Colon

dr Putra Hendra SpPD

UNIBA
1. Irritable Bowel Syndrome
(IBS)
2. Inflammatory Bowel
Disease(IBD)
3. Diverticulitis
Irritable Bowel Syndrome
 Functional Disorders
Functional disorders
structural nomal
biochemical normal

Several functional gastrointestinal disorders

Functional dyspepsia
Irritable bowel syndrome (IBS)
Functional abdominal pain
Abdominal migraine
Aerophagia

4
PATHOGENESIS OF FUNCTIONAL
BOWEL DISEASE

5
Summary

6
 Irritable Bowel Syndrome

Abdominal pain sewaktu defecation dan

membaik setelah defecation
Feses encer dan lebih sering waktu sakit
Merasa belum semua keluar
Mucus per rectum
Visible abdominal distention (bloating)
Labs and sigmoidoscopy negative
 Irritable Bowel Syndrome
Treatment
Reduce stress
Drug therapy
Constipation - bulking agent (psyllium),
lactulose/milk of magnesia
Diarrhea - bulking agent, loperamide,
cholestyramine
Bloating - simethicone (OTC)
Pain/cramping - dicyclomine/Bentyl, Donnatal,
hyoscyamine/Levsin
Diet therapy - eat fiber!
 Diverticular Disease
Diverticulosis

Herniation of the mucosal lining of the

intestine through a defect in the muscular
layer of the intestine
 Diverticular Disease
Diverticulosis
Characteristic findings on radiologic or
endoscopic exam
No fever or leukocytosis
Possibly some intermittent left lower quadrant
pain
Usually asymptomatic
Eat more fiber!!!
Diverticular Disease
 Diverticular Disease
Diverticulitis
Acute abdominal pain
Constipation or bowel irregularity
LLQ tenderness and possible mass
Fever and leukocytosis
Characteristic radiographic signs
Diverticulosis
 Diverticular Disease
Diverticulitis - Treatment
Antibiotics
Liquid diet or NPO
Can be managed as an outpatient in mild
cases
NG tube if obstructed
10-20% of patients have a recurrence
Surgery is an option in appropriate cases
Diverticulitis
Inflammatory Bowel Disease
IBD
Inflammatory Bowel Disease
Two major types of IBD
Crohns disease
Incidence - 5 per 100,000 persons
Prevalence - 90 per 100,000 persons
Ulcerative colitis
Incidence - 10 per 100,000 persons
Prevalence - 200 per 100,000 persons
Inflammatory Bowel Disease
Etiology - not clearl.
genetic predisposition
environmental exposures.
Crohns Disease - affects mouth to anus
melibatkan transmural
Ulcerative colitis terbatas di colon hanya
melibatkan mucosal
 Aetiology & Pathogenesis
The aetiology of Crohns disease is unknown. There are many proposed
pathogenic mechanisms, some of which are represented in this diagram.

Genetic Environmental
susceptibility factors

Host
Immune
Response

Crohns Disease

As there is no one cause, it is likely that Crohns disease is an outcome of

interactions between genetic predisposition, environmental factors and the
subsequent reaction of the host immune system.
 Environmental Factors
A wide range of environmental factors have been
Environmental
factors found to play a role:

Smoking Patients with CD are more likely to have been smokers and smoking
may worsen CD and increase the risk of relapse/surgical intervention.

Diet Active CD may improve when a normal diet is changed to a liquid

formula diet.

Bacterial infection There is some evidence implicating E. coli, M.

paratuberculosis, the measles virus and L. monocytogenes in the pathogenesis of
CD. This data is controversial and requires further research to clarify.

Drugs the oral contraceptive pill has been linked epidemiologically with CD.
Relapse may be precipitated by NSAIDs.
 Immune response
Host Both the potential genetics underlying CD and the
Immune
Response
environmental and host factors surrounding the patient
may be considered as initiating factors for CD, but the
exact aetiology is unknown.

What is known is that mucosal immunity is dysregulated in CD leading to a

prolonged inflammatory response in the gut.

