Inflammatory Bowel Disease (IBD) & Irritable Bowel Syndrome (IBS)

Inflammatory Bowel Disease

Any disease that causes inflammation of the bowel. • Usually it refers to two chronic diseases that cause inflammation of the intestines: Ulcerative colitis (UC) and Crohn's disease (CD).

Ulcerative colitis (UC) only affects the large gut, but Crohn's disease (CD) may affect ANY part of the gut; common location being Ileo- colic, only small intestine and only large intestine. *Think Complete Crohn's

Usually Inflammatory Bowel Disease refers to two chronic diseases that cause inflammation of the intestines: Ulcerative colitis (UC) and Crohn's disease (CD). Where does each affect the GI tract? (Mouth to Anus)

Irritable bowel syndrome (IBS)

Female patients with ___ commonly report worsening symptoms during the premenstrual and menstrual phases. Bleeding per rectum, loss of weight, nocturnal diarrhea, severe constipation or diarrhea, fever, precludes diagnosis. In a patient with ___ -Diarrhea is more common in man, constipation is more common in woman. Features of peritonitis are absent; all investigations are normal.

D. Crohn's disease

A 24-year-old woman, presents to her physician's office with a 4-week history of 5 loose, non-bloody stools daily. She also complains of right lower quadrant postprandial abdominal pain, 18 pound weight loss, and bilateral joint pains. She has an 8 pack year smoking history. Her vitals are : BP 118/72mmHg, P 88bpm SR, Temp 98oF, RR 16/min, SpO2: 98% On physical examination: her conjunctivae and mucus membranes are pale, her abdominal exam reveals a soft, non-distended abdomen, BS present and active, a moderately tender 5-cm mass in the right lower quadrant of her abdomen is palpable; DRE reveals scant stool on gloved index finger and FOB is negative. Investigations: Stools culture: negative for enteric pathogens, CBC with diff: Hb 10.2 g/dL), Metabolic panel: normal metabolic ;Thyroid Function tests( TFT's): normal. Her barium enema is shows a 10-cm narrowing in the terminal ileum with cobble stone appearance of the bowel mucosa and a separation of bowel loops. What is the most likely diagnosis? A. Ulcerative colitis B. Ischemic colitis C. Shigellosis D. Crohn's disease E. Typhoid fever

A) Perforation of sigmoid colon

A 24-year old Jewish man presents with a 4 month history sporadic mild diarrhea, which has become bloody over the last 2 days. In addition, he now reports colicky abdominal pain with urgency, tenesmus, and incontinence. His vitals are: BP 100/70mmHg, P 110bpm SR, RR: 24/min, T: 99.8◦F, SpO2: 98%. Abdominal examination reveals: distended, tympanitic abdomen, bowel sounds are present but sparse , severe tenderness on palpation of the lower left lower abdomen with guarding. No abdominal masses were palpable. Digital rectal examination showed presence of blood and mucus on the gloved index finger. A limited colonoscopy (sigmoidoscopy) is performed and the finding is showed in the image. Which of the below is the most immediate life-threatening sequela of this patient's current condition? A) Perforation of sigmoid colon B) Acute blood loss of 250 ml C) Acute dilatation of colon D) Fistula formation with the bladder. E) Cancer colon.

C) Colonoscopy with biopsy *As she mentioned several times, you want to ALWAYS 1st - EXCLUDE THE MALIGNANCY!

A 60-year-old man with a previous diagnosis of IBS presents to the physician with bleeding per rectum. The DRE reveals bloody stool on the gloved index finger. What is the most important investigation that the physician should order? A) Barium enema B) Plain abdominal X-Ray C) Colonoscopy with biopsy D) MRI of abdomen E) Endoluminal ultrasound or echo-ultrasound.

Spasm

Brief note on Radiologic Investigation of Crohn's Disease: The distal small bowel with narrowing and irregularity of several segments. The terminal ileum (arrows) is severely narrowed, an appearance called the "string sign," which is often due to?

1. Common 2. Human herpesvirus 6 3. Non-keratinized 4. Recurrent 5. Stress

Complications of Crohn's disease: Aphthous Ulcers - They are very ___ - Their cause is uncertain, may have an association with ___ - Found on freely moving, ___ mucosa (eg, buccal and labial mucosa and not attached gingiva or palate). - May be single or multiple, are usually ___, and appear as painful small round ulcerations with yellow-gray fibrinous centers surrounded by red halos. - ___ seems to be a major predisposing factor to the eruptions of aphthous ulcers.

