IBD

Inflammatory
Bowel Disease (IBD)

Presented by:

M. Sufian
student of Nutrition Sciences(B/Sc)

Science & Research Branch of Islamic Azad University(SRBIAU)

All Rights Reserved by M Sufian
1/13/2012 1
m_sufian@behestandarou.com

Contents:
• Introduction
• Occurrence & Commonness
• Pathophysiology
• Diagnosis
Symptoms
Signs
• Complications
• Treatments
Medical
Surgical
• Q&A
• References

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Introduction:

• IBD:Chronic inflammatory diseases of GI tract of
unknown etiology
• Commonly refers to
1) ulcerative colitis
Ulcerative colitis (UC) affects only the large intestine (*)

2) Crohn’s disease
Crohn’s disease (CD) can affect any part of the
gastrointestinal tract but most frequently attacks the distal
third of the small intestine & the colon

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Introduction (continued)
• Diagnosed using clinical, endoscopic, and
histologic criteria
• No single finding is absolutely diagnostic for one
disease or the other
• Approx. 20% of patients have clinical picture that
falls between ulcerative colitis and Crohn’s
disease (indeterminate colitis)
• Many of the treatments available are effective
for both diseases
• Extraintestinal manifestations may be present in
both

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Occurrence & Commoness
• Approx. 1 million people in U.S. have ulcerative
colitis (UC) or Crohn’s disease (CD)
• Most commonly observed in industrialized
nations; lowest in developing regions (also
higher rate in urban areas vs. rural areas)
• Incidence higher in Ashkenazi Jews
• Incidence is slightly higher in females than males
• Vast majority diagnosed between ages 15-40

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Pathophysiology
• Still under investigation
• ? Defect in function of the intestinal immune
system (breakdown in defense barrier)
• Exposure of mucosa to microorganisms results in
inflammatory process causing
ulceration, bleeding and loss of fluids and
electrolytes
• ? Genetic predisposition (esp. when ileal disease
involved)

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Pathophysiology(Cont’d)

1/13/2012 7

Pathophysiology(Cont’d)

Pathophysiology in
Crohn's disease vs. ulcerative colitis
Crohn's disease Ulcerative colitis
Autoimmune Widely regarded as
disease an autoimmune No consensus
disease
Cyypkine Associated with Vaguely associated
response Th17 with Th2

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Diagnostic:
Symptoms

Symptoms in Crohn's disease vs. ulcerative colitis

Crohn's disease Ulcerative colitis

Often porridge-like[6], Often mucus-like
Defecation
sometimes steatorrhea and with blood[6]
Tenesmus Less common[6] More common[6]

Fever Common[6] Indicates severe disease[6]

Fistulae Common[7] Seldom
Weight loss Often More seldom

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Diagnostic:
Signs
Findings in diagnostic workup in Crohn's disease vs. ulcerative colitis
Sign Crohn's disease Ulcerative colitis

Terminal ileum involvement Commonly Seldom

Colon involvement Usually Always
Rectum involvement Seldom Usually[8]
Involvement around
Common[7] Seldom
the anus

No increase in rate of primary
Bile duct involvement Higher rate[9]
sclerosing cholangitis

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Diagnostic:
Signs
Findings in diagnostic workup in Crohn's disease vs. ulcerative colitis
Sign Crohn's disease Ulcerative colitis
Patchy areas of inflammation Continuous area of
Distribution of Disease
(Skip lesions) inflammation[8]
Deep geographic and
Endoscopy Continuous ulcer
serpiginous (snake-like) ulcers
May be transmural, deep into
Depth of inflammation Shallow, mucosal
tissues[2][7]
Stenosis Common Seldom
May have non- necrotizing
Non-peri-intestinal crypt
Granulomas on biopsy non-peri- intestinal crypt
granulomas not seen[8]
granulomas[7][10][11]

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Ulcerative colitis vs. Crohn’s
• Rectal bleeding common • Occasional rectal bleeding
• Abdominal pain uncommon • Abdominal pain common
• Rectal involvement almost 100% • Rectal involvement 50%
• Fistula formation rare • Fistula formation common
• Stricture & obstruction rare • Stricture and obstruction common
• Perirectal, perianal abscesses • Perirectal, perianal abscesses
uncommon common
• Continuous involvement • Discontinuous involvement
• Mucosa & submucosa involved • Transmural
• Small bowel not involved (*) • Small bowel often involved
• Risk of malignancy greatly • Risk of malignancy increased
increased

