Level of competent :

3A

INFLAMMATORY BOWEL
DISEASE
(IBD)
Centre of Gastroentero-Hepatology, Wahidin Sudirohusodo
Hospital Teaching
Internal Medicine, Faculty of Medicine, Hasanuddin
University

Upper & Lower GI Diseases Lecture of Gastroentero-Hepatology

System, FKUH

Introduction

DEFINITION a chronic
inflammation of the
intestine that is marked by
remission & relapses and
distills clinically into
ulcerative colitis (UC) and
Crohns disease (CD).

CD, initially described in 1932

by Drs Burrill Crohn, Gordon
Oppenheimer,
and
Leon
Ginzburg,
is
an
idiopathic
transmural chronic inflammatory
disorder affecting any part of
the gastrointestinal tract.
UC, have been described by Drs
Wilks and Moxon in 1875; is a
diffuse mucosal inflammation
limited to the colon.

Epidemiology

Typicallypresent at a
relative young age, often
in adolescence
The median age of
diagnosis CD and UC is
the third and fourth
decade of life, respectively
Female predominance in
CD and male

Crohns disease (CD) :

Incidence rates were

generally lower and were
broadly similar for men
and women, with rates for
both sexes declining with
increasing age
Ulcerative colitis (UC) :

Incidence rates for men

remaining fairly constant
with increasing age,
whereas for women
decreased.

Pathogenesis

Three major contributory

factors: genetic
susceptibility,
environmental triggers,
and immune activation
Dysregulated mucosal
immune respone to
antigenic components of
the normal commensal
microbiota that reside
within the intestine in a
genetically susceptible
host

Modifying enviromental
factors (e.g tobacco, OCPs,
appendectomy)
Mucos
al
immu
ne
respo
ns
Regulatio
n of
immune
response
?

Commen
sal
Microbial
Antigen
Regulatio
n of
barrier &
bacteria?

Genetics
(e.g.
chromosomes
5 and 16)

T
Regulator
y
response
Th1,Th2 or
Th17
mediated
inflammat
ory
response

Tissue
injury
Clinical
symptom
s

General symptoms

Chronic diarrhea
Abdominal pain &
cramping
Blood in stool
Reduced appetite
Weight loss
Fever

Distiguishing Features of UC
& CD
ULCERATIVE COLITIS

CROHNS DISEASE

Pain crampy, lower abdominal,

relived by bowel movement

Pain constant, often in right lower

quadrant (RLQ), not relieved by
bowel movement

Bloody stool

Stool usually not grossly bloody

No abdominal mass

Abdominal mass, often in RLQ

Affect only colon

May affect small & large bowel,

occasionally esophagus &
stomatch

Mucosal disease (granulomas are

not a feature)

Transmural disease (granulomas

found in a minority patients)

Continuous from rectum

May be discontinous (skip area)

DIAGNOSIS
Anamnesis :

sign & simptoms

Onset & course of

symptoms

Growth retardation &

failure to develop sexual
maturity

Physical examination :
Often thin & undernourished,
anemia, tachycardia, low grade
fever, mild-moderate
abdominal tenderness (UC), a
tender mass in RLQ
Toxic megacolon or abscess :
Abdominal distention, rebound
tenderness, absence of bowel
sound & high fever
Extraintestinal manifestation
may be evident : hepatobiliary,
dermatologic, oral, occular,
musculoskeletal, hematologic

Diagnostic studies

Laboratory : CBC, urinalysis,

serum chemistery,
serologic: ANCA
(Antineutrophil cytoplasmic
Antibodies), ASCA (Ab
Saccharomyces cerevisiae)

Stool examination

Endoscopy LGI + mucosal

biopsy

Plain abdomen, CT
abdomen, CT
enterography-colonography

Pil cam imaging

Barium enema shold not be

performed

COMPLICATIONS

Perforation, abscess,
fistula, obstruction
Anemia, osteoporosis
Life-threatening
hemorrhage (rare)
Toxic megacolon
Colorectal cancer

DIFFERENTIAL DIAGNOSIS

Bacterial colitis
(campylobacter, shigella,
salmonella, E.coli)
Clostridium difficileassociated colitis
Parasitic colitis
(amebiasis)
Ischemic colitis
Radiation colitis

Sexual transmitted
colitis (CMV, herpes)
Crohns disease lookalikes (lymphoma,
yersinia, tuberculosis)
GI malignancy
Irritable Bowel
Syndrome (IBS)

GENERAL PRINCIPAL OF THERAPY

Dependent on several distinct

factors : disease location (eg,
ileocecal vs colonic or proctitis
vs pancolitis), severity (mild,
moderate, or severe), and
complications.
Should be individualized
based on the patients prior
symptomatic response and
tolerance to specific medical
therapies.

Therapy is sequential to
treat acute disease and
then
to
maintain
remission.

TREATMENT

Surgery : due to complication

Diet and nutrition

Drugs :
5-Aminosalicylates : sulfasalazine 1-4g/day twice daily, mesalamine 24g/day 3-4times daily, olsalazine 1-3g/day twice daily
Steroids oral-iv in CD : budesonide 9mg/d, prednisone/
methylprednisolone 40-60mg/d
Antibiotics : ciprofloxacin 500mg twice daily, metronidazole 1-1.5g/d (in
CD with perianal disease)
Immunomodulators : azatioprine2-2.5mg/kg/d or mercaptopurine 11.5mg/kg/d, methotrexate 15-25mg im once daily (inchronic active &
steroid dependent)
Anti-Tumor Necrosis Factor (TNF) : Infliximab 5mg/kg at week 0,2,6

Prognosis

75% have to surgery

25% can managed
using medical therapy
(UC)
Risk for CRC 8-10 years
later

References

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Lippincott Williams & Willkins. 2009;pp244-263.

Blumberg RS. Inflammatory Bowel Disease : Imunologic considerations. In Current diagnosis & treatment
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companies, 2009,pp11-21.

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Inflammatory Bowel Disease. MIMS Gastroenterology Indonesia. 2 nd Edition. CMP Medica. 2009/2010.

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Italy. 2006

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