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Inflammatory bowel disease

Causes of colonic inflammation

  • Infection - bacteria, viruses, parasites
  • Ulcerative colitis
  • Crohn's' disease
  • Radiation enteritis
  • Ischaemic colitis
  • Microscopic colitis
  • Drug-induced colitis

Ulcerative colitis

  • Prevalence in UK is about 80 /100,000
  • Peak age of onset 20 - 35 yrs
  • Characteristic feature - acute mucosal inflammation with crypt abscesses

Histological appearance of ulcerative colitis

Crohn’s disease

  • Prevalence in UK is about 40/100,000
  • Incidence is increasing possibly due to increased recognition
  • Characteristic feature - patchy transmural inflammation with non-caeseating granuloma

Pathophysiology

  • Both Crohn's disease and ulcerative colitis have some pathophysiological features in common
  • Both result from inappropriate activation of the mucosal immune system
  • This process is driven by the normal luminal flora
  • May result form defective barrier function of the intestinal epithelium
  • Genetic factors contribute to susceptibility as demonstrated by:
    • Variable prevalence in different populations
    • Increased incidence in first degree relatives
    • Increased concordance in monozygotic twins
    • Concordance in site and type of disease in affected families
  • Possible environmental factors include:
    • Smoking
    • Use of NSAIDs
    • Luminal flora

Pathological features

Ulcerative colitis Crohn's disease
Lesions continuous - superficial Lesions patchy - penetrating
Rectum always involved Rectum normal in 50%
Terminal ileum involved in 10% Terminal ileum involved in 30%
Granulated ulcerated mucosa Discretely ulcerated mucosa
No fissuring Cobblestone appearance with fissuring
Normal serosa Serositis common
Muscular shortening of colon Fibrous shortening
Fibrous strictures rare Strictures common
Fistulae rare Enterocutaenous or intestinal fistulae in 10%
Anal lesions in <20% Anal lesions in 75%
Anal fistulae & chronic fissures
Malignant change well recognised Possible malignant change

Terminal ileal Crohn's disease

Severe ulcerative colitis with pseudopolyp formation

Picture provided by Manickam Vairavan, Consultant surgeon, Sandwell and West Birmingham Hospitals NHS Trust.

Picture provided by David Lockwood, Princess Alexandra Hospital, Brisbane, Australia

Clinical features of inflammatory bowel disease

Ulcerative colitis

  • 30% disease confined to rectum

  • 15% develop more extensive disease over 10 years

  • 20% total colonic involvement from onset

  • Patients generally fall into following categories:

    • Severe acute colitis

    • Intermittent relapsing colitis

    • Chronic persistent colitis

    • Asymptomatic disease

  • Assessment of disease severity

    • Mild = < 4 stools per day.  Systemically well

    • Moderate = > 4 stools per day.  Systemically well

    • Severe = > 6 stools per day.  Systemically unwell

    • Systemic features include tachycardia, fever, anemia, hypoalbuminaemia

  • Endoscopic grading of ulcerative colitis

    • 0 = normal

    • 1 = loss of vascular pattern or granularity

    • 2 = Granular mucosa with contact bleeding

    • 3 = Spontaneous bleeding

    • 4 = Ulceration

Crohn’s disease

  • Clinical features depend on site of disease

  • 50% have ileocaecal disease

  • 25% present with colitis

  • Systemic features are more common than in ulcerative colitis

Extraintestinal manifestations

  • Associated with disease activity
    • Skin
      • Erythema nodosum
      • Pyoderma gangrenosum
    • Joints
      • Asymmetrical non-deforming arthropathy
    • Eyes
      • Anterior uveitis
      • Episcleritis
      • Conjunctivitis
    • Hepatobiliary conditions
      • Acute fatty liver
    • Thromboembolic disease
  • Unrelated to disease activity
    • Joints
      • Sacroilitis
      • Ankylosing spondylitis
    • Hepatobiliary conditions
      • Primary sclerosing cholangitis
      • Cholangiocarcinoma
      • Chronic active hepatitis
      • Gallstones
    • Amyloid
    • Nephrolithiasis

Pyoderma gangrenosum

Medical management of inflammatory bowel disease

  • Treatment depends on
    • Type of disease
    • Site of disease
    • Disease severity
  • Different drugs may be used for active disease and those in remission

