1. CROHN’s DISEASE Definition
Granulomatous inflammatory disease, non specific, producing necrosis and scaring of segments of gastrointestinal tract, which is chronic and develops in recurring episodes :
Acute phase (inflammation) = deep ulcers +/- perforations with abscess formation and adhesions to adjacent structures
Chronic phase (fibrotic) = stricture formation.
Epidemiology
High incidence in Scandinavia, N-V Europe and N-E of North America
Maximum incidence y;
More in Caucasians and Jewish population
More in women

2. CROHN’s DISEASE Ethiology: Unknown, probably multifactorial;
Potential factors involved:
Genetic:
Both twins develop disease;
Higher chance for an individual with familial clustering of Crohn’s;
Infectious:
Sugested by the presence of granuloma
There is evidence for: viruses, bacteria and mycobacteria
Concomitent infections – E. coli, Clostridia, Campylobacter.
Alergies:
Alergens in food and inhaled (fungus, molds) – anamnestic data, alergic testing and more favorable results with specific hyposensitisation
Food:
Elimination of weath flour and sugar = evident augmentation

3. CROHN’s DISEASE Immunological
Association with: arthritis, eritema nodosum: complex Ag-Ab should be present
Presence of Ab against different Ag structures and increase concentration of IgA;
Inflammatory infiltration and epitheliod granuloma formation = high level immune cell mediated reaction against Ag structures;
Corticoids and immune suppresive medication are highly effected in Crohn’s disease;
Probable: immune changes at the level of the mucosa with hyperactive immune response against foreign Ag with cross reaction and nonspecific tisular injury (innocent bystander)

4. CROHN’s DISEASE

5. CROHN’s DISEASE Pathology: distribution: Number of lesions
Terminal ileum and colon 90% of cases;
Oro pharinx, esophagus, stomach and duodenum – very rare;
Number of lesions
Numerous lesions with normal segments in between ESSENTIAL of diagnostic

6. Macroscopy
Edema, eritema, ulcerations, pseudopolyps, fibrosis, sclerosis
Acute phase: bowel
edema, enlarged, inflammed (redish), inert
friabile;
Limits: very clearly delimited
Diseased areas are separated by normal segments ;
Mesentery
Edema, infiltrated with lymph node hypertrophy
Sometimes more extensive then bowel lesions

7. CROHN’s DISEASE
Presence of ulcer and ulcerations – can be very small or serpent like + transverse ulcers producing the image of islands (cobblestone);
Fissures and ulcers are the origin of fistulas (entero-enteric, entero-colic, entero-cutaneous, entero-vezical, entero-vaginal)

8. BOALA CROHN
pseudopolyps

9. Fibrosis, sclerosis, structure formation
Bowel wall very thick (up to 1cm)
Structures, short or long, unic or multiple;
Advanced stages: on long continuous stenosis

10. CROHN’s DISEASE
Mycroscopy: characteristic = granuloma with epithelioid giganto cellular cells :
Giant cells + Langerhans cells + limphocytes (+ plasma cells, eosinophils and PMN);
Never caseous necrosis≠tuberculosis;
Same inflammation in regional lymphnodes
Inflammatory infiltration is found through all strata of the bowel wall;

11. CROHN’s DISEASE Symptoms A. symptoms associtaed with bowel problems
Insidios onset but mai also be sudden;
A. symptoms associtaed with bowel problems
PAIN
Dull pain, medium intensity in the RLQ
Colicky when associated with obstruction: may be projected in the upper abdomen.
DIARHEA
4-6/day – watery or semisolid
Proportional to extent of lesions and activity of disease;
Bleeding per rectum: distal lesions.
NAUSEA, VOMITING, BORBORISM.
B. general symptoms
fever 38 0C, +/- chills
Weight loss: diarhhea plus reduced surface for nutrient absorbtion

12. CROHN’s DISEASE C. extraintestinal Skin Urinary Joints Ocular
„metastatic” ulcers – submamar, subpubian, abdomen;
Parastomal ulceration
Anal and perianal ulcerations:
eritema nodosum;
Aftoid oral ulcerations
Pyoderma gangrenosum.
Joints
Peripheral arthriits
Spondilitis ankilopoetica
Artralgia.
Hepatobiliary
Sones due to interruption of enterohepatic cycle;
Granulomatous hepatitis;
Steatosis ;
Cholangitis;
Fibrosis.
CROHN’s DISEASE
Urinary
Stones;
Hydronefrosis;
Fistula.
Ocular
Iridociclitis ;
keratitis;
conjunctivitis;
uveitis
Hematological
anemia;
trombocitosis;
limfocitosis – B12, ferum, folic. acid deficit

