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Inflammatory Bowel Disease Myra Lalas Pitt A NASOGASTRIC TUBE IS SEEN COURSING THE ESOPHAGUS WITH ITS TIP OVER THE GASTRIC ANTRUM. SCATTERED AIR-FLUID LEVELS ARE DEMONSTRATED IN THE UPRIGHT IMAGE. SMALL AMOUNT OF AIR IS SEEN WITHIN THE LARGE BOWEL. CONTRAST IS DEMONSTRATED WITHIN THE BLADDER. THE VISUALIZED BONY STRUCTURES APPEAR GROSSLY UNREMARKABLE. THERE IS NO EVIDENCE FOR PNEUMOPERITONEUM. MULTIPLE DILATED LOOPS OF SMALL BOWEL WITH ILEUM PREDOMINANCE ASSOCIATED WITH AIR-FLUID LEVELS AND A TRANSITIONAL POINT. ORAL CONTRAST IS LIMITED TO THE STOMACH. DIFFUSE ABDOMINAL ASCITES IS NOTED. FINDINGS LIKELY REPRESENT PARTIAL SMALL BOWEL OBSTRUCTION. EARLY COMPLETE SMALL BOWEL OBSTRUCTION CANNOT BE EXCLUDED. REPEAT IMAGING IS RECOMMENDED. GIVEN THE PREDOMINANTLY DISTAL SMALL BOWEL INVOLVEMENT WITH WALL THICKENING, INFLAMMATORY BOWEL DISEASE WITH STRICTURE IS A POSSIBLE ETIOLOGY FOR THE SMALL BOWEL OBSTRUCTION. Definition • Comprised of 2 major disorders: Crohn’s Disease and Ulcerative Colitis Ulcerative Colitis (limited to the mucosal layer) Crohn’s Disease (transmural inflammation) Lesions are continuousno skipped lesions YES NO Surgical excision is curative YES NO Toxic megacolon can occur YES YES Growth retardation and pubertal delay YES YES Epidemiology Age at onset Incidence Crohn Disease Ulcerative Colitis Bimodal, 15–25 yr and 50– 70 yr Recent studies show unimodal distribution (peak in the 20s–30s with diminishing incidence later) 16–20 yr 4.5/100,000 2.1/100,000 Pathophysiology • Pathogenesis is multifactorial. • The most widely accepted theory of pathogenesis is that in genetically susceptible individuals: environmental trigger (can be normal gut flora or a ubiquitous environmental agent) ↓activates chronic, dysregulated immune response. Signs and Symptoms Crohn Disease (%) Ulcerative Colitis (%) Abdominal pain 62–95 33–71 Diarrhea 66–77 67–90 Weight loss 80–92 39–43 Rectal bleeding 14–60 52–90 Growth impairment 30–33 6 Perirectal disease 25 — Extraintestinal manifestation 15–25 2–16 Extraintestinal Manifestations Skeletal Arthritis, arthralgia, ankylosing spondylitis, digital clubbing (hypertrophic osteoarthropathy), osteopenia, osteoporosis, aseptic necrosis Cutaneous Erythema nodosum, pyoderma gangrenosum, aphthous ulcers, vesiculopustular eruption, necrotizing vasculitis Ocular Uveitis, episcleritis, corneal ulceration, retinal vascular disease Hepatic Primary sclerosing cholangitis, bile duct carcinoma, autoimmune chronic active hepatitis, fatty liver disease, cholelithiasis Endocrine Growth failure, pubertal delay Hematologic Autoimmune hemolytic anemia, thrombocytopenic purpura, thrombocytosis, thrombophlebitis, thromboembolism, arteritis Renal Nephrolithiasis (classically oxalate stones) Cardiac Pericarditis, myocarditis, heart block Pancreatic Acute pancreatitis (Crohn disease > ulcerative colitis) Neurologic Peripheral neuropathy, myelopathy, myasthenia gravis Erythema Nodosum Pyoderma Gangrenosum Differential Diagnosis • Infectious Bacterial (salmonella, shigella, campylobacter, Escherichia coli 0157/h7, yersinia, mycobacteria) Parasitic (Amebiasis, giardia) Viral (cytomegalovirus [CMV], herpes) Clostridium difficile pseudomembranous colitis AIDS TB • Rheumatologic/ Autoimmune Bechet disease Chronic Granulomatous Disease SLE • Vascular disorders Hemolytic uremic syndrome Henoch-Schönlein purpura Polyarteritis nodosa • Obstetric and gynecologic Pelvic inflammatory disease Ectopic pregnancy Endometriosis • GI Tumors Eosinophilic Colitis Hirschsprung disease/enterocolitis Irritable Bowel Syndome PUD Work- up • • • • • • CBC CMP ESR, CRP Stool cultures Stool for O&P Stool for C. diff • • • • UGIS CT Scan Endoscopy Colonoscopy Abdominal computerized tomography (CT) scan showing thickened bowel wall due to Crohn disease. Ulceration of the ileum in a patient with Crohn disease Colonoscopic image from a patient with ulcerative colitis demonstrating diffuse erythema with ulcerations. Treatment Primary goals of therapy: 1. Induction and maintenance of remission 2. Prevention of disease complications (such as fistula, stricture, abscess, and cancer) 3. Control of postoperative disease recurrence 4. Maintenance of normal growth and development 5. Maximization of quality of life. From Peds in Review References Glick, S. and R. Carvalho. “Inflammatory Bowel Disease:” Pediatrics in Review Vol. 32 No. 1 January 1, 2011 pp. 14 -25 (doi: 10.1542/pir.32-1-14) Lowry AW, Bhakta KY, Nag PK, "Chapter 16. Gastroenterology" (Chapter). Lowry AW, Bhakta KY, Nag PK: Texas Children's Hospital Handbook of Pediatrics and Neonatology: http://www.accesspediatrics.com/content/7437895. Silverstein, Stu. Laughing Your Way to Passing the Pediatric Boards. 2008, Medhumor Medical Publications: USA Stephens Michael C, Kugathasan Subra, Sato Thomas T, "Chapter 410. Inflammatory Bowel Disease" (Chapter). Colin D. Rudolph, Abraham M. Rudolph, George E. Lister, Lewis R. First, Anne A. Gershon: Rudolph's Pediatrics, 22e: http://www.accesspediatrics.com/content/7037639. www.uptodate.com