Inflammatory Bowel Disease

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• Inflammatory Bowel Disease
• - a clinical perspective

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Crohns Symptoms and signs

• depend on the extent and severity of inflammation
  
• Symptoms
• onset of symptoms is typically insidious
• the clinical course is characterized by recurring
  episodes of symptomatic disease interspersed with
  periods of remission
• Abdominal pain and diarrhoea are the most typical
  symptoms
• Unlike ulcerative colitis, diarrhoea is often
  non-bloody
• Fever and weight loss are common in active
  disease.
• Signs
• abdominal tenderness, most classically in the
  right lower quadrant
• An abdominal mass may be palpable.
• wasting and cachexia indicate significant
  malnutrition
• Typical symptoms of small bowel obstruction eg.
  distension, may be present in stenosing disease
• Perianal and cutaneous fistulae are readily
  identified on a careful perineal and skin
  examination.
• Note involvement of the rectum will bring about
  bloody diarrhoea however this is not considered
  common with the terminal ileum the preferential
  site.

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Ulcerative Colitis- Symptoms and signs

• depend on the extent and severity of inflammation
  
• Signs
• Unlike Crohn disease, ulcerative colitis is
  frequently acute or subacute in onset
• Like Crohn disease, the subsequent clinical
  course is one of recurring episodes of
  symptomatic disease interspersed with episodes of
  relative (or complete) quiescence.
• Overt rectal bleeding and tenesmus are virtually
  universally present and may be the only symptoms
  in patients with proctitis alone
• diarrhoea, cramps, urgency and abdominal pain are
  more frequent complaints.
• Nausea, fever, weight loss indicate severe
  disease.
• Signs
• mild abdominal tenderness, often most localized
  in the hypogastrium or left lower quadrant.
• Digital rectal examination may disclose visible
  red blood.
• As with Crohn disease, signs of malnutrition may
  be evident.
• Severe tenderness, fever, or tachycardia in
  serious disease

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Complications

• CROHNS
• As the inflammation in Crohn disease is typically
  transmural, this frequently leads to
  complications of penetrating and stenosing
  disease, including perforation, abscess,
  fistulae, and obstruction
• Active small bowel disease or extensive small
  bowel resection may lead to malabsorption
• Deficiencies in iron, folate, vitamin B12, and
  fat-soluble vitamins (A, D, E, and K) are common,
  with resulting complications including anaemia
  and osteoporosis
• Because Crohn disease has a predilection for the
  ileum, bile salt reabsorption is frequently
  compromised ? bile-saltinduced diarrhoea
  (responsive to bile-acid sequestrants), fat
  maldigestion and steatorrhea
• Extensive small bowel disease or resection can
  also lead to short gut syndrome, with
  protein-calorie and micronutrient deficiency and
  dependence on parenteral nutrition
• Malabsorption of fatty acids ? renal calculi.
  Calcium readily binds unabsorbed fatty acids,
  allowing oxalate to be taken up by the bowel in
  greater quantity. Subsequent renal excretion of
  this excess oxalate promotes the precipitation of
  calcium oxalate calculi.
• Increased risk of colorectal cancer,
  adenocarcinomas of stomach and cholangiocarcinoma
• UC
• Severe haemorrhage is more common
• Toxic megacolon with subsequent infarction and
  perforation while still uncommon, is more likely
• Risk of colorectal cancer (CRC) is significantly
  increased (also slightly increased in Crohns)
• IBD may also cause extraintestinal complications
• The diagnosis of PSC may precede or follow that
  of IBD symptoms and signs may arise years after
  colectomy.
• Of the dermatologic considerations, erythema
  nodosum is most common. Pyoderma gangrenosum is
  rarer and more worrisome.
• Uveitis is of special concern, as it can lead to
  blindness if untreated. Patients with eye pain,
  redness, and visual disturbance require urgent
  ophthalmologic evaluation (mainly associated with
  colonic)

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Extraintestinal Signs
Table 33. Common extraintestinal manifestations of inflammatory bowel disease.


System or Site  Manifestation 
Hepatobiliary Primary sclerosing cholangitis
Hepatobiliary Cholangiocarcinoma
Hepatobiliary Gallstones
Dermatologic Erythema nodosum
Dermatologic Pyoderma gangrenosum
Dermatologic Sweet syndrome
Oral Aphthous ulceration
Ocular Episcleritis
Ocular Uveitis/iritis
Musculoskeletal Enteropathic arthropathy
Musculoskeletal Sacroiliitis
Musculoskeletal Ankylosing spondylitis
Musculoskeletal Osteopenia/osteoporosis
Hematologic Thromboembolic disease
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Prognosis

• relapsing illnesses
• 75 of patients with Crohn disease can expect to
  have surgery over the course of the illness
• The majority of patients with ulcerative colitis
  can be managed using medical therapy with the
  prospect of surgery reaching 25

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• No single symptom, physical finding, or test
  result can diagnose IBD. The diagnosis of both
  Crohn disease and ulcerative colitis is a
  clinical one, based on compatible patient
  history physical examination and laboratory,
  radiographic, endoscopic, and histological
  findings. 

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Quiz
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Obstruction

• 1. a) Name the major causes of intestinal
  obstruction? AND
• b) What are the clinical manifestations of
  intestinal obstruction?

10

• Collectively, hernias, intestinal adhesions,
  intussusception, and volvulus account for 80 of
  mechanical obstructions
• tumors and infarction account for only about 10
  to 15 of small bowel obstructions.
• The clinical manifestations of intestinal
  obstruction include abdominal pain and
  distention, vomiting, and constipation

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Congenital

• 2 a) What is the underlying abnormality in
  Hirschsprung's disease? AND
• b) How does it present?

