IBD Part 1 - pathophysiology and pt assessment

Question 1

what is ibd?

Answer 1

Inflammatory Bowel Disease
(IBD) is a term used to describe
two chronic inflammatory
diseases of the GI tract:
ulcerative colitis (UC) and
Crohn’s disease (CD)

IBD is associated with
significant morbidity and
decreased quality of life with
a high relapse rate.

Question 2

Epidemiology

Answer 2

§ One in 140 people in Canada are living with IBD
§ Canada has among the highest rates in the world.
§ IBD can be diagnosed at any age but most are diagnosed before age 30.*
§ Male = Female
§ Smokers less likely to develop UC, more likely to develop CD.
*note: seniors are the fastest growing group of Canadians with IBD, and prevalence
in children has risen >50% in last 10 yea

Question 3

Etiology

Genetics

Answer 3

§ Increased risk with family history
§ Higher rates in Ashkenazi Jewish, South Asian
§ Possible loci on chromosomes

Question 4

Etiology

Environmental factors

Answer 4

§ Geographical location (?improved sanitation/hygiene)
§ Lifestyle
• ?diet (polyunsaturated fats, refined sugars, low fiber) – all inconclusive
• Recent research implicates processed food – proinflammatory
§ Smoking (CD)

Question 5

why canada have higher rates

Answer 5

we are living in a more sterile environment
Babies dont have a ton of bacteria in GI tract
Normal exposre, symbiotic relationship

Exposure to bacteria is important for children

Question 6

Etiology

Infectious

Answer 6

§ May be more common after GI infection
§ People with the disease have higher concentrations of GI bacteria
§ Causative vs impaired handling
of bacteria?
High conc of GI bacteria
Antibiotics in crohn's disease

We dont know if higher conc is causative or because immune system is not functioning properly and can’t handle having all that bacteria so it causes inflammation

Question 7

Etiology

Immunologic

Answer 7

§ Immune dysregulation:
• Pro-inflammatory cytokines (ie TNF- a, IL-1)
• Epithelial barrier function
• Loss of oral tolerance
§ Reactive oxygen species
§ Antioxidant defense mechanism

Inflamm in batteria , increases in permeability, greater exposure
Loss of immune tolerance to things we normally tolerate
- eating
Release pro inflamm cytokines, direct GI damage, also brins in diff inflamm cells like macrophages, neutrophils
Direct damage to GI tract

Question 8

Immune Theory:

t helper cells which types increase?

Answer 8

§ Inappropriate reaction of the immune system
§ Tumor Necrosis Factor – alpha (TNF-a) – pivotal proinflammatory cytokine
§ Mechanisms include both:
• Autoimmune (body finds foreign)
• Inappropriate T-cell responses to own antigens
(Th1activity increase in Crohns Disease, Th2 activity
increase in Ulcerative Colitis)
• Non-autoimmune

Question 9

Ulcerative Colitis
Pathophysiology

areas of inflammation

Answer 9

§ restricted to colon
• (95% of the time rectum is involved)
§ ileum not involved except as
backwash ileitis in patients who have panulcerative colitis (involvement of the entire colon)
Limited to colon, no SI
Rectum is involved
Backwash, some can go back into ileum 
Only when whole colon is inovlved pancolities
Disease is not in ileum

Question 10

define proctisis, left-sided colitis, pancolitis

Answer 10

Proctitis – disease involving only
rectum
Left-sided colitis – disease involving
sigmoid colon +/- descending colon
Pancolitis – disease involving entire
colon

Question 11

Ulcerative Colitis
§ Depth of inflammation
§ Distribution of lesions:

Answer 11

mucosal/submucosal layers of the GI tract (1st 2 layers)
continuous distribution of leisons

Crypt abscesses (necrotic lesions in the colonic crypts of Lieberkühn)
Ø pseudopolyps +
Ø ulcers are the defining lesions – collar-button
Pseudo polyps, raised aireas of mucosa, not true polyps

Question 12

Ulcerative Colitis

Signs and Symptoms:

Answer 12

§ Abdominal pain: Most common pain location is left side of abdomen
- Majority rectum is involved, on the left side
§ Frequent bowel movements, diarrhea
§ Tenesmus: Feeling of have to pass stolls all the time
§ Mucous in stools
§ Blood in stools: iron deficiency anemia
§ Severe disease: systemic symptoms – fever, weakness, dehydration, electrolyte abnormalities, tachycardia, anemia

Mucus is a sign of inflammation
Blood earlier in GI tract (SI), will see it as darker
More red is more low in GI tract

Question 13

Ulcerative Colitis

Extra-intestinal Manifestations

Answer 13

§ Arthritis/Arthralgia
§ Hepatobiliary – abnormal LFTs, fatty liver, hepatitis, cirrhosis
§ Dermatologic - Erythema Nodosum
§ Eye inflammation
§ Oral lesions
§ Gall stones

Skin effects, hives eyes
Erythema nodosum: raised reddish/pinksih areas painful to touch
Mechanism on gallstones on eclass

