Inflammatory Bowel Disease

Inflammatory bowel disease (IBD) is a chronic inflammatory disorder of unknown etiology involving the Gastrointestinal (GI) tract.  IBDs is usually categorized into Ulcerative Colitis (UC) & Crohn’s Disease (CD). Peak occurrence is between ages 15 and 30 and between ages 60 and 80, but onset may occur at any age. IBD is more commonly seen in women and Jewish people are more prone to develop IBD. Smoking may prevent Ulcerative Colitis (UC) but may cause Crohn’s Disease (CD). Pathogenesis of IBD involves activation of immune cells by unknown inciting agent (? Micro-organism, dietary component, bacterial or self-antigen) leading to release of cytokines and inflammatory mediators. There is a genetic component related to this disease suggested by increased risk in first-degree relatives of patients with IBD. Acute flares of the diseases may be precipitated by infections, nonsteroidal anti-inflammatory drugs (NSAIDS & Stress).
Ulcerative Colitis (UC): In this disease there is colonic musosal inflammation; rectum is almost always involved, with inflammation extending continuously proximally for a variable extent. Clinical Manifestations: Bloody diarrhea, mucus with stools, fever, abdominal pain, tenesmus, weight loss. In severe cases; dehydration, anemia, hypokalemia, hypoalbuminemia. Complications: Toxic megacolon, colonic perforation, cancer risk related to extent and duration of colitis. Diagnosis: Sigmoidoscopy or colonoscopic findings: including mucosal erythema, granularity, friability, exudate, hemorrhage, ulcers, inflammatory polyps. Barium Enema showing loss of haustrations, ulcerations and mucosal irregularity. Crohn’s Disease (CD): Crohn’s disease is a chronic inflammatory disorder that may involve any part of alimentary tract from mouth to anus, but with a propensity for the distal small intestine and proximal large bowel. Inflammation in Crohn’s disease often is discontinuous. Clinical Manifestations: Fever, abdominal pain, diarrhea (often without blood), fatigue, weight loss, growth retardation in children, acute ileitis mimicking appendicitis, anorectal fissures, fistulas, abscesses. Clinical course falls into 3 broad patterns i) inflammatory, ii) Stricturing, and iii) Fistulizing. Complications: Intestinal obstruction, intestinal fistulas to bowel, bladder, vagina, skin; bile salt malabsorption leading to cholesterol gall stones, intestinal malignancy, amyloidosis. Diagnosis: made on sigmoidoscopy, colonoscopy (showing nodularity, ulcers, skip areas, strictures); barium enema and CT abdomen showing thickened matted bowel loops or an abscess. Extra-intestinal manifestations of UC & CD: peripheral arthritis, ankylosing spondylitis and sacroilitis, erythema nodosum, aphthous ulcers, conjunctivitis, episcleritis, iritis, uveitis, fatty liver, cholangiocarcinoma, chronic hepatitis.

1) Supportive: Antidiarrheal agents, IV hydration and blood transfusion in severe disease.

2) Sulfasalazine and Aminosalicylates (5-ASA): useful in colonic disease of mild to moderate severity.

3) Glucocorticoids: useful in severe disease and ileal or ileocolonic chronic disease.

4) Immunosuppressive Agents: azathioprine, 6-mercaptopurine. Useful as steroid-sparing agents and in intractable or fistulous CD.

5) Metronidazole: appears effective in colonic CD and refractory perianal CD.

6) Others: Cyclosporine in severe UC and intractable crohn’s fistula. Infliximab: monoclonal antibody to tumor necrosis, factor induces responses in both UC and CD refractory to 5-ASA, glucocorticoids and 6-mercaptopurine. Adalimumab: is humanized version of the anti-TNF antibody that is used in both UC & CD. Natalizumab: is an anti-integrin antibody with activity against CD. Vedolizumab: monoclonal antibody which is more gut selective in its effects. Surgery: ulcerative colitis – colectomy (curative) for intractability, toxic megacolon, cancer, dysplasia, ileal pouch-anal anastomosis. Chron’s Disease – resection for fixed obstruction for stricturoplasty.




Source: greaterkashmir.com