinic matitatea hepatic dispare

  • dr cora pop BIICOLITA ULCERATIV Complicaii localeCARCINOMUL COLORECTAL7-14% la 25 aniRiscul crete dup 8 ani de boal cu 0,5-1% /anDisplazie neoplazie a mucoasei, precede cancerul invaziv; displazie de grad mic, nalt, nedefinit

  • dr cora pop BIICOLITA ULCERATIV Complicaii sistemiceArticulare 10-15% Artropatii acute articulaii mari, sau articulaii mici, afectare simetricSacroileita 9-11%Spondilita anchilozant 1-3%

  • dr cora pop BIICOLITA ULCERATIV Complicaii sistemiceUveit i episclerit 5-15%Eritem nodos 10-15%Pyoderma gangrenosum 1-2%Colangit sclerozant 2-7%Steatoz OsteoporozLitiaza renala

  • dr cora pop BIICOLITA ULCERATIV Diagnostic diferenialCOLITA INFECIOAS ACUT-Salmonella/Shigella/ Yersinia /Amebia/Chlamydia /E. coli /Mycobacterium tuberculosis

  • dr cora pop BIICOLITA ULCERATIV Diagnostic diferenialCOLITA ISCHEMICCOLITA MEDICAMENTOASCOLITA DE IRADIERE

  • dr cora pop BIICOLITA ULCERATIV Diagnostic diferenialBOALA CROHNConserv rectul, afecteaz intestinul subireAspectul histologic5-10% nu pot fi diferenate (colit nedeterminat)

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  • dr cora pop BIICOLITA ULCERATIV msuri generale de tratament Repaus la pat la cei cu stare general alteratAgeni antidiareici tinctur de belladon, codein, opiacee Transfuzii de sngedeficitul de K, hipoproteinemie, depleie de ap i sareDieta- rezidii alimentare n cantitate sczut

  • dr cora pop BIICOLITA ULCERATIV Tratament medicamentosRECTITASupozitoare cu mesalamin Supozitoare cu hidrocortizonRar necesar steroizi oral

  • dr cora pop BIICOLITA ULCERATIV Tratament medicamentosRECTOSIGMOIDITACei fr toxicitate clisme cu mesalamin; 5ASASalazopirina 2-4 g/zi efecte secundare mai mari (din cauza sulfapiridinei)

  • dr cora pop BIICOLITA ULCERATIV Tratament medicamentos SALAZOPIRINAEfecte secundareGrea, cefalee, disconfort epigastric, rash, agranulocitoz, hemoliz, scaderea numarului de spermatozoizi1 mg folat oral

  • dr cora pop BIICOLITA ULCERATIV Tratament medicamentosBOAL EXTINS DINCOLO DE SIGMOID

    salazopirin oralAdugare de clisme cu mesalamin -pentru un control mai rapid al boliiOlsalazina dimer 5ASA

  • dr cora pop BIICOLITA ULCERATIV Tratament medicamentosCORTICOIZI ORAL

    Colit extins, scadere ponderala, anemie prednison de la nceputCei ce nu rspund la prednison recidiveaz frecvent azatioprin, 6 mercaptopurin, colectomie

  • dr cora pop BIICOLITA ULCERATIV Tratament medicamentosPREDNISON40-60mg/ zi prednison;La ameliorarea simptomelor, prednisonul se scade cu 5mg/ sptLa 20mg prednison se reia 5ASA

  • dr cora pop BIICOLITA ULCERATIV Tratament medicamentosBOAL SEVER- toxicitate sever sistemic

    SpitalizareMetilprednisolon 60-80mg Antibiotice intravenosSe evit opiaceele, anticolinergicele, antidiareicele (megacolon toxic)Fr rspuns n 1 sptmn colectomie Ciclosporina i.v. poate grbi colectomia

  • dr cora pop BIICOLITA ULCERATIV Tratament chirurgicalINDICATIIHemoragieAbsena remisiei cu tratament medical timp de 7-10 zileCorticodependen sau intoleran la azatioprin, Alterarea calitii vieii

