1. Inflammatory Bowel Disease
Dr K Ingram

2. Objectives Revision of pathophysiology and presentation of IBD
Recall key differences between CD & UC
Learn a logical, stepwise technique to enable recall of investigation and management
Apply knowledge in a clinical scenario

3. Definition
Crohn’s Disease (CD) – a chronic, relapsing, inflammatory disease characterised by transmural granulomatous inflammation
Ulcerative Colitis (UC) – a chronic, relapsing, inflammatory disorder of the colonic mucosa

4. Crohn’s Disease Epidemiology Pathophysiology
Bimodal distribution (Teens/20s & Older Adults)
Exacerbated by smoking
Pathophysiology
Mouth → Anus (rectal sparing)
Terminal Ileum > Small Bowel > Colon
Areas of unaffected bowel in between (Skip lesions)
Crohn’s colitis very difficult to distinguish from UC

5. Crohn’s Disease Histologically: Transmural inflammation
Aphthous ulceration
Cobblestone mucosa
Stricture formation (string-sign)
Fistulae
Entero
-enteric
-cutaneous
-vesical
-vaginal
Retroperitoneal
Cobblestone mucosa due to deep fissures from ulceration
Stricture formation occurs secondary to fibrosis following acute inflammation
Definition of a fistula

6. Crohn’s Disease Clinical Features: Symptoms Signs
Diarrhoea +/- PR bleeding
Colicky abdominal pain
Weight loss
Fever, malaise
Vomiting (2o to obstruction; late)
Pyrexia
Anaemia
Anorexia
Clubbing
Aphthous ulcers
Abdominal tenderness
RIF mass
Perianal abscess / fistulae / skin tags
Often described as painful diarrhoea compared with bloody diarrhoea of UC

7. Clubbing Stages: Common causes:
1) Normal appearance and angle but increased fluctuancy of nail bed
2) Loss of angle between nail and nail bed
3) Increased curvature of the nail
4) Expansion of terminal phalanx
Common causes:
Cardiology – SBE, cyanotic congenital HD
Respiratory – IPF, bronchial carcinoma, bronchiectasis, CF
GI – IBD, coeliac disease, cirrhosis

8. Crohn’s Disease Extra-intestinal features Complications
Conjunctivitis / episcleritis / iritis
Erythema nodosum (panniculitis)
Pyoderma gangrenosum
Large joint arthritis / sacroiliitis
Complications
Small bowel obstruction
Perforation
Toxic dilatation

9. Crohn’s Disease Differential diagnosis: Ulcerative colitis Carcinoma
Malabsorption
Diverticular disease
Infective
Thyrotoxicosis

10. Ulcerative Colitis Epidemiology Pathophysiology Histologically
Young adults (15-30) most commonly affected
Women > Men
Smoking can be protective
Pathophysiology
Continuous, superficial mucosal ulceration
Nearly always affects rectum
Rectum (Proctitis) 50%
Left colon 30%
Pancolitis 20%
Histologically
Areas of continuous mucosal inflammation

11. UlcerATIVE COLITIS Clinical Features: Symptoms Signs
Gradual onset diarrhoea +/- blood & mucus
Crampy abdominal pain
Urgency
Tenesmus
Fever, malaise
Weight loss
Pyrexia
Tachycardia
Anorexia
Clubbing
Aphthous ulcers
Tender, distended abdomen
Abdominal pain often relieved by defaecation
Fever & tachycardia only in active disease

12. Ulcerative colitis Grading severity of acute disease
Truelove-Witt Criteria1:
Mild
Moderate
Severe
No stools per day
<4
4-6
>6
Temperature
Afebrile
Intermediate
>37.8
Heart Rate
Normal
>90
Haemoglobin (g/dl)
>11
<10.5
ESR
<20
20-30
>30

13. Ulcerative colitis Extra-intestinal features Complications
As for Crohn’s Disease
Complications
Toxic megacolon
>6cm of TC on AXR
Fever, tachycardia, dehydration, ↑WBC
Perforation
Bleeding
Colon cancer – surveillance crucial
Primary Sclerosing Cholangitis
Colon cancer – 10% risk for every 10 years of UC