14. CROHN’s DISEASE Clinical examination
general: malnurishes, pale, cutaneous lesions;
abdomen:
inspection
nothing
Regional distension (stenosis);
P.O. scars – important postapendectomy .
palpation
Pain in the RLQ
Guarding: perforative complications;
Palpable bowel loop in RLQ, deep, badly delimited, painful.
percution
dull
ascultation
borborism, sometime.
perineal region
Perianal fistula;
ulcerations;
fissure.
rectal
Often nothing;
Sometimes diffuse inflammation.
Fistula
entero-cutaneous  visible;
entero-vezical
disuria, polakiuria
pneumofecaluria.
recto-vaginal – symptoms and visible on direct examination.
in the gallbladder: similar with acute cholecistitis
retroperitoneal – diffuse celulitis (very severe but very rare)

15. CROHN’s DISEASE Paraclinical Lab
anemia – most oftem microcytic, hypochromc but macrocytic anemia can develop (B12 deficit)
leucocitosis
In acute phase
in complications (absces, fistula)
trombocitosis
ESR increased;
Electrolite embalance due to diarhea

16. Radiology - barium meal
Alternation of normal and affected areas
Early stages
nonspecific;
irregular folds, thickened folds;
Ulcers: deep in the wall aspect of rose thorn associating 3 aspects
Pseudopolyps;
Small spiculiform lateral ulcerations
Large ulcers ;
IRREGULAR COBLESTONE
Advanced stages
No more folds;
Rigid stenotic tube
Stenosis + distended segments above;
Fistulas.
particular
Terminal ileum – rigid cord;
Cecum – filling defect on the inner border + retraction.

17. Endoscopy GOLD STANDARD
Small lesions + biopsy + extent of lesions + monitor
Rectoscopia:
75% normal;
Coblestones aspect
Ulcers or stenosis
friable mucosa that bleeds on touch.
Colonoscopy – similar + ileum!!!
Gastroscopy

18. Biopsy Others: Laparoscopy Deep + multiple Even in normal area.
Plain abdominal X-ray – in onclusive disease;
Bone X-ray for associated bone disease;
Fistulography.
Laparoscopy

19. CROHN’s DISEASE Diagnostic: positive Clinical scenario Radilogy
Young pt with diarhhea, abdominal pain I RLQ (often) +/- mass on palpation +/- fissure or fistula perianal..
Radilogy
segmentary, discontinuous lesions and asymetric lesion;
Deep transmural ulcers;
„cobblestone”, „string sign”, presence of pseudopolipilor;
Stenosis and fistula.
Endoscopy
Skip lesions;
Multiple ulcers associated with edematous mucosa +/- stenosis
Pathology
epithelio-giganto-celular granuloma;
lymphocytes and plasma cells infiltration - suggestive

20. Diferential 1. Ileal disease
BOALA CROHN
Diferential 1. Ileal disease
Acute ileitis
Acute apendicitis, apendiceal plastic peritonitis.
tuberculosis
More general signs and PPD+;
Biopsy.
Adnexal tumors.
Ileal carcinoid tumors: carcinoid syndrome
Radiation enteritis
After RXT and diseapears after months.
Cecal tumors – local aspects may be misleading

21. Diferential 2. colonic disease
BOALA CROHN
Diferential 2. colonic disease
Ulcerative colitis
Colonic cahnges in laxative abuse
Watery diarrhea in a person that uses laxatives
Rx – loss of haustrations and signs of iritable bowel syndrome.
Ischemic colitis
Diverticulosis
Cancer
Poliposis
IBS

22. Complications - local Abscess formation Fistula Stenosis
Inflamatory or scars;
Incomplete obstruction
GI Bleeding - mostly from colic origin
Perforation: free perforation with peritonitis is very unusual.
Toxic megacolon – rare but very serious disease
Toxic status + fever + major abdominal pain + bloody and mucus diarrhea + abdominal distension
RX massive distension and destructuring

