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Inflammatory Bowel Diseases: Modern Disorder Insights

Explore the rising prevalence of UC & CD in developed nations since the mid-20th century. Learn about genetic influences, risk factors for CRC, surgical indications, treatment options, and prevention strategies including probiotics. Discover optimal drug delivery methods, like rectal 5-ASA, and the efficacy of combination therapies. Address systemic toxicity and recognize indicators of acute pancreatitis in IBD patients. Understand toxic megacolon, its identification criteria, and clinical management with hydrocortisone and metronidazole.

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Inflammatory Bowel Diseases: Modern Disorder Insights

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  1. UC & CD are disorders of modern society: their frequency in developed countries has been increasing since the mid-20th century. • Children:CD is more prevalent than UC • The highest incidence & prevalence: Northern Europe & North America • A westernized environment & lifestyle:Smoking, high fat & sugar diets, stress, & high socioeconomic status • UC:Smoking is associated with milder disease, fewer hospitalization, & a reduced need for medications. • UC:Appendectomy in early life is associated with a decreased incidence • CD:Appendectomy in early life is associated with a increased incidence

  2. Genetic influences: play a greater role in CD than in UC • Is genetic screening indicated to assess the risk of UC? NO, (given the large number of implicated genes & the small additive effect of each) • Human Microbiome project aims to define the composition of the intestinal microbiota in conditions of health & disease. • The density of microbiota is greater in IBD patients than in healthy control subjects.

  3. Risk factors for CRC: • Long duration of the disease (regardless of clinical activity) • Extensive involvement • Severe inflammation • A young age at onset • The presence of PSC • Family history of CRC • Surveillance colonoscopy for patients at risk: there is no clear evidence that such surveillance increases survival. • Pancolitis: inflammation up to ileocecal valve, with occasional limited involvement of the distal ileum (Backwash ileitis) • Better detection of suspicious mucosal patterns & dysplasia:Chromoendoscopy, NBI, & autofluorescence imaging

  4. UC: • Proctitis may present with constipation • A small area of inflammation surrounding the appendiceal orifice (cecal patch) can be identified in patients with left sided colitis, proctosigmoiditis, or proctitis. • Cancer:up to 20-30% after 30 years • CD: • Video capsule endoscopy • Single balloon enteroscopy • Double balloon enteroscopy

  5. Pillcam SB capsule (originally named the M2A capsule)

  6. Indication for surgery: • Failure of medical therapy • Intractable fulminant colitis • Toxic megacolon • Perforation • Uncontrollable bleeding • Intolerable side effects of medication • Stricture that are not amenable to endoscopic therapy • Unresectable high-grade or multifocal dysplasia • DALM (Dysplasia associated lesion or mass) • Cancer • Growth retardation in children

  7. Unlike CD, UC may respond to probiotics: • Escherichia coli strain Nissle 1917 (200 mg/day) • VSL#3 (3600 colony-forming units/day/for 8 weeks) • Pouchitis: • An inflammation caused by an immune response to the newly established microbiota in the ileal pouch (dysbiosis). • Metronidazole, ciprofloxacin, rifaximin. • Probiotics can be effective for preventing recurrence. • Pouch failure is a condition requiring pouch excision or permanent diversion.

  8. Suppository: Rectum • Foam enema: Proximal sigmoid • Liquid enema: Splenic flexure • Rectal 5-ASA induces earlier & better results than oral mesalazine in the treatment of active proctitis. In active left-sided colitis there is proximal colonic stasis & fast colonic transit through the inflamed colon. This results in reduced exposure of the distal colon to the oral agent. The combination of both oral & rectally delivered 5-ASA has greater efficacy & speed of response in patients with distal colitis than either administration route used alone. • Cyclosporine is only a bridge. • The expanding use of anti-TNFa agentshas not decreased the need for colectomy for UC patients.

  9. Do not forget these etiologies of acute pancreatitis in a patient with IBD: • AZA • 6-MP • 5-ASA • Sulfasalazine • Steroid • Granuloma may be seen: • CD • TB • Lymphoma • Behcet's disease • Yersinia

  10. Systemic toxicity • Toxic megacolon: • Colonic distension (supine film >6 cm) • Plus at least 3 of the following: • T>38ºC • HR >120 • Neutrophilic leukocytosis >10,500 • Anemia • PLUS at least 1 of the following: • Dehydration • Altered sensorium • Electrolyte disturbances • Hypotension Decreased incidence Smooth muscle inflammation  paralyzes  dilatation Hydrocortisone 100 mg/tid-qid Third generation + Metronidazole

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