Imflammatory bowel disease: Ulcerative colitis and Crohn's dz
Describe what each causes?
Ulcerative only is muscosa and occasionally submucosa (all throughout)
Crohns is tranmural (skip lesions)
Etiologic theories of IBD?
Most common in 2nd & 3rd decades, but can affect any age.
Males = females.
Pathophysiology of IBD?
–Defect in the function of the intestinal lumen
–Breakdown of the defense barrier of the gut
–Exposure of mucosa to microorganisms or their products
–Results in chronic inflammatory process mediated by T cells.
Systemic complications of IBD related to imflammatory activity:
1. Oral? 1
2. Eye? 2
3. Cutaneous? 2
4. Cardiac? 1
5. Muskuloskeletal? 1
HLA B28 presentation
Systemic complications of IBD related to small bowel pathophysiology:
1. Gallbladder? 1
2. Intestinal? 1
3. Renal? 4
1. What is Ulcerative Colitis?
2. Always includes what? Spreads where?
3. What kind of inflammation does it cause with distal colitis? 2
4. –Extensive colitis aka?
1. uInvolves the mucosal surface of colon with the formation of crypt abscesses.
2. Always includes the rectum, spreads proximally
Is uniformly continuous, NO SKIP LESIONS
1. 50% is where?
2. 30% is where?
3. 20% is where?
WHY WOULD WE DO A colonscopy and not a sigmoidoscopy?
1. –50% rectosigmoid (Proctosigmoiditis)
2. –30% to splenic flexure (Left sided colitis)
3. –20% extend proximally (Pancolitis)
THey are at much higher risk for cancer
What are the two pictures showing?
ALWAYS HAVE TO BE THINKING ABOUT COLON CANCER
Ulcerative Colitis Clinical Course?
1. –Flare-ups and remissions.
2. –More common in nonsmokers.
3. –Disease severity may be lower in active smokers and may worsen in patients who stop smoking.
4. –Higher risk for development of cancer.
1. Onset of flares occasionally appears to coincide with what?
2. What is the development of cancer in UC related to? 2
1. Onset occasionally appears to coincide with smoking cessation
-related to extent and duration of disease and
-age at diagnosis
Signs and symptoms:
–Mild to moderate disease
1. Bloody diarrhea (hallmark)***
2. Lower abdominal cramps
–Relieved with defecation
3. Fecal urgency
Signs and symptoms of severe disease UC?
1. Rectal bleeding
2. Left lower quadrant cramps
3. Severe diarrhea
4. Fever (high grade fever would be perforation)
5. Anemia (blood loss- iron deficiency)
Ulcerative Colitis: Systemic associations?5
–Central (axial) arthritis
–Erythema nodosum (raised rash on the skin that isnt itchy)
What is sclerosing cholangitis?
Sclerosing cholangitis: disease of bile ducts that causes inflammation and obstruction,
80% of these patients have UC,
Treatment: liver transplant.
2. Sed rate and CRP
4. –Perinuclear antineutrophil cytoplasmic antibodies (pANCA) - a lot of people don't have this but still have the disease.
1. What would the CBC show us? 2
2. Sed rate and CRP?
3. CMP? 3
-anemia is common due to multiple factors
2. Sed rate and CRP
-elevated sedimentation rate & C-RP reflect acute phase (only elevated while having symptoms)
-decreased serum albumin
-prolonged clotting time
Describe the following for mild, moderate and severe UC
–Weight loss: ?
–Albumin : ?
–Stools: less than 4/day
–Pulse: less than 90
–Weight loss: none
–ESR: less than 20
–Albumin : normal
–Hematocrit : 30-40
–Weight loss: 1-10%
–Albumin : 3-3.5
–Stools: >6/day (mostly bloody)
–Hematocrit : less than 30
–Weight loss: >10%
–Albumin : less than 3
What is an ulcerative colitis diagnosis based on?
Diagnosis is usually based on
1. clinical presentation,
2. sigmoidoscopic demonstration of inflammation and
3. the exclusion of bacterial and parasitic infection.
What 4 things would give us our diagnosis of UC?
(dignosis is best made at?)
1. –Bloody diarrhea (differentiates from Crohn’s)
2. –Plain abdominal xrays
4. –CT Scan – (complications)
–diagnosis is best made at Sigmoidoscopy.
Ulcerative colitis treatment?
–Reduce dietary fiber during an exacerbation.
–Prescribe folic acid supplements with Sulfasalazine.
–Oral iron may be needed with rectal bleeding and documented iron deficiency anemia.
–Frequent follow-up and close monitoring.
–Short course of Loperamide for troublesome diarrhea.
--Periodic colonoscopy and biopsy in patients with pancolitis lasting more than 8 years
Mild to Moderate UC Disease medical treatment? 4
1. –Sulfasalzine (suicidal thoughts and severe depression in males)
2. –Olsalazine (non sulfa)
4. –May have to add prednisone
Taper to lowest therapeutic dose needed
UC uModerate to Severe Disease treatment? 3
May need to consider immunosuppresive therapy for patients who need constant high doses of steroids
If the UC is limited to the rectosigmoid what can we do?
1. Proctocolitis (limited to rectosigmoid)
3. Oral or topical (enema, suppository)
4. Hydrocortisone (Enema, Suppositories, Foam)
Ulcerative colitis indications for surgery?
Ulcerative colitis surgical options?
What is Crohns Dz?
Transmural involvement with formation of fistulas, narrowing of lumen, obstruction.
Can involve any segment of the G.I. tract.
List them from most common to least common 5
–Ileocolitis = 45%
–Ileitis = 28%
–Colitis = 15%
–Gastroduodenitis = 7%
–Jejunoileitis = 5%
What does crohns usually spare?