ULCERATIVE COLITIS DEFINITION

Transcription

1 DR R DE LACY

2 ULCERATIVE COLITIS DEFINITION Inflammation of the lining of the large bowel (colon and rectum) Aetiology is poorly understood Genetic factors - aggregation in families - identical twin concordance 10% - dizygotic twin concordance 3% - ethnic diff in incidence - genetic markers and linkages Environmental factors diet, breastfeeding

3 ONSET Adolescence to early adulthood yrs, seeing patients as young as 3 years of age

4 SYMPTOMS Rectal bleeding Diarrhoea Abdominal cramps Weight loss Fever

5 CLASSIFICATION ULCERATIVE PROCTITIS PROCTOSIGMOIDITIS LEFT-SIDED COLITIS PANCOLITIS FULMINANT COLITIS

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7 SEVERITY OF DISEASE Mild disease - less than 4 stools/day -with or without blood - mild abdominal pain or cramping -tenesmus - no systemic signs of toxicity - normal ESR

8 SEVERITY OF DISEASE Moderate disease - > 4 stools/day Severe disease - minimal signs of toxicity - anaemia not requiring transfusion - moderate abdominal pain - low grade fever - > 6 bloody stools/day - evidence of toxicity - fever, tachycardia -anaemia - elevated ESR

9 SEVERITY OF DISEASE Fulminant disease- > 10 stools/day - continuous bleeding -toxicity - abdominal tenderness & distension - anaemia blood transfusion - colonic dilation - toxic megacolon - colonic perforation

10 EXTRA-INTESTINAL MANIFESTATIONS Aphthous ulcer of the mouth Clubbing Iritis, uveitis, episcleritis Seronegativearthritis Ankylosingspondylitis Sacroiliitis Erthyemanodosum Pyodermagangrenosum Primary sclerosing cholangitis Autoimmune haemolytic anaemia Deep vein thrombosis & pulmonary embolism

11 DIAGNOSIS FBC anaemia, thrombocytosis U&E hypokalaemia, hypomagnesemia, pre-renal Liver function tests X-ray Urinalysis Stool culture ESR CRP Perinuclear antineutrophil cytoplasmic antibody (p- ANCA), a myeloperoxidase antigen, is found more commonly in ulcerative colitis

12 ENDOSCOPY Full colonoscopy to the ceacum and terminal ileum Loss of the vascular appearance of colon Erythema and friability of mucosa Superficial ulceration, confluent Pseudopolyps Continuous from the rectum, universally involved Biopsy for histology and culture - CMV

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16 HISTOLOGY Distortion of crypt architecture Cryptitis Crypt abscesses Haemorrhage or inflammatory cells in the lamina propria

17 DIFFERENTIAL DIAGNOSIS Crohn s disease Indeterminate colitis Infective colitis Pseudomembranous colitis Ischaemic colitis Chemical colitis

18 Comparison of Crohn Disease and Ulcerative Colitis Feature Crohn Disease Ulcerative Colitis Rectal disease Occasional Common Abdominal mass Common Not present Ileal involvement Common None ( backwash ileitis) Perianal disease Common Unusual Strictures Common Unusual Fistula Common Unusual Transmural involvement Common Unusual Crypt abscesses Less common Common Granulomas Common Unusual Risk of colonic cancer Slightly increased Greatly increased

19 MANAGEMENT MEDICATION Aminosalicylates sulfasalazine Corticosteroids prednisone Azathioprine Infliximab

20 SURGERY COLECTOMY Indications Failed medical management Exsanguinating haemorrhage Colonic perforation Carcinoma Toxic megacolon

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25 CROHN S DISEASE Idiopathic, chronic transmural inflammation Leads to fibrosis and obstructive symptoms Affects gastrointestinal tract from mouth to anus Imbalance between pro and anti-inflammatory mediators 30% small bowel involvement 30% colon only involvement 40% small and colon

26 PRESENTATION Chronic diarrhoea Abdominal pain Low-grade fever Weight loss Fatigability Cologastric fistulae- feculent vomiting Enterovesicular fistulae- recurrent UTI, pneumaturia Enterovaginal fistulae- feculent vaginal discharge Enterocutaneous fistulae- feculent skin soiling Intraabdominal, retroperitoneal abscesses

