Inflammatory Inflammatory Bowel DiseaseBowel Disease

A Aljebreen, MD, FRCPCA Aljebreen, MD, FRCPC

Jan 2010Jan 2010

ObjectivesObjectives

Introduction Introduction Classifications Classifications Clinical featuresClinical features DiagnosisDiagnosis Management Management Conclusion Conclusion

Introduction Introduction

IBD characterized by a tendency for IBD characterized by a tendency for chronic or relapsing immune chronic or relapsing immune activation and inflammation within activation and inflammation within the gastrointestinal tract (GIT)the gastrointestinal tract (GIT)

CrohnCrohn’’s disease (CD) and ulcerative s disease (CD) and ulcerative colitis (UC) are the 2 major forms of colitis (UC) are the 2 major forms of idiopathic IBD.idiopathic IBD.

Less common entitiesLess common entities

Microscopic colitis (collagenous and Microscopic colitis (collagenous and lynphocytic)lynphocytic)

OthersOthers Diversion colitisDiversion colitis Radiation colitisRadiation colitis Drug induced colitisDrug induced colitis Infectious colitisInfectious colitis Ischemic colitis Ischemic colitis

CD and UCCD and UC

CD is a condition of CD is a condition of Chronic inflammation potentially involving Chronic inflammation potentially involving

any location of the GIT from mouth to anus.any location of the GIT from mouth to anus. It is a lifelong disease arising from an It is a lifelong disease arising from an

interaction between genetic and interaction between genetic and environmental factorsenvironmental factors

UC is an inflammatory disorder that UC is an inflammatory disorder that affects the rectum and extends affects the rectum and extends proximally to affect variable extent of proximally to affect variable extent of the colon.the colon.

Epidemiology Epidemiology

CD:CD: 11stst peak 15-30 years of age, 2 peak 15-30 years of age, 2ndnd peak around peak around

60 y60 y There is a definite incidence surge in Saudi There is a definite incidence surge in Saudi

Arabia over the last 10 yearsArabia over the last 10 years UC:UC:

High incidence areas: US, UK, northern High incidence areas: US, UK, northern EuropeEurope

Young adults, commoner in femalesYoung adults, commoner in females

Genetics Studies suggested that 1st degree

relatives of an affected patient have a risk of IBD that is 4-20 times higher than that of general population.

The best replicated linkage region, IBD1, on chromosome 16q contains the CD susceptibility gene, NOD2/CARD15.

Having one copy of the risk alleles confers a 2–4-fold risk for developing CD, whereas double-dose carriage increases the risk 20–40-fold.

EtiologyEtiology

Mutations within the NOD2/ CARD15 gene contribute to CD susceptibility.

Functional studies suggest that inappropriate responses to bacterial components may alter signaling pathways of the innate immune system, leading to the development and persistence of intestinal

inflammation. Initiating pathogen?Initiating pathogen?

Infectious?Infectious? ? Possibly non-pathogenic commensal enteric flora? Possibly non-pathogenic commensal enteric flora

Pathogenesis

The mucosa of CD patients is dominated by Th1 (T helper), which produce interferon-γ and IL-2.

In contrast, UC dominated by Th2 phenotype, which produce transforming growth factor (TGF-) and IL-5.

Activation of Th1 cells produce the down-regulatory cytokines IL-10 and TGF-.

Environmental Environmental PrecipitantsPrecipitants

Factors: NSAIDs use (?altered intestinal

barrier), and Early appendectomy (increase UC

incidence) Smoking (protects against UC but

increases the risk of CD).

CD: PATHOLOGY

Early Findings: Aphthous ulcer. The presence of granulomas

Late findings: Linear ulcers. The classic cobble stoned appearance

may arise. Transmural inflammation Sinus tracts, and strictures. Fibrosis.

transmural inflammation with transmural inflammation with predominance of the inflammation in the predominance of the inflammation in the mucosa and submucosamucosa and submucosa..

