CHRONIC

INFLAMMATORY
DISORDES
OF THE BOWEL
 IBD- ETIOLOGY

 IBD: ulcerative colitis and Crohn’s

 Etiology ? obscure: separated

diseases or different facets of the
same disease
 IBD- ETIOLOGY

 Chronic inflammation of the bowel

wall- diarrhea

 Dietary factors, infective agents and

autoimmunity- proposed in the
etiology of IBD.
 ULCERATIVE COLITIS
ACUTE INFLAMMATORY ATTACK

 Loose blood-stained stools streaked

with mucus
 Severe diarrhea- 20 loose stools/day
 The urge to defecate is the worst sy.
 Dehydration, electrolyte disturbances
 Anemia due to blood loss
 Progressive dilatation- paralytic colon
 TOXIC MEGACOLON
 High fever, tachycardia, hypotension
 Dehydration, severe anemia

 Plain abdo.X ray- colon diameter>6

cm. indicates imminent perforation

 Instant barium enema- if diagnosis is

in doubt, colonoscopy is CI.

 Severe distension- perforation- fecal

peritonitis
EMERGENCY TOTAL COLECTOMY
 ULCERATIVE COLITIS
CLINICAL FEATURES
 Intestinal symptoms
• Diarrhea with blood, mucus and pus
• Abdominal pain, tenesmus, cramps
• Tenderness mostly in the LIF
 Extraintestinal symptoms
• Anemia, fever, weight loss
• Arthritis, erythema nodosum, eye sy.
 Concomitant diseases
• Primary sclerosing cholangitis
• Secondary amyloidosis
• Ankylosing spondylitis
 CLINICAL SEVERITY OF THE
ATTACK- UC
 Mild attack
• Mild diarrhea < 4/day, blood and mucus
• No fever, no tachycardia, no anemia
 Moderate attack
• 5-8 motions/day
 Severe attack
• > 8 motions/day
• Blood loss- anemia, hb.< 10g/dl
• Fever, tachycardia
 PLAIN ABDO-X RAY
GROSSLY DISTENDED COLON
TOXIC MEGACOLON
TOXIC MEGACOLON
BARIUM ENEMA- ULCERATIVE
COLITIS: the haustral pattern is
lost, irregular mucosa thickening
and deep ulcers
BARIUM ENEMA- UC : stenosis
of the ascending and transverse
colon, lost of haustral pattern
BARIUM ENEMA-UC: narrowed
bowel, haustral pattern lost,
mucosa irregularly thickened and
ill-defined
 TOXIC MEGACOLON
INTRAOPERATIVE VIEW
 ULCERATIVE COLITIS
MULTIPLE BLEEDING ULCERS
 UC- red mucosa, the tendancy for
the inflammed tissue to throw itself
up into inflammatory pseudopolyps
 TOTAL COLECTOMY DONE FOR
CLINICALLY SEVERE INTRACTABLE
CHRONIC ULCERATIVE COLITIS-
MULTIPLE INFLAMMATORY
PSEUDOPOLYPS
 Laboratory findings
ulcerative colitis
 Disease activity
• ESR,WBC, HB, Total protein
• Orosomucoid, C-reactive protein
 Deficiencies
• Albumin
• Hb. Iron, electrolyte abnormalities
 Exclusion of infectious causes
• Stool culture
• Mucosa biopsy
 ULCERATIVE COLITIS
COMPLICATIONS
 PERFORATION AND PERITONITIS
 TOXIC MEGACOLON
 RESISTANCE TO MEDICAL THERAPY
 DEVELOPMENT OF COLORECTAL
CANCER:
• LONG STANDING UC>10 YEARS
• INVOLVEMENT OF THE WHOLE COLON
• PRESENCE OF SEVERE DYSPLASIA
 ULCERATIVE COLITIS
RADIOLOGICAL FINDINGS

 Diffuse granularity of mucosa

 Deep and undermining ulcers
 Loss of normal haustral pattern
 Tubular appearance
 Pseudopolyps
 ENDOSCOPY
ULCERATIVE COLITIS
 Acute attack
• Diffuse erythema
• Granularity and friability of the mucosa
• Hemorrhage, mucus, pus
• Shallow, confluent ulceration
• Pseudopolyps
 Inactive stage
• Pale, red atrophic mucosa
• Sporadic pseudopolyps
 SIGMOIDOSCOPIC GRADING OF
MUCOSAL APPEARANCES IN U C
 Grade I- normal mucosa
 Grade II- hyperemic mucosa
 Grade III- bleeding on light contact
or spontaneously
 Grade IV- severe change with an
excess of mucus, pus, mucosal
hemorrhage and ulcers
 ULCERATIVE COLITIS
MANAGEMENT
 The choice of treatment depends on:

• The severity of attacks

• The amount of colon involved

• The extent of chronic symptoms

• The risk of long-term complications

 ULCERATIVE COLITIS
TREATMENT
 Local corticosteroids preparations
 Systemic corticosteroids
 Oral sulphasalazine
 Anti-diarrheal agents: codeine
phosphate or loperamide and bulking
agents, methylcelulose- reduce stool
frequency
 High protein diet, oral iron drugs
 Surgical removal
 MEDICAL THERAPY OF THE
ACUTE ATTACK- U C
 Mild attack
• Mesalazina(5-ASA) 2g/day, pills/sup.
 Moderate attack
• PDN 60mg/day, 5-ASA
 Severe attack
• IV nutrition, fluids, blood transfusion
• IV steroids
• 5-ASA
• Broad spectrum antibiotics
 ULCERATIVE COLITIS
SURGERY
 Required in 20% of pts. with UC
 Fulminant cases- urgent colectomy
• Toxic megacolon
• Hemorrhage
• Perforation
 Malignant change
 Chronic disabling symptoms:
• Intractable diarrhea with urgency,
• Failure to maintain adequate nutrition
 ULCERATIVE COLITIS
SURGERY