23. Complications - general
Extraintestinal may be considered part of the disease or complications if severe
Cutaneous, joints, liver, small vessels (thromboembolic disease, Takayashu disease
Renal
Urinary lithiasis Obstructions due to mechanical compression of urethers;
Neuropsyhic:
Sciesures or tetany due to hypoC and hypoMg
Anorexia
Psihosis.
Malabrobtion with consequences on growth.
Amiloidosis (visceral and renal) – after 10 years of evolution
Endocrine:
amenoreea, infertility, late puberty
Small bowel or colonic cancer – after many years

24. TREATMENT Medical Symptomatic General Pain therapy Bed rest
Psihoterapy;
Dietary
hypercaloric, hperproteic, vitamines (folic, A, D, K, C, B12) and minerals (Ca++, Mg++, K+, Fe++, Zn++);
EXCLUDE:
Food with many fibers )mostly in pt with stenosis;
Milk – intolerance ;
Lipids in case of malabsorbtion of lipids.
MAJOR situations- TPN
Symptomatic
Pain therapy
Treat diarrhea:
codeine phosphat
Treat dep on cause:
No spices ;
No milk - intolerance;
Bile salts: interruption of the liver-enteric cycle;
Atb - infection
Treat electrolytic imbalance.
Traet anemia : Fe, B12, folic acid

25. TREATMENT - pathogenic
ANTIINFLAMMATORY
5ASA
Salazopirine: better in colonic disease
ANTIBIOTICS
Metronidazol.;
Chinolone
CORTICOIDS - may induce remission
IMMUNE SUPRESSION
Azatioprina (Imuran) – prevention of recurrence;
6 mercaptopurine
Cyclosporine
Methotrexat
BIOLOGICAL Infliximab (Remicade)

26. TREATMENT SURGICAL Indications Limited resection of involved bowel
Acute complications
local complications – stenosis, fistula;
Unclear diagnostic.
Limited resection of involved bowel
Enterostomy – end later resection

27. TREATMENT A. Crohn ileocolic Indications:
fistula;
obstruction;;
Percutaneous drainage and resections

28. TREATMENT B. Colonic Crohn Indication 3 operaţii: same;
megacolon toxic.
3 operaţii:
proctocolectomy (abdomino-perineal) with permanent ileostomy;
Total colectomy and ileostomy but rectum in place;
Total colectomy plus ileorectal anastomosis.

29. TREATMENT Anal and perianal
Treatment of the abscess and fistula + treatment of Crohns.
If refractory disease n the rectum - proctectomy

30. TREATMENT Obstruction ileon: colon: Ileon resection;
Ileo-cecal resection
By pass.
colon:
by-pass;
Ileostomy or colostomy.

31. TREATMENT
Stenosis
rezections
Stricture-plasty

32. Long term complication
Cancer
High risk for pt with long term Crohns, strictures and scleroiss cholangitis
Colonoscopic monitoring – 2-3 y
Displastic lesions: colectomy

33. ULCERATIVE COLITIS Ethiology unknown
More frequent USA, England, northern countries;
Onset 18-30y
Under 18 very severe;
Over 50 very unusual.
More often in male pt

34. UC Genetic factors Infection Enzimatic Psihosomatic Family clustering;
Possible implication of a defect in IgA production
Infection
Numerous germs isolated but not clear;
Atb not very good;
Probably secondary and cause of recurrence .
Enzimatic
Increased synthesis of lizozim – destroys the protective mucus;
Not clear if primary or secundary .
Psihosomatic
Patients are more psichologically vulnerable to conflict;
Emotional problems involved in onset and maintenance of new episodes

35. UC mucosa: subacute: Pathology Acute: chronic red
Macroscopy
serosa
Acute
Reddish and glittering;
chronic
Pale or pale with red spots.
Intestinal wall
Initially:
Distended, thin;
Advanced
Shortening of the length;
Narrow lumen;
No haustrations;
Thick wall (due to the muscle layer);
Fulminant disease
Very dilated bowel.
Severe
Friable, paper-like.
mesocolon
initially
normal.
advanced
retracted;
Large lymph nodes.
Sometimes psudopolyps
mucosa:
Acute:
red
Small erosions – ulcers (superficial. Not deep);
brittle;
Continuous lesions
Wieschelmann pseudiopolyps
subacute:
Patches of renewed musosa near the lesions
Intense renewal – mucosal bridges and vegetations
chronic
Wide spread lesions with incomplete healing of the mucosa;
Thin mucosa; UC

36. UC
Particular aspects – affects only the mucosa of the rectum and the colon
First rectum then colon
The lower the segment the more aggressive the disease;
The lesions are continuous;

37. UC Microscopy: Dilation of vessels folllowed by haemmorhage;
limfocites and plasmocites;
Deep glands are full of neutrophils – abcess of the crypts – ulcerations and pseudopolips.
histology:
Granulocyte infiltration is specific
If inflammation spreads to all layers – toxic megacolon.