In CD, a dominant CD4 Th1 reaction is induced. The mechanisms for this are
displayed diagrammatically on the next page.
 Epidemiology

World wide distribution Incidence: 7/100 000

but more common in pop/yr
the West.

The incidence is lower in

Females are non-white races.
affected more Epidemiology
than males
1.2:1 Jews are more affected
than non-Jews

Bimodal age distribution:

20-40 yrs/60-80 yrs The incidence is rising

Prevalence: 100/100 000 pop/yr

 Epidemiology
Crohns disease (CD) is a chronic relapsing inflammatory condition
usually with flare-ups alternating with periods of remission, and an
increasing disease severity and incidence of complications as
time goes on.

It can affect any part of the gastrointestinal tract from the mouth to the anus.
For typical sites & proportion of patients affected see below:

Extensive Small Terminal Ileum

Bowel 5% only 20%

Ileocaecal 45% Colon only 25%

Other: anorectal,
gastroduodenual, oral only
5%
 Crohns Disease
Symptoms
Right lower quadrant pain and diarrhea,
biasanya intermittent
Hematochezia (sebagian kecil penderita)
Low fever and weight loss also possible
High fever and pain may be indicative of a
complication, e.g., perirectal abscess.
 Crohns Disease
Signs
Abdominal pain , especially RLQ
Palpable mass in RLQ is possible
Rectal exam may reveal a perirectal mass
Abdominal distention
Peritoneal signs in patients who have
fistulized or ruptured.
 Crohns Disease
Complications
Fistula formation - up to 40% of patients
Enteroenteric
Enterovesicular - recurrent UTIs and pneumaturia
Enterocutaneous - rectovaginal, fistula-in-ano
Perforation/abscess formation
Stricture/ small bowel obstruction
Cancer
Nutritional deficiencies
 Diagnosis
Radiology and imaging

Barium follow-through
Colonoscopy, terminal ileoscopy findings consistent
& biopsy: These allow direct with Crohns include
visualisation and allows for a an asymmetrical
biopsy of the mucosa to be alteration in mucosal
taken. This is central to pattern with deep
macroscopic and microscopic ulceration and areas of
diagnosis. narrowing or
stricturing.

Ultrasound & CT
scanning: Can help
define thickness of the
bowel and mesentery
and can be useful to
evaluate disease
progress & chart
fistula formation.
 Diagnosis of IBD

Crohn's disease with the characteristic patchy erythema (left

panel) and ulceration (right panel) that occur next to areas of
normal mucosa. Courtesy of James B McGee, MD. From Uptodate
2007
 Crohns Disease
Tablet Enteroscopy
Swallow a small pill that is a video recorder.
Records a video image of the small bowel.
Transmits an image to a video receiver that
then visualizes the small bowel.
 Crohns Disease
Lab findings - generally nonspecific
ESR usually elevated
Anemia - both low iron from anemia of chronic
disease and low B12 secondary to ileal
involvement or resection
Leukocytosis
thrombocytosis
Hypoalbuminemia
 Lab Findings
p-ANCA Antiglycan
antibodies

Crohns Positive in 15% Positive in 75%

Disease

Ulcerative Positive in 85% Positive in 5%

Colitis
 Crohns Disease
Classic findings
Skip lesions - Crohns does not affect the
intestinal mucosa in a continuous fashion
Cobblestoning owing to mucosal fissures
Luminal narrowing/strictures - string sign
Fistulas
Aphthous ulcers
Angular Cheilitis
Aphthous Ulcers
Figure 1 Image of a fissure in ano suspicious for squamous cell carcinoma in a 56-
year-old female patient with ileocolic Crohn's disease

Galandiuk S and Davis BR (2008) Infliximab-induced disseminated histoplasmosis in a patient with Crohn's
disease
Nat Clin Pract Gastroenterol Hepatol doi:10.1038/ncpgasthep1119
Crohns Disease
 Crohns Disease
Differential diagnosis:
Colonic disease - infectious
Bacterial colitis - Salmonella, Shigella,
Campylobacter
Ameba (Amoeba if youre British)
CMV
Colonic disease noninfectiousUlcerative
Colitis, radiation, ischemia
Acute appendicitis with RLQ pain
Ectopic pregnancy, tubo-ovarian
 Intestinal Complications
Anal and perianal complications
Fissure in ano or fistula in ano
Haemorrhoids
Skin tags
Perianal or ischiorectal abscess
Anorectal fistulae

Undernutrition
Caused by reduced food intake, malabsorption, increased protein loss from
inflamed bowel and the increased metabolic demands of being sick.

