inflammatory bowel disease

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    11-May-2015

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  • 1.Inflammatory Bowel Disease Dr. Rahul Arora

2. Inflammatory bowel disease (IBD) is an immune-mediated chronic intestinal condition. Ulcerative colitis (UC) and Crohn's disease (CD) are the two major types of IBD. Inflammatory Bowel Disease Introduction 3. Etiology and Pathogenesis A consensus hypothesis is that in genetically predisposed individuals, both exogenous factors (e.g., normal luminal flora and multiple pathogens like Salmonella sp., Shigella sp., Campylobacter sp., Clostridium difficile ) and host factors (e.g., intestinal epithelial cell barrier function, innate and adaptive immune function) cause a chronic state of dysregulated mucosal immune function that is further modified by specific environmental factors (e.g., smoking and psychosocial factors). 4. Defective Immune Regulation in IBD In normals, tolerance may be responsible for the lack of immune responsiveness to dietary antigens and the commensal flora in the intestinal lumen. In IBD this suppression of inflammation is altered, leading to uncontrolled inflammation. The mechanisms of this regulated immune suppression are incompletely known. During the course of infections in the normal host, full activation of the gut-associated lymphoid tissue occurs but is rapidly superseded by dampening the immune response and tissue repair. In IBD this process may not be regulated normally. 5. The Inflammatory Cascade in IBD Inflammatory cytokines, such as IL-1, IL-6, and TNF, have diverse effects on tissues. They promote fibrogenesis, collagen production, activation of tissue metalloproteinases, and the production of other inflammatory mediators. 6. Clinical Presentation Inflammatory bowel disease 7. Mild Moderate Severe Bowel movements 6 per day Blood in stool Small Moderate Severe Fever None 37.5C mean Tachycardia None 90 mean pulse Anemia Mild >75% 75% Sedimentation rate 30 mm Endoscopic appearance Erythema, decreased vascular pattern, fine granularity Marked erythema, coarse granularity, absent vascular markings, contact bleeding, no ulcerations Spontaneous bleeding, ulcerations Ulcerative Colitis: Disease Presentation 8. Different Clinical, Endoscopic, and Radiographic Features 9. Ulcerative Colitis Crohn's Disease Clinical Gross blood in stool Yes Occasionally Mucus Yes Occasionally Systemic symptoms Occasionally Frequently Pain Occasionally Frequently Abdominal mass Rarely Yes Significant perineal disease No Frequently Fistulas No Yes Small-intestinal obstruction No Frequently Colonic obstruction Rarely Frequently Response to antibiotics No Yes Recurrence after surgery No Yes ANCA-positive Frequently Rarely ASCA-positive Rarely Frequently 10. Endoscopic Rectal sparing Rarely Frequently Continuous disease Yes Occasionally "Cobblestoning" No Yes Granuloma on biopsy No Occasionally Radiographic Small bowel significantly abnormal No Yes Abnormal terminal ileum Occasionally Yes Segmental colitis No Yes Asymmetric colitis No Yes Stricture Occasionally Frequently 11. Infectious Etiologies Bacterial Salmonella Shigella Toxigenic Escherichia coli Campylobacter Yersinia Clostridium difficile Gonorrhea Chlamydia trachomatis Mycobacterial Tuberculosis Mycobacterium avium Parasitic Amebiasis Isospora Hookworm Viral Cytomegalovirus Herpes simplex HIV Fungal Histoplasmosis Candida Aspergillus Diseases that Mimic IBD 12. Noninfectious Etiologies Inflammatory Diversion colitis Collagenous/lymphocytic colitis Ischemic colitis Radiation colitis/enteritis Solitary rectal ulcer syndrome Eosinophilc gastroenteritis Neutropenic colitis Behet's syndrome Graft-versus-host disease Neoplastic Lymphoma Metastatic carcinoma Carcinoma of the ileum Carcinoid Familial polyposis Drugs and Chemicals NSAIDs Phosphasoda Cathartic colon Gold Oral contraceptives Cocaine Chemotherapy 13. IBD is associated with variety of extraintestinal manifestation. Almost one-third of the patients have at least one. 14. Extraintestinal manifestation Dermatologic 1. Erythema nodosum occurs in up to 15% of CD patients and 10% of UC patients The lesions of EN are hot, red, tender nodules measuring to 5cm in diameter and are found on the anterior surface of the legs, ankles, calves, thighs and arms 2. Pyoderma gangrenosum (PG) seen in 1 to 12% of UC patients and is less common in CD colitis. may occur years before the onset of bowel symptoms. Lesions are common on the dorsal surface of the feet and legs but may occur on the arms, chest and even face. 15. pyoderma vegetans, pyostomatitis vegetans, Sweet's syndrome, and metastatic CD. Psoriasis affects 510% of patients with IBD and is unrelated