INFLAMMATORY BOWEL

DISEASE (IBD)
INFLAMMATORY BOWEL DISEASE (IBD)

A group of chronic inflammatory of

intestinal idiopathic .
The two main disease categories are
Crohn’s disease (CD) and ulcerative
colitis (UC)
PATHOGENESIS

The pathogenesis of IBD is incompletely

understood.
Genetic and environmental factors such as
altered luminal bacteria and enhanced
intestinal permeability play a role in the
dysregulation of intestinal immunity, leading to
gastrointestinal injury.
SYMPTOMS
 Diarrhea:

 Stool may contain mucus or blood.

Inkontinentia

 Constipation:

 May be the primary symptom in UC limited to

the rectum (proctitis).
 Pain or rectal bleeding with bowel movement

 Bowel movement urgency

 Abdominal cramps and pain

SYMPTOMS
 General :
 Fever
 Loss of appetite
 Weight loss
 Fatigue

 Extraintestinal :
 Musculoskeletal → peripheral or axial arthropathy
 Cutaneous → erythema nodosum, pyoderma
gangrenosum
 Ocular → scleritis, episcleritis, uveitis
DIAGNOSIS

 History & physical examintation

 Fecal test : Culture, Ocult blood test , calprotectine
 Exclude intestinal TB --> interferon gamma release assay
(IGRA) has a high specificity for the diagnosis of TB. (to
differentiate gastrointestinal TB from CD in Asian
populations )
DIAGNOSIS

 Imaging and endoskopi

 (imaging to exclude toxic megacolon, bowel obstruction
or perforasion)
 Barium double-contrast enema/barium small-bowel
radiography : to see fistula, changes in intestinal
 Examine for ulcers, inflammation, bleeding, stenoses.
 Histology : Noncaseating granuloma (Chron’s), Caseating
granuloma (TB),dysplasia
FECAL CALPROTECTIN TEST

 Calprotectin is a small calcium-binding protein and is a

member of the S100 family of zinc-binding proteins ,
contribute to ∼60% of the protein content of the cytosol
in neutrophils
 Found in 1980

 When active inflamation occur, PMN neutrophil migrate

from circulation to intestinal mucose.
FECAL CALPROTECTIN TEST

 Any disturbance to the mucosal archi-tecture --> leakage

of neutrophils, and hence, calprotectin, into the lumen -
-> excreted in feces.
 Aim : to differentiate IBD from IBS (sensi 82%, spesi 77%)
To evaluate disease activity Monitoring response to
treatment
CASCADE EXAMINATION
Limited resources available
 Physical examination.
 Stool tests for infective sources, fecal leukocytes.
 CBC, serum albumin.
 HIV and TB testing in high, chest X-ray (CXR).
 Flexible full-length colonoscopy and ileoscopy with
biopsies if histological interpretation is available.
 If endoscopy is not available but barium studies are, then
both a small-bowel barium study and a barium enema
should be obtained.
CASCADE EXAMINATION
Medium resources available
 Physical examination.
 Stool tests for infection.
 Stool for fecal leukocytes, fecal calprotectin (not
necessary if endoscopy available)
 CBC, serum albumin, serum ferritin, C-reactive protein
(CRP).
 HIV and TB testing in high-risk populations, chest X-ray
(CXR).
 Colonoscopy or ileoscopy
 CT scan of the abdomen.
EXCLUDE TUBERCULOSIS

IBD and intestinal tuberculosis

 Intestinal TB must be excluded before a diagnosis of IBD is
made.
 A causal association between Mycobacterium and IBD
remains unproven.
 In high-risk populations , if TB cannot be excluded, a trial
of anti-TB therapy is justified and corticosteroids should
be withheld.
EXCLUDE TUBERCULOSIS
IBD and intestinal tuberculosis
 sequences of symptoms occur as TB: fever, abdominal
pain, diarrhea; CD: abdominal pain, diarrhea, and fever
(the latter is often absent).
 TB has a continuous course, while there is a history of
remissions and relapses in CD.
 Ascites may be present in TB, but is uncommon in CD.
MAYO SCORE

 A numerical disease activity instrument

 It is the sum of scores from four components

stool
rectal bleeding
frequency

physician's
sigmoidoscopic
global
findings
assessment.

 It ranges from 0 to 12, with the higher total score indicating a more
severe disease
MAYO SCORE
Score Variable
Mucosal
Variable Score
Appearance
Stool frequency
0 Normal Normal 0
1 1-2 stools/day > normal Mild friability 1
2 3-4 stools/day > normal Moderate 2
3 >4 stools/day > normal friability
Rectal Bleeding Exudation, 3
spontaneous
0 None bleeding
1 Streaks of blood Physician Global
2 Obvious blood Assessment
3 Mostly blood
Normal 0
Mild 1
Moderate 2
Severe 3
TREATMENT
The goal of treatment is to:
 Improve and maintain patients’ quality of life
 Treat acute disease:
 Eliminate symptoms and minimize long-term adverse

effects
 Reduce intestinal inflammation and if possible heal the

mucosa
 Maintain corticosteroid-free remissions (decreasing the
frequency and severity of recurrences and reliance on
corticosteroids)
 Prevent complications, hospitalization, and surgery
 Maintain good nutrition
TREATMENT
 Limited resources available
 1.In endemic areas and when there is limited access to
diagnosis, anti-ameba therapy should be administered.
 2.Sulfasalazine or mesalazine for all mild to moderate colitis and
for maintenance of remission.
 3.Corticosteroid enemas for distal colon disease
 4.Oral prednisone for moderate to severe disease (acute severe
disease requires intravenous corticosteroids).
 5.CMV and C. difficile should be actively sought in patients with
refractory disease
 6.Azathioprine for corticosteroid dependence. Methotrexate can
be considered if azathioprine is not available or if there is
intolerance, but this is unproven in UC.
TREATMENT

Medium resources available

 Sulfasalazine can be used for mild to moderate colitis.

 5-ASA enemas or suppositories for distal disease. Steroid

enemas are also an option, but typically not for maintenance.
 Combination therapy with oral and rectal 5-ASA may be more
effective in active distal disease or even active pancolitis.
 If remission is not maintained with 5-ASA, then azathioprine
or 6-MP/AZA should be considered; if azathioprine fails, anti-
TNF should be considered.
 If biological agents are available, then depending on the
severity of the illness their use may be indicated instead of
trials of immunomodulator monotherapy.
SYSTEMATIC REVIEW: THE USE OF MESALAZINE IN INFLAMMATORY
BOWEL DISEASE
R. BERGMAN M. PARKES

 The efficacy of mesalazine in the treatment of mild to

moderately active UC is established, although the
impact and speed of action of oral therapy alone is
modest. Higher dosing regimes appear safe and may
improve efficacy
 The type of topical formulation should be tailored to
extent of UC in the patient to be treated: suppositories
for proctitis, foam enemas for recto‐sigmoid UC and
liquid 5‐ASA for extensive disease.
SYSTEMATIC REVIEW: THE USE OF MESALAZINE IN
INFLAMMATORY BOWEL DISEASE R. BERGMAN M. PARKES

 Topical 5‐ASAs are significantly more effective than

equivalent topical steroid preparations.
 Maintenance therapy with mesalazine reduces the risk
of relapse for patients with UC, and probably reduces
their risk of CRC.
 Evidence for efficacy of mesalazine in CD for either
treatment of activity or maintenance of remission is
unconvincing.
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