Question 14

Ulcerative Colitis

Complications:

Answer 14

§ anemia (iron deficiencies)
§ intestinal obstruction
§ malnutrition, malabsorption syndromes (severe)
§ toxic megacolon
§ colorectal cancer
• risk dependent on duration and extent of involvement (after 20 years)
• > 20% risk

Scarring, obstruction may happen
May not eat as effectively
The more the colon is involved, tjhe greater the risk of colorectal cancer
Greater than 20%
Long term UC , surgery to remove colon and reduce risk

Question 15

what is toxic megacolon

Answer 15

Loss of normal tone, dilation of GI tract
Not able to remove gas
Perforate, life threatening with bacteria

Question 16

Crohn’s Disease
§ Areas of inflammation:
§ Depth of inflammation:
§ Distribution of lesions:

Answer 16

§ Areas of inflammation:
• anywhere in the GI tract
• terminal ileum is most common site
§ Depth of inflammation: transmural
§ Distribution of lesions: discontinuous (skip)
§ Granulomas and fibrosis are common
Fibrosis, body is healing itself
Granulomas: clustors of inflamm cells together
Skip lesions lead to cobblestone
Characteristic description of CD: cobblestone
appearance of the GI tract

Question 17

Crohns colitis
Crohns ileitis
Crohns ileocolitis

define

Answer 17

• Crohns colitis – disease involving only colon
• Crohns ileitis – disease involving only ileum
• Crohns ileocolitis – disease involving both ileum
and colon

Question 18

Crohn’s Disease

Signs and Symptoms:

Answer 18

§ Abdominal pain – right lower quadrant most common
§ Frequent bowel movements, diarrhea
§ Mucous in stools
§ Blood in stools – depends on location of disease (ie rectal)
§ Systemic symptoms (more common compared to UC): fever, weight loss, weakness, dehydration, electrolyte
abnormalities

Similar to UC
Right lower, due to ileum involvement
Rectal involvement, blood stool
More systemic systems
Weight loss, malnutrition

Question 19

Crohn’s Disease

Extra-intestinal manifestation

Answer 19

Liver, eyes, joints

Slow growth patterns in chldren, first signs they have it

Question 20

Crohn’s Disease

Complications

Answer 20

Complications
§ Nutritional deficiencies may be more common in CD (as compared to UC)
• malnutrition, malabsorption syndromes
§ Anemia (folate, Vit B12, iron deficiencies)
§ Fistulas (intestinal, perineal, bladder, vagina)
• Fistulas in anal and rectal are most common

Depending on where in the tract
Fistula: Abnormal passage or connection b/w 2 organs or into skin
- lots of inflamm, body healing itself
Bacteria can populate

Question 21

fistulas

Answer 21

Anorectal
Stool contents coming out into the skin
Can fix with bioiligcs, TNFa, surgery
fistula between 2 organs
Rectum and vagina

Question 22

Crohn’s Disease - other complications

Answer 22

§ Strictures: narrowing of GI tract, body healing itself, tigher structures
§ Bowel obstruction
§ Abscesses
§ Sinus tract infections: infection into skin especially with fistulas
§ Renal stones
§ Osteoporosis: ltered absorption of Vitaim D and calcium affected

Question 23

Patient Assessment - IBD

Medical history

Answer 23

Medical history
§ abdominal pain, location
§ diarrhea: stool frequency, mucous, blood in stools
§ weight loss
§ extraintestinal manifestations (e.g., oral ulcers,
arthritis, erythema nodosum, iritis, fever)

If full colon is removed, lots of extraintestinatl manifestations improve, reactopm systemic , improves for UC

Not as much for CD because its throughout the body

Question 24

Patient Assessment - IBD

Physical assessment

Answer 24

§ abdominal tenderness, presence of abdominal mass,
malnutrition, perianal disease (fistulae, abscess)
§ growth failure in children
§ extraintestinal manifestations

Question 25

Patient Assessment - IBD

Laboratory Tests

Answer 25

§ Measures of inflammation:
• Increased erythrocyte sedimentation rate (ESR), Creactive protein (CRP)
• Increased white blood count
§ Albumin
§ Stool cultures – r/o other infectious causes
§ Others: Hemoglobin, Fe, B12, folate,

Some kind of inflammation is occuring
With ESR
Increased WBC means inflamm
Albumin lost in GI tract

Question 26

Patient Assessment - IBD

which visualizations can be used (3)

Answer 26

Endoscopy: telescope to visualize inside GI tract
Endoscopy
• Endoscopic mucosal findings – location of disease,
ulcerations, cobblestone for CD
• Flexible sigmoidoscopy
• Colonoscopy: a thin flexible telescope (colonoscope) to look at the lining of the colon. Samples (biopsies) for laboratory analysis and removal of lesions (such as polyps) can be done at the same time

Biopsy
• Histology from biopsy

Radiology - Barium enema
• Contraindicated in severe UC
• risk of toxic megacolon
Toxic megacolon is a greater risk of UC
Because of the 2 layerrs affected in UC