38. UC Clinic digestive symptoms General diarrhea: Abd pain:
First in 30-50% cases;
Main symptom 4/5;
Feces in a sero-hematic liquid full of puss
2-3 up to stools/day;
Sometimes just blood per anum
Abd pain:
Colicky – left side
characteristic:
tenesmus;
No more pain after a stool is passed.
General
Fever –septic;
Weight loss;
Vomiting;
Tachycardia - depending on amount of lost fluids.

39. UC Clinical exam Rectal exam abdomen: inspection:
reduction of subcutaneous tissue; bloating - especially supraumbilical - installation may highlight acute toxic dilatation of the colon.
percution:
timpanism increased in the case of toxic dilatation of the colon;
painful;
auscultation: multiple air-liquid noises uncomplicated ulcerative colitis tranquility in ulcerative colitis complicated by megacolon.
Rectal exam
sphincter tone: increased due to pain; decreased in severe forms;
rectal wall: rigid; granular mucosa; stricture areas;
Mucosa: endoscopy inflammatory exudate in the rectal mucosa, or the presence of blood, mucus, pus; highlights other injuries: cancer, hemorrhoids, abscesses, fistulas, etc..

40. UC general: stool: apathy or restlessness, anxiety; palor;
in severe forms, extensive: stools are unformed, with feces floating in a serous fluid, blood mixed with mucus and pus;
bulky stools with much blood. in mild forms
stool can be formed with blood and mucus; in forms limited to the rectum: stools, wrapped in blood and mucus;
emissions of blood and mucus without stool.
general:
apathy or restlessness, anxiety; palor;
dehydration, malnutrition;
detection of systemic events: eye; articulation; skin.

41. UC Laboratory: leukocytosis - active phases; anemia; hypoalbuminemia;
electrolytes: significant changes only in severe forms; lowering of Na +, K +, Cl-, Mg + +;

42. UC Simple x-ray or radioscopy Active phase: Radiology
Always first (perforation, incontinence)
Active phase:
No haustrations;
Thick wall;
Cobblestone aspect – psudopolyps;
Distended lumen;

43. UC Late, advanced stages mucosal relief is deleted;
haustations disappear completely;
size is reduced;
linear shape;
distensibility is greatly reduced;
angles rounded;
sometimes stenosis;
rigid tube (microcolia).

44. UC Endoscopy Inititial stages: Florid stages: Late stages: biopsy:
Red mucosa with vessels visible;
Friable mucosa;
Bleeding is spontaneous and difuse;
Grainy aspect;
Blood, mucus and pus in the lumen;
Florid stages:
Ulcerations that may converge with one-another;
Crypt abscesses;
False membranes.
Late stages:
Atrophy of the mucosa;
Lack of haustrations;
Pseudopolyps;
biopsy:
Exfoliative cytology

45. UC
CT, MRI

46. UC Local complications May appear in acute UC Due to chronic disease
Perforation
Acute dilation
Massive bleeding (more than 3000 ml in 24 hours
Perianal lessions
Due to chronic disease
Stenosis of the rectum and colon
Pseudopoliposis
Cancer

47. UC general complications
articular
most frequently;
5 categories:
Rheumatoid arthritis;
Spondilitis;
Erythema nodosum;
Joint pain;
Acute toxic arteritis
Spondilitis is the only one that can persist after surgery and medical treatment.
ophtalmologic
conjunctivitis; uveitis; iritis; episcleritis; keratitis; retinitis.
cutaneous and mucous:
cutaneous
Erythema nodosum;
pyoderma gangrenosum;
Urticaria, acnea, dermatitis.
mucous – stomatitis;
liver – chronic liver disease and cirrhosis;
Kidney - stones, hidronefrosis

48. UC Diferential Crohn’s disease Colorectal cancer Diseneteria
Ischemic colitis
Polyposis
Bacilarry colitis
Irritable bowel syndrome
Diverticulosis
Piles

49. UC Treatment Objectives: A. Treatment of the acute stage
Reduce the time that the patient spends in acute stages of the disease.
Prevent relapses and complications;
A. Treatment of the acute stage
1. bed rest
2. food intake
3-5 days of a colon sparing diet
Small, frequent meals;
No milk
3. psihotherapy
4. correct nutritional and hydroelectrolitical imbalances.