UC: PATHOLOGY The inflammation is predominantly

confined to the mucosa. Non-specific (can be seen with any

acute inflammation) The lamina propria becomes edematous. Inflammatory infiltrate of neutrophils Neutrophils invade crypts, causing

cryptitis & ultimately crypt abscesses. Specific (suggest chronicity):

Distorted crypt architecture, crypt atrophy and a chronic inflammatory infiltrate.

Diagnosis Diagnosis

Exclude other possibilities (need Exclude other possibilities (need good history, physical exam, labs, good history, physical exam, labs, imaging and endoscopy with biopsy)imaging and endoscopy with biopsy)

There are many distinguishing There are many distinguishing features of CD and UC.features of CD and UC.

In about 5% it is classified as In about 5% it is classified as indeterminate because of indeterminate because of overlapping features.overlapping features.

Distinguishing characteristics of Distinguishing characteristics of CD and UCCD and UC

Feature CDUC

Location SB or colonOnly colon (rarely

“backwash ileitis”

Anatomic distribution

Skip lesionsContinuous, begins distally

Rectal involvement

Rectal spareInvolved in >90%

Gross bleeding

Only 25%Universal

Peri-anal disease

75%Rare

Fistulization Yes No

Granulomas 50-75%No

Endoscopic features of CD Endoscopic features of CD and UCand UC

Feature CDUC

Mucosal involvement

Discontinuous

Continuous

Aphthous ulcers

Common Rare

Surrounding mucosa

Relatively normal

Abnormal

Longitudinal ulcer

Common Rare

Cobble stoningIn severe cases

No

Mucosal friability

Uncommon Common

Vascular pattern

Normal distorted

Pathologic features of CD Pathologic features of CD and UCand UC

Feature CDUC

Transmural inflammation

Yes Uncommon

Granulomas 50-75%No

Fissures Common Rare

Fibrosis Common No

Submucosal inflammation

Common Uncommon

Radiologic features of CD Radiologic features of CD and UCand UC

Feature CDUC

Nodularitygranularity

cobble stoningstring sign of SB

Collar button ulcers

UC: PresentationUC: Presentation Must exclude infectious cause before Must exclude infectious cause before

making Dx.making Dx. Rectal Bleeding Rectal Bleeding Diarrhea:Diarrhea:

frequent passage of loose or liquid stool, often frequent passage of loose or liquid stool, often associated with passing large quantities of associated with passing large quantities of mucus.mucus.

Abdominal Pain:Abdominal Pain: it is not a prominent symptom. it is not a prominent symptom.

Anorexia, nausea, feverAnorexia, nausea, fever……

DDX of UCDDX of UC

InfectiousInfectious Drug inducedDrug induced Microscopic colitisMicroscopic colitis

UC: PresentationUC: Presentation

Mild attack:Mild attack: Most common form, mainly left sided Most common form, mainly left sided

colitis, <4 BM/day with no bloodcolitis, <4 BM/day with no blood Moderate attack:Moderate attack:

25% of all patients, 4-6 BM/day with blood.25% of all patients, 4-6 BM/day with blood. Severe or fulminant colitis:Severe or fulminant colitis:

~ 15% of cases, >6BM/day, bloody, fever, ~ 15% of cases, >6BM/day, bloody, fever, weight loss, diffuse abd tenderness, weight loss, diffuse abd tenderness, elevated WBC, most refractory to medical elevated WBC, most refractory to medical therapytherapy

CDCD

Anatomic Anatomic distributiondistribution

CD activity CD activity indexindex

DDx DDx (lymphoma, (lymphoma, Yersinea Yersinea Enterocolitis, Enterocolitis, TB)TB)

CD: clinical CD: clinical presentationspresentations

Disease of the ileum: May present initially with a small bowel

obstruction. Patients with an active disease often present

with anorexia, loose stools, and weight loss. Perianal disease

In 24% of patients with CD. Skin lesions include superficial ulcers, and

abscesses. Anal canal lesions include fissures, ulcers, and

stenosis.