27 PRESENTATION 50-70% children have terminal ileum involvement 30-40% children gastric or duodenal inflammation Pancreatitis 30% patients peri-anal complications-skin tags, perianal abscesses & fistulae, anal fissures

28 DIFFERENTIAL DIAGNOSIS Amoebiasis Appendicitis Behcet disease Celiac disease Gastroenteritis-bacterial/viral Giardiasis Ulcerative colitis IBS

29 DIAGNOSIS FBC anaemia, thrombocytosis U&E hypokalaemia, hypomagnesemia, pre-renal Liver function tests- hypoalbuminaemia X-ray Urinalysis Stool culture ESR CRP Anti-S cerevisiaeantibodies [ASCA]) are found more commonly in Crohn disease higher rate of surgery

30 DIAGNOSIS Barium studies-rigidity, pseudodiverticula, fistulization, and submucosal edema. An upper GI series, together with a small bowel followthrough (SBFT) and spot films of the terminal ileum

31 DIAGNOSIS CT is helpful in the assessment of extramural complications, as well as hepatobiliary and renal complications. It may show bowel wall thickening, mesenteric edema, abscesses, or fistulae. MRI has been shown to yield a higher sensitivity and specificity than ileocolonoscopy(criterion standard) for both the diagnosis of Crohn disease and the determination of severity. MRI is especially useful in the evaluation of pelvic and perianal disease when investigating for evidence of perianal disease MRI can be superior to CT in demonstrating pelvic lesions. Because of differential water content, MRI can differentiate active inflammation from fibrosis, and can distinguish between inflammatory and (fixed) fibrostenotic lesions in Crohn disease.

32 DIAGNOSIS MR Enterography(MRE) and CT enterography(cte) are being used increasingly for evaluation of the small bowel. Both of these modalities are as sensitive and specific as SBFT for detecting small bowel inflammation and may be more accurate for detecting extraenteric complications, including fistulae and abscesses. MRE is a particularly attractive option because of the lack of radiation exposure.

33 DIAGNOSIS Ultrasonography is a quick and inexpensive screening method to aid in the diagnosis of IBD or in repeated evaluation of patients for complications. Abdominal ultrasonography can be used to rule out gallbladder and kidney stones. This modality can also detect enlarged lymph nodes, abscesses, stenoses, and fistulae. This technique allows the differentiation of simple from complex fistulae, as well as the assessment of the tracts of the fistulae in relation to the sphincter muscle.

34 DIAGNOSIS Radionucleotidescanning may be helpful in assessing the severity and extent of the disease in patients who are too ill to undergo colonoscopy or barium studies. Leukocytes labeled with either technetium-99m (99m Tc)- HMPAO or indium-111 (111 In) can be used to assess for active bowel inflammation Compared with the111 In label, the99m TcHMPAO label has better imaging characteristics and can be imaged much sooner after injection. However, imaging must typically be performed within an hour after injection of99m Tc-HMPAO-labeled leukocytes, as there is normal excretion into the bowel after this time, unlike111 Inlabeled leukocytes, which have no normal bowel excretion.

35 DIAGNOSIS Colonoscopy can be helpful when single-contrast barium enema has not been informative in evaluating a colonic lesion. Useful in obtaining biopsy tissue, which helps in the differentiation of other diseases, in the evaluation of mass lesions, and in the performance of cancer surveillance. Colonoscopy also enables dilation of fibrotic strictures in patients with long-standing disease. Postoperative period to evaluate surgical anastomoses to predict the likelihood of clinical relapse as well as the response to postoperative therapy.

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39 DIAGNOSIS Upper GI endoscopy with biopsy is helpful in differentiating Crohndisease from peptic ulcer disease in patients with upper GI tract symptoms. Endoscopic retrograde cholangiopancreatography (ERCP) is helpful both as a diagnostic procedure and a therapeutic tool in patients with sclerosingcholangitis and stricture formation. Endoscopic ultrasonography (EUS) and magnetic resonance cholangiopancreatography(mrcp) may provide equally valuable information without invasive complications.