  • dr cora pop BIICOLITA ULCERATIV Tratament chirurgicalColectomie subtotal (pstrarea rectului) mai puin periculoas dectcolectomia totalProctectomia -cu ileostomie i anastomoz ileoanal- poate fi efectuat ulterior

  • dr cora pop BIICOLITA ULCERATIVSUPRAVEGHERE COLONOSCOPICanual dup 8-10 ani de evoluieNu e concludent n determinarea speranei de supravieuireDisplazia de orice grad colectomie

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    COLITA ULCERATIV Tratamentul pe baza activitii

    Activitatea boliiOpiune terapeutic principalUoar 5ASA, nicotinModerat 5ASA, corticosteroizi oral, Sever Corticosteroizi i.v., ciclosporin, chirurgie

  • dr cora pop BIIBOALA CROHNepidemilogieCauza necunoscut

    Distribuie bimodal: decada a 3-a i a 6-aMai frecvent la sexul masculin, cu 20%Incidena a crescut n 30 aniFumatul dubleaz risculRisc de 15 ori mai mare la rudele de grad I

  • dr cora pop BIIBOALA CROHNmanifestari clinice

    Afecteaz tractul digestiv de la esofag la anusMultiple manifestri extraintestinaleDistribuie: ileon distal 30%, colon 20%, intestin subire i gros 50%

  • dr cora pop BIIBOALA CROHN manifestari clinice BOALA ILEAL DISTAL durere n fosa iliac dreapt, diaree, scdere ponderal, rareori sngerare vizibil, ocluzia (crampe, durere abdominal postprandial, meteorism, diaree)

  • dr cora pop BII BOALA CROHN manifestari clinice BOALA PERIANAL -fisuri -fistule enterovezicale/enterice/cutanate /rectovaginale -abcese -poate preceda cu civa ani debutul afeciunii

  • dr cora pop BIIBOALA CROHNmanifestari cliniceBOALA EXTRAINTESTINALAAFECTARE TEGUMENTAR eritem nodos- pyoderma gangrenosum ( ulcere sterile profunde)UVEIT COLANGIT SCLEROZANT

  • dr cora pop BII BOALA CROHNmanifestari clinice

    AFECTARE ARTICULAR - artrit periferic nedistructiv a articulaiilor mari 15-20%, - spondilit anchilozant 3-5%, -sacroileit 9-11%

  • dr cora pop BIIBOALA CROHNexamen fizic

    Febr CaexieFormaiuni palpabile abcese, anse inflamate, comasate

  • dr cora pop BIIBOALA CROHN Explorri paracliniceTESTE DE LABORATOREXAMEN RADIOLOGICngustarea lumenului ileonului distal, fistuleTOMOGRAFIE COMPUTERIZATAbcese, ngroarea peretelui intestinal, distinge BC de apendicit

  • dr cora pop BIIBOALA CROHNcolonoscopie

    Diagnostic iniial/ recidivei/supravegheaz displaziaRect frecvent normal, inflamaie discontinu, ulcere aftoase pe fond de mucoas ormal

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  • dr cora pop BII BOALA CROHN complicaiiCancer colorectalTumori maligne de intestin subireLimfoameMalabsorbieOsteoporoz

  • dr cora pop BII BOALA CROHNDiagnostic diferenialCOLITA ULCERATIVAfectare parcelarConserv rectulEndoscopieHistologie COLIT NEDETERMINAT 5-10%

  • dr cora pop BIIBOALA CROHN Diagnostic diferenial AFECIUNI MANIFESTATE CU DIAREE CRONICSindrom de intestin iritabilDiareea medicamentoas

  • dr cora pop BIIBOALA CROHN Tratament BOAL UOARTratament ambulatoriu/Tolereaz dieta oralSalazopirina mai puin eficace dect preparatele ce conin mesalaminAsacol elibereaz mesalamina n ileonul distal i colon; Metronidazol Ciprofloxacin

  • dr cora pop BIIBOALA CROHN Tratament BOAL SEVERCorticosteroizi -Prednison 40-60 mg/zi, -Efecte secundare hiperglicemie, HTA, osteoporoz, necroz aseptic de old, miopatie depresie, insomnie, -Budesonid foarte eficace topic-Metilprednisolon