14. Ulcerative colitis Toxic Megacolon
AXRs taken 48h apart – note the increased diameter in 2nd image plus oedema of bowel wall

15. Ulcerative colitis Differential Diagnosis Crohn’s Disease Infective
Consider C.difficile
Ischaemic colitis
Carcinoma
Malabsorption
Diverticular disease
C.Diff causes pseudomembranous colitis – always get a stool culture

16. Investigations Bedside Bloods Observations
Stool culture (MC&S and C.Diff)
Urine dip +/- bHCG
Bloods
FBC / U&E / LFT / ESR / CRP
Haematinics
Blood cultures
pANCA (UC)
FBC – high WBC/Plts, low Hb, microcytosis
ESR/CRP – elevated
U&Es – evidence of dehydration / baseline
LFTs – low albumin suggests severe disease

17. Investigations Imaging Special Tests Erect CXR Abdominal X-ray
CT abdomen/pelvis
Special Tests
Endoscopy +/- biopsy
Acute
Flexi-sigmoidoscopy ONLY
Chronic
Sigmoid-/Colonscopy
Barium
Meal/Follow-through – strictures in Crohn’s
Enema – drainpipe colon/loss of haustra, apple-core stricture (malignancy)
CXR – exclude pneumoperitoneum
AXR – look for dilatation
CT – assess disease extent, identify fistulae etc
NB – caution when using endoscopy in acute disease due to risk of perforation

18. investigations
Drainpipe Colon
String Sign
Apple-core stricture

19. Management Conservative Medical Surgical Acute Chronic
Types of resection
See pharmacology handout

20. Conservative management
Dietary advice
Low fibre, elemental diet

21. Medical management Acute Chronic Steroids – induce remission
Mild disease – prednisolone PO
Severe disease – hydrocortisone IV
NB – avoid long-term use due to side-effects
Chronic
5-ASA → CCS → Immunosuppression → Biologicals
Side effects of steroids: osteoporosis, cataracts, bleeding/bruising, thining of skin, weight gain, ‘Cushingoid’ appearance, proximal muscle weakness, diabetes

22. Medical management 5-ASAs e.g. mesalazine Steroids e.g. prednisolone
1st line therapy in IBD
Good for acute disease (remission) & maintenance
Anti-inflammatory
Steroids e.g. prednisolone
Good for acute disease and inducing remission
NOT for long-term use
Immunosuppression e.g. azathioprine, MTX
Steroid-sparing agents
NB – methotrexate used in Crohn’s ONLY

23. Medical management Biologicals e.g. infliximab
Monoclonal Ab against TNFα
Used predominantly for CD (esp. fistulae)
NICE guidelines:
Severe, active Crohn’s disease AND
Refractory immunomodulatory drugs / cannot tolerate side-effects / experienced toxicity AND
Surgery inappropriate
Can also be used in acute UC unresponsive to IV steroids

24. Medical management Contraindications to infliximab
Sepsis
Deranged LFTs
Active TB
Pregnancy / Breastfeeding
Side effects of infliximab
Hypersensitivity reactions
Reactivation of TB
ALWAYS test for TB before commencing (Monospot)
Increased risk infections e.g. VZV, candida
Increased risk of malignancy e.g. lymphoma

25. Surgical resection Crohn’s (~65%): UC (<15%):
Acute, severe bleeding
Strictures
Fistulisation
Obstruction, Perforation
Non-resolving inflammatory mass
UC (<15%):
Perforation
Toxic megacolon
Toxic megacolon – initially IV fluids, high dose steroids IV. Surgery if increasing size despite treatment or suspected perforation or failure of symptoms to settle within 24-48hrs of medical Rx