Short bowel syndrome

Develops when extensive bowel resection leads to excessive malabsorption
of fluids, electrolytes and nutrients.

Cancer
With Crohns colitis, there is a increased risk of colorectal carcinoma
There is an small increased risk of rarer small intestinal and anal cancers
occurring in cites of prolonged inflammation.
 Extra-intestinal complications
There are many systemic associations and complications of CD, most affecting the
liver and biliary tree, joints, skin and eyes:

Sclerosing Cholangitis occurs in a small

proportion of patients. The pathogenesis is
unknown and the condition is characterised by
an inflammatory obliterative fibrosis of the
biliary tree (the white in the diagram->). It
progresses slowly and a liver transplant is the
only cure.

Ankylosing spondylitis affects about 5% of patients

with Crohns colitis. The patient presents with back
pain and stiffness and the diagnosis can come years
before the CD.
 Extra-intestinal complications
Erythema nodosum occurs in ~8% of Crohns
colitis patients when disease is active. Hot, red
tender nodules appear on the arms and legs and
subside after a few days.

Pyoderma gangrenosum occurs in ~2% of CD

patients, starting as a small pustule, then
developing into a painful, enlarging ulcer, most
commonly on the leg.

In addition to these conditions, other complications and associations include

episcleritis and uveitis (occuring in 5% of patients with active disease), osteoporosis
(as a consequence of chronic inflammation, malabsortion and treatment with
corticosteroids) and arthropathy.
 Medical management
Dietary advice and nutritional support including vitamin supplementation to
counter-act any deficiencies that develop.

Diarrhoea can be controlled by anti-diarrhoeals such as loperamide, codeine

phosphate or co-phenotrope. If the diarrhoea is due to bile acid malabsorption,
then this can be treated with colestyramine.

Likely to be beneficial in inducing remission:

Corticosteroids (oral)
Aminosalicylates
(azathioprine/mercaptopurine trade off between benefits and harms)
Methotrexate
Infliximab

Likely to maintain remission:

Smoking cessation
(Unknown if the following are effective: enteral nutrition, fish oil, probiotics)

The BNF information about the drugs on this page can be seen HERE
 Surgical management
Surgery is indicated for perforation or haemorrhage (emergency) or for small-bowel
obstruction, Crohn's colitis, abscess (intra-abdo and perianal), fistulas and
inflammation unresponsive to medical therapy.

Approximately 80% of patients with CD will require surgery at some point.

The principle of surgery is to conserve as much bowel as possible as 60% of

patients need further surgery.

Surgery is not curative.

In small bowel CD resection is likely to be beneficial whereby discrete sections are

removed and an end-to-end anastomosis created. The benefits of strictureplasty to
widen a narrowed lumen are unknown at this time.

In colonic CD segmental and subtotal colectomy is likely

to be beneficial. In a segmental colectomy the part of the
colon affected is removed and an end-to-end anastomosis
created in remaining colon and in a subtotal colectomy the
ileum is sewn/stapled to the sigmoid colon as seen in diagram.
 Prognosis
Mortality
The cumulative mortality is approximately twice that of the general population.
Death is primarily due to sepsis, pulmonary embolism and complications of the
surgery or immunosuppressive agents used as treatments.

Morbidity
The pattern of CD is a lifelong duration with periods of active disease alternating
with periods of remission. The disease causes significant disability with only 75% of
patients being fully capable of work in the first year of disease and 15% of patients
unable to work after 5-10years of the disease.