1. Edema 2. Bowel wall thickening 3. Fibrosis 4. Transmural inflammation 5. Cutaneous fistulae

Complications of Crohn's disease: Intestinal obstruction - Causes: • ___ • ___ from inflammatory mass • ___ of the bowel wall Fistula formation -___ and deep ulcers may lead to adhesions and fistula formation. Fistulae can be formed between: • the small bowel loops • small and large bowel • small bowel with urinary bladder or vagina ___ can occur after any surgery as well

1. B12 2. D & Calcium 3. Osteoporosis 4. Gross Hemorrhage

Complications of Crohn's disease: Vitamin deficiencies: • Vitamin ___: secondary to ileal disease. • Vitamin ___ malabsorption may lead to osteoporosis. ___ may also be a complication of prolonged corticosteroid therapy. ___ from the deep ulcers (bleeding less common than in UC)

1. Gall stone formation, cholesterol 2. Calcium oxalate stones 3. Hyperoxaluria

Complications of Crohn's disease: Stone formation • ___ -Diseased terminal ilium cannot absorption bile salts, lowers the bile acid pool & thus precipitates the cholesterol crystals in the gall bladder. This may results in ___ stone formation. • ___ in the kidneys-Malabsorption increases accumulation of fat within the gut lumen. Calcium is bound to unabsorbed fat so that oxalate remains free in the lumen and absorbed in the circulation. • More absorption of oxalate leads to ___ and precipitates oxalate stone formation.

Anal Crohn's disease Peri-anal abscess and fistula formation(common, present in about 25% of cases).

Complications of Crohn's disease: What can occur near the anus?

• Resection is curative in UC, Resection is not curative in CD.

Crohn's disease vs. Ulcerative Colitis: In which is surgery/resection a cure?

1. terminal ileum and cecum 2. small intestine only 3. large intestine only 4. *Terminal ileum*

Crohn's disease: • In 35% of cases the disease in confined to ___. • In 30% of cases the disease in confined to ___. • In 30% of cases the disease in confined to ___. • Rarely other parts of GI tract are involved. • ___ is the hallmark location.*

Bowel Resection and Colostomy

Crohn's disease: What are the 2 kinds of Surgical Treatment?

• Intestinal obstruction, refractory to medical therapy • Protracted bleeding, perforation, fistula • Failure of medical treatment • Malignant or premalignant changes • Fulminating colitis • Perianal diseases

Crohn's disease: What are the Indications for surgery? *Surgery is not curative but to relieve the symptoms refractory to medical therapy*

1. Caucasians 2. Jewish 3. 15 - 35 4. non-smokers 5. smoking 6. Crohn's disease (CD)

Inflammatory Bowel Disease: • More common in ___ than other racial groups. • Common in ___ population • Mean age of onset is ___ years. • *Both ulcerative colitis (UC) and Crohn's disease (CD) are very common*. • Ulcerative colitis (UC) is the disease of ___. Severity may worsen if the patient stops ___. • Incidence of ___ is increasing in number.

• Medication Supplementation Mesalazine Corticosteroids Cyclosporine, Infliximab can be used in severe cases • Surgery

IBD: Treatment both for UC & CD. What are they?

Ulcerative colitis (UC) and Crohn's disease (CD). Both pursue protracted and remittent course.

Inflammatory Bowel Disease is always associated with which 2 diseases?

Diagnosis of exclusion

Irritable Bowel Syndrome: A __ is a medical condition ,the existence of which cannot be established with complete confidence by examination or testing. Diagnosis is therefore by elimination ( and testing/investigation) of other reasonable possibilities.

Structural Pathology

Irritable Bowel Syndrome: Extremely common functional Gastro-intestinal disorder with absence of?

*Is a Diagnosis of Exclusion* Dont want to diagnose this if they might have a worse disease. Should be last case scenario!

Irritable Bowel Syndrome: What did she continuously mention about diagnosing this disease?

History PE Formulate a Differential Diagnosis Investigations and Imaging Management Plan (e.g. Treatment) • For acute patients: Revert to the ABC's and resuscitate in order to stabilize before proceeding to deal with the Chief Complaint in the order above • Review the PE Skills for the Abdominal Exam: Semester 1 and Semester 2 PE Skills reading material Semester 1 and Semester 2 PE Skills demonstration videos

Recall the Clinical approach to every patient is always?