26. Types of Resection Crohn’s Disease: Ulcerative Colitis: Small bowel
Stricturoplasty
Localised rections
Large bowel
Panproctocolectomy + ileostomy
Subtotal colectomy + ileorectal anastomosis
Ulcerative Colitis:
Total colectomy + ileostomy + oversewing of rectal stump
Creation of J-pouch (or completion proctectomy)
Ileostomy reversal
Small bowel – risk of short bowel syndrome; malabsorption (diarrhoea, fatigue, weight loss, oedema (low albumin), offensive stools). Need dietary supplements (iron, B12, folic acid) and vitamins.
Panproctocolectomy – removal of entire large bowel and anus
Smaller resections of large bowel associated with high relapse rates and further surgery
Completion proctectomy – removal of rest of rectum and anus leaving a permanent ileostomy

27. Crohn’s Vs UC Crohn’s Disease Ulcerative Colitis
Mouth → Anus (rectal-sparing)
Colon only
Transmural
Mucosa only
Skip lesions
Continuous area of inflammation
Fistulae
No Fistulae
Bimodal distribution
Older age groups
Smoking exacerbates
Smoking protective
PR bleeding less common
PR bleeding common
“String sign”
“Drainpipe colon”
Granulomas seen at biopsy
Granulomata rare

28. Clinical scenario 29 year old female History: Examination:
1/12 loose, watery stools of ↑ frequency
Occasional blood and ‘slime’ mixed in
Crampy LIF pain
Lethargy
Examination:
Pyrexial (38.2)
Abdomen soft but mild distension & tender LIF
PR – painful ++, fresh blood & mucus

29. Clinical scenario Differentials Investigation
Ulcerative colitis (acute flare)
Crohn’s Disease
Infective diarrhoea
Diverticulitis
Carcinoma – must always be excluded
Investigation
Acute:
Bedside – obs, urine, stool
Bloods – FBC / U&Es / LFTs / CRP / ESR / haematinics /cultures
Imaging – Erect CXR, AXR, CT abdo/pelvis
Special tests – flexi-sigmoidoscopy ONLY

30. Clinical scenario Investigations (cont.) Initial management
Long-term
Immunology bloods e.g. p-ANCA
Colonoscopy +/- biopsy when acute flare resolved
Consider barium investigations
Initial management
Analgesia / anti-pyretics
IV fluids
IV steroids
Long-term management
Conservative
Medical
Surgical

31. Clinical scenario Compare Crohn’s & UC: Crohn’s Disease
Ulcerative Colitis
Mouth → Anus (rectal-sparing)
Colon only
Transmural
Mucosa only
Skip lesions
Continuous area of inflammation
Fistulae
No Fistulae
Bimodal distribution
Older age groups
Smoking exacerbates
Smoking protective
PR bleeding less common
PR bleeding common
“String sign”
“Drainpipe colon”
Granulomas seen at biopsy
Granulomata rare

32. Clinical scenario Scoring system for acute UC: Mild Moderate Severe
No stools per day
<4
4-6
>6
Temperature
Afebrile
Intermediate
>37.8
Heart Rate
Normal
>90
Haemoglobin (g/dl)
>11
<10.5
ESR
<20
20-30
>30

33. Clinical scenario Extra-intestinal features of IBD:
Conjunctivitis / episcleritis / iritis
Erythema nodosum (panniculitis)
Pyoderma gangrenosum
Large joint arthritis / sacroiliitis
Explain a colonoscopy:
Check initial knowledge
Avoid jargon
Basic description of procedure
Few risks/benefits
Check understanding
Offer literature / opportunity for questions
Colonoscopy – risks – bleeding, infection, perforation. Benefits – aid diagnosis, take biopsies etc. Throat spray or sedation. Day case procedure.

34. Key Points Key differences between Crohn’s & UC
Extra-intestinal manifestations
Eyes, joints, skin
Investigations – only flexi-sig in acute flare
Medical management – acute & chronic
Always test for TB for commencing infliximab
Surgical management – types of resection
Explain a colonoscopy
Explain a stoma

35. References
1) Truelove SC, Witts LJ. Cortisone in ulcerative colitis: final report on a therapeutic trial. Br Med J 1955;ii:1041–8.
2) Goldberg A, Stansby G. Surgical Talk (2nd Ed.), Imperial College Press, 2005, pp