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Treatment

Management in Crohn's disease vs. ulcerative colitis
Crohn’s disease Ulcerative colitis
Mesalazine less useful[12] More useful[12]
Antibiotics Effective in long-term[13] Generally not useful[14]
Often returns following Usually cured by
Surgery
removal of affected part removal of colon

1/13/2012 45

Treatment (Medical)
1. Anti-inflammatory
agents(aminosalicylates,corticosteroids)
2. Immunosuppressant
3. Antibiotics
4. TNF (Tumor Necrosis Factor) inhibitors
5. Anti-diarrheal agents
6. Antispasmodic agents
7. Supportive therapy

** 75% of ulcerative colitis patients respond well to medical management

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1-Anti-inflammatories (aminosalicylates)
• Sulfasalazine (Azulfidine)-combination of sulfapyradine (anti-
bacterial) + 5-aminosalicylic acid (5-ASA)
– Greatest effect on IBD; mainstay of outpatient medical
treatment for mild-mod. active UC & CD
– Originally used to treat rheumatoid arthritis
– Possesses both anti-inflammatory & antibacterial properties
– Partially absorbed in jejunum but remainder passes to colon
– Therapeutic action of 5-ASA compounds: inhibition of
prostaglandin & leukotriene synthesis, free radical scavenging,
impairment of white cell adhesion and function, inhibition of
cytokine synthesis
– Watch for folate deficiency, abdominal discomfort & allergies to
sulfa compounds

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1-Anti-inflammatories (aminosalicylates)

• Mesalamine group- Asacol, Pentasa, Rowasa
– Coating 5-ASA with acrylic resins- permits drug delivery to distal
bowel & colon
– Effective for ileal & colon involvement
– Rapid absorption
– Enemas and suppositories
– Fewer side effects than sulfasalazine
– Olsalazine-delayed absorption;useful in colonic disease

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1-Anti-inflammatories (corticosteroids)
• Treatment of choice for acute attack IBD (including IV treatment;
enemas for acute proctitis)
• Generally used for moderate-severe IBD
• Not to be used for maintaining remission due to multiple & severe
side effects *
• Prednisone-synthetic glucocorticoid;powerful anti-inflammatory
action
– Usually tapered doses
– IV use- methylprednisolone, dexamethasone
• Budesonide (Entocort EC)- newer type
– Synthetic steroid coated with ethylmethylcellulose which delays its
release until ileum & descending colon
• **Side effects often outweigh benefits if used for prolonged
period of time

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2-Immunosuppressants

• Reduce inflammation by suppressing immune system’s
response (which might damage digestive tissue) to
invading virus or bacterium
• Azathioprine (Imuran) & mercaptopurine (6-MP,
Purinethol)
– help reduce signs and sx of IBD and heal fistulas from CD
– inhibits mitosis
– Increases risk of neoplasia
– Serious hepatic, renal, & hematological side effects

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2-Immunosuppressants

• Methotrexate (Rheumatrex)- used for patients
who do not respond to other medications
• Cyclosporine (Neoral, Sandimmune)-
administered IV for CD with fistulas

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3-Antibiotics

• IBD is associated with frequent bacterial
infections especially with toxic
megacolon, fistulas and fulminant disease
• Most effective antibiotics: metronidazole
(Flagyl), ampicillin, cephalosporins, amonioglyco
sides, ciprofloxacin (Cipro)

1/13/2012 52

4-TNF (tumor necrosis factor) inhibitors

• TNF is a protein produced by immune system;
chemical messenger that can cause
inflammation & tissue damage
• Etanercept (Enbrel) – TNF receptor blocker;
binds to alpha & beta TNF
– Used to treat RA; not yet FDA approved for treating
Crohn’s

1/13/2012 53

4-TNF Inhibitors

• Infliximab (Remicade)- neutralizes cytokine TNF
alpha
– Increased risk infections (reactivation of TB or
granulomatous disease)
– Usually for moderate-severe disease
– May be used for long-term therapy

