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Inflammatory Bowel DiseaseInflammatory Bowel Disease
David S. Kauvar, MDDavid S. Kauvar, MDCPT, MC, USACPT, MC, USA
Department of General SurgeryDepartment of General Surgery
Brooke Army Medical CenterBrooke Army Medical Center
Fort Sam Houston, TXFort Sam Houston, TX
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OutlineOutline
OverviewOverview
EpidemiologyEpidemiology
Clinical featuresClinical features
EtiologyEtiology
PathologyPathology
WorkupWorkup
Medical and Surgical TherapyMedical and Surgical Therapy
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OverviewOverview
Two similar but distinct diagnosesTwo similar but distinct diagnoses
Ulcerative ColitisUlcerative Colitis
Confined to ColonConfined to Colon
Crohn's DiseaseCrohn's Disease
Small/Large BowelSmall/Large Bowel Intestinal and ExtraIntestinal and Extra--Intestinal featuresIntestinal features
Medical and Surgical TherapyMedical and Surgical Therapy
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EpidemiologyEpidemiology
Ulcerative ColitisUlcerative Colitis
Prevalence 60/100KPrevalence 60/100K
Incidence 6/100KIncidence 6/100K
Industrial NationsIndustrial Nations
White, JewishWhite, Jewish
Men = WomenMen = Women
Onset 15Onset 15--40 y40 y
5% after 60 y5% after 60 y
Crohn'sCrohn's Prevalence 10Prevalence 10--
70/100K70/100K
Incidence 1Incidence 1--6/100K6/100K
Industrial NationsIndustrial Nations
Jewish, Educated,Jewish, Educated,
UrbanUrban
Men = WomenMen = Women
1515--30 y, 5530 y, 55--60 y60 y
Both carry increased risk of colon cancer
Risk is proportional to duration of active disease
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Distinguishing Clinical FeaturesDistinguishing Clinical Features
Ulcerative ColitisUlcerative Colitis
Bloody diarrheaBloody diarrhea
ContinuousContinuous
colitiscolitis
Rectum toRectum toCecumCecum
Crohn'sCrohn's
NonNon--bloodybloody
diarrheadiarrhea
Perianal diseasePerianal disease
DiscontinuousDiscontinuous
ColitisColitis
Skip lesionsSkip lesions
anywhere inanywhere in
GI tractGI tract
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PresentationPresentation
Ulcerative ColitisUlcerative Colitis 60% Mild Colitis60% Mild Colitis
Bloody DiarrheaBloody Diarrhea
Abdominal painAbdominal pain
25% Moderate Colitis25% Moderate Colitis
AnemiaAnemia
MalnutritionMalnutrition
15% Severe Colitis15% Severe Colitis Toxic MegacolonToxic Megacolon
PerforationPerforation
SepsisSepsis
Crohn'sCrohn's
NonNon--Bloody DiarrheaBloody Diarrhea
Abdominal PainAbdominal Pain
Weight LossWeight Loss
1010--20% Appendicitis20% Appendicitis
2525--50% Peri50% Peri--AnalAnal
DiseaseDisease StrictureStricture--ObstructionObstruction
Fistula with AbscessFistula with Abscess
Can mimic AppendicitisCan mimic Appendicitis
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Ulcerative ColitisUlcerative Colitis
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CrohnsCrohns
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ExtraExtra--Intestinal FindingsIntestinal Findings((Either DiseaseEither Disease))
CutaneousCutaneous PyodermaPyoderma
gangrenosumgangrenosum
Erythema nodosumErythema nodosum
OcularOcular ConjunctivitisConjunctivitis
EpiscleritisEpiscleritis
UveitisUveitis
IritisIritis
IridocyclitisIridocyclitis
MusculoskeletalMusculoskeletal
ArthritisArthritis
AnkylosingAnkylosing
SpondilitisSpondilitis BiliaryBiliary
Primary SclerosingPrimary Sclerosing
CholangitisCholangitis
All except Biliary can improve in Ulcerative Colitis
once the Colon is removed
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Pyoderma GangrenosumPyoderma Gangrenosum
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Erythema Nodosum
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Conjunctivitis
EpiscleritisUveitis
Iritis
Iridocyclitis
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Ankylosing Spondylitis
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Primary SclerosingPrimary Sclerosing
CholangitisCholangitis
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EtiologyEtiology
Ulcerative Colitis & Crohn'sUlcerative Colitis & Crohn's
InfectionInfection
Immune (auto?)Immune (auto?)
GeneticGenetic
Environmental factorsEnvironmental factors
No one really knows for sureNo one really knows for sure
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Bacteria & VirusesBacteria & Viruses
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DNA Repair and Class II MHC Genes
99--10% of UC patients have an affected family member10% of UC patients have an affected family member
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Immune dysfunctionImmune dysfunction
in the bowel wallin the bowel wall
InappropriateInappropriate
cytokine productioncytokine production
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PathologyPathology
Ulcerative ColitisUlcerative Colitis
ContinuousContinuous
Rectum toRectum toCecumCecum
MucosalMucosal
Crypt AbscessesCrypt Abscesses
Lead pipeLead pipe
PseudopolypsPseudopolyps
Crohn'sCrohn's
DiscontinuousDiscontinuous
TransmuralTransmural
Skip LesionsSkip Lesions-- LipsLips
to Anusto Anus
GranulomasGranulomas
Creeping fatCreeping fat
CobblestoneCobblestone
Fistulas, StricturesFistulas, Strictures
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Ulcerative ColitisUlcerative Colitis
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RectumCecum
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CrohnsCrohns
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Crohn's strictureCrohn's stricture
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Crohn's Colon UlcerCrohn's Colon Ulcer
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Crohn's EnterocolonicCrohn's EnterocolonicFistulaFistula
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Crohn'sCrohn's
stricture withstricture with
obstructionobstruction
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Crohn's skip lesionsCrohn's skip lesions
Ulcerative ColitisUlcerative Colitis
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The Workup of IBDThe Workup of IBD
Ulcerative ColitisUlcerative Colitis
HistoryHistory
ColonoscopyColonoscopy
BiopsyBiopsy
SBFTSBFT
CT ScanCT Scan
Crohn'sCrohn's
HistoryHistory
ColonoscopyColonoscopy
BiopsyBiopsy
SBFTSBFT CT ScanCT Scan
Pill Cam?Pill Cam?