to bowel activity. Perianal skin tags are found in 7580% of patients with CD, especially those with colon involvement. Oral mucosal lesions, seen often in CD and rarely in UC, include aphthous stomatitis and "cobblestone" lesions of the buccal mucosa. Other Dermatologic Manifestations: 16. Extraintestinal manifestation Rheumatologic Peripherial arthritis developes in 15 to 20% of IBD patients, is more common in CD. It is asymmetric, polyarticular and migratory. Most often affects large joints of the upper and lower extremities Ankylosing spondylosis (AS) occurs in 10% of IBD. Sacroilitis is symetrical, occurs equally in UC and CD, often asymptomatic 17. Extraintestinal manifestation Ocular The incidence of ocular complications in IBM patients is 1 to 10% The most common is conjunctivitis, anterior uveitis, episcleritis Symptoms include: ocular pain, photophobia, blurred vision, headache 18. Extraintestinal manifestation Urologic The most frequent genitourinary complications are: calculi, ureteral obstruction, fistulas The highest frequency of nephrolithiasis (10-20%) occurs in patients with CD. Hepatobiliary Cholelithiasis Primary Sclerosing Cholangitis (PSC) 19. Metabolic bone disorder Patients with IBD have an increased prevelance of osteoporosis secondary to vitamin D deficiency, calcium malabsorption, malnutrition, corticosteroid use. Thromboembolic Disorders venous and arterial thrombosis Other Disorders More common cardiopulmonary manifestations include endocarditis, myocarditis, pleuropericarditis and interstitial lung disease. secondary or reactive amyloidosis. Pancreatitis 20. Management of Ulcerative Colitis Acute to induce remission 1. oral +- topical 5-ASA 2. +- oral corticosteroids eg 40mg prednisolone 3. Azathioprine (Chronic active) 4. iv steroids/Colectomy/ cyclosporin (severe) Maintaining remission 1. oral +- topical 5-ASA 2. +- Azathioprine (frequent relapses) 21. Management of Crohns Disease Acute to induce remission 1. oral high dose5-ASA 2. +- oral corticosteroids 3. Azathioprine (Chronic active) 4. Methotrexate (intolerant of azathioprine) 5. iv steroids/ metronidazole/elemental diet/surgery/infliximab Maintaining remission 1. Smoking cessation 2. oral 5-ASA limited role 3. +- Azathioprine (frequent relapses) 4. Methotrexate (intolerant of azathioprine) 5. Infliximab infusions (8 weekly) 22. Inflammatory Bowel Disease Nursing care Report Sign/Symptoms of patients Provide emotional support Skin care Record frequency of stools and type Monitor bowel sounds Vitals and I/O Watch for dehydration Monitor Hydration & Electrolytes Weigh daily Dietary consult Watch for complications If OR, follow routine 23. Oral 5-ASA Preparation Preparation Formulation Delivery Dosing Per Day Azo-bond Sulfasalazine (500 mg) (Azulfadine) Sulfapyridine-5-ASA Colon 36 g (acute) 24 g (maintenance) Olsalazine (250 mg) (Dipentum) 5-ASA-5-ASA Colon 13 g Balsalazide (750 mg) (Colazal) Aminobenzoyl- alanine-5-ASA Colon 6.759 g Delayed-Release Mesalamine (400, 800 mg) (Asacol) Eudragit S (pH 7) Distal ileum-colon2.44.8 g (acute) 1.64.8 g (maintenance) Claversal/Mesasal/Salofalk (250, 500 mg) Eudragit L (pH 6) Ileum-colon 1.53 g (acute) 1.53 g (maintenance) Sustained-Release 24. DRUGS DOSAGE CORTICOSTEROIDS Prednisone 4060 mg/day Budesonide 9 mg/day, then tapered IMMUNOSUPPRESANTS Azathioprine 2.03.0 mg/kg per day 6- Mercaptopurin e 1.01.5 mg/kg per day(oral) Methotrexate 25 mg/week per orally Cyclosporin 24 mg/kg per day intravenously 25. THANK YOU 26. Differential diagnosis of painful defecation Colonic/rectal disorders: 1. Infectious agent (bacterial, viral, parasitic) 2. Constipation 3. Colitis or proctitis (inflammation of the colon / rectum). 4. Cancer or polyp 5. Foreign bodies Perineal(around the anus) disorders: 1. Anal sac abscess or cancer 2. Perineal hernia Abdominal cavity masses Pelvic masses or fractures Prostate disorders 27. However, in an IBD patient, the normal flora is likely perceived as if it were a pathogen. Anaerobic organisms, particularly Bacteroides and Clostridia species, and some aerobic species such as Escherichia may be responsible for the induction of inflammation. Psychosocial factors can contribute to worsening of symptoms. Exogenous Factors 28. Colonic pseudopolyps 29. DRUGS USED IN IBD 1. Prednisone is usually started at doses of 4060 mg/d for active UC that is unresponsive to 5-ASA therapy. 2. Budesonide is used for 23 months at a dose of 9 mg/d, then tapered. 3. Azathioprine (2.03.0 mg/kg per day) 4. 6-MP (1.01.5 mg/kg per day) 5. MTX (25 mg/week) is effective in inducing remission and reducing glucocorticoid dosage; 15 mg/week is effective in maintaining remission in active CD. 6. Cyclosporin is most effective given at 24