Transcript Inflammatory Bowel Disease [PPT]

Inflammatory Bowel Disease
Professor Ravi Kant
FRCS (England), FRCS (Edin), FRCS (Glasg),FRCS (Irel),
FAMS, MS, DNB, FACS, FICS
Professor of Surgery
Professor Ravi Kant
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Fellow Mayo Clinic, USA
Fellow NCI Milan, Italy
Fellow Univ. College of London (UCL), UK
Fellow NCI, Tokyo, Japan
Award of Excellence by Govt. of Delhi 1995
Award: Japan Surgical Society (1992)
Award: American Society of Lasers 1991
Award by Association of Surgeons of India
Professor Ravi Kant
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Professor since 1995
Faculty member since 1984
Post graduation: 1981
WHO Fellow
Commonwealth Fellow
Married to Bina since 1982
Daughter Tina, dentist in USA, married.
Inflammatory bowel disease
1932
• Crohn BB, Ginzburg L, Oppenheimer GD
"Regional ileitis: a pathologic and clinical
entity. 1932". Mt. Sinai J. Med. 67 (3):
263–8. PMID 10828911
Ulcerative colitis
Site Almost always involves
Rectum (95%) &
Descending colon / Sigmoid
A/-
Crohn's disease
(regional ileitis)
Any where in GIT,
Commonest in ILEUM
Rectum often spared
Unknown
Unknown, ? vasculitis
10 Siblings= 15 X
Smoking 3 X 
10 Siblings= 15 X
Mucosal immunological Auto-immune
Weakened mucosal
TH receptor
barrier
Defective mucosal
? Variant of TB
metabolism of butyrates
A/-
UC
? TB
? Mycobacterium Para Avian
Tuberculosis (PAT) (Johne’s
disease in Cattle)
=Variant of TB
(Naser 2005 IBD)
Mannose =Yeast antigenantibody reaction
?
Yeast
Cure
CD = Crohn's disease
(regional ileitis)
√
X
A/-
UC
▼Sulphite
reducing
bacteria
Cure
√
CD = Crohn's disease
(regional ileitis)
Listeria monocytogenes
Paramyxovirus,
Measles virus
X
H2S (Hydrogen Sulfide) theory
Roediger WE, Moore J, Babidge W
(1997). "Colonic sulfide in pathogenesis and
treatment of ulcerative colitis". Dig. Dis.
Sci. 42 (8): 1571-9.
doi:10.1023/A:1018851723920. PMID 9286
219.
Levine J, Ellis CJ, Furne JK, Springfield J,
Levitt MD (1998). "Fecal hydrogen sulfide
production in ulcerative colitis". Am. J.
Gastroenterol. 93 (1): 83– 7.
doi:10.1111/j.1572-
UC
CD = Crohn's disease
(regional ileitis)
Isotretinoin (Accutane)
1. Reddy D, Siegel CA, Sands BE, Kane S (2006). "Possible
association between isotretinoin and inflammatory bowel
disease". The American journal of gastroenterology 101 (7):
1569–73.
2. Borobio E, Arín A, Valcayo A, Iñarrairaegui M, Nantes O,
Prieto C (2004). "[Isotretinoin and ulcerous colitis]" (in
Spanish; Castilian). An Sist Sanit Navar 27 (2): 241–3.
3. Reniers DE, Howard JM (2001). "Isotretinoin-induced
inflammatory bowel disease in an adolescent". Ann
Pharmacother 35 (10): 1214
Etiology
Ulcerative colitis
Crohn's disease
(regional ileitis)
Chromosome 6
Chromosome 16 IBD
1 locus= NOD2 gene
16, 12, 6, 14, 5,
19, 1,and 3
OCTN1 and
OCTN2.
40X incidence
when allele
variants of NOD 2
gene on both
chromosomes
MAGUK
family
NOD gene in Crohn’
(Ogura 2000 in Nature)
NOD Gene & Crohn’s
• Ogura. Nature 2000 (411): 603-6.
• Cuthbert A. Gastroenterology 2002
• Kaser. Cell 2008
Crohn’s (Am GI Asso)
Transmural
Colon
involvement in
Crohn’s
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
Crohn's disease
-Inflammation involve
only the mucosa
involved
full
thickness of bowel wall
-
involving the serosa
-Cobble stone
-superficial ulceration
-Exudation
pseudopolyposis
-
-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
Clinical
feature
-Watery or bloody
diarrhea
-Rectal discharge
of mucus
-Proctitis
-Lt sided & total
colitis
Crohn’s disease
-Chronic diarrhea
-Abdominal pain
-Food fear
wt loss
-pyrexia
-RIF pain (??
Appendicitis)
-as abdominal mass
-acute intestinal
obstruction
-multiple perianal
fissures, fistula &
abscess
Pseudopolyps in UC
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
Clinical
feature
Fat wrappings
(creeping
mesentry)
TH
Receptor
TH1
(Cytokine
response
)
TH 2
TH 17
Elson 2007:
Gastroenterology
Ulcerative colitis
Extracolonic
manifest
ation
Crohn’s disease
(regional ileitis)
1-Arthritis.
2-skin disorder-
1-Peripheral
Arthritis,
erythema nodosum, Ankylosing
spondylitis,
pyoderma Sacro-ilitis
gangrenosum.
2-skin conditionerythemanodosum,
pyoderma
gangrenosum.
Pyoderma gangrenosum
EIM
Extraintesti
nal
manife
station
Ulcerative colitis
Crohn’s disease
3- Eye diseaseIritis
4-Bile duct cancer
5-Sclerosing
cholangitis (5%)
6-Hepatic disease
7-UrologyNephrolithiasis
3- Eye diseaseIritis
4-Bile duct cancer
5-Sclerosing
cholangitis (0.4%)
6-Hepatic disease
Primary Sclerosing Cholangitis
in UC
• 40-60% UC: Primary Sclerosing
Cholangitis
