1. Inflammatory bowel disease (IBD) includes ulcerative colitis and Crohn's disease, which are characterized by chronic inflammation of the gastrointestinal tract. 2. Ulcerative colitis commonly affects the rectum and lower colon, while Crohn's disease can impact any part of the GI tract and often presents as transmural inflammation with skip lesions. 3. Treatment for IBD depends on disease severity and location but commonly includes 5-aminosalicylates, corticosteroids, immunomodulators, antibiotics, biologics, and potentially surgery for complications.

1. z
Inflammatory
bowel disease
o Ulcerative colitis
o Crohn’s dissease

2. z Irritable bowel disease
 Epidemiology
 Pathogenesis:
1. Defective immune regulation
o T cells anergy, to antigens,inhibitory cytokines
elevation[IL-10,TGF]
1. Inflammatory cascade-
2. Exogenous factors
3. Psychosocial factors

3. z Ulcerative colitis
 PATHOLOGY
1-Macroscopic:40-50%rectum,30-40%
rectosigmoid,20% total colons
 Pathologic Changes
I. Mild and moderate inflammation
Oedematous,granular like sand paper
I. Severe inflammation
Oedematous,Hemorrhagic,ulcerative
I. Fulminant disease
Thin and severely ulcerative
2-Microscopic:vascular congestion,oedema,infiltration of
neutrophil,lymphocyte,macrophage and plasmacells,crypt abcess and
inflammation

4. z
Sign and symptoms of Ulcerative colitis
 SYMPTOMS
 Diarrhea
 Rectal bleeding
 Tenesmus
 Abdominal Cramps
 SIGNS
 Pain in proctitis
 Abdominal tenderness in extensive
colitis
 Hepatic tympani in toxic megacolon
 Signs of peritonitis in Perforation

5. z
Diagnosis of Ulcerative colitis
 Sign and symptoms
 Laboratory findings:
ESR,CRP elevation,leukocytosis,HB falls
PANCA positive 60-70% UC,ASCA positive in 60-
70% of Crohn,s disease
 Radiography:Abdominal X-ray
 Endoscopy,colonoscopy,sigmoidoscopy
 Biopsy

6. z
Differential
diagnosis of
ulcerative
colitis

7. z
Ulcerative
Colitis
Complications
1. Local
complications
2. Systemic
Complications

8. z
Local complications of Ulcerative colitis
1. Massive GI Bleeding-10%
2. Toxic megacolon-5%
3. Obstruction-10%
4. Perforation-peritonitis
5. Cancer:0.5-1% risk of cancer
every year

9. z

10. z
Systemic complications
of Ulcerative Colitis
1. Dermatologic Manifestations-Erythema nodusum,pyoderma
gangrenosum,pyoderma vegetans,sweets syndrome,psoriasis
2. Rheumatologic manifestations-Arthtiritis,ankylosing
spondylitis,Sacroilitis
3. Ocular Manifestations-conjunctivitis,iritis,uveitis,Episcleritis
4. Hepatobiliary manifestations:fatty liver,cholelithiasis
5. Urologic:nephrolithiasis,obstruction,fistula
6. Metabolic bone disorder:osteoporosis,osteonecrosis
7. Thromboembolic disorders

11. z
Treatment of
Ulcerative colitis
 Mild to moderate distal colitis
 Mild to moderate colitis
1. 5-ASA agent
2. Corticosteroids
3. Immunomodulating agent
4. Probiotic
5. Antibiotic
6. Surgical treatment
 Severe colitis

12. z

13. z Severe Colitis
 General Measurements:
o TPN
o Volume replacement
o Electrolyte correction
o Blood transfusion
 Corticosteroids:
o Methylprednisolone 40-60mg
o Hydrocortisone 300mg/day
 Anti TNF therapy:infliximab 5mg/kg
 Cyclosporine:2-4mg/kg/day

14. z
Surgical Treatment
 Indications
 Fulminant disease
 Toxic megacolon
 Colonic Perforation
 Massive colonic hemorrhage
 Colonic obstruction
 Colonic cancer prophylaxis

15. z
 Pathology
I. MACROSCOPIC:30-40% small intestine, 40-
55%small intestine and colons,15-20 only colons
Transmural,segmentalsatellite ulceration,cobblestone
I. MICROSCOPIC:
Aphtoid ulceration,crypt abcess,lymphoid
aggregation,transmural inflammation

16. z CLINICAL FINDINGS OF CROHN’S DISESE
I. Ileocolitis: RLQ,Diarrhea
II. Enterovesical fistulas,Enterovaginal
fistulas
III. Jejuno ileitis:Malabsorption
IV. Colitis with perianal
disease:fever,diarrhea,abdominal
pain and cramps,hematochezia
V. Gastroduodenal
disease:nausea,vomiting,epigast
ric pain

