Inflammatory Bowel Disease: Ulcerative Colitis & Crohn’s Disease

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Inflammatory Bowel Disease: Ulcerative Colitis & Crohns Disease. . . IBD IBD . Inflammatory Bowel Disease (IBD). chronic, relapsing, immunologically-mediated inflammatory condition of the GI tract - PowerPoint PPT Presentation

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  • Inflammatory Bowel Disease:Ulcerative Colitis & Crohns Disease

  • IBD

    IBD

  • Inflammatory Bowel Disease (IBD)chronic, relapsing, immunologically-mediated inflammatory condition of the GI tractPresentation varies widelyCharacterized by exacerbations & remissionsAffects males and females equally

  • Ulcerative ColitisCrohns DiseaseLimited to colon+rectumContinuousmucosalMouth to anusTransmuralSkip lesionsgranulomasIndeterminate Colitis5-10%Spectrum of Disease

  • Inflammatory Bowel Disease (IBD)

  • Etiologic Theories in Inflammatory Bowel Disease

  • Key Differences Between UC and CrohnsUC

    ColorectalMucosal continuousCrohns

    Mouth to anusTransmuralSkip areasgranulomas

  • CHARACTERISTIC FEATURES OF ULCERATIVE COLITIS

  • UC Extraintestinal Manifestations

  • Clinical Presentation: CDPatchy, transmural inflammationAffects any part of the GI tractCan have skip lesionsStricturingObstructionsFistulizingEntero-enteric, entero-vesical, analHemorrhage is less common than UC

  • INFLAMMATION

  • OBSTRUCTION

  • FISTULIZATION

  • CONFINED PERFORATION

  • CD DiagnosisColonoscopySerpiginous ulcersCobblestoningSkip areasBiopsyTransmural inflammatory infiltrate Noncaseating granulomas

  • Medical Treatment of IBD5-ASA medications-blocks production of PG and LT, inhibits bacterial peptide-induced neutrophil chemotaxis, scavengesreactive oxygen metabolites, inhibits NF-kB

    6-MP / azathioprine-suppresses T cell function

    Steroids

    Infliximab- binds soluble TNF, may lead to monocyte apoptosis

    Cyclosporine- Inhibits lymphocyte activation

  • Treating severe CD (and UC)Infliximab (Remicade)Chimeric anti-TNF monoclonal AbStrong anti-inflammatory effectEffective in both active and fistulizing CDNeeds repeated infusions

    Remission: 39-45% at 30 weeks*Fistula closure: initial response 69% complete response at 12 mths: 36%***ACCENT-1, **ACCENT-2

  • Ileal pouch anal anastomosis(IPAA)

  • Surgery for CDGeneral GuidelinesIndications:Failure of medical therapyComplicationsSuspicious for CA

    Surgery is not curativeRepeated operations may be necessaryPrinciple: Bowel conservation

  • SummaryIBD is a chronic inflammatory condition of the GI tract with unclear etiology and no known cureA spectrum of diseaseRequires multidisciplinary approach

    ***Overly aggressive T cell response to commensal enteric bacteria ina genetically susceptible host, precipitated or reactivated by environmental factors***Clinical and basic research in inflammatory bowel disease has suggested that three factors are critically important in the development of inflammatory bowel disease in the a given individual. First, patients inherit genes that predispose to inflammatory bowel disease. These genes may result in abnormalities in the mucosal immune system such as overproduction of pro-inflammatory cytokines or under-production of anti-inflammatory or regulatory cytokines. Finally, a triggering event must occur to set in motion the chronic inflammation. This triggering event is generally believed to be bacteria but may include other environmental factors such as smoking or NSAIDS.

    Susceptibility is inherited, polygenic (effects on barrier function, immunoregulation

    Exaggerated T cell response to commensal bacteria

    **Greater risk among first degree relativesGreater concordance in monozygotic twins******The left-hand panel is a close-up view of the mucosa of Crohns disease of the colon and the middle panel is a similar view of Crohns disease of the small bowel. Both illustrate the cobblestone pattern created by the intersection of long longitudinal and transverse ulcerations with edematous mucosa intervening. The right-hand panel shows an actual cobblestone road, to exemplify the appropriateness of the descriptor. [Figure courtesy of Noam Harpaz, M.D.]

    ****70% have endoscopic recurrence at 6wks to 6 months20% symptomatic at 1 yr17-58% require another operation within 10 yrs

    Stricturoplasty alloqs conservation of bowel length, initially used in TB strictures, first used for CD in 1979*

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