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• a distal intestinal segment that lacks both the
  Meissner submucosal and the Auerbach myenteric
  plexus ("aganglionosis")
• Coordinated peristaltic contractions are absent
  and functional obstruction occurs, resulting in
  dilation proximal to the affected segment.
• Patients typically present neonatally, often with
  a failure to pass meconium in the immediate
  postnatal period

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Acquired

• 3 a) Diverticula can be found anywhere in the
  intestinal tract, but the colon (particularly the
  sigmoid) is by far the commonest site. WHY?
• b) The disease is generally acknowledge to
  result from a diet deficient in fibre. What is
  the mechanism?

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• Nerves and blood vessels penetrate the inner
  circular muscle layer of the muscularis propria,
  forming weak points.
• In the rest of the intestines the gaps are
  reinforced by the external longitudinal layer of
  the muscularis propria.
• In the colon, the longitudinal layer is gathered
  up to form the taeniae coli, thus cant provide
  this protection and the mucosa buldges into the
  subserosa
• Why the sigmoid?- sigmoid motility is
  particularly sensitive to bulk of stool
• Low fibre low bulk of colonic content
  increased intra-luminal pressure generated to
  push content along pressure pushes mucosa into
  the wall

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• 4 a) Haemorrhoids- Which vessels are affected?
• b) How do they present?

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• Haemorrhoids are varicosities resulting from
  dilatation of the internal haemorrhoidal/rectal
  venous plexus
• Haemorrhoids present with rectal bleeding as
  streaks of blood on the outside of the stool

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• 5. List some infective causes of bloody
  diarrhoea.

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• Campylobacter spp.
• Shigellosis
• Salmonellosis
• Enteric (typhoid) fever
• Escherichia coli (Enteroinvasive (EIEC)
  Enterohemorrhagic (EHEC) )

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• 6 a) What is the pathogenesis of pseudomembranous
  colitis?
• b) How is it diagnosed?

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• Disruption of normal colonic flora by
  antibiotics, allows C difficile overgrowth
• Immunoassay for c. difficile toxin in stool

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• 7 a) What is the diagnostic criteria of Irritable
  Bowel Syndrome (IBS)?
• b) What are the pathological features?

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• Diagnosis of exclusion. 3 Criteria
• Abdominal pain or discomfort for atleast
  3days/month for 3 months
• Improvement with defecation
• A change in stool frequency or form
• Despite very real symptoms the gross and
  microscopic appearance is normal.

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8. Match the Number to the (most) correct letter

• Fistula 1. herniations of mucosa in intestinal
  wall
• Fissure 2. cavity or blind-ended channel
• Sinus 3. loss of superficial layer of mucosal
  surface
• Ulcer 4. abnormal, inflammatory connections
  between two hollow structures
• Erosion 5. penetrating ulcers forming grooves
  or cleft
• Polyp 6. mass that protudes into lumen of gut
• Diverticula 7. full thickness loss of the mucosa

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1. 4
2. 5
3. 2
4. 7
5. 3
6. 6
7. 1

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• 9. IBD is an idiopathic disorder and the
  responsible processes are only beginning to be
  understood. Which of the following is not thought
  to be involved in the pathogenesis of IBD?
• a) genetics
• b) inappropriate mucosal immune response
• c) intestinal microbiota
• d) intestinal epithelial dysfunction
• e) autoimmunity

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• e)
• neither Crohn disease nor ulcerative colitis is
  thought to be an autoimmune disease

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• 10. The incidence of IBD is low, however the
  prevalence is high. What does this mean? What
  factors of the disease contribute to this?

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• Means not alot of people are getting diagnosed,
  but a lot of people living with IBD.
• due to
• presenting in relatively young people
• Long course of disease- normally dont die from
  IBD itself

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11. The incidence in developing countries is on
the rise. What is the hypothesis behind this??
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• Hygiene Hypothesis
• Improved food storage conditions and decreased
  food contaminations ? reduced frequency of
  enteric infections? inadequate development of
  regulatory processes to limit mucosal immune
  responses pathogens that should be
  self-limiting trigger overwhelming immune
  response and chronic inflammatory disease
  insusceptible hosts

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12. Decide which of the following
signs/symptoms/complications is more likely to be
related to Crohns/ UC

• Bloody diarrhoea
• R lower quadrant abdominal pain
• L lower quadrant abdominal pain
• Feeling of incomplete emptying of the rectum and
  urgency
• Rectovaginal fistula
• Toxic megacolon
• Fever

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• Bloody diarrhoea (UC or rectal involvement of C)
• R lower quadrant abdominal pain (C)
• L lower quadrant abdominal pain (UC)
• Feeling of incomplete emptying of the rectum and
  urgency (UC)
• Rectovaginal fistula (C)
• Toxic megacolon (UC)
• Fever either acute, or exacerbations

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13. Name 3 conditions that can lead to
haemorrhoids?
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• Pregnancy- uterus compresses vena cava
• Portal Hypertension
• Constipation- straining

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14. What are the mechanisms by which bacteria
cause diarrhoea?
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• Toxins- ingestion of preformed toxins or
  toxigenic organism
• Mucosal adherence
• Mucosal invasion

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15. What are carcinoid tumours and what are the
symptoms of carcinoid syndrome??
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• A diverse group of tumours of enterochromaffin
  cell origin, by definition capable of producing
  serotonin. May (also?) secrete gastrin, insulin,
  glucagon
• Bronchoconstriction, flushing, diarrhoea and CCF

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16. When does diarrhoea warrant investigation?
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• Ill patient- fever etc.
• Recently returned traveller
• chronic