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UC & CD are disorders of modern society : their frequency in developed countries has been increasing since the mid-20 th century. Children : CD is more prevalent than UC The highest incidence & prevalence : Northern Europe & North America

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Genetic influences : play a greater role in CD than in UC

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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

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.

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


    • 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

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

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.

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.

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

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