  • dr cora pop BIIBOALA CROHN Tratament Modulatori imuni -Azatioprin 6 mercaptopurin 6 tioguanina (activ) -Efecte secundare grea, rash, pancreatit, hepatit, supresie medular-Infliximab foarte scump; produs prin tehnici de biologie molecular -anti TNF;

  • dr cora pop BIIBOALA CROHN Tratament chirurgical

    complicaii -ocluzii, -hemoragii, -abcese-fistule

    *********Figure 2.Common Cellular Pathways of Activation in Inflammatory Bowel Disease.Activation of the protean transcriptional regulatory factor nuclear factorkB (NFkB) is acommon pathway central to cell activation and the production of diverse inflammatory mediators,including a variety of cytokines and chemokines. It also modulates resistance toprogrammed cell death (apoptosis). Several inflammatory factors implicated in inflammatorybowel disease activate NFkB by eventually stimulating an intermediate kinase suchas NFkBinducing kinase (NIK) or mitogen-activated protein kinase kinase 1 or 3 (MEKK1or MEKK3) or by binding to receptor-interacting protein 2. These lead to phosphorylation ofthe inhibitor ofkB kinase (IKK) and subsequent dissociation of NFkB (itself a dimer). NFkBthen travels to the nucleus, where it can effect gene transcription. The phosphorylated constituentsare subject to degradation by proteosomes after ubiquitination. The spectrum ofmediators that activate this pathway includes inflammatory cytokines such as interleukin-1and tumor necrosis factor (TNF), which bind to their respective cell-surface receptors, aswell as microbial products such as lipopolysaccharide, which bind to cell-surface receptorsthat are members of the toll-like receptor family of pattern-recognition receptors. The pathwayis also activated by NOD2 (also referred to as CARD 15), an intracytoplasmic receptorthat is activated by the entry, through mechanisms yet to be defined, of bacterial lipopolysaccharideinto the cytoplasm. NOD2 is the product of theIBD1gene; germ-line mutations,which are present in many patients with Crohns disease, appear to alter the activation ofthe NFkB pathway. MyD88 denotes myeloid differentiation factor 88.Figure 2.Common Cellular Pathways of Activation in Inflammatory Bowel Disease.Activation of the protean transcriptional regulatory factor nuclear factorkB (NFkB) is acommon pathway central to cell activation and the production of diverse inflammatory mediators,including a variety of cytokines and chemokines. It also modulates resistance toprogrammed cell death (apoptosis). Several inflammatory factors implicated in inflammatorybowel disease activate NFkB by eventually stimulating an intermediate kinase suchas NFkBinducing kinase (NIK) or mitogen-activated protein kinase kinase 1 or 3 (MEKK1or MEKK3) or by binding to receptor-interacting protein 2. These lead to phosphorylation ofthe inhibitor ofkB kinase (IKK) and subsequent dissociation of NFkB (itself a dimer). NFkBthen travels to the nucleus, where it can effect gene transcription. The phosphorylated constituentsare subject to degradation by proteosomes after ubiquitination. The spectrum ofmediators that activate this pathway includes inflammatory cytokines such as interleukin-1and tumor necrosis factor (TNF), which bind to their respective cell-surface receptors, aswell as microbial products such as lipopolysaccharide, which bind to cell-surface receptorsthat are members of the toll-like receptor family of pattern-recognition receptors. The pathwayis also activated by NOD2 (also referred to as CARD 15), an intracytoplasmic receptorthat is activated by the entry, through mechanisms yet to be defined, of bacterial lipopolysaccharideinto the cytoplasm. NOD2 is the product of theIBD1gene; germ-line mutations,which are present in many patients with Crohns disease, appear to alter the activation ofthe NFkB pathway. MyD88 denotes myeloid differentiation factor 88.

    ************************************************************************Renal Complications StonesEnteric hyperoxaluria oxalate stonesUric acid stonesInfectionDehydrationBladder fistulasRetroperitoneal fistulization hydroureter and hydronephrosisAmyloidosisSeen somewhat more with colonic than small - bowel Crohn's disease, appears to be associated mainly with chronic suppuration******