Inflammatory Bowel Disease

Crohn's Disease: Prevalence

- Approximately 80 % of patients have small bowel involvement, usually in ILEOCECAL Transmural- result in stricters; Ulcers start in the submucosal layer and extend out in both directions. (UC starts in mucosal layers)

Ulcerative Colitis Clinical Manifestations

- Diarrhea with Blood - Bowel movements are frequent and in small volumes - May also have colicky abdominal pain, urgency, tenesmus, & incontinence - Patients with mainly distal disease may have constipation with frequent discharge of blood and mucus - Onset of symptoms is gradual - progressive over several weeks - Symptoms may be preceded by a self-limiting episode of rectal bleeding that occurred weeks or months earlier - Most patients at first presentation of UC have mild symptoms, 27% first present with moderate symptoms, 1 % first present with severe disease

Crohn's Disease: Bleeding

Although stools frequently reveal the presence of microscopic levels of blood (eg, positive guaiac or immunochemical test), gross bleeding is less frequent than in ulcerative colitis. An exception to this are some patients with Crohn colitis.

Inflammatory Bowel Disease

Both as inflammatory disorders that cause intestinal ulcerations Both present with abdominal cramping and frequent loose bloody stools. Exacerbation/remission pattern.

Diverticular Disease

Common disease that is age dependent and common in advanced countries. Caused by increased intracolonic pressure brought about by age (narrowing of the colon with age) and a diet low in fiber and high in refined foods Excessive intra-colon pressure causes herniation of the colon mucosa at weak points along the colon wall Usually asymptomatic unless diverticuli become inflamed, infected, or rupture

Crohn's Disease: Diarrhea

Diarrhea is a common presentation, but often fluctuates over a long period of time. (Diarrhea with UC is associated with inflammation in the colon) Diarrhea associated with CD may have multiple causes, including: - Excessive fluid secretion and impaired fluid absorption by inflamed small or large bowel - Bile salt malabsorption due to an inflamed or resected terminal illeum - Steatorrhea related to loss of bile salts

Crohn's Disease

Entire GI tract (mouth - anus) Depth of ulcers: Deep, sometimes penetrating Pattern: Patchy, skip lesions Most Common: Iliosecal (illeus to cecum) Ulcers lead to scar tissue/stricture

Ulcerative Colitis: Severe

Extensive colon involvement that may extend to cecum, frequent loose stools (>6 per day) severe cramps, fever > 37.5, hypotension, tachycardia, anemia, bleeding often necessitates transfusion, may suffer rapid weight loss leading to poor nutritional state

Crohn's Disease: Clinical manifestations

Fatigue, prolonged diarrhea with abdominal pain, weight loss, and fever, with or without gross bleeding, are the hallmarks of CD Abdominal pain: Crampy abdominal pain is a common manifestation of CD, regardless of disease distribution. Strictures often lead to repeated episodes of small bowel, or less commonly colonic, obstruction. A patient with disease limited to the distal ileum frequently presents with right lower quadrant pain

Ulcerative Colitis: Mild

Four or fewer stools per day with or without blood, no signs f systemic toxicity, no signs of anemia, physical examination often normal, ulcers confined to the rectum or rectosigmoid. Intermittent rectal bleeding - mild diarrhea, mild cramping pain, some periods of constipation.

Ulcerative Colitis: Toxic Megacolon

Inflammatory process extends beyond the mucosa to involve the muscle layers of the colon, Toxic megacolon is characterized by colonic diameter ≥6 cm or cecal diameter >9 cm and the presence of systemic toxicity. Causes an obstruction bc not enough muscle to push the stool forward.

Ulcerative Colitis: Moderate

Involves more of the colon, frequent loose bloody stools (>4 per day), abdominal tenderness to palpation, mild anemia not requiring blood transfusion, abdominal pain that is not severe, minimal signs of systemic toxicity such as low grade fever, adequate nutrition is maintained usually

Crohn's Disease

Malabsorption Perianal Disease: Perianal pain and drainage from large skin tags, anal fissures, perirectal abscesses, and anorectal fistulas. Systemic Symptoms: Fatigue is common. Weight loss due to obstruction induced loss of appetite or malabsorption. Fevers caused by chronic inflammation or perforation/peribowel infection.

Tenomas

Muscle spasms in the rectum, strong urge to defect but not producing much

Ulcerative Colitis

Only colon Depth of ulcers: Shallow (mucosa) Pattern: Continuous Normal progression: Rectum and ascend into the colon

Ulcerative Colitis: Perforation

Perforation of the colon most commonly occurs as a consequence of toxic megacolon. Perforation with peritonitis has been associated with 50 percent mortality in patients with ulcerative colitis

Ulcerative Colitis: Severe Bleeding

Severe Bleeding - Bleeding may be severe in up to 10 percent of patients. Massive hemorrhage occurs in up to 3 percent of patients with ulcerative colitis and may necessitate urgent colectomy

Crohns Fistulas:

Two neighboring hollow epithelial-lined organs and ulcer create a channel between them. (Eg path between colon and vagina, colon and bladder). Common sites include intestine and bladder, skin, bowel, & vagina Enteroenteric fistulas (2 loops of bowel) may be asymptomatic or present as a palpable mass Enterovesical (bladder) fistulas leads to recurrent UTIs Enterovaginal fistulas may present with passage of gas or feces from the vagina Enterocutaneous fistulas can cause bowel contents to drain to the surface of the skin

Main complications

Ulcerative Colitis: Toxic Megacolon Crohns: Fistulas

Ulcerative Colitis: Fulminant colitis

With more than 10 stools per day, continuous bleeding, abdominal pain, distension, and acute, severe toxic symptoms including fever and anorexia. Patients with fulminant colitis are at high risk of developing toxic megacolon.