5-Aminosalicylic acid

  • Used in mild / moderate ulcerative colitis and Crohn's disease
  • 5-ASA block production of  prostaglandins and leukotrienes
  • Sulfasalazine was first agent described
  • Now compounds available to release 5-ASA at site of disease activity
  • Mesalazine is conjugated to prevent absorption in small intestine
  • Topical preparation may be used in those with left-sided colonic disease
  • Maintenance therapy of proven benefit in those with ulcerative colitis
  • Of unproven benefit in those with Crohn's disease

Corticosteroids

  • Often used in those in whom 5-ASA therapy is inadequate
  • Also used in those presenting with acute severe disease
  • Can be given orally, topically or parenterally
  • Use should be limited to acute exacerbations of disease
  • Of no proven value as maintenance therapy in either ulcerative colitis or Crohn's disease
  • Use must be balanced against side effects

Immunosuppressive and immunomodulatory agents

  • Often used in those in whom steroids can not be tapered or discontinued
  • Agents used include:
    • Azathioprine -effective in both ulcerative colitis and Crohn's disease
    • Methotrexate - effective in Crohn's disease
    • Cyclosporin
    • Inflixitab - anti-TNF-alpha therapy

Surgery for inflammatory bowel disease

Indications for surgery - Ulcerative colitis

  • 20% of patients with ulcerative colitis require surgery at some time
  • 30% of those with total colitis require colectomy within 5 years

Emergency

  • Toxic megacolon

Toxic megacolon complicating ulcerative colitis

  • Perforation
  • Haemorrhage
  • Severe colitis failing to respond to medical treatment

Elective

  • Chronic symptoms despite medical therapy
  • Carcinoma or high grade dysplasia

Surgical options

Emergency

  • Total colectomy with ileostomy and mucus fistula

Elective

  • Panproctocolectomy and Brooke ileostomy
  • Panproctocolectomy and Kock continent ileostomy
  • Total colectomy and ileorectal anastomosis
    • Maintains continence but proctitis persists
  • Restorative proctocolectomy with ileal pouch
    • Need adequate anal musculature
    • Need for mucosectomy unclear
    • May need defunctioning ileostomy

ileoanal pouch

Picture provided by Fernando Lisboa,  Universidade Federal de Rio Grande do Norde, Brazil

Pouch design

Ileoanal pouch design

Functional results of ileoanal pouch

  • Mean stool frequency is six per day
  • Perfect continence
    • During day (90%)
    • At night (60%)
  • Gross incontinence (5%)

Morbidity

  • 50% develop significant complications
  • Small bowel obstruction (20%)
  • Pouchitis (15%)
  • Genitourinary dysfunction (6%)
  • Pelvic sepsis  (5%)
  • Fistula (5%)
  • Pouch failure (6%)
  • Anal stenosis (5%)
  • Larger capacity pouches reduce stool frequency

Indications for surgery - Crohn’s disease

Absolute

  • Perforation with generalised peritonitis
  • Massive haemorrhage
  • Carcinoma
  • Fulminant or unresponsive acute severe colitis

Elective

  • Chronic obstructive symptoms
  • Chronic ill health or debilitating diarrhoea
  • Intra-abdominal abscess or fistula
  • Complications of perianal disease
  • Surgery should be as conservative as possible
  • No evidence that increased resection margins reduce risk of recurrence
  • If possible improve preoperative nutritional state

Crohn's stricture

Surgical Options

  • Limited resections
  • 30% undergoing ileocaecal resection require further surgery
  • Strictureplasty often successful
  • Bypass procedures rarely required

Crohn's strictureplasty

Bibliography

Bullen T F,  Hershman M J.  Surgery for inflammatory bowel disease.  Hosp Med 2003;  64:  719-723.

Holdsworth C D.   The current management of inflammatory bowel disease.  Curr Pract Surg 1992; 4: 163 - 167.

Köhler L,  Troidl H.  The ileoanal pouch: a risk - benefit analysis.  Br J Surg 1995; 82: 443 - 447.

Miller M,  Windsor A C J.  Ulcerative Colitis.  Hosp Med 2000;  61:  698-705.

Podolsky D K.  Inflammatory bowel disease.  N Eng J Med 2002;  347:  417-429.

Rampton D S.  Management of Crohn's disease.  Br Med J 1999;  319:  1480-1485.

Roy M A.  Inflammatory Bowel Disease.  Surg Clin N Am 1997;  77:  1419-1431

Sagar P M,  Taylor B A.  Pelvic ileal reservoirs: the options. Br J Surg 1994; 81:325 - 332.

Stebbing J F,  Mortensen N.  Ulcerative Colitis and Crohn's Disease.  Surgery 1995; 13: 73 - 80.

 

 
 

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