 Proctocolectomy with ileostomy

 Colectomy+ ileo-rectal anastomosis
• Need for long-life annual endoscopic
examination of the remnant rectum
 Total colectomy, mucosal
proctectomy, ileoanal anastomosis
 CROHN’S DISEASE
 Chronic relapsing inflammatory
disease of the GI tract
 Potentially affects any part of the
tract, usually affects the small bowel
 Terminal ileum is most commonly
affected- terminal ileitis
 May affect one or more GI segments
with intervening parts completely
spared
 CROHN’S DISEASE

 Large bowel is affected in at least

25% of cases, either alone or in
association with disease elsewhere
 May affect the perineal region
 With each exacerbation, old or new
areas may become involved
 PATHOPHYSIOLOGY
CROHN’S DISEASE
 Inflammation extends diffusely
through the entire thickness of the
bowel wall.
 The wall becomes grossly thickened
by inflammatory edema
 The epithelium remains largely intact
but is criss-crossed by deep fissured
ulcers- “cobblestone” surface
appearance
 PATHOPHYSIOLOGY
CROHN’S DISEASE

 Granulomas containing multinucleate

giant cells are scattered througout
the inflammed bowel wall
 Granulomas are diagnostic feature
 Longstanding inflammation leads to
progressive fibrosis of the thickened
bowel wall- elongated strictures
 EFFECTS OF MUCOSAL
INFLAMMATION

 Diarrhea streaked with mucus and

blood if the colon is involved
 Luminal narrowing- partial
obstruction- grumbling and colicky
abdominal pain
 Pain is the predominant feature in
Crohn’s disease
 BARIUM FOLLOW THROUGH
SMOOTH NARROWING OF THE
TERMINAL ILEUM
CROHN’S DISEASE
CROHN’S DISEASE
COLONIC CROHN’S DISEASE
ENDOSCOPIC VIEW
COLONIC CROHN’S DISEASE
COBBLESTONING
 EFFECTS OF MUCOSAL
INFLAMMATION

 Extensive disease- malabsorbtion:

protein malnutrition, iron and folate
vit.B12 deficiency, anemia and
diarrhea
 In kids- marked growth retardation
 Diminished recirculation of bile salts-
gall stone formation
 EFFECTS OF TRANSMURAL
INFLAMMATION
 Transmural inflammation may
progress to surrounding structures
 Inflammation of parietal peritoneum-
localized peritonitis
 Tough, fibrotic postinflammatory
adhesions
 Localized abscess formation- free
perforation is rare
 EFFECTS OF TRANSMURAL
INFLAMMATION

 Fistulas may develop:

• Gastro-colic fistula- fecal vomiting
• Ileo-rectal fistula- diarrhea
• Entero-vesical fistula- severe UTI,
pneumaturia
• Entero-vaginal fistula- vaginal passage of
feces
• Entero-cutaneous fistula
 BARIUM ENEMA
COLO-INTESTINAL
CROHN’S FISTULA
 PERIANAL INFLAMMATION
 Common in Crohn’s disease

 Recurrent perianal abscesses

 Characteristic bluish, boggy piles

 Anal fissures
PERIANAL CROHN’S
DISEASE
 SYSTEMIC FEATURES

 Non-gastrointestinal manifestations:
• Arthropathy
• Eye disorders
• Skin lesions
EXTRADIGESTIVE SIGNS- IBD
 PERIANAL INFLAMMATION

 Multiple fistulae commonly develop

between rectum and perianal skin-
“pepper pot” perineum
 Paradoxically, this is more common
associated with small bowel disease
than colorectal disease
 CLINICAL PICTURE
 Abdominal pain
 Weight loss
 General malaise
 Diarrhea is less distressing and less
likely to contain blood
 Generalized wasting and anemia
 Tenderness, inflammatory mass,
scars from previous surgery
 CLINICAL PICTURE

 Perineal and rectal examination

 Rectoscopy
 DIFFERENTIAL DIAGNOSIS
ULCERATIVE COLITIS

 Infectious colitis: salmonella,

shigella, clostridium difficile
 Crohn’s disease of the colon
 Ischemic colitis
 Radiation colitis
 Malignancy of the colon
APPROACH TO INVESTIGATION

 USS of the abdomen

 Isotope scan. indium-labelled WBC
 Barium enema
 Barium follow-through
 Videocapsule endoscope
 CROHN’S DISEASE
MANAGEMENT
 Corticosteroids
 Metronidazol- perianal disease
 Elemental diets
 TPN with complete bowel rest
 Sulphasalazine
 Anti-diarrheal drugs
 CROHN’S DISEASE
SURGICAL MANAGEMENT
 INDICATIONS:
• Acute exacerbation unresponsive to
steroids
• Acute complications:abscess,
perforation, major hemorrhage
• Intolerable long-term symptoms
• Entero-cutaneous or internal fistulas
 CROHN’S DISEASE
SURGICAL MANAGEMENT

 Resection of the diseased segment

 Panproctocolectomy with ileostomy

 Abscess drainage with resection

 Fistulectomies