• Colectomy will NOT reverse PSC
• Rx Transplant
• CA @ 20y < N
• Dvorchik J. Hepatology 2002 35:380
Post Colectomy in UC
Reverse
Arthritis
Pyoderma
gangrenosum (+/-)
No change
Primary Sclerosing
Cholangitis
Ankylosing
Spondylitis
Arthritis in UC
• Improves after Colectomy.
• 20 X N
Sacroiliatis & Ankylosing
Spondylitis in UC
• RX of UC- No change in Symptoms
• 20 X N
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
Crohn’s disease
(regional ileitis)
Investig --sigmoidoscopy- -small bowel
ation
enema
=Goligher’s
Criterion (1968)
- Ba Enema
-colonoscopy
-sigmoidoscopy
-biopsy
-colonoscopy
(=Floren’s
-biopsy
Criterion)
N
UC
CD
Ulcerative colitis. Double-contrast
barium enema study shows
pseudopolyposis of the descending
colon
Crohn’s disease
(regional ileitis)
Stricture
Multiple strictures
Abscess
Contrast
• String sign of Kantor
• Sterlien’s sign
• Fleischner’s sign
Imaging
• MRI > CT
• CT enteroclysis
• Capsule endoscopy
• 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)
Inv Ulcerative colitis
Crohn's disease
P-ANCA
ASCA (Saccharomyces
(antineutrophil cerevisiae )
cytoplasmic
Specificity
antibodies
(C- ANCA for
Wegner’s
granulomatosis
)
antilaminaribioside
[ALCA], antichitobioside
(ACCA],
antimannobioside
[AMCA], antiLaminarin
[anti-L] and antichitin
[(anti-C]93][94][95][96]
Peri-nuclear staining
Granular cytoplasmic stain
Rx
Ulcerative colitis
Crohn’s disease
(regional ileitis)
1-sulfasalazine.
2-azithioprine in resistance
cases.
3-steroids:
Topical (Predsol enemas)
Oral(30 – 40mg
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)
70% need Surgery
Ulcerative colitis
Crohn’s
disease
(regional ileitis)
Complicat -Fulminating
-stricture Rx
ion
colitis & toxic
-adhesion Rx
dilatation ( mega
colon)
-perforation
-sever
Iowa hypothesis
• Helminthic therapy using the whipworm Trichuris
suis
• fecal bacteriotherapy
► Th2 white cell response in the diseased area
• Summers RW, Elliott DE, Urban JF, Thompson
RA, Weinstock JV (2005). "Trichuris suis therapy
for active ulcerative colitis: a randomized
controlled trial". Gastroenterology 128 (4): 825–
32
Bristol & Bath hypothesis
• ▲ Immunity
• CB1 & CB 2 receptors (Cannabis)
• Wright K, Rooney N, Feeney M. "Differential
expression of cannabinoid receptors in the
human colon: cannabinoids promote epithelial
wound healing". Gastroenterology 2005 129 (2):
437–53. doi:10.1053
/j.gastro.2005.05.026. PMID 16083701
Vienna Classification of
Crohn’s
• Age at diagnosis1
A1, <40 years
A2, > or = 40 years
• Location2
L1, terminal ileum3
L2, colon4
L3, ileocolon5
L4, upper GI6
• Behaviour
B1, non-constricting nonpenetrating7
B2, stricturing8
B3, penetrating9
Cancer risk in UC
• 3.5%
• 20y=12%
COMPLICATIONS OF IBD
(Exclude extra GI complication which
are regarded as Medical)
Complications of IBD
Principle:
Basically same as any chronic ulceration in GIT;
viz.
1. Bleeding → Massive vs. non-massive
2. Fibrosis → Stenosis
3. Perforation → Peritonitis
4. Penetration → Fistulation
5. Malignant change
ULCERATIVE COLITIS vs CROHN’S DISEASE
A Comparison of Complications
COMPLICATION
U.C.
CROHN’S
1
Bleeding
Usually massive
Usually non-massive
2
‘Fibrosis’
Stenosis
Thick wall
Late
Early Obstruction
Hose pipe appearance common
3
Perforation
Rare 
Common +++
4
Penetration → fistula
Rare 
Common +++
5
Malignant Change
Common +++
Rare 
FISTULA
• Define Fistula
• Define Sinus
DEFINITIONS
• Fistula – abnormal connection between
two epithelial surface
• Sinus abnormal opening onto one
epithelial surface. The deep end is closed
(or blind).
• List 4 types of fistulae in Crohn’s
disease
FISTULAE IN CROHN’S DISEASE
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Entero-CUTANEOUS
Entero-colic
Entero-vesical
Entero-enteric
Entero-uterine
[ Fistula-in-ano]
MODE OF PRESENTATION OF FISTULAE
(CROHN’S DISEASE 1/5)
Basically: 2 types
1. External
2. Internal
[ Rarely, both ]
EXTERNAL FISTULAE
MODE OF PRESENTATION (2/5)
If external, fistula discharge gut content: e.g.
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Gastric
Duodenal
Small bowel
Colon (Faecal fistula)
MODE OF PRESENTATION (3/5) OF
INTERNAL ENTERIC FISTULAE
• List at least two common non-emergency
modes of presentation of Entero-Enteric
(colonic) fistulae
MODE OF PRESENTATION OF ENTEROENTERIC FISTULAE (4/5)
• Diarrhea
• Severe weight loss
•  Fever (=Abscess)
Mechanism:
• By-pass or short circuit
• Bacteria overgrowth
PRINCIPLES OF SURGICAL MANAGEMENT
COMPONENTS OF MANAGEMENT
Phase I
Medical
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Phase II
Surgical
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Phase 3