People with CD are also more at risk of developing certain cancers and other
complications as mentioned under the clinical features section of this module.
Ulcerative Colitis
 Ulcerative Colitis
Symptoms
Bloody diarrhea
Crampy abdominal pain
Tenesmus - urgent feeling of needing to
evacuate to the rectum.
Fever, weight loss also possible
15-25% have extra-intestinal manifestations
 Ulcerative Colitis
Signs
LLQ pain - mild to severe
Can be very ill in patients with toxic
megacolon: fever, tachycardia, orthostasis
 Ulcerative Colitis
Lab Findings - as in Crohns, nonspecific
ESR usually elevated in active disease
Mild anemia
Leukocytosis
Thrombocytosis (acute phase reactant)
Stool studies negative (culture, C.diff toxin,
O&P)
 Ulcerative Colitis
Imaging Studies
As disease affects the rectum and extends
proximally, flexible sigmoidoscopy/endoscopy
can be the definitive study. This allows for
direct visualization and biopsy sampling.
Contrast radiography/ACBE may show
mucosal changes and distal ulcers.
Classic long-standing finding is the lead pipe
colon.
Lead pipe colon
Ulcerative Colitis
Ulcerative Colitis
Ulcerative Colitis
 Ulcerative Colitis
Differential Diagnosis
Infection: Campylobacter, Shigella,
Salmonella, Yersinia, E. coli 0157:H7,
amebiasis, Clostridium difficile
Noninfectious: Crohns disease, ischemic
colitis, radiation colitis
Immunocompromised host: CMV, HSV, GC,
Blastocystis hominis, Chlamydia
 Ulcerative Colitis
Complications
Toxic Megacolon: 15-50% mortality
Perforation
Cancer: increasing risk of dysplasia with
increased time from onset of disease.
Time from onset: 20 30
Risk of cancer 5-13% 13-34%
 Ulcerative Colitis
Prognosis
Severity of disease is somewhat predictive of the
future course and the need for colectomy.
In one study, the colectomy rate was 24% at 10 years
and 30% at 25 years.
Rate of colectomy is much higher in patients with
pancolitis. Those with isolated ulcerative proctitis
have essentially the same cancer risk as the baseline
population.
Of note, total colectomy is 100% curative!
 Summary
Ulcerative Colitis Crohns
Clinical findings
Perianal Disease Rare Common (1/3 pts)
Fistulas Rare Common (up to
40%)
Abscess Rare 20%
Stricture Rare Common
Colonoscopy findings
Rectal involvement Always Usually spared
Pattern Continuous from rectum Skip lesions
Radiologic findings
Ileal involvement Rare, backwash ileitis 75%
Histologic findings
Depth of inflammation Mucosa to submucosa Transmural
Granulomas Uncommon 20% of biopsies
 IBD - Rx
Education
Support groups
Psychologic therapy as indicated
Oral sulfa drugs for IBD
 IBD - Rx
Corticosteroids - extremely useful for
treating acute flares and in maintaining
remission in moderate to severe disease.
Start Solu-medrol at 125mg IV q6hr, then
switch to po Prednisone at 40-60mg qD.
Taper over 8-12 weeks if possible.
 IBD - Rx
Immunosuppressive drugs
Azathioprine and 6-Mercaptopurine
Purine analogs that may inhibit T cell function
Infliximab (Remicade )and other TNF
inhibitors
Tumor Necrosis Factor (TNF)
Antibiotics - acute treatment
metronidazole/Flagyl - covers anaerobic
bacteria. Especially useful in perirectal
disease.
 Corticosteroids
Side Effects
Cushingoid Psychosis
appearance Aseptic necrosis of
Osteoporosis bone/hip
Hypertension Neuropathy
Diabetes Myopathy
Peptic ulcer
Extra-intestinal Manifestations
of IBD
Reactive arthropathy - present with active
disease
Episcleritis - seen more commonly in
Crohns disease
Erythema Nodosum - Crohns > UC
Pyoderma Gangrenosum - UC > Crohns
Extra-intestinal Manifestations
of IBD
Sacroiliitis - 10% patients with IBD.
Association with HLA-B27
Scleritis and uveitis
Primary sclerosing cholangitis - usually
with UC
Erythema
Nodosum
Pyoderma Gangrenosum