• Eye lesions -Episcleritis, Uveitis. • Skin lesions-Erythema nodosum (CD), Pyoderma Gangrenosum (UC). • Arthritis- Enteropathic arthritis (usually peripheral, can be migratory), Spondylitis, Sacroiliitis. Common in both UC & CD. • Immune and Idiopathic thrombolytic Purpura- Common with UC. • Thromboembolism - Hypercoagulability precipitates DVT, PE, CVA, even if the disease is not active. • Osteoporosis. • Gall stones for CD • Primary sclerosing cholangitis for UC not for CD.

Recap: Extraintestinal lesions of IBD( both UC & CD)

Irritable bowel syndrome (IBS) (Two of above are usually present) Criteria fulfilled for the last 3 months with symptom onset at least 6 months prior to diagnosis.

Recurrent abdominal pain or discomfort is the most common presentation and altered bowel motion. It lasts at least 3 days per month in the last 3 months (Key symptom) associated with two or more of the following: 1. Pain or discomfort improvement with defecation. 2. Onset associated with a change in frequency of stool. 3. Onset associated with a change in appearance of stool.

Characteristics of Crohn's Disease

These are characteristics of which disease: • Any part of GIT is affected, involves full bowel wall thickness. Skip lesions are present. • Complications more common to ___ Strictures and fistula formation. Erythema nodosum Perianal diseases like fistulae, abscesses or anal fissure are common in ___ • About 37% of UC patients and 75% of CD require surgery

Characteristics of Ulcerative colitis

These are characteristics of which disease: • ___ affects only colon and mucosa is mainly involved. -Lesions are confluent, 1/3 of patients requires resection & resection is curative. •Complications more common to ___ - Acute dilatation and perforation of colon (common in first episode, especially in severe disease). Life-threatening hemorrhage Colon cancer. Primary sclerosing cholangitis Pyoderma gangrenosum.

Ulcerative Colitis (UC): Clinical features *Key - it's a long disease & 95% have reoccurrence!

These are clinical presentations of which disease: • Repeated bloody diarrhea with or without mucus; negative stool cultures. • Lower abdominal cramps, fecal urgency and tenesmus. • Anemia, low serum albumin, unintended weight loss. • Course is unpredictable, characterized by periodic exacerbations and periods of complete remission. • Only 5% have an initial attack without recurrence.

Ulcerative Colitis (UC) : macroscopic features *Picture slide 11 - patches of inflammation that are very red

These are macroscopic features of which disease: • Innumerable ulceration with diffuse, superficial, confluent inflammation of the colorectal mucosa. • Begins in the rectum and extends proximally to involve any contiguous length of colon. • The small intestine is not involved, except in the setting of extensive colitis, in which the most distal terminal ileum may display similar superficial inflammation, termed backwash ileitis. (Ileocecal junction) • Severity of symptoms correlates with the extent of disease.

Crohn's disease (CD)

These are signs of which disease: • An inflammatory mass may be palpated in the right lower quadrant of the abdomen. • *Patchy*, transmural inflammation can lead to fistula formation, phlegmon, strictures and obstruction, perforation, abscess formation, and peritonitis. • Edema, bowel wall thickening, and fibrosis of the bowel wall within the mass account for the radiographic "string sign" of a narrowed intestinal lumen. • Extension of the mass can cause obstruction of the right ureter or bladder inflammation, manifested by dysuria and fever.

Irritable bowel syndrome (IBS)

These are symptoms of which disease? • Real disease with abdominal pain, bloating, change in bowel habit, (Constipation or diarrhea). - Abnormal GI motility - Related to stress. - Poorly understood - Normal morphology Altered bowel habit. Abdominal distension. Feeling of incomplete defecation. Passage of mucus per rectum. Pain is often exacerbated by eating or emotional stress and improved by passage of flatus or stools

Ulcerative Colitis - UC: Clinical Signs, Endoscopic appearance

This is the endoscopic appearance of which disease: • Physical signs of proctitis include a tender anal canal and bright red blood on rectal examination. • With more extensive disease, patients have tenderness to palpation directly over the colon. • Patients with a toxic colitis have severe pain and bleeding, and those with megacolon have hepatic tympany. Both may have signs of peritonitis if a perforation has occurred. •Sigmoidoscopy/colonoscopyappearance- friable mucosa with innumerable superficial ulcerations; biopsy is the key to the diagnosis.

1. Endoscopy -Innumerable rectal ulcers with inflamed mucosa. 2.Barium enema-Loss of haustration, Granular mucosa with ulcerations, Pipe stem colon and Pseudopolyps

UC: Investigation: They use an endoscopy and barium enema, what is found in each?

