Inflammatory Bowel Disease (IBD) – At A Glance

Inflammatory bowel disease (IBD) is chronic inflammatory disorder of the GI tract without any identifiable cause and it is comprised of….

  • Ulcerative colitis
  • Crohn’s disease
 
It is always not possible to pathologically differentiate between these two, therefore another entity is added called “Indeterminate colitis” 

Incidence 
  • Ulcerative colitis 
    • 26 per 100 000 individuals 
    • Both sexes are equally affected 
    • Less common in smokers
    • Two peek presentations
      • 15-25 years 
      • 55-65 years
  • Cronh’s disease
    • 6 per 100 000 individuals 
    • Females are more affected 
    • Smoking increases the risk
  • More common in developing countries


Aetiology Of IBD
 
This remains unknown and it is believed to be due to….
  • Genetic predisposition (Ulcerative colitis has an associated family history)
  • Autoimmune state / Dysregulated immune state
  • Post-infection of the gut
  • Environmental factors
  • Dietary factors 
 
 
Clinical Features Of IBD
 
Ulcerative Colitis
Cronh’s Disease
• Insidious and intermittent presentation
• Bloody diarrhoea with mucous
• Associated with urgent defecation
• Abdominal pain in the lower left quadrant
• Constipation

• Tenesmus

• Diarrhoea – Usually non bloody
• Abdominal pain in right iliac fossa and sometimes a mass can be felt
• Weight loss is more pronounced
• Mouth ulcers
• Perianal disease – Anal fissure, ulcer, infection

• Intestinal obstruction – Due to strictures

Extra-intestinal manifestations
 

Extra-intestinal manifestations include….

  • Skin
    • Pyoderma gangrenosum
    • Erythema nodosum 
  • Mucous membranes
    • Aphthous ulcers of mouth and vagina 
  • Eyes
    • Uveitis – Common in UC
    • Episcleritis – Common in CD
  • Skeletal 
    • Arthritis – Most common extra-intestinal manifestation 
    • Ankylosing spondylitis 
    • Athropathy
  • Hepatobiliary 
    • Gallstones
    • Cirrhosis
    • Pimary sclerosing cholangitis
  • Renal
    • Nephrolithiasis
  • Clubbing
Inflammatory bowel disease (IBD)

Histopathological Features Of IBD

Ulcerative Colitis
Cronh’s Disease
• Inflammation begins at the rectum
• Commonly involves the rectum and sigmoid colon
• Continuous disease ; backwash ileitis may occur

• Never spread beyond ileocaecal valve

• Lesions can occur anywhere from mouth to anus
• Commonly involves the terminal ileum
• Skip lesions are present / Patchy involvement
• Involves only mucosa and submucosa
• Crypt abscess | Inflammatory cells are the lamina propria 

• Goblet cells and mucin are depleted from gland epithelium
• Contact bleeding
• Inflammatory pseudopolyps  

• Transmural involvement
• Granuloma (Non caseating epithelioid cell aggregates with Langhans’ giant cells)

• Goblet cells present

 

Investigations Of IBD

  • Sigmoidoscopy / Colonoscopy 
    • Should not be performed during acute colitis – Increased risk of perforation 
    • Biopsy should be obtained
    • Helps to differentiate between UC and CD by identifying the above mentioned factors
 
Fig : Sigmoidoscopy findings

  • Barium enema 
    • In UC
      • Decreased haustrations
      • Colon become short and narrow – Hosepipe / drainpipe colon
      • Superficial ulceration involving rectum and extending proximally 
      • Pseudopolyps  
    • In CD
      • Skip lesions
      • Common in terminal ileum | Rectal sparing
      • Cobblestone appearance of mucosa
      • Rose thorn ulcers
      • Fistulas 
      • Strictures
  • Barium meal
    • In CD – Kantor’s string sign can be seen
      • Long narrowed areas with proximal dilatation
  • Haematological tests
    • Complete blood count
      • Anaemia
      • Leukocytosis
      • Thrombocytosis in acute CD
    • ESR, CRP is raised 
    • Serum albumin – Low
    • Antibody tests
      • pANCA – Present in UC
      • ASCA – Present in CD
 
 
Medical Management Of IBD
Ulcerative colitis 
  • During active disease
    • Rectal aminosalicylates (Rectal mesalazine) or rectal steroids
      • Rectal mesalazine is superior than steroids
    • Oral aminosalicylates and oral steroids
  • During remission
    • Oral aminosalicylates – Mesalazine
 
Cronh’s disease
  • During active disease
    • Advice to cease smoking 
    • Steroids – Oral / IV
    • Azathoprine is used as a second line drug in active disease
    • Methotraxate can be given to patients who cannot tolerate Azathioprine
    • Infliximab – Refractory disease 
    • Perianal disease – Metronidazole 
 
General measures
  • Correction of anaemia
  • Correction of electrolyte imbalances 
  • Nutritional supplementation
  • DVT prophylaxis
 
 
Surgical Management Of IBD
This is discussed in a separate topic. Click the link below to read about the surgical management of IDB. 
 

Complications Of IBD

  • In UC
    • Toxic megacolon 
    • Peforation
    • Haemorrhage
    • Malignant transformation
  • In CD
    • Stricture 
    • Fistula
    • Perianal sepsis
    • Perforation 
 
 
Consequences Of Terminal Ileal Crohn’s
  • Impaired absorption of….
    • Albumin 
    • Bile salts
    • Vitamin B12
    • Calcium
  • Leading to….
    • Hypoalbuminaemia  Peripheral oedema, hypotension 
    • Bile salts → Reduced fat absorption  Reduced absorption of vitamin A, E, D, K
      • Vitamin K → Clotting factor deficiency (II, VII, XI, X) → Coagulopathy
      • Vitamin A → Reduced vision
      • Vitamin D → Hypocalcaemia
    • Vitamin B12 deficiency → Megaloblastic anaemia, peripheral neuropathy
    • Hypocalcaemia → Bone pain, pathological fracture 
 
 
Criteria To Detect Acute Severe Colitis
  • Stool frequency more than 6 times a day
  • ESR more than 30 mm/hr
  • Tachycardia more than 90 bpm
  • Temperature more than 37.8 °C
  • Anaemia 
  • Tender distended abdomen 
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