17. z
Laboratory and radiographic findings in
crohn’s disease
 ESR,CRP elevated
 Hypoalbuminemia,Anemia,Leuko
cytosis in progressive disease
 Cobblestone
 Aphtous ulcer
 Stricture
 Fistula
 Abcess

18. z
Local complications of Crohn’s disease
 Intestinal obstruction
 Abcess
 Fistulas
 Perianal disease
 Bleeding
 Malabsorption
 carcinoma

19. z
Differential diagnosis of Crohn’s disease
 Ulcerative colitis
 Irritable bowel syndrome
 Appendicitis
 Yeresina enterocolitis
 Intestinal lyphoma
 Tuberculosis
 Diverticolosis
 Ischemic colitis NSAID induced collitis

20. z Treatment of Crohn’s disease
Goals:symptoms relieving, controlling inflammatory process,preventing
complications
1. Nutrition
2. Symptomatic medications
3. Specific drug therapy
 5-Aminosalicylic acid agent
 Antibiotics
 Corticosteroids
 Immunomodulating drugs
 New immunomodulating drugs

21. z
Treatment of Crohn’s disease
 NUTRITION
 Resected terminal ileum:low fat diet, vit B12
100mcg IM monthly
 High fiber Diet
 Avoiding carbohydrates in lactose intolerance
 Entral therapy
 Parentral therapy

22. z
Treatment of Crohn’s disease
 Symptomatic medications
 Secretary Diarrhea
:Cholestyramine,Colestipol,Colesevelam
 Bacterial overgrowth:Broad spectrum Antibiotics
 Loperamide 2-4mg QId

23. z
Treatment of Crohn’s disease
 Specific Drug Therapy
I. 5-Aminosalicylic agent
II. Antibiotics
III. Corticosteroids
IV. Immunomodulating drugs
V. Anti TNF therapy{newer immunomodulating drugs}

24. z
Treatment of Crohn’s disease
 5-ASA AGENTS
 Mesalamine 2.4-
4.8g/day
 Sulfasalazine 3-4g/day
• Antibiotics
 Ciprofloxacin 500mg BID
 Metronidazole 10-
15mg/kg/day
 Rifaximin
 Levofloxacin

25. z
Treatment of Crohn’s disease
 Corticosteroids
 Budesonide 9mg OD for 8-
16weeks
 Prednisolone,Methylprednisolo
ne 40-60 mg for 8-15weeks
 Side
effects:cataract,HTN,Diabetes
melitius
,oskteoporosis,asceptic
necrosis of hips
 Immunomodulating drugs
 Azathioprine 1.5-2.5mg/kg/day
 Mercaptopurine 1-1.5mg /kg/day
 Methotrexate 25mg IM or SC weekly for12
weeks
 Anti TNF therapy{newer immunomodulating
drugs}
 Infliximab 5mg/kg 0.2.6 weeks then
maintenance therapy
 Adalimumab 160mg 1st week 80mg 2nd week
then 40mg every 2weeks

26. z
Surgical treatment
 Indication
 Small intestine
 Unresponsive to medical therapy
 Stricture and obstruction
 Massive hemorrhage
 Refractory fistula
 Abcess
 Colon and rectum
 Cancer prophylaxis
 Colonic obstruction
 Refractory fistula
 Fulminant disease
 Perianal disease
unresponsive to medical
therapy

27. z
INFLAMMATORY BOWEL DISEASE
AND PREGNANCY
I. Patients with quiescent UC and CD have normal fertility rates
II. perirectal, perineal, and rectovaginal abscesses and fistulae can result in
dyspareunia
III. Infertility in men can be caused by sulfasalazine
IV. Spontaneous abortions, stillbirths, and developmental defects are increased with
increased disease activity, not medications
V. Most CD patients can deliver vaginally, but cesarean delivery may be the preferred
route of delivery for patients with anorectal and perirectal abscesses and fistulas
VI. Sulfasalazine,mesalamine,Balsazide are safe in pregnancy
VII. Safest antibiotics:ampicillin,cephalosporins,metronidazole
VIII. Methootrexate is contraindicated

28. z
Cancer and IBD
 UC
A. Long-standing UC are at increased risk
B. 2% after 10 years, 8% after 20 years,18% after 30 years of disease
C. Risk factors for cancer in UC include long-duration disease, extensive
disease, family history of colon cancer, PSC
Crohn’s disease
A. Risk factors:long-duration and extensive disease, bypassed colon
segments, colon strictures, PSC, family history of colon cancer.
B. cancer risks in CD and UC are probably equivalent for similar extent and
duration of disease