40 DIAGNOSIS Escherichia coli anti-ompc(outer membrane porinc) can be found in greater than 50% of Crohndisease cases, and in only a small percentage of ulcerative colitis cases. Pseudomonas fluorescens(anti-12) may be found in greater than 50% of Crohndisease cases and in only 10% of ulcerative colitis cases. Flagellinlike antigen (anti-cbir1) is associated independently with small bowel, intestinal penetrating, and fibrostenosingdisease. These tests further increase sensitivity and diagnostic value.

41 MANAGEMENT Chronic diarrheain Crohndisease responds well to antidiarrheal agents such as loperamide(2-4 mg), diphenoxylatewith atropine (1 tab), and tincture of opium (8-15 gtt). Such agents may be administered up to 4 times daily, but they should not be given to patients with active colitis because of the risk of developing toxic megacolon. Patients with terminal ilealdisease may not absorb bile acids normally, which can lead to secretory diarrheain the colon. These patients may benefit from bile acid sequestrants(eg, cholestyramine[2-4 g], colestipol [5 g] bid/tidac). Abdominal cramps may be reduced with hyoscyamine(0.125 mg). These drugs should not be used if there is the possibility of a bowel obstruction.

42 MANAGEMENT OF INFLAMMATION Anti-inflammatory drugs or antibiotics are helpful. Sulfasalazine does not alleviate small bowel disease. Mesalamine(Asacol, Rowasa, Canasa) that release 5-ASA in the distal small bowel secondary to ph changes more useful in patients with small intestinal Crohndisease. Antituberculosis therapy, macrolides, fluoroquinolones, 5- nitroimidazoles, and rifaximin(alone or in combination) have been shown to induce remission in active Crohndisease and ulcerative colitis. Further trials of antibiotic therapy are necessary in order to determine the best course of single or combination antibiotic therapy. Long-term maintenance with mesalamine(800 mg tid) may delay clinical relapse. Prednisone (Deltasone, Orasone) (40-60 mg/d) is generally helpful in acute inflammation.

43 MANAGEMENT OF INFLAMMATION Steroids are not indicated for maintenance therapy because of serious complications, such as aseptic necrosis of the hip, osteoporosis, cataract, diabetes, and hypertension. Accordingly, once remission is achieved, the agent is slowly tapered (5-10 mg q1-2wk). If steroid withdrawal proves difficult, immunosuppressants such as azathioprine (Imuran) (2 mg/kg/d) or its active metabolite, 6-MP, may be considered. Response is usually observed within 3-6 months. Mycophenolatemofetil (CellCept) 500 mg twice a day in 2 divided doses is well tolerated by patients and can be used to reduce the steroid dose.

44 MANAGEMENT OF FISTULAE Fistulae between bowel loops (eg, ileoileal, ileocecal, ileosigmoid) are usually benign and may not produce any major problems. Medical management is used to treat underlying infections and symptoms with oral metronidazole (Flagyl, 1 g/d) for at least 1-2 months. Infliximab is effective in patients who have refractory perianal and enterocutaneousfistulae. Current clinical practice is to use it as an intravenous (IV) infusion of 5 mg/kg at 0 weeks, 2 weeks, and 6 weeks, followed by maintenance IV infusions every 8 weeks. On average, the effect lasts for 12 weeks.

45 SURGERY INDICATIONS Persistent symptoms despite high-dose corticosteroids Treatment-related complications, including intraabdominal abscesses Medically intractable fistulae Fibrotic strictures with obstructive symptoms Toxic megacolon Intractable haemorrhage Perforation Cancer

46 SURGERY Crohn disease has no surgical cure. Within 20 years of the onset of symptoms, 75-80% of patients with Crohn disease require surgery Twenty to 30% of patients experience a recurrence of disease within the first postoperative year. Hence, every attempt at conserving the small bowel should be made in the surgical approach to Crohn disease. The most common complication of Crohndisease is small bowel obstruction, occurring in 30%-50% of patients

47 SURGERY The most common complication of surgery for Crohn disease is the development of intraperitoneal adhesions. Patients with Crohndisease undergoing abdominal surgery are also at an increased risk for developing enterocutaneousfistulae as a result of their surgery.