Inflammatory Bowel Disease Professor Ravi Kant MS FRCS

Inflammatory Bowel Disease Professor Ravi Kant MS, FRCS (Edin), FRCS (Glasg), FAMS, DNB, FACS, FICS Professor of Surgery

Inflammatory bowel disease

Ulcerative colitis Site Almost always involves Rectum (95%) & Descending colon / Sigmoid A/- Unknown Crohn's disease (regional ileitis) Any where in GIT, Commonest in ILEUM Rectum often spared Unknown, ? vasculitis Smoking 3 X 10 Siblings= 15 X Mucosal immunological Auto-immune Weakened mucosal TH receptor barrier Defective mucosal ? Variant of TB metabolism of butyrates

Ulcerative colitis p. ANCA ASCA CARD 15 gene (also known Crohn's disease (regional ileitis) as the NOD 2 gene) Th 2 cytokine response Th 17 cytokine response opiate receptor antagonist Naltrexone (also L ow-dose naltrexone) TH receptor activation of the CB 1 and CB 2 cannabinoid receptors Defective mucosal ? Variant of TB metabolism of butyrates

Ulcerative colitis Etiology Crohn's disease (regional ileitis) Ankylosing spondylitis Chromosome 16 IBD 1 locus= NOD 2 gene 40 X incidence when allele variants of NOD 2 gene on both chromosomes

Ulcerative colitis Site Almost always involves rectum & Descending colon / Sigmoid Crohn's disease (regional ileitis) Commonest in Ileum 60% Rectum often spared Anal lesions are common

Ulcerative colitis Patho Gross only the mucosa involved - -superficial ulceration -Exudation - pseudopolyposis Crohn's disease -Inflammation involve full thickness of bowel wall involving the serosa -Cobble stone -deep fissured ulcer -LN enlarged -Fistula -Skip areas Micro -Crypt abscess common -Inflammatory polyps -Highly vascular granulation tissue Crypts are reduced in # Crypts appear atrophic= pipe stem Crypt abscess rare Non caseating giant cell granuloma present in 60%

Ulcerative colitis Crohn’s disease Clinical -Watery or bloody -Chronic diarrhea feature diarrhea -Abdominal pain -Rectal discharge -Food fear of mucus wt loss -Proctitis -pyrexia -Lt sided & total -RIF pain (? ? colitis Appendicitis) -as abdominal mass -acute intestinal obstruction -multiple perianal fissures, fistula & abscess

Ulcerative colitis Clinical Toxic megacolon feature Fulminating colitis Perforation Severe hemorrhage Severity Mild Moderate Severe Crohn’s disease Intra-abdominal fistula • Entero-enteric • Entero-cutaneous Complex anal fistula DD TB

Ulcerative colitis Crohn’s disease Fat wrappings TH 2 TH 17 Clinical feature

Ulcerative colitis Extracolonic manifest ation 1 -Arthritis. 2 -skin disordererythema nodosum, pyoderma gangrenosum. Crohn’s disease (regional ileitis) 1 -Peripheral Arthritis, Ankylosing spondylitis, Sacro-ilitis 2 -skin conditionerythemanodosum, pyoderma gangrenosum.

Ulcerative colitis 3 - Eye disease. Iritis Extracolonic 4 -Bile duct cancer manifest 5 -Sclerosing ation cholangitis 6 -Hepatic disease 7 -Urology- Nephrolithiasis Crohn’s disease 3 - Eye disease. Iritis 4 -Bile duct cancer 5 -Sclerosing cholangitis 6 -Hepatic disease

Ulcerative colitis Investig -CBC ation -stool culture -plain film of abdomen -Barium enema -sigmoidoscopy -colonoscopy -biopsy Crohn’s disease (regional ileitis) -small bowel enema - Ba Enema -sigmoidoscopy -colonoscopy -biopsy

Ulcerative colitis. Double-contrast barium enema study shows pseudopolyposis of the descending colon Crohn’s disease (regional ileitis)

Contrast • String sign of Kantor • Sterlien’s sign • Fleischner’s sign

• Endoscopic image of ulcerative colitis affecting the left side of the colon. The image shows confluent superficial ulceration and loss of mucosal architecture Crohn's disease (regional ileitis)

Rx Ulcerative colitis Crohn’s disease (regional ileitis) 1 -sulfasalazine. 2 -azithioprine in resistance cases. 3 -steroids: Topical (Predsol enemas) Oral(30 – 40 mg prednisolone) 4 -high-fiber diet & bulk forming agents as methylcellulose. 1 -Sulfasalazine. 2 -Azithioprine in resistance cases. 3 -Steroids 1 -supplementary diet. 2 -elemental diets 3 -supplement of oral iron. 4 - TPN 6 - Metronidazole/ Antibiotics

Rx Ulcerative colitis Crohn's disease Sulfasalazine INFLIXIMAB=MAB against TNF-α for Internal Fistula Azathioprim Elemental diet, TPN Steroids-Topical Sulfasalazine Steroids-Oral Steroids high-fiber diet & bulk forming agents as methylcellulose Metronidazole.

Rx Ulcerative colitis Surgical: -indication Panproctocolectomy + permanent ileostomy Crohn’s disease (regional ileitis)

Ulcerative colitis Crohn’s disease (regional ileitis) Complicat -Fulminating -stricture Rx ion colitis & toxic -adhesion Rx dilatation ( mega colon) -perforation -sever hemorrhage

Vienna Classification of Crohn’s • Age at diagnosis 1 A 1, <40 years A 2, > or = 40 years • Location 2 L 1, terminal ileum 3 L 2, colon 4 L 3, ileocolon 5 L 4, upper GI 6 • Behaviour B 1, non-constricting nonpenetrating 7 B 2, stricturing 8 B 3, penetrating 9

Cancer risk in UC • 3. 5% • 20 y=12%