CD ilitis: DDxCD ilitis: DDx

LymphomaLymphoma

Yersinea Enterocolitis andYersinea Enterocolitis and TBTB

CD: clinical CD: clinical presentationspresentations

colonic disease The typical presenting symptom is diarrhea,

occasionally with passage of obvious blood. proctitis

May be the initial presentation in some cases of CD

Extra-intestinal manifestations Extra-intestinal manifestations of IBDof IBD

Arthritis:Arthritis: Peripheral arthritis, usu paralels the disease Peripheral arthritis, usu paralels the disease

activityactivity Ankylosing Spondylitis, 1-6%, sacroiliitisAnkylosing Spondylitis, 1-6%, sacroiliitis

Ocular lesions:Ocular lesions: Iritis (uvietis) (0.5-3%), episcleritis, keratitis,Iritis (uvietis) (0.5-3%), episcleritis, keratitis,

Skin and oral cavity:Skin and oral cavity: Erythema nodosum 1-3%Erythema nodosum 1-3% Pyoderma Gangrenosum 0.6%Pyoderma Gangrenosum 0.6% Aphthus stomatitis, metastatic CD.Aphthus stomatitis, metastatic CD.

Extra-intestinal manifestations Extra-intestinal manifestations of IBDof IBD

Liver and Biliary tract disease:Liver and Biliary tract disease: Pericholangitis, fatty infiltration, PSC Pericholangitis, fatty infiltration, PSC

(1-4%, more with UC), (1-4%, more with UC), cholangiocarcinoma, gallstonescholangiocarcinoma, gallstones

Thromboembolic disease, vasculitis, Thromboembolic disease, vasculitis, Renal disease (urolithiasis, GN), Renal disease (urolithiasis, GN), clubbing, amyloidosis.clubbing, amyloidosis.

Complications of IBDComplications of IBD

BleedingBleeding StrictureStricture FistulaFistula Toxic megacolonToxic megacolon CancerCancer

How to diagnose IBDHow to diagnose IBD

History History Physical examinationsPhysical examinations Labs Labs Radiology Radiology Endoscopy Endoscopy Histopathology Histopathology

Case scenario 1Case scenario 1

17 year old female presented with 1 year history of intermittent abdominal cramps and increasing abdominal gases and bloating.

What other history you want?

Case scenario 2Case scenario 2

65 year old male presented with 6 months history of bleeding per rectum.

What other history you want? What else you need?

Treatment Treatment

Goals of therapyGoals of therapy Induce and maintain remission.Induce and maintain remission. Ameliorate symptomsAmeliorate symptoms Improve pts quality of lifeImprove pts quality of life Adequate nutritionAdequate nutrition Prevent complication of both the Prevent complication of both the

disease and medicationsdisease and medications

5-Aminosalicylic Acids5-Aminosalicylic Acids

The mainstay treatment of mild to moderately active UC and CD (induction).

5-ASA may act by blocking the production of prostaglandins

and leukotrienes, inhibiting bacterial peptide–induced

neutrophil chemotaxis and adenosine-induced secretion,

scavenging reactive oxygen metabolites

5-Aminosalicylic Acids5-Aminosalicylic Acids

For patients with distal colonic disease, a suppository or enema form will be most appropriate.

Maintenance treatment with a 5-aminosalicylic acid can be effective for sustaining remission in ulcerative colitis but is of questionable value in Crohn's disease.

Corticosteroids

Topical corticosteroids can be used as an alternative to 5-ASA in ulcerative proctitis or distal UC.

Oral prednisone or prednisolone is used for moderately severe UC or CD, in doses ranging up to 60 mg per day.

IV is warranted for patients who are sufficiently ill to require hospitalization; the majority will have a response within 7 to 10 days.