Length

Ulcerative Colitis -The *colitis* usually remains constant from the onset because of its extent. The ___ of the involved colon classifies UC

1. Proctitis 2. proctosigmoiditis 3. Left-sided colitis 4. Pancolitis *These diseases are prone to be more severe from the proximal to the distal colon. *Think U is towards end of alphabet, so distal part is more severe.

Ulcerative Colitis: • ___ (limited to the rectum) and ___ (limited to the rectum & sigmoid)- 1/3 . • ___ (extending up to the splenic flexure): 1/3 . • __ (extending into the transverse colon or more proximally):1/3.

- Dietary changes: Avoid insoluble fibers (wholegrain bread, bran, cereals, nuts and seeds, except golden linseeds). - Antidiarrheal agents, like loperamide. - Antispasmodic, like, dicyclomine. - Tricyclic antidepressants like amitriptyline. - 5-HT4 agonists. - 5-HT3 antagonists (Alosetron)

What are some GI Drugs and Treatment?

• Diseases *refractory to treatment*, especially after high continuous dose of corticosteroid for 2-3 days or long-term *corticosteroids* to control symptoms. • *Acute dilatation of colon with or without perforation*. • Severe *dysplasia or carcinoma* on surveillance in review colonoscopy. • Patients with *severe disease* (eg, severe hemorrhage) who do not improve at 7-10 days.

What are the Indications for Surgery in UC?

Crohn's Disease

What disease is this associated with: Morphology - Thickening of the entire wall of the bowel with deep ulceration, skip lesions; thickening of mesentery and local lymph node enlargement. -Biopsy from colon may show full-thickness inflammation of the wall and several non-caseating granulomas.

Irritable Bowel Syndrome

What disease is this: • Extremely common functional Gastro-intestinal disorder with *absence of structural pathology.* • About 15% of the population may be affected in US. • Clinical features -onset around age 20, with more than 3 months duration. Women are far more commonly affected. Onset is uncommon after the age of 45.

It lasts *at least 3 days per month in the last 3 months*

What is the KEY symptom of Irritable bowel syndrome (IBS)?

The pathophysiology of this condition is not clear; it appears to result from a varying combination of *disturbances in visceral motor and sensory function*, often associated with significant affective disorders.

What is the etiology of IBS?

Etiology: *inappropriate immune response* that occurs in *genetically susceptible* individuals as the result of a *complex interaction* among environmental and microbial factors and the intestinal immune system.

What is the etiology of Inflammatory Bowel Disease

Extent of disease, a short interval between attacks, and onset of the disease after 60 years of age.

What is the prognosis of Ulcerative Colitis?

Toxic megacolon with perforation

What is this: • Supine radiograph demonstrates marked mucosal nodularity and thickening of the transverse colon.There is free intraperitoneal air in Morrison pouch (open arrow)and outlying small bowel loops(Rigler sign)

Ulcerative Colitis - UC: fulminating disease-signs and symptoms • Fulminating- occurring suddenly and with great intensity or severity

What type of disease is associated with these symptoms: -Rapid progression (over 1-2 weeks) of symptoms and signs of severe toxicity (hypovolemia, hemorrhage requiring transfusion, and abdominal distention with tenderness) • *Toxic megacolon* -Colonic dilation of > 6 cm on radiographs with signs of toxicity, occurring in < 2%, heightens risk of perforation. • Diagnosis is *clinical & radiological*. Fever, anemia tachycardia, and leukocytosis, may be present.

Ulcerative Colitis - UC: severe disease- signs and symptoms *Picture on slide 14

What type of disease is associated with these symptoms: • Anorexia, weight loss, impaired nutrition, abdominal pain, fever. • Increased bowel frequency & fluid loss -> hypovolemia. • >6 bloody bowel movements per day and more blood in stool. • Presence of blood in the colonic lumen. • Dilated intestinal loops. • Increased ESR & CRP, decreased Albumin, Hb%

Crohn's disease

___ is a chronic inflammatory disease of the intestines. It primarily presents as pain abdomen, diarrhea fever and weight loss. Bleeding anorexia and weakness may be present. Pain is mainly due to acute or subacute obstruction, inflammatory mass or abdominal abscess.

Primary sclerosing cholangitis (PSC)

___ is a disorder of unknown etiology that is characterized by progressive, inflammatory changes with sclerosis, and obliteration of the medium-sized and large biliary tree. A vast majority of patients (prevalence rates range from 70% to 90%) have underlying inflammatory bowel disease, especially ulcerative colitis.