IBD

1. IBD

2. Epidemiology

3. Pathology – Ulcerative Colitis • Macroscopic • Usually involves rectum (40-50%) and extends proximally to involve all (20%) or part (30-40%) of the colon  all mucosa ulcerated in between • Backwash ileitis – inflammation extends 1-2cm in terminal ileum (10-20%) (little significance) • Mild inflammation – erythematous mucosa, fine granular surface (sandpaper) • Severe disease – haemorrhagic mucosa, oedema, ulceration • Long-standing disease – inflammatory polyps (due to epithelial regeneration), mucosa atrophic and featureless, entire colon shortened and narrowed • Fulminant disease – toxic colitis/megacolon (bowel wall thins, mucosa severely ulderated)

4. Pathology – Ulcerative Colitis • Mucosa has a lumpy, bumpy appearance because of areas of inflamed but intact mucosa separated by ulcerated areas

5. Pathology – Ulcerative Colitis • Microscopic • Process usually limited to mucosa and superficial submucosa unless fulminant disease (deeper layers) • Chronic features • Crypt architecture distorted (bifid, reduced number, gap between bases and muscularis mucosae) • Basal plasma cells and multiple basal lymphoid aggregates • Mucosal vascular congestion, oedema, focal haemorrhage and an inflammatory cell infiltrate may be present • Neutrophil infiltration can ultimately give rise to crypt abscesses

6. Pathology – Ulcerative Colitis • Diffuse mixed inflammation, basal lymphoplasmacytosis, crypt atrophy, irregularity and superficial erosion

7. Pathology – Crohn’s Disease • Macroscopic • Can affect any part of GIT • 30-40% small bowel disease alone • 40-55% involving small and large intestines • 15-25% colitis alone • The terminal ileum is involved 90% of the time when there is small intestine involvement • Rectum often spared • Can skip areas (unlike Ulcerative Colitis) • Rarely involves liver and pancreas • 1/3rd with Colonic involvement may present with perirectal fistulas, fissures, abscesses, anal stenosis • Transmural process

8. Pathology – Crohn’s Disease • Macroscopic CONTINUED • Mild disease • Aphthous or small superficial ulcerations • Active disease • Stellate ulcerations fuse longitudinally and transversely to demarcate islands of mucosa that often normal • ‘cobblestone’ appearance • Focal inflammation and formation of fistula tracts  fibrosis and stricturing of bowel  narrower, fibrotic  chronic bowel obstructions • Pseudopolyps can be found

9. Pathology – Crohn’s Disease • Portion of colon with stricture in Crohn’s Disease

10. Pathology – Crohn’s Disease • Microscopic • Aphthoid ulcerations and focal crypt abscesses with loose aggregations of macrophages •  Noncaseating granulomas in all layers of the wall • Granulomas are a pathognomonic feature of Crohn’s but are rare in mucosal biopsies • About ½ of surgical removal cases reveal granulomas • Submucosal or subserosal lymphoid aggregates (away from ulceration)

11. Pathology – Crohn’s Disease • Mixed acute and chronic inflammation, crypt atrophy, and multiple small epitheliod granulomas in mucosa

12. Presentation – Ulcerative Colitis • Pain can present as lower abdominal discomfort or mild central abdominal cramping • Severe cramps occur with severe attacks

13. Presentation – Ulcerative Colitis • Diagnosis relies upon: • History • Symptoms • Negative stool sample for C.difficile toxin, ova and parasites • Sigmoidoscopic appearance • Histology of rectal or colonic biopsies Barium enema with acute ulcerative colitis - Inflammation of entire colon

14. Presentation – Ulcerative Colitis • Either fibrostenotic-obstructing pattern or penetrating-fistulous pattern • The site of disease influences the clinical manifestation: • Ileocolitis • Most common terminal ileum • Chronic history of recurrent episodes of right lower quadrant pain and diarrhoea • May mimic acute appendicitis • Pain colicky, relieved by defecation • Low-grade fever possible; high-grade  abscess • Possible mass • Bowel obstruction due to oedema, fibrosis, stricture • Jejunoileitis • Malabsorption and steatorrhoea • Nutritional deficiencies  may lead to fractures due to decreased vitamin D; megaloblasticanaemiaetc • Diarrhoea

15. Presentation – Ulcerative Colitis • Colitis and Perianal disease • Low-grade fever • Malaise • Diarrhoea • Crampy abdominal pain • Sometimes haematochezia • Gross bleeding not as common • Pain due to faecal matter passing through narrowed and inflamed segments • Bowel obstruction  stricturing • Colonic disease may fistulise into the stomach or duodenum, causing faeculent vomiting or malabsorption • Perianal – incontinence, large haemorrhoidal tags, anal strictures, anorectal fistulae, perirectal abscesses • Gastroduodenal Disease • Nausea • Vomiting • Epigastric pain • Possible chronic gastric outlet obstruction • Elevated ESR and CRP; in more severe: hypoalbuminaemia, anaemia, leukocytosis • Possible perforation of fistulas can lead to complications

16. DDx

17. Joint involvement • Arthritis in patients with IBD occurs slightly more commonly in the spine • As in reactive arthritis, the sacroiliac joint is the most frequent to become inflamed • Other joint inflammation may correlate more closely with disease activity in the bowel • Most common: knuckle and finger joints, knees, ankles, elbows, shoulders • Generally upper limbs more frequently • Doesn’t typically cause destruction of the joint • Increased joint infection risk and loss of blood supply can lead to avascular necrosis and an acutely swollen or painful joint should be investigated accordingly to rule this out. • http://jkms.org/Synapse/Data/PDFData/0063JKMS/jkms-13-39.pdf