50. 5. antiinflammatories and antibiotics
a) salazopirin
b) 5-aminosalicilic acid
c) corticoids and ACTH
d) antibiotics
fever;
sepsis.
e) immunosuppressive treatment
6-mercaptopurin;
6-tioguanin;
Azatioprin
Metrotrexate
Ciclosporin

52. UC B. Prevent relapse 1. Salazopirin 2. diet.
1,5-2 g/day 6-9 months;
2-2,5 g/day 10 days/month.
2. diet.
3. avoid psychological stress, respiratory or digestive tract infections;
4. follow up.

53. C. Surgery 1. total proctocolectomy and permanent ileostomy
2. total colectomy, treatment of the rectal stump and reestablishment of the continuity of the digestive tract 6-12 months later
Risc of a disease progression or relapse
Cancer risk.
3. total colectomy with ileorectal anastomosis in the same procedure;

54. Diverticular disease Definition Frequency
Herniation of the colic mucosa through defects of the muscle layers
Frequency
Incresed with aging:
Sex: ♂:♀ = 2:1;
Incidence:
Maximal in Western Europe
Minimal în Africa and Asia.
More frequent in urban patients and in patients with stressfull jobs.

55. Diverticular disease Aethiology Precise cause is unknown.
Development of diverticulae:
Muscle contraction:
Hipertrophy of the circular musculature
Shortening of longitudinal fibers;
The result is pressure pockets that push the mucosa throus the muscle fibers
Weak spots in the colonic wall

56. Diverticular disease In time:
Weakening of the wall due to fatty inflammation;
Low fiber intake - constipation;
Psychological stress;
In time:
Stasis of feces – fecaliths – ulcerations of the mucosa due to mechanical irritation – increase in septic fenomenae.
Closed cavity – increase in virulence of germs and increase in mucus secretion – congestion – inflammation – thickening of the wall

57. Pathology Number – rarely unique: Topography: Structure: Colon:
Entire colon:
Most frequent on descending and sigmoid;
Rectum is not affected.
Structure:
Body and sometimes also a neck
!False diverticulae!
Colon:
Shortened and thickened teniae;
Arches of circular musculature between diverticulae;
Normal nercous plexuses.

58. Diagnosis Clinical: Asimptomatic Atypical digestive symptoms:
Symptoms usually due to complications.
Paraclinical:
Barium enema, colonoscopy

59. Complications A. Diverticulitis
30% of patients with diverticular disease ;
One or more diverticulae
Due to stasis of feces
peridiverticulitis
simptoms:
Very painful – left iliac fosa;
Irregular bowel habits;
Bloating;
Nausea;
Fever;
Clinical exam:
Tumor mass in left iliac fosa
painful;
Lower limit of tumor can be assessed on rectal digital exam
Above the tumor the descending colon is short and rigid

60. CT, US

61. Diverticular disease B. Haemmorhage
Frequent due to vecinity of vessels ;
More frequent in the right colon;
clinical:
Large haemmorhage;
Rarely melena;
Reocurring frequently.
paraclinical:
scintigraphy
arteriography:
pancolonoscopy
laparotomy.

62. C. Fistulae - due to an abscess: exterior: interiore:
colo-cutaneous
interiore:
colo-enteric, colo-colic
colo-uretheral
colo-vesical
colo-uterine:
colo-vaginal
3 syndroms:
General septic;
Pericolic abscess;
Peritonitis

63. D. Perforation E. Obstruction Barium enema; Colonoscopy + biopsy.
First a pericolic abscess and then peritonitis
E. Obstruction
Mechanical - due to inflammation
clinical:
Suboclusive syndrom
Low obstruction + fever:
Tumor mass in the left iliac fossa
Barium enema;
Colonoscopy + biopsy.

64. TREATMENT Profilaxis of complications: diverticulitis Medical
Avoid constipation;
No spices;
Mild antispastics;
diverticulitis
High fiber intake and laxatives;
Antiinflammatory drugs
Antibiotics.

65. Segmental resection of affected colon;
Surgery
Segmental resection of affected colon;
In emergency – 2 step procedure:
Hartmann I followed by reestablishment of continuity
Colostomy in emergency followed by resection with anastomosis after acute fase passes.