8/6/2019 Idiopathic Inflammatory Bowel Disease

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o pa c n a mma o ry o we s ease

Inflammatory Bowel Disease (IBD)Crohn Disease (CD) Ulcerative Colitis (UC)

Chronic relapsing disease (unknown origin) Ulceroinflammatory diseaseAffect colon (but limited to mucosa, submucosa except in severe cases)Begins in rectumExtends proximally in continuous fashion (sometimes involve entire colon)

20 30 y/o peak age 20 25 y/o peak ageEtiologyGenetic loci in chromosome 3, 7, 12, 16Microbial pseudomonas, atypical mycobacteriaSmokingAssociated withy Migratory polyarthritisy Sarcoiliitisy

Ankylosing spondylitisy Uveitisy Erythema nodosumy P ericholangitis

EtiologyGenetic (familial)Association with immune related conditionsy Uveitisy Erythema nodosumy VasculitisAntineutrophilic cytoplasmic antibodies (ANCAs)

Associated withy Migratory polyarthritisy Sarcoiliitisy Ankylosing spondylitisy Uveitisy Erythema nodosumy P ericholangitis

ImmunologyChronic, recurrent inflammationP resence of systemic manifestations (autoimmune diseases)Cytotoxic T cellsy Sensitized to bacterial, other antigensy

amage intestinal wallCyclosporiney Inhibitor of cell mediated immunityy Used to prevent rejection of transplanted organsy R elieve symptoms of CDS ite of InvolvementSmall intestine alone (30%)Small intestine, colon (40%)Colon alone (30%)Duodenum, stomach (uncommon)

CommonYoung persons Elderly Women

Ileal + Caecal Colitis Anorectal CD spread toexternal genitalia

S ite of InvolvementR ectum, R ectosignoid (50%)P ancolitis (much less frequent)Colonic involvement (continuous from distal colon)(skip lesions are not present)

PathologyMesenteric lymph nodes enlarged, matted togetherLoops of bowel become adherent, fistulae (due to)y Deep mural ulcersy P enetrate to adjacent bowel loops, organs

(bladder, uterus, vagina, skin)y Most fistulae end blindly in

(mesentery, retroperitoneal structures, abscess cavities in peritoneal cavity)P erianal fistulae lesions in rectum, anusSkip lesions (Sharp demarcation between)y Diseased bowel segmentsy Adjacent uninvolved normal bowel segments

PathologySevere disease broad-based ulceration in mucosa (distal colon, entire colon)P seudopolyps (isolated islands of regenerating mucosa)Undetermined edges of adjacent ulcersy Interconnected to create tunnelsy Covered by mucosal bridgesUlcers do no replicate serpentine ulcers of Crohn DiseaseToxic megacolonHealing of active disease P rogressive mucosal atrophy Flattened mucosaDiffuse mononuclear inflammatory infiltrate (in lamina propria)

G ross ExaminationBowel appears thickened, edematous Intestinal lumen narrowed by edema (in long standing edema, fibrosis)Nodular swelling, fibrosis, ulceration of mucosa ( Cobblestone appearance)Ulcersy Early ulcers shallow, aphthous, serpiginousy Later ulcers deeper, linear clefts, fissures Mesenteric fat wraps around bowel ( creeping fat )

G ross ExaminationHyperaemiaEdemaGranularityFriabilityEasy bleeding

Crohn s ColitisEdematous colonic mucosaCobblestone appearance

Crohn s Colitis

Ulcerative Colitis

Ulcerative Colitis

Crohn s ColitisCreeping fat Ulcerative Colitis (Dysplasia Adenocarcinoma)

8/6/2019 Idiopathic Inflammatory Bowel Disease

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Inflammatory Bowel Disease (IBD) (cont.)

Crohn Disease (CD) Ulcerative Colitis (UC)

Crohn s DiseaseDeep fissure

Ulcerative Colitis

Ulcerative ColitisCrypt abscess

MicroscopicEarly phasey Chronic inflammatory process (confined to mucosa, submucosa)y Small superficial mucosal ulcerations

Mucosal, submucosal edema y Destruction of mucosal architecture

R egenerative changes in crypts, villous distortions (frequent)P yloric metaplasia, P aneth cell hyperplasia (common in)y Small intestiney ColorectumMicroscopic Hallmark

y Transmural nodular lymphoid aggregatesy P roliferative changes

(muscularis mucosae, submucosal nerves, myenteric plexus)Discrete noncaseating epitheloid granulomas y Mostly in submucosay W ith multinucleated giant cells, hyaline material (at center)

MicroscopicCrypt abscessy Neutrophilic infiltrate in epitheliumy P roducing collections in crypt luminaDestruction of mucosa Ulceration (submucosa) R aw exposed muscularis

Granulation tissuey Fill the ulcer cratersy R egeneration of mucosal epitheliumSubmucosal fibrosisMucosal disarrayAtrophy

Clinical Features (Variable, unpredictable)R ecurrent diarrhoea Crampy abdominal painFever (insidious, days weeks)Melaena

Clinical FeaturesBloody mucoid diarrhoea (days, weeks, months)Asymptomatic interval (months, years, decades)Insidious onsety Crampsy Tenesmusy Colicky lower abdominal painGross bloody stool (UC > CD)y Severe blood lossy Fluid, electrolyte imbalance (emergency)Clostridium difficileExtraintestinal migratory polyarthritis

Complications

Fistula formation to other loops of bowely Urinary bladdery Vaginay P erianal skinAbdominal abscesses, peritonitis Intestinal stricture, obstruction Massive intestinal bleed (rare)Toxic dilatation of colon, small intestine (rare)

R isk of carcinoma (less than UC)

Complications

Colonic carcinomaUncommon life-threateningy Severe diarrhoeay Electrolyte imbalancey Massive haemorrhagey Toxic megacolon with perforation, peritonitis

Pathological Features (Crohn s Disease, Ulcerative Colitis)Lesion - Macroscopic Crohn s Disease (CD) Ulcerative Colitis (UC)

Thickened bowel wall Typical UncommonLuminal narrowing Typical UncommonSkip lesions Common AbsentR colon predominant Typical AbsentFissure, fistulae Common AbsentCircumscribed ulcers Common AbsentConfluent linear ulcers Common AbsentP seudopolyps Absent Common

Lesion - MicroscopicTransmural inflammation Typical UncommonSubmucosal fibrosis Typical AbsentFissure Typical R areNon-caseating granulomas Common AbsentCrypt abscess Uncommon Typical