Ahmad Hormati Assistant Professor of Gastroenterology Qom University of Medical Sciences.

Complications of IBD

Acute complications of ulcerative colitis :

1. Severe bleeding – Bleeding may be severe in up to 10 percent of patients. Massive hemorrhage occurs in up to 3 percent of patients with ulcerative colitis at some time in their disease course and may necessitate urgent colectomy

2. Fulminant colitis and toxic megacolon : Patients with ulcerative colitis may develop fulminant colitis with more than 10 stools per day, continuous bleeding, abdominal pain, distension, and acute, severe toxic symptoms including fever and anorexia. Patients with fulminant colitis are at high risk of developing toxic megacolon as the inflammatory process extends beyond the mucosa to involve the muscle layers of the colon. Toxic megacolon is characterized by colonic diameter ≥6 cm or cecal diameter >9 cm and the presence of systemic toxicity

3. Perforation: Perforation of the colon most commonly occurs as a consequence of toxic megacolon [3]. However, it may also occur in the absence of toxic megacolon in patients with the first episode of ulcerative colitis due to lack of scarring from prior attacks of colitis. Perforation with peritonitis has been associated with 50 percent mortality in patients with ulcerative colitis3

Chronic complicationsof UC : Long-term complications of ulcerative colitis include strictures, dysplasia, and colorectal cancer.

1.Stricture : Benign strictures can occur due to repeated episodes of inflammation and muscle hypertrophy in about 10 percent of cases with ulcerative colitis [55]. Strictures are most frequently seen in the rectosigmoid colon and may cause symptoms of obstruction. Strictures in ulcerative colitis should be considered malignant until proven otherwise by endoscopic evaluation with biopsy. Surgery is indicated for strictures that cause continued symptoms of obstruction or that cannot be fully evaluated to exclude malignancy.55

2.Dysplasia or colorectal cancer — Patients with ulcerative colitis are at increased risk for colorectal cancer (CRC).The extent of colitis and duration of disease are the two most important risk factors for CRC The risk of CRC appears to be highest in patients with pancolitis, while those with proctitis and proctosigmoiditis are probably not an increased risk of CRC, regardless of the duration of disease.The CRC risk begins to increase 8 to 10 years following the onset of symptoms in patients with pancolitis.In prospective study, the cumulative incidence of CRC was 2.5 percent after 20 years and 7.6 percent after 30 years of disease.Patients with left-sided colitis have almost the same risk of CRC and dysplasia as those with pancolitis but the risk of CRC increases only after 15 to 20 years.

Other factors that are associated with an increased risk of CRC include endoscopic and histological severity of inflammation, positive family history of sporadic colorectal cancer (twofold increased risk), postinflammatory pseudopolyps (twofold increased risk), and the presence of primary sclerosing cholangitis (fourfold increased risk)

3.Mortality : Patients with ulcerative colitis may have a slightly higher overall mortality compared with the general population (HR 1.2, 95% CI ).The overall mortality appears to be highest in the first year after ulcerative colitis diagnosis (HR 2.4, 95% CI ). Long-term, cause-specific mortality may also be increased in patients with ulcerative colitis (infectious disease HR 1.6, 95% CI ; gastrointestinal disorders other than ulcerative colitis HR 1.3, 95% CI ; and colorectal cancer HR 1.5, 95% CI ). However, mortality rates appear to have decreased over time

complications of Crohn disease:

1.CANCER RISK — Studies conflict regarding the risk of colon cancer in patients with longstanding Crohn colitis. Increases in incidence of squamous cell carcinoma of the anus and skin, duodenal neoplasia, testicular cancer, and miscellaneous other cancers have all been reported in Crohn disease (CD), although the strength of these associations is unclear.

