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CD deliverd sep22 final yr.pptx

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CD deliverd sep22 final yr.pptx

  1. 1. Definition it is a conditions characterized by idiopathic chronic inflammation of bowel. . Inflammation limited to mucosal layer of colon. Full thickness inflammation involving any part of the Gl tract from mouth to anus)
  2. 2. CD VS UC
  3. 3. EPIDEMIOLO GY  It can affect any part of GIT from mouth to anus.  most common in North America and Northern Europe with annual incidence of 8 per 100 000.  Prevalence of around 145 per 100 000 in UK.  most commonly diagnosed between the ages of 25 and 40 years.  especially prevalent 3 to 5 times higher in the ashkenazi Jews.
  4. 4. EPIDEMIOLOGY Cosnes et al, 2011
  5. 5. AETIOLOGY  gut mucosa and the normal gut bacteria becomes deranged,  Genetic. 10% first deg relatives.50% in monozygotic twins.  NOD2/CARD15 genes .  Environmental . jews  Infection.mycobacterium DNA.M Johne’s disease of cattle.  Smoking increase risk three fold.cessationeffect equal to medicine.  diet high in refined foodstuff.  sanitation esp in children in childhood.
  6. 6. PATHOGENESIS  increased gut mucosal permeability with ncreased passage of luminal antigens. an abnormal immune- mediated response to colonisation of the gut .  induce a cell-mediated inflammatory response  release of proinflammatory cytokines  a defect in suppressor T-cells function.
  9. 9. CLINICAL FEATURES post prandial colicky pain. • Anorexia, Nausea ,vomiting, • intermittent Fever,wight loss • appendicitis • tender mass inRIF • intestinal obstruction. • local or diffuse Peritonitis. • gall stones • mild prolong Diarrhea. • blood in stool. • anemia,Weight loss common • fulminant colitis
  10. 10.  Gut perforation  Enterocutaneous fistula.interloop,ileovesical,rectovaginal fistulaileosigmoid fistula-profuse diarrhoea.  Periana skin bluish. abscesses and fistulae,Incontinence,watering-can perineum.  Rectal bleeding Growth failure  ‘Metastatic’ CD can occur in the vagina and/or  skin with nodular ulcers,  Malnutrition, vitamin deficiencies
  11. 11. MANIFESTATIONS  retarded growthand sexual development in child.  Amyloidosis.  osteoporosis  Joint pain.  Iritis. uveitis  aphtous ulcers, dysphagia.  Sclerosing cholangitis.  erethema nodosum. pyoderma gangrenosum
  12. 12. PATHOLOGY  terminal ileum is most commonly (65%) alone or with colon  Colitis alone upto a one-third  perianal lesions up to 50–75% cases. 25% per cent of patients  with small bowel disease, but in 75% of patients with Crohn’s  colitis.  characterized by skip lesions, adhesions & fistulas between gut loops.  cobblestone appearance on endoscopy and contrast studies.  fat wrapping of inflamed part of bowel.
  13. 13. PATHOLOGY •areas of normal mucosa in between areas of inflammation ulcerations WITH mucopurulent exudate.. AREA OF STRICTURING AND PRESTENOTIC DILATATIONS. • NC l Granuloma in 60%.most common in anorectal disease. • Submucosal or subserosal lymphoid aggregates. Fissure,fistula,abscess formation
  14. 14. Clinical Features Clinical Feature Ulcerative Colitis Crohn's Inflammation Superficial, continuous Full thickness, patchy Mucosal Ulcers Superficial Deep, linear Involvement Rectum, colon mouth to anus Extra-intestinal Yes Yes Fistulas No Yes Symptoms Bloody diarrhea, Diarrhea, pain, weight loss
  15. 15. Normal colon
  16. 16. WORK UP  BLOOD TESTS  calprotectin test  ENDOSCOPY  ULTRASOUND STUDY  CT SCAN  labelled white cell scan  MR enterography) or enteroclysis
  17. 17. LABORATORY TESTS CBC,RFT,LFT,CRP. ESR-elevated Anemia Leukocytosis hypoalbuminemia Stool RE
  18. 18. Colonoscopy
  19. 19. CT Enterography
  21. 21. MEDICAL TREATMENT 1-CORTICOSTEROID  moderate to severe disease,RAPID remission in 70–80% of cases .  short courses only,Not used for maintenance.  Prednisone (40-60 mg/day) acute episode.  Budesonide ileal or right-side colonic disease  usually replaced with immunomodulatory agents  adrenal suppression.
  22. 22. MEDICAL TREATMENT 2-ASA AGENTS  Mesalamine. small bowel  Mesalazine Asacol,Pentasa  Olsalazine (5-ASA dimer cleaves in colon)  limited efficacy in small bowel CD
  23. 23. MEDICAL TREATMENT 3-immunosuppressive agents . AZATHIOPURINE-6MP used for CURRENTLY STD maintenance therapy,Inhibit cell-mediated responses TPMT activity TEST, myelosuppression Cyclosporine 80% remission.
  24. 24. MEDICAL TREATMENT. 4-MONOCLONAL ANTIBODIES  currently widely used for induction and maintenance.  also appear to be effective treatments for perianal disease  early and aggressive THERAPY at high risk for early RECURRENCE.  Suppress cell mediated immunity, 1ST Gen MAB. Infliximab. TNF BLOCKER.ESP pediatric CD. 2ND-Gen MAB adalimumab. TNF-α blocker. SC 1-2 WKLY 3-RD GEN MAB. integrin Ab. vedulizumab and etrolizumab binds α4β7 and α4β1 receptors .ptevent WBCs migration at site inflammation. COSTLY,,MALIG Contraindications Active infection, tuberculosis ,history of malignancy
  25. 25. MEDICAL TREATMENT  Antibiotics. metronidazole peripheral neuropathy, ciprofloxacin Achilles tendinitis and tendon rupture ESP IN PERIANAL  Antidiarrheal Agents. Loperamide,diphenoxylate.  Bile acid sequestrants .cholestyramine, colestipol  Anticholinergic agents.dicyclomine,hyoscyamine, propantheline
  26. 26. MEDICAL TREATMENT NUTRITIONAL SUPPORT  Elemental diet or parenteral nutrition REMISSION IN 80%  enteral tube or even intravenous feeding
  27. 27. SURGERY IN CD  70% of patients with CD will require a bowel resection in the first decade  fundamental principle is to preserve healthy gut and to maintain adequate function
  28. 28. INDICATIONS OF SURGERY IN CD recurrent intestinal obstruction. persistent or massive acute bleeding. perforation of the bowel. failure of medical therapy. steroid dependent disease. intestinal fistula. perianal disease (abscess, fistula, stenosis). malignant change.
  29. 29. OPERATIONS DONE FOR CD  Strictureplasty  Ileocaecal resection  Segmental resection  Proctectomy and proctocolectomy.  Colectomy and ileorectal anastomosis  Subtotal colectomy and ileostomy  Temporary loop ileostomy.
  30. 30. INDICATIONS OF DELAYED ANASTOMOSIS OR ILEOSTOMY  Intra-abdominal septic compli_x0002_cations are more common if  current high-dose steroid therapy (≥10mg prednisolone for ≥4 weeks before surgery);  current preoperative monoclonal antibody therapy;  preoperative significant weight loss (>10% premorbid weight).  pre-existing abdominal sepsis (notably abscess or fistula);  serum albumin <32 g/L.
  31. 31. APPROACH  ‘step-up’ approach. ESTB TO NEWER.  TOP-DOWN APPROACH. NEWER TO ESTB