1/13/2012 54

5-Antidiarrheal agents

• Decrease peristalsis & therefore intestinal
motility
• Improves diarrhea& prevents loss of fluid &
electrolytes
• Loperamide (Imodium), Atropine (Lomotil)
• Cholestyramine (Questran)- inhibits
enterohepatic reuptake of bile salts

1/13/2012 55

5-Antispasmodic agents

• Treat functional disturbances of GI motility
• Dicyclomine (Bentyl)- anticholinergic; blocks
action of acetylcholine at parasympathetic sites
in secretory glands, smooth muscle & CNS

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6-Supportive therapy

• (In addition to adequate nutritional support)
– Vitamin B12
– Iron
– Folic acid

1/13/2012 57

Surgical Treatment

• **Surgical removal of large bowel (colectomy)
will result in cure for ulcerative colitis
• Not the case for Crohn’s; surgical removal of the
affected bowel segment in CD will not prevent
the later appearance of disease at an adjacent or
distant site

1/13/2012 58

Surgical Treatment (Ulcerative Colitis)

• Main indications: failure of medical treatment,
complications (toxic megacolon, perforation) and
risk of malignancy
• Resection of colon & rectum
(panproctocolectomy) is curative
– Fecal diversion via ileostomy or ileo-anal anastomosis
in form of ileal pouch
• Pouch may cause mechanical problems (40% develop
inflammation resembling UC, 15% may need further surgery)

1/13/2012 59

Surgical Treatment (Ulcerative Colitis)

• 10% will have colectomy during 1st year of dx
– 4% will have surgery during 2nd year
– 1 % annually in subsequent years
– Extent of colitis at diagnosis affects need for
subsequent surgery (colectomy rate for patients with
pancolitis is 32%)

1/13/2012 60

Surgical Treatment (Crohn’s Disease)

• Limited to dealing with complications such as
stricture formation, perforation and fistulae
• 30% need surgery within 1st year
• For the remainder, surgery rate is 5% per year
• Following resection, 30% will require further
surgery within 5 years, & 50% within 10 years
• Complications are frequent; least invasive
procedures desirable

1/13/2012 61

Underwriting IBD: Mild Ulcerative Colitis

Distal or rectal involvement only
• 5 or fewer stools/day
• Tx with retention enemas or oral anti-
inflammatory meds
• No systemic or extracolonic manifestations

1/13/2012 62

Moderate Ulcerative Colitis

• No currently active pancolitis
• No serious complications
• No worse than mild anemia
• Treatment may require intermittent use of oral
steroids or other cytotoxic drugs

1/13/2012 63

Severe Ulcerative Colitis

• Active pancolitis with frequent
diarrhea, abdominal pain
• Severe & typical systemic findings
• Weight loss > 10% of body weight
• Lab results reveal moderate-severe anemia
and/or hypoalbuminemia
• Recent (w/in 5 yrs) toxic megacolon or multiple
surgeries
• Treatment requires high doses of steroids or
multiple cytotoxic medications

1/13/2012 64

Other considerations (UC)

• Cirrhosis or sclerosing cholangitis (documented
or suspected)
• Alkaline phosphatase or LFT elevations w/out
liver biopsy or work-up
• Fatty liver or pericholangitis confirmed by liver
biopsy + significant LFT elevations
• (Postpone?) Recent diagnosis
• (Postpone?) 0-6 months following surgery

1/13/2012 65

Underwriting IBD (Mild Crohn’s Disease)

• Use of anti-diarrheal meds, no antibiotic or
immunosuppressive therapy
• Near normal bowel habits
• Infrequent attacks
• No anemia, normal sed rate

1/13/2012 66

Moderate Crohn’s Disease

• Medications needed to control symptoms (ie,
Flagyl, Asacol, Azulfidine)
• Limited disease
• No more than 2 surgeries
• Sed rate up to 2x normal

1/13/2012 67

Severe Crohn’s Disease

• Multiple (3 or more) surgeries
• Multiple medications including oral
steroids, immunosuppressants, TNF inhibitors
• Extensive disease
• Anemia, elevated sed rate
• Weight loss (> 10% body weight)

1/13/2012 68

Crohn’s Disease- Favorable factors

• Normal CBC
• Ileal involvement only
• Stable weight
• Non-steroidal meds only
• Colonoscopies every 12-24 months
• Older age

