Inflammatory Bowel Disease

Macad, Ceffrian Juriel E.

Medical Clerk
Southwestern University-PHINMA
Inflammatory Bowel Disease
IBS- is a chronic idiopathic inflammatory disease of the GIT

2 major Types:
Ulcerative Colitis
Chron’s Disease
 Epidemiology
• Affect >2 M individuals in
North America
• India and China had the
highest IBD incidences in
Asia.
 Ulcerative Colitis
Macroscopic Features
• Mild Inflammation: Erythematous
mucosa with a fine granular surface
(sandpaper-like).
• Severe Disease: Hemorrhagic,
edematous, and ulcerated mucosa.
• Long-standing Disease: May present
with inflammatory polyps
(pseudopolyps) from epithelial
regeneration
Remission and Long-term Changes:
•Mucosa may appear normal during
remission.
•Long-term disease may lead to
atrophic, featureless mucosa and
narrowing/shortening of the colon.
Ulcerative Colitis Vascular and Inflammatory Changes:
•Mucosal vascular congestion with
Microscopic Features edema and focal hemorrhage.
Major Histologic Features: •Inflammatory cell infiltrate includes
•Distorted Crypt Architecture: neutrophils, lymphocytes, plasma
• Crypts may be bifid and reduced in cells, and macrophages.
number. •Leads to cryptitis and may progress
• Gaps between crypt bases and the to crypt abscesses.
muscularis mucosae are often Ileal Changes in Backwash Ileitis:
observed.
•Villous atrophy and crypt
•Chronicity Indicators: regeneration.
• Presence of basal plasma cells and
multiple basal lymphoid •Increased inflammation with
aggregates. neutrophils and mononuclear cells in
the lamina propria.
•Patchy cryptitis and crypt abscesses,
with neutrophils invading the
epithelium, particularly in the crypts.
 Endoscopic Features:
Crohn’s Disease •Mild disease: Aphthous or small
superficial ulcerations.
• Can involve any part from the mouth •Active disease: Stellate ulcerations that
to the anus. fuse, creating islands of normal mucosa.
• Unlike ulcerative colitis (UC), the •Characteristic "cobblestone" appearance
rectum is often spared in CD. visible endoscopically and on barium
• Characterized by segmental radiography.
involvement and skip areas Perianal Disease:
throughout the intestines. •Present in one-third of patients,
• Unlike UC, CD affects all layers of the manifesting as:
bowel wall. • Perirectal fistulas
• Fissures
• Abscesses
• Anal stenosis
 •Lymphoid Aggregates:
Crohn’s Disease •Submucosal or subserosal lymphoid aggregates,
especially away from ulcerated areas.
Early Lesions:
•Skip Areas:
•Characterized by aphthoid
•Presence of gross and microscopic skip areas
ulcerations and focal crypt
throughout the bowel.
abscesses.
•Transmural Inflammation:
Granulomas:
•Accompanied by deep fissures penetrating the
•Formed by loose aggregations of
bowel wall.
macrophages.
•May lead to the formation of fistulous tracts or
•Noncaseating granulomas are a
local abscesses.
hallmark of CD.
•More commonly found in surgical
resection specimens than in
mucosal biopsies.
Clinical Presentation: Ulcerative Colitis
• Major Symptoms: • Symptoms with Disease Extension:
• Diarrhea • Blood is usually mixed with stool or presents
• Rectal bleeding as grossly bloody diarrhea.
• Rapid transit through the inflamed intestine
• Tenesmus (urgency and feeling of may occur.
incomplete evacuation)
• Severe disease may result in liquid stools
• Passage of mucus containing blood, pus, and fecal matter.
• Crampy abdominal pain • Diarrhea often occurs nocturnally and/or
postprandially
• Proctitis Symptoms:
• Fresh blood or blood-stained mucus, • Physical Examination Findings:
either mixed with stool or streaked • Proctitis: Tender anal canal and blood on
on the surface. rectal examination.
• Tenesmus is common; abdominal • More extensive disease: Tenderness over the
pain is rare. colon upon palpation.
• Proximal transit slows, leading to • Toxic colitis: Severe pain and bleeding.
constipation in distal disease. • Megacolon: Hepatic tympany; may show signs
of peritonitis if perforation occurs.
Laboratory , Endoscopic, and Radiographic Features : UC
•Laboratory Findings: •Endoscopic Findings:
• Acute-Phase Reactants: • Mild Disease: Erythema,
• Rise in C-reactive protein (CRP), decreased vascular pattern,
platelet count, and erythrocyte
sedimentation rate (ESR). mild friability.
• Decrease in hemoglobin. • Moderate Disease: Marked
• Fecal Markers: erythema, absent vascular
• Fecal Lactoferrin: Sensitive and pattern, friability, erosions.
specific for detecting intestinal • Severe Disease: Spontaneous
inflammation. bleeding and ulcerations.
• Fecal Calprotectin: Correlates
with histologic inflammation,
predicts relapses, and detects
pouchitis.
• The Montreal classification helps
in the standardized assessment
of UC.
• It defines both the extent
(location) and severity (symptom
burden) of the disease.
• Useful for guiding treatment
decisions and monitoring disease
progression.
• Important for clinical trials and
research studies to ensure
consistent terminology.
Complications: Ulcerative Colitis
• Toxic Megacolon:
• Defined as a transverse or right colon diameter of >6 cm with loss of
haustration in severe UC attacks
• Perforation:
• Most dangerous local complication; physical signs of peritonitis may be
subtle, especially in patients on glucocorticoids.
• Strictures:
• Benign strictures can arise from inflammation and fibrosis.
• Strictures that are impassable with a colonoscope should be presumed
malignant until proven otherwise.
• Such strictures indicate the need for surgery.
• Perianal Issues:
• Patients may develop anal fissures, perianal abscesses, or hemorrhoids.
• Extensive perianal lesions should raise suspicion for Crohn's disease (CD)
rather than UC.
 Signs and Symptoms of Crohn’s Disease
• Ileocolitis:
• Common site: terminal ileum
• Symptoms: chronic right lower
quadrant pain, diarrhea, may mimic
appendicitis
• Pain: colicky, relieved by defecation;
low-grade fever common
• Weight loss: typically 10–20% due to
diarrhea and anorexia
• Radiographic "string sign": indicates
narrowed bowel
• Bowel obstruction: can be
intermittent or chronic
• Fistula formation possible (e.g.,
enterovesical, enterocutaneous)
 Signs and Symptoms of Crohn’s Disease
• Jejunoileitis:
• Leads to malabsorption and
steatorrhea • Gastroduodenal Disease:
• Nutritional deficiencies: anemia, • Symptoms: nausea, vomiting,
hypoalbuminemia, etc. epigastric pain
• Need for intravenous iron and • Usually involves second part of
supplementation of various vitamins
and minerals duodenum
• Possible chronic gastric outlet
• Colitis and Perianal Disease: obstruction in advanced cases
• Symptoms: low-grade fevers, malaise,
diarrhea, crampy abdominal pain,
hematochezia
• Risk of strictures and bowel obstruction
• Possible fistulas affecting other organs
• Perianal disease: incontinence,
hemorrhoids, anal strictures, abscesse
Laboratory, Endoscopic, and Radiographic Features of Crohn’s Disease