CorticosteroidsCorticosteroids

No proven maintenance benefit in No proven maintenance benefit in the treatment of either UC or CD. the treatment of either UC or CD.

Many and serious side effects. Many and serious side effects. Budesonide: Budesonide:

less side effects, less side effects, its use is limited to patients with distal its use is limited to patients with distal

ileal and right-sided colonic diseaseileal and right-sided colonic disease

Immunosuppressive Agents

These agents are generally appropriate for patients in whom the dose of corticosteroids cannot be tapered or discontinued.

Azathioprine & 6-MP The most extensively used immunosuppressive agents. The mechanisms of action unknown but may include

suppressing the generation of a specific subgroup of T cells. The onset of benefit takes several weeks up to six The onset of benefit takes several weeks up to six

months.months. Dose-related BM suppression is uniformly observedDose-related BM suppression is uniformly observed

Immunosuppressive Agents

MethotrexateMethotrexate Effective in steroid-dependent active Effective in steroid-dependent active

CD and in maintaining remission.CD and in maintaining remission. CyclosporineCyclosporine

Severe UC not responding to IV steroid Severe UC not responding to IV steroid &need urgent proctocolectomy.&need urgent proctocolectomy.

50% of the responders will need 50% of the responders will need surgery within a year.surgery within a year.

Anti-TNF Therapy Anti-TNF Therapy

It is a chimeric monoclonal antibody, binds soluble TNF.

Infleximab, Adalimumab (Humira) and Certolizumab

Prompt onset, effects takes 6weeks to max of 6m.

Indicated in fistulising crohns, moderate to severe CD

Infleximab also indicated in severe ulcerative colitis

Side effects They are safe and usually tolerable Acute infusion reactions, which may include

chest tightness, dyspnea, rash, and hypotension. Delayed hypersensitivity reactions, consisting of

severe polyarthralgia, myalgia, facial edema, urticaria, or rash, are an unusual complication occurring from 3 to 12 days

after an infusion.

Side effectsSide effects

Increase risk of infections including exacerbations of abdominal abscess or increasing upper respiratory infections.

Reactivation of tuberculosis has been observed and has resulted in disseminated disease and death.

INDICATIONS FOR SURGERYINDICATIONS FOR SURGERY

In patients with UC:In patients with UC: Severe attacks that fail to respond to medical therapy. Severe attacks that fail to respond to medical therapy. Complications of a severe attack (e.g., perforation, Complications of a severe attack (e.g., perforation,

acute dilatation). acute dilatation). Chronic continuous disease with an impaired quality Chronic continuous disease with an impaired quality

of life. of life. Dysplasia or carcinoma.Dysplasia or carcinoma.

In patients with CDIn patients with CD Obstruction, severe perianal disease unresponsive to Obstruction, severe perianal disease unresponsive to

medical therapy, difficult fistulas, major bleeding, medical therapy, difficult fistulas, major bleeding, severe disabilitysevere disability

30 % relapse rate30 % relapse rate

IBD Sequelae IBD Sequelae UC:UC:

Risk of cancer begins after 8 years, risk of Risk of cancer begins after 8 years, risk of pancolitis 7% at 20 years and 17% at 30 pancolitis 7% at 20 years and 17% at 30 years.years.

Increased risk: early age of onset, pancolitis.Increased risk: early age of onset, pancolitis. Need for colonoscopic screening after 8 yearsNeed for colonoscopic screening after 8 years

CD:CD: True incidence of cancer is uncertain, but True incidence of cancer is uncertain, but

could be as high as UCcould be as high as UC Need the same screening policy.Need the same screening policy.

IBD conclusionIBD conclusion

It is a chronic disordersIt is a chronic disorders Need to exclude other possibilitiesNeed to exclude other possibilities Need to differentiate between the Need to differentiate between the

twotwo Need long term management with Need long term management with

primary goal to induce then maintain primary goal to induce then maintain remission and prevent complications remission and prevent complications of both the disease and drugs.of both the disease and drugs.