1/13/2012 69

Crohn’s Disease- Unfavorable Factors

• Low blood counts on CBC
• Multiple sites in GI tract
• Low and/or fluctuating weight
• Steroid use
• Surgical intervention (multiple)
• Poor follow-up/compliance

1/13/2012 70

Crohn’s Disease – other consideratons
• Cirrhosis or sclerosing cholangitis (documented or
suspected)
• Alkaline phosphatase or LFT elevations w/out liver biopsy
or work-up
• Fatty liver or pericholangitis confirmed by liver biopsy +
significant LFT elevations
• Consider postponing if recent diagnosis (0-1 year since
dx)
• (Postpone?) If CD diagnosed > 10 yrs ago (w/colonic
involvement) and there is no recent colonoscopy
• (Postpone?) Colonoscopy/biopsy shows any degree of
dysplasia

1/13/2012 71

Questions?

1/13/2012 72

References
1. ^ Baumgart DC, Carding SR (2007). "Inflammatory bowel disease: cause and immunobiology.". The Lancet 369 (9573): 1627–40.
doi:10.1016/S0140-6736(07)60750-8. PMID 17499605.
2. ^ a b Baumgart DC, Sandborn WJ (2007). "Inflammatory bowel disease: clinical aspects and established and evolving therapies.".
The Lancet 369 (9573): 1641–57. doi:10.1016/S0140-6736(07)60751-X. PMID 17499606.
3. ^ Xavier RJ, Podolsky DK (2007). "Unravelling the pathogenesis of inflammatory bowel disease.". Nature 448 (7152): 427–34.
doi:10.1038/nature06005. PMID 17653185.
4. ^ "Crohn's & Colitis Foundation of America".
5. ^ Elson, CO; Cong, Y; Weaver, CT; Schoeb, TR; Mcclanahan, TK; Fick, RB; Kastelein, RA (2007). "Monoclonal Anti–Interleukin 23
Reverses Active Colitis in a T Cell–Mediated Model in Mice". Gastroenterology 132 (7): 2359. doi:10.1053/j.gastro.2007.03.104.
PMID 17570211.
6. ^ a b c d e f internetmedicin.se > Inflammatorisk tarmsjukdom, kronisk, IBD By Robert Löfberg. Retrieved Oct 2010 Translate.
7. ^ a b c d Hanauer, Stephen B.; William Sandborn (2001-03-01). "Management of Crohn's disease in adults" (PDF). American Journal
of Gastroenterology 96 (3): 635–43. doi:10.1111/j.1572-0241.2001.03671.x. PMID 11280528. Retrieved 2009-11-07.
8. ^ a b c Kornbluth, Asher; David B. Sachar (July 2004). "Ulcerative colitis practice guidelines in adults (update): American College of
Gastroenterology, Practice Parameters Committee" (PDF). American Journal of Gastroenterology 99 (7): 1371–85.
doi:10.1111/j.1572-0241.2004.40036.x. PMID 15233681. Archived from the original on April 6, 2008. Retrieved 2009-11-07.
9. ^ Broomé, Ulrika; Annika Bergquist (February 2006). "Primary sclerosing cholangitis, inflammatory bowel disease, and colon
cancer". Seminars in Liver Disease 26 (1): 31–41. doi:10.1055/s-2006-933561. PMID 16496231.
10. ^ Shepherd, NA. (August 2002). "Granulomas in the diagnosis of intestinal Crohn's disease: a myth exploded?". Histopathology 41
(2): 166–8. doi:10.1046/j.1365-2559.2002.01441.x. PMID 12147095.
11. ^ Mahadeva, U.; Martin, JP.; Patel, NK.; Price, AB. (July 2002). "Granulomatous ulcerative colitis: a re-appraisal of the mucosal
granuloma in the distinction of Crohn's disease from ulcerative colitis.". Histopathology 41 (1): 50–5. doi:10.1046/j.1365-
2559.2002.01416.x. PMID 12121237.
12. ^ a b c Pages 152-156 (Section: Inflammatory bowel disease(IBD)) in:Elizabeth D Agabegi; Agabegi, Steven S. (2008). Step-Up to
Medicine (Step-Up Series). Hagerstwon, MD: Lippincott Williams & Wilkins. ISBN 0-7817-7153-6.

1/13/2012 73

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