INFLAMMATORY  BOWEL  DISEASE

 

CROHN'S (Regional enteritis, Granulomatous ileitis)  

          

Overview:                                                                                  

  1. Commonly involves small bowel (terminal ileum), but may  involve  any  portion of GI tract.
                                                          
  2. Age of onset 2d and 4-6th decade.

Pathology:                                                                               

  1. Transmural involvement, non-necrotizing granulomas.
                                                            
  2. Skip areas of normal bowel "cobble stone" on colonoscopy.

S & S:    

  1. Presentation depends on disease pattern. The classic presentation is  that of diarrhea and colicky abdominal pain,  wght loss, malabsorption. 10%  have acute onset resembling appendicitis.
                                 
  2. Fistulas and perianal abscesses are common.
                         
  3. Extraintestinal manifestations present in up to 20 %  of pts with IBD (See U.C.)
                                                       
  4. Bleeding is less common than in U.C.                                                                                             

Complications:                                                                       

  1. SBO/LBO, perforation, abscesses (liver, retroperitoneal, perianal), malabsorption, electrolyte imbalance, anemia (2ry to anemia of chronic disease, Fe deficiency or megaloblastic anemia due to B12 malabsorption), CA (< than U.C.), fistulas, chronic diarrheas due to bile acid malabsorption, Ca oxalate kidney stones.
     
  2. Note! Pts are frequently  on steroids that may mask many symptoms.

DX:

  1. In ER presumptive dx can be done by history  and CT  findings.
     
  2. Endoscopy, although  a good diagnostic tool, has no place in ER

Treatment:                                                                              

  1. Chronic uncomplicated disease:
                                                
      1. Sulfasalazine 1 gm q6h, Corticosteroids,
         
      2. Acute exacerbations are treated with high dose IV steroids, NPO.
         
      3. Immunosuppressants if above do not work (azathioprine, cyclosporine, 6-mercaptopurine).
         
      4. Metronidazole also helpful for fistulas and perianal manifestations.
         
      5. Imodium, Lomotil and Cholestyramine may be used for diarrhea after infectious causes  of diarrhea are ruled out.
                                                                                          
  2. Treatment of complications:
                                                      
      1. Most complications are treated in usual fashion.                   

 

 

ULCERATIVE  COLITIS

 

Overview:

  1. Involves only colon. The rectum above dentate line is always involved, and the disease spreads proximally without skip lesions.
     
  2. Age of onset 15-30 and 50-80.
     
  3. Flair of  UC may be triggered by smoking cessation

Pathology:

  1. Mucosa and submucosal involvement (not transmural).
     
  2. Ulcerations and pseudopolyps, crypt abscesses  

S & S:

  1. Intermittent attacks of bloody diarrhea with tenesmus, wgt loss, fever.
     
  2. Extraintestinal manifestations are similar to Crohn's. These are:  skin (erythema nodosum, pyoderma gangrenosum), eye (uveitis,  episcleritis), GB (cholesterol gallstones and primary sclerosing cholangitis in UC), reactive arthritis (correlates with disease activity), and ankylosing spondylitis that may occur even without flair. 
                                                                                             
  3. Bleeding is common.

Complications:

  1. Massive colonic hemorrhage.
     
  2. Toxic megacolon (hypotension, tachycardia, ill appearing pt, abdominal pain).
     
  3. Colon  CA (x 30 more common  than in Crohn's)

DX:

  1. As in Crohn's.

Treatment:

  1. Chronic uncomplicated disease:
     
      1. Sulfasalazine 1 gm PO q6h  or Mesalamine 5-ASA 1 gm PO q6h  or 500 mg suppository or  Steroids PO or Enema)
         
      2. Avoid imodium and lomotil in  U.C. since they can predispose to Toxic Megacolon.
         
  2. 2. Treatment of complications:
     
      1. as in Crohn's 
         
      2. Toxic Megacolon requires special attention. This is treated with high dose steroids,  aggressive electrolyte and IVF replacement, NPO, NGT,  broad spectrum antbx, +/- rectal tube, transfuse prn, frequent abdominal  xrays, surgery consult.

 

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