IBD

• Inflammatory Bowel Disease

  A general term for a group of immune-mediated, determinate genetic chronic inflammatory disorders of unknown etiology involving the gastrointestinal tract
• Major groups of Inflammatory Bowel Disease

  • Ulcerative colitis (UC)
  • Crohn's disease (CD)
  • Indeterminate colitis
• Ulcerative Colitis (UC)


  • Inflammatory changes involving the colonic mucosa and submucosa in a continuous fashion, starting always at the rectum and extending proximally
• Crohn's Disease (CD)


  • Transmural inflammation of any segment of the GIT in a discontinuous fashion (skip lesions)
• The peak age of onset of UC and CD is between 15 and 30 years. A second peak occurs between the ages of 60 and 80
• The male to female ratio for UC and for CD is ≈ 1 : 1
• Urban areas have a higher prevalence of IBD than rural areas
• High socioeconomic classes have a higher prevalence than lower socioeconomic classes
• IBD runs in families. If a patient has IBD, the lifetime risk that a first-degree relative will be affected is ~10%
• Why did IBD emerge in developed nations only in the middle of the 20th century?
• Why did it emerge initially as ulcerative colitis but now Crohn's disease has become the predominate form of IBD in developed nations?
• Why is IBD emerging in recent years in developing nations and why is it that ulcerative colitis is the predominate form in these countries?
• Why does smoking cause worse course of disease in CD and is as "protector" factor in UC?
• Why incidence is more often in the medium with high income, high hygienic level?
• "Hygiene" hypothesis


  Posits that the reduction in access to transmissible intestinal microorganisms (i.e. living in a cleaner environment) has reduced the ability of the immune system to become tolerant to these and other such organisms, and hence when it encounters these organism later in life it develops aberrant responses
• "Lifestyle Westernization" Hypothesis


  Changes in the lifestyle in Eastern Europe and Asia during the last two decades have resulted in a more "westernized" standard way of living. "Westernization" of lifestyle means: life rhythm acceleration; increased consumption of refined sugar, fatty acids, hydrolyzed fats (fast food), cereals and bread and reduced consumption of natural products, fruit, vegetables and fibers; increased stress load; increased administration of medicines
• Undoubtedly, the environment has an important role in IBD
• Pathogenetic factors of IBD

  • Genetic factors
  • Immune factors
  • Microbial agents
  • Environmental factors
• Pattern of Disease Onset

  • Acute severe
  • Moderate
  • Mild
• Remission


  Complete resolution of symptoms and endoscopic mucosal healing
• Relapse


  A flare of symptoms in a patient with established UC who is in clinical remission, either spontaneously or after medical treatment
• Evolution of UC


  • With infrequent relapses (≤1/year)
  • With frequent relapses (≥2 relapses/year)
  • Continuous (persistent symptoms of active UC without a period of remission)
• Distribution of Ulcerative Colitis

  • E1 Proctitis (Involvement limited to the rectum)
  • E2 Left-sided (Involvement limited to the proportion of the colon distal to the splenic flexure)
  • E3 Extensive (Involvement extends proximal to the splenic flexure, including pancolitis)
• Disease Activity in UC (adapted from Truelove and Witts')

  • Mild
  • Moderate
  • Severe
• Intestinal Clinical Features of UC

  • Bloody diarrhea (often nocturnal and/or postprandial)
  • Rectal bleeding
  • Urgency and frequent trips to the toilet
  • Predefecational cramps
• Systemic Clinical Features of UC

  • Malaise
  • Anorexia
  • Weight Loss
  • Fever
  • Anemia
  • Symptoms of dehydration
• Extraintestinal Manifestations of UC

  • Musculoskeletal (Arthritis, Sacroiliitis, Ankylosing spondylitis)
  • Skin (Aphthous ulcerative stomatitis, Erythema nodosum, Pyoderma gangrenosum)
  • Ocular (Episcleritis, Uveitis)
• Common Complications of UC include Massive bleeding, Perforation with peritonitis, Toxic dilatation of the colon (toxic megacolon), Malignization, Severe anemia, Sepsis
• Physical Examination in UC

  • General well-being, pulse rate, blood pressure, body temperature, body weight and height, abdominal examination for distention and tenderness, perineal inspection, digital rectal examination, oral inspection, and check for eye, skin and/or joint involvement
• Endoscopic Findings in UC

  • Continuous lesions from rectum (always) to proximal parts of colon (only), Diffuse erythema, Loss of mucosal vascularity, Friability of the mucosa, Superficial ulcerations, Exudate consisting of mucus, blood, pus, Pseudopolyps
• Laboratory Tests for UC

  • Full blood count, serum urea, creatinine, electrolytes, liver enzymes, iron studies, C-reactive protein (CRP), Erythrocyte sedimentation rate (ESR), Microbiological testing for infectious diarrhea including Clostridium difficile toxin, Faecal inflammatory markers like calprotectin
• Differential Diagnosis for UC

  • Infectious colitis (Salmonella, Shigella, Campylobacter jejuni, Yersinia enterocolitica, Clostridium difficile, Chlamydia)
  • Tuberculosis
  • Ischemic colitis
  • Radiation enteritis
  • Drug induced enterocolitis
  • Diverticulitis
  • Appendicitis
  • Colon cancer
  • Lymphoma
• Crohn's Disease (CD)


  • Transmural inflammation of any segment of the GIT in a discontinuous fashion (skip lesions)
• Montreal Classification of CD

  • Localization (L1 - ileum, L2 - colon, L3 - ileocolon, L4 - upper segment of GIT)
  • Evolution forms (B1 - without stenosis or penetration, B2 - with stenosis, B3 - with penetration, B1(or 2 or 3) p - with perianal affectation)
• Clinical Features of CD

  • Abdominal pain
  • Fever
  • Weight loss
  • Palpable inflammatory mass in abdomen
  • Perianal disease: anal fissures, abscess, fistula
  • Nonbloody diarrhea
• Extraintestinal Manifestations of CD

  • Musculoskeletal (Arthritis, Sacroiliitis, Ankylosing spondylitis)
  • Skin (Aphthous ulcerative stomatitis, Erythema nodosum, Pyoderma gangrenosum)
  • Ocular (Episcleritis, Uveitis)
• Common Complications of IBD

  • Intestinal strictures and obstruction
  • Fistulization
  • Abdominal abscess
  • Cancer
  • Severe extraintestinal manifestation
  • Osteoporosis
  • Malignization
• Endoscopic Findings in CD

  • Skip lesions of any segment of the GIT, Aphthoid ulcerations, Deep linear ulcers which with segments of edematous or uninvolved mucosa lead to the characteristic pattern called "Cobblestone", Strictures, Fistulas
• UC and CD Treatment

  • Aminosalicylates (oral, rectal: Sulfasalazine, Mesalamine)
  • Corticosteroids (local, systemic)
  • Immunosuppressive agents (azathioprine etc.)
  • Biotherapy (infliximab, adalimumab etc.)
• Recommendations for Management of Mild-Moderate Distal Colitis

  • Oral aminosalicylates, topical mesalamine, or topical steroids
  • Topical mesalamine agents are superior to topical steroids or oral aminosalicylates
  • Combination of oral and topical aminosalicylates is more effective than either alone
  • Mesalamine enemas or suppositories may be effective in patients refractory to oral aminosalicylates or topical corticosteroids
  • Oral prednisone or infliximab may be required for unusual patients refractory to other agents