Inflammatory Bowel Disease

Dr. Rahul Arora

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 DiseaseIntroduction

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).

Defective Immune Regulation in IBDIn 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course of infections in the normal host, full activation of the gut-associated lymphoid tissue occurs but is rapidly superseded by dampening the immune response and tissue repair.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.

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.

Clinical PresentationInflammatory bowel disease

Mild Moderate Severe

Bowel movements <4 per day 4–6 per day >6 per day

Blood in stool Small Moderate Severe

Fever None <37.5°C mean >37.5°C mean

Tachycardia None <90 mean pulse >90 mean pulse

Anemia Mild >75% 75%

Sedimentation rate <30 mm >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

Different Clinical, Endoscopic, and Radiographic Features

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

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

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

Noninfectious Etiologies

Inflammatory

Diversion colitis

Collagenous/lymphocytic colitis

Ischemic colitis

Radiation colitis/enteritis

Solitary rectal ulcer syndrome

Eosinophilc gastroenteritis

Neutropenic colitis

Beçhet'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

IBD is associated with variety of extraintestinal manifestation.

Almost one-third of the patients have at least one.

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.

pyoderma vegetans, pyostomatitis vegetans, Sweet's syndrome, and metastatic CD.

Psoriasis affects 5–10% of patients with IBD and is unrelated to bowel activity.

Perianal skin tags are found in 75–80% 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:

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

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

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.

HepatobiliaryCholelithiasis Primary Sclerosing Cholangitis (PSC)

Metabolic bone disorderPatients 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 DisordersMore common cardiopulmonary manifestations include endocarditis, myocarditis, pleuropericarditis and interstitial lung disease. secondary or reactive amyloidosis. Pancreatitis

Management of Ulcerative Colitis Acute to induce remission1. oral +- topical 5-ASA2. +- oral corticosteroids eg 40mg prednisolone3. Azathioprine (Chronic active)4. iv steroids/Colectomy/ cyclosporin (severe) Maintaining remission1. oral +- topical 5-ASA2. +- Azathioprine (frequent relapses)

Management of Crohn’s Disease

Acute to induce remission1. oral high dose5-ASA2. +- oral corticosteroids 3. Azathioprine (Chronic active)4. Methotrexate (intolerant of azathioprine)5. iv steroids/ metronidazole/elemental

diet/surgery/infliximab Maintaining remission1. Smoking cessation2. oral 5-ASA limited role3. +- Azathioprine (frequent relapses)4. Methotrexate (intolerant of azathioprine)5. Infliximab infusions (8 weekly)

Inflammatory Bowel DiseaseNursing care

Report Sign/Symptoms of patients

Provide emotional support

Skin careRecord frequency of

stools and typeMonitor bowel

soundsVitals and I/O

Watch for dehydration

Monitor Hydration & Electrolytes

Weigh dailyDietary consultWatch for

complicationsIf OR, follow

routine

Oral 5-ASA PreparationPreparation Formulation Delivery Dosing Per Day

Azo-bondSulfasalazine (500 mg) (Azulfadine)

Sulfapyridine-5-ASA

Colon 3–6 g (acute)2–4 g (maintenance)

Olsalazine (250 mg) (Dipentum)

5-ASA-5-ASA Colon 1–3 g

Balsalazide (750 mg) (Colazal)Aminobenzoyl-alanine-5-ASA

Colon 6.75–9 g

Delayed-ReleaseMesalamine (400, 800 mg) (Asacol)

Eudragit S (pH 7) Distal ileum-colon

2.4–4.8 g (acute)1.6–4.8 g (maintenance)

Claversal/Mesasal/Salofalk (250, 500 mg)

Eudragit L (pH 6) Ileum-colon 1.5–3 g (acute)1.5–3 g (maintenance)

Sustained-Release

DRUGS DOSAGE

CORTICOSTEROIDSPrednisone 40–60 mg/day

Budesonide 9 mg/day, then tapered

IMMUNOSUPPRESANTSAzathioprine 2.0–3.0 mg/kg per day

6-Mercaptopurine

1.0–1.5 mg/kg per day(oral)

Methotrexate

25 mg/week per orally

Cyclosporin 2–4 mg/kg per day intravenously

Infliximab(Anti-TNF Antibody)

5 mg/kg per day intravenously

THANK YOU

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

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

Colonic pseudopolyps

DRUGS USED IN IBD1. Prednisone is usually started at doses

of 40–60 mg/d for active UC that is unresponsive to 5-ASA therapy.

2. Budesonide is used for 2–3 months at a dose of 9 mg/d, then tapered.

3. Azathioprine (2.0–3.0 mg/kg per day) 4. 6-MP (1.0–1.5 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 2–4 mg/kg per day intravenously in severe UC

7. intravenous infliximab (5 mg/kg)