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ColonoscopyColonoscopy
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Ulcerative Colitis:Ulcerative Colitis:
PseudopolypsPseudopolyps
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Chrons: Severe UlcersChrons: Severe Ulcers
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SBFTSBFT
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Crohn's: Stricture/ObstructionCrohn's: Stricture/Obstruction
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Crohn's: Stricture
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Crohn's: Entero-Colonic
Fistula
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CAT ScanCAT Scan
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Crohns: CT appearanceCrohns: CT appearance
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Ulcerative Colitis: Pneumatosis IntestinalisUlcerative Colitis: Pneumatosis Intestinalis
in toxic Megacolonin toxic Megacolon
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TreatmentTreatment
MedicalMedical
Similar for both diseasesSimilar for both diseases
SurgicalSurgical
Can provide a cure for UCCan provide a cure for UC
Only palliative for CrohnsOnly palliative for Crohns
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Medical TherapyMedical Therapy
UCUC 55--ASAASA
SteroidsSteroids
AntibioticsAntibiotics
ChemotherapyChemotherapy
AzathioprineAzathioprine
CyclosporineCyclosporine
MethotrexateMethotrexate Biologics?Biologics?
RemicadeRemicade
Crohn'sCrohn's 55--ASAASA
SteroidsSteroids
BedesonideBedesonide ChemotherapyChemotherapy
AzathioprineAzathioprine
CyclosporineCyclosporine
MethotrexateMethotrexate FlagylFlagyl
BiologicsBiologics
InfliximabInfliximab
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55--ASA MedsASA Meds
Similar to aspirinoral and intraluminal
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SteroidsSteroids
AntiAnti--inflammatory activityinflammatory activity----oral and intraluminaloral and intraluminal
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Antibiotics/AntiviralsAntibiotics/Antivirals
Uncertain role in both diseasesUncertain role in both diseases
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ChemotherapyChemotherapy
ImmunosuppressiveImmunosuppressive effects
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BiologicsBiologics
TargetedImmune Modulation TherapyTargetedImmune Modulation Therapy
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Surgery in UCSurgery in UC
CurativeCurative Disease confined to ColorectalDisease confined to Colorectal
mucosamucosa
IndicationsIndications Failure of Medical TherapyFailure of Medical Therapy
Eliminate cancer riskEliminate cancer risk
Improve extracolonic diseaseImprove extracolonic disease Total ProctoTotal Procto--ColectomyColectomy
Anastomosis vs StomaAnastomosis vs Stoma
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Total ProctocolectomyTotal Proctocolectomy
No stoma, temporary stoma, permanent stomaNo stoma, temporary stoma, permanent stoma
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End IleostomyEnd Ileostomy
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JJ--Pouch ReconstructionPouch Reconstruction
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JJ--Pouch ReconstructionPouch Reconstruction
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Surgery in CrohnsSurgery in Crohns
Treat complications and symptomsTreat complications and symptoms
IndicationsIndications
Obstruction, fistula, abscess, bleedingObstruction, fistula, abscess, bleeding
LongLong--term pancolitis (cancer risk)term pancolitis (cancer risk)
OperationsOperations
Stricturoplasty, resection, bypass,Stricturoplasty, resection, bypass,
drainagedrainage
Guiding principle: Preserve BowelGuiding principle: Preserve Bowel
LengthLength
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Surgery in CrohnsSurgery in Crohns
Recurrent DiseaseRecurrent Disease
60% @ 5y60% @ 5y
95% @ 20y95% @ 20y
Need for more SurgeryNeed for more Surgery
20% @5y20% @5y
33% @10y33% @10y
50% @20y50% @20y
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Take Home PointsTake Home Points
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PresentationPresentation
Ulcerative ColitisUlcerative Colitis Bloody DiarrheaBloody Diarrhea
No PeriNo Peri--Anal diseaseAnal disease
Toxic MegacolonToxic Megacolon
CrohnsCrohns
Non Bloody DiarrheaNon Bloody Diarrhea Abdominal pain/obstructionAbdominal pain/obstruction
PeriPeri--Anal diseaseAnal disease
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PathologyPathology
Ulcerative ColitisUlcerative Colitis
Continuous; Rectum to CecumContinuous; Rectum to Cecum
Confined to mucosaConfined to mucosa
CrohnsCrohns
Discontinuous; Small BowelDiscontinuous; Small Bowel
Full thicknessFull thickness
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WorkupWorkup
Both UC and CrohnsBoth UC and Crohns
H & PH & P
Colonoscopy, BiopsyColonoscopy, Biopsy
Small Bowel follow throughSmall Bowel follow through
CT ScanCT Scan
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TreatmentTreatment
Ulcerative ColitisUlcerative Colitis
Medical TherapyMedical Therapy
Surgery is curativeSurgery is curative
CrohnsCrohns
Surgery for complications onlySurgery for complications only
Preserve Bowel lengthPreserve Bowel length
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Thank You.Thank You.