Patients receiving thiopurines for inflammatory bowel disease have an increased risk of developing lymphoproliferative disorders.Analyses of lymphoma risk in patients receiving biologic agents directed against tumor necrosis factor (TNF)-alpha are confounded by concomitant use of immunosuppressive agents in most of these patients. It is unclear whether exposure to both an immunomodulator and an anti- TNF agent increases the risk of non-Hodgkin lymphoma relative to those treated with immunomodulators alone.However, one type of lymphoma, the hepatosplenic T- cell lymphoma, seems to occur mainly in young male patients receiving a combination of anti-TNF andazathioprine.azathioprine

PROGNOSIS : Approximately 10 to 20 percent of patients experience a prolonged remission after initial presentation. Another study found that 53 percent of patients developed stricturing or penetrating disease at 10 years follow-up. Predictors of a severe course include age less than 40, the presence of perianal or rectal disease, smoking, low education level, and initial requirement for glucocorticoids

Factors associated with complications included disease extent at baseline: 1.Patients with ileal disease had a 9-fold increased risk compared with those with colonic disease, and patients with ileocolonic disease had a 6-fold increased risk. 2.In addition, use of mesalamine or sulfasalazine in the first 90 days increased the risk of complications twofold. 3. Finally, perianal disease increased the risk of complications, though the results were of borderline significance (HR 1.69, 95% CI 0.99 to 2.86).mesalaminesulfasalazine

AGA guideline : ●Overall, 13 percent of patients will have a relapse-free course, while 20 percent have annual relapses, and 67 percent have a combination of years in relapse and years in remission within the first eight years after initial diagnosis ●Fewer than 5 percent will have a continuous course of active disease. ●Recurrence of perianal fistulas after medical or surgical therapy is common (59 to 82 percent)

Many patients with CD ultimately require surgical intervention with intestinal. Some patients tend to follow a pattern of either recurrent obstruction or recurrent perforations. earlier postoperative recurrence and the need for more surgery. Genetic studies have suggested that there may be a molecular basis for more aggressive disease. However, clinically distinct disease patterns have not been observed in all studies

Mortality — Studies addressing whether overall life expectancy is decreased in patients with CD. Estimates of the standardized mortality ratio (an approximation of the risk of death compared to the general population) from population-based studies range from no increased risk to a fivefold increased risk of death.

CD may involve the entire gastrointestinal tract from mouth to the perianal area: ●Approximately 80 percent of patients have small bowel involvement, usually in the distal ileum, with one-third of patients having ileitis exclusively. ●Approximately 50 percent of patients have ileocolitis, which refers to involvement of both the ileum and colon. ●Approximately 20 percent have disease limited to the colon. In contrast to rectal involvement in patients with ulcerative colitis, one-half of CD patients with colitis have sparing of the rectum. ●Approximately one-third of patients have perianal disease. ●Approximately 5 to 15 percent have predominant involvement of the mouth or gastroduodenal area,

Diarrhea — Diarrhea is a common presentation. Diarrhea associated with CD may have multiple causes, including: ●Excessive fluid secretion and impaired fluid absorption by inflamed small or large bowel ●Bile salt malabsorption due to an inflamed or resected terminal ileum ●Steatorrhea related to loss of bile salts

Fistulas — Transmural bowel inflammation is associated with the development of sinus tracts. Fistulas are tracts or communications that connect two epithelial-lined organs. Common sites for fistulas connect the intestine to bladder (enterovesical), to skin (enterocutaneous), to bowel (enteroenteric), and to the vagina (enterovaginal).

Phlegmon/abscess — All sinus tracts do not lead to fistulas. Sinus tracts may present as a phlegmon, a walled off inflammatory mass without bacterial infection that may be palpable on physical examination. Ileal involvement is suggested by a mass in the right lower quadrant.

Malabsorption — Bile acids are normally absorbed by specific receptors in the distal ileum. Bile salt malabsorption occurs when more than 50 to 60 cm of terminal ileum is diseased or resected. Unabsorbed bile salts enter the colon resulting in a secretory or "bile salt" diarrhea.

Eye inflammation* Liver and bile duct inflammation Skin lesions Arthritis and joint pains Kidney stones Growth failure in children Lower bone density* Subfertility* IBD: Systemic Complications *Higher incidence in women. Gallstones Ovaries Uterus