•Laboratory Findings: • Endoscopic Features:

• Elevated ESR and CRP levels • Notable characteristics:
• Severe disease may show: • Rectal sparing
• Hypoalbuminemia • Aphthous ulcerations
• Anemia • Fistulas
• Leukocytosis • Skip lesions
• Fecal calprotectin and lactoferrin • Colonoscopy allows:
used to differentiate IBD from IBS
and assess CD activity • Examination and biopsy of
lesions and strictures
• Fecal calprotectin is more • Dilation of strictures (more
sensitive for ileocolonic/colonic effective for fibrotic
inflammation strictures)
• Radiographic Findings:
• Early small bowel changes:
• Thickened folds
• Aphthous ulcerations
• Cobblestoning

• Advanced disease may show:

• Strictures
• Fistulas
• Inflammatory masses
• Abscesses
• Macroscopic findings in colonic
CD:Multiple small ulcers (aphthous)
• Enlargement and deepening of ulcers
over time
•Imaging Techniques:
• CT enterography and MR
enterography: equally accurate for
identifying small-bowel inflammation
• Small-bowel ultrasound (SBUS):At
least as sensitive as MR and CT
enterography
• High sensitivity (94%) and specificity
(97%)
• Oral contrast can enhance detection
to 100%
• Best for distal small-bowel
assessment; limited by operator skill
and availability
 Crohn’s Disease: Complications
• Perforation:
• Transmural Process:
• Occurs in 1–2% of patients, primarily in the
ileum. • Leads to serosal adhesions that facilitate fistula
formation.
• Can also happen in the jejunum or due to toxic • Reduces incidence of free perforation.
megacolon.
• Peritonitis from free perforation, especially in
the colon, may be fatal. • Increased Risks:
• Systemic glucocorticoid therapy raises the risk
• Abscess Formation: of intraabdominal and pelvic abscesses,
• Intraabdominal and pelvic abscesses occur in especially in patients without prior surgery.
10–30% of patients. • Other Complications:
• Standard treatment: CT-guided percutaneous • Intestinal obstruction (40% of patients).
drainage. • Massive hemorrhage.
• Most patients require resection of the affected • Malabsorption.
bowel segment despite drainage. • Severe perianal disease.
• High failure rate for percutaneous drainage of
abdominal wall abscesses.
Treatment
• 5-ASA Agents
• Glucocorticoids
• Antibiotics
• Azathioprine and Mercaptopurine
• Tacrolimus
• Methotrexate
• Cyclosporine
• Biologic Therapies
 5-ASA agents
• 5-ASA agents are effective in inducing and maintaining remission in
ulcerative colitis (UC).
• Sulfasalazine is effective for mild to moderate UC but has a high rate
of side effects, limiting its use.
• Sulfasalazine can impair folate absorption, so patients should receive folic
acid supplements.
• Balsalazide (an azo-bonded mesalamine) is effective in the colon.
• Lialda is a once-daily formulation designed for colon release using
Multi-Matrix System (MMX) technology.
• Apriso uses extended-release technology (Intellicor), delivering
mesalamine to the terminal ileum and colon with sustained release.
• Pentasa uses ethylcellulose coating to release 5-ASA throughout the
GI tract from the small intestine to the distal colon.
• Salofalk Granu-Stix, an unencapsulated mesalamine formulation, is
used in Europe for UC remission.
Glucocorticoids
• Glucocorticoids are effective for patients with moderate to severe UC who
do not respond to 5-ASA therapy.
• Glucocorticoids induce 60-70% remission in moderate to severe Crohn's disease
(CD)
• Prednisone is commonly started at 40–60 mg/day for active UC.
• Budesonide (Uceris) is a newer glucocorticoid for UC that is colon-targeted
and has minimal glucocorticoid side effects, given at 9 mg/day for 8 weeks
with no taper required.