Both medical
& surgical
Diagnosis Established
 (Differential Diagnosis)
 Initial Rx
Indications for Surgery
 Pre-op Preparations
 Surgical Procedures
 Post-op courses
 Post-op complication
After care or follow-up
INITIAL MANAGEMENT OF IBD
• IBD = “Medical” disorder
• Initial management = MEDICAL
• Dx established
- Endoscopy
- Biopsy
- Barium series
• Initial Rx = MEDICAL
INDICATIONS FOR SURGERY IN IBD
• List any 4 indications for surgery for IBD
INDICATIONS FOR SURGERY IN IBD
= COMPLICATIONS
1. Bleeding
2. Fibrosis = Stenosis = Obstruction
3. Malignant change (esp. Ulcerative Colitis)
4. Penetration = Fistula
5. Penetration = Peritonitis
Abscess
6. Toxic Megacolon
PRE-OP PREPARATION
• List any 4 important features of pre-op
preparation for IBD.
PRE-OP PREPARATION FOR IBD
•
Same for ALL complication
• Same for any chronic GI
condition
esp. if colon is involved
COMPONENTS
TARGET
Alb ≥ 3g%
 Alb ≥ 10g%
1. Nutrition

2. Colon

3. Type & hold
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4. Informed consent

Collapsed & Emphy. Colon
 Antibiotics on-call to OR
PRBC 4 units
 Fresh frozen plasma: 4 units
Colostomy possible
 ICU bed
SURGICAL PROCEDURES FOR IBD
• Depends on
(i) Pathology and
(ii) SITE involved.
• If pus collection → Drain
• Resection often required
• Colostomy (Ileostomy) fashioned when
primary anastomosis contraindicated.
POST OP COMPLICATIONS AFTER
BOWEL RESECTION FOR IBD
• List any 4 major complications relating to
bowel resection for IBD (EXCLUDE
Anesthetic complications)
Vienna Classification : Crohn’s
• Stricturing
• Penetrating
• Inflammatory
Gasche C. Inflammatory Bowel Diseases
2000;6:8-15