• Topical glucocorticoids (hydrocortisone enemas or budesonide foam) are
beneficial for distal colitis and can be used as an adjunct for rectal
involvement plus proximal disease.
• Hydrocortisone enemas are absorbed from the rectum and may cause
adrenal suppression with prolonged use.
• Glucocorticoids are not used for maintenance therapy in UC or CD; once
remission is achieved, they should be tapered at a rate of 5–10 mg/week
based on clinical response.
 Azathioprine & Methotrexate
Antibiotics Mercaptopurine
• Antibiotics have no role in • Azathioprine is quickly • Methotrexate (MTX) inhibits
absorbed and converted to dihydrofolate reductase,
the treatment of active or MP, which is metabolized to
thioinosinic acid, an inhibitor impairing DNA synthesis.
quiescent UC. of purine synthesis and cell
proliferation. MTX may have
• UC patients after colectomy • Efficacy of these drugs can be
•
anti-inflammatory properties
and IPAA, usually responds seen within 3-4 weeks, but by reducing IL-1 production.
may take up to 4-6 months.
to treatment with a variety
• Therapeutic monitoring can Dosing:
of antibiotics including be done by measuring
metronidazole and 6-thioguanine and ● Intramuscular (IM) or
6-methylmercaptopurine
ciprofloxacin levels, the end products of MP subcutaneous (SC) doses
metabolism. range from 15-25 mg/week
Recommended doses:
● Azathioprine: 2-3 mg/kg/day
● Mercaptopurine: 1-1.5
mg/kg/day
 Tacrolimus Biologic Agents
Cyclosporine
• Cyclosporine A (CSA) is a • Tacrolimus is a macrolide • Biologic therapy is now
commonly used as an initial
antibiotic with
lipophilic peptide that inhibits treatment for patients with
immunomodulatory properties
both cellular and humoral moderate to severe Crohn’s
similar to CSA but 100 times
immunity, primarily by blocking disease (CD) and ulcerative
more potent. colitis (UC) to prevent future
IL-2 production in T-helper Unlike CSA, tacrolimus does not complications.
lymphocytes. depend on bile or mucosal
• CSA has a faster onset of integrity for absorption, making High-risk UC patients likely to need
it effective in patients with biologics:
action than mercaptopurine
(MP) and azathioprine. proximal small-bowel Crohn’s ● Moderate to severe disease.
• It is most effective in severe disease. ● Steroid-dependent or
steroid-refractory disease.
ulcerative colitis (UC) refractory
Tacrolimus is used for: ● Refractory pouchitis.
to IV glucocorticoids, with 82%
response when given at 2-4 ● Children with refractory IBD. High-risk CD patients likely to need
● Adults with extensive biologics:
mg/kg/day IV
• CSA can be an alternative to small-bowel involvement. ● Under 30 years old.
colectomy. ● Adults with ● Extensive disease, perianal
glucocorticoid-dependent or or severe rectal disease,
• CSA levels should be maintained
refractory UC and CD, and deep ulcerations in the
between 150–350 ng/mL. colon.
refractory fistulizing CD.
● Stricturing or penetrating
disease behavior
Nutrition Therapy
Exclusive Enteral Nutrition (EEN):
● Effective for inducing remission in active Crohn's disease (CD), comparable to glucocorticoids.
● Not as effective for maintaining remission.
Total Parenteral Nutrition (TPN): An alternative to bowel rest for managing active CD.
Ulcerative Colitis (UC): Active UC does not respond well to elemental diets or TPN.
Dietary Maintenance for CD:
● Adapted from epidemiologic studies, but research outcomes show significant variability.
● Associations found with low fiber, refined carbohydrates, animal fats, red meat, and processed
meat linked to IBD onset.
Dietary Recommendations:
● Emphasize maximizing fiber intake from fruits and vegetables.
● Limit higher-risk foods.