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• UC & CD are disorders of modern society: their frequency in
developed countries has been increasing since the mid-20th century.
• Children: CD is more prevalent than UC
• The highest incidence & prevalence: Northern Europe & North
America
• A westernized environment & lifestyle: Smoking, high fat & sugar
diets, stress, & high socioeconomic status
• UC: Smoking is associated with milder disease, fewer hospitalization, &
a reduced need for medications.
• UC: Appendectomy in early life is associated with a decreased
incidence
• CD: Appendectomy in early life is associated with a increased incidence
• Genetic influences: play a greater role in CD than in UC
• Is genetic screening indicated to assess the risk of UC?
NO, (given the large number of implicated genes & the small additive
effect of each)
• Human Microbiome project aims to define the composition of the
intestinal microbiota in conditions of health & disease.
• The density of microbiota is greater in IBD patients than in healthy
control subjects.
• Risk factors for CRC:
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Long duration of the disease (regardless of clinical activity)
Extensive involvement
Severe inflammation
A young age at onset
The presence of PSC
Family history of CRC
Surveillance colonoscopy for patients at risk: there is no clear evidence that
such surveillance increases survival.
• Pancolitis: inflammation up to ileocecal valve, with occasional limited
involvement of the distal ileum (Backwash ileitis)
• Better detection of suspicious mucosal patterns & dysplasia:
Chromoendoscopy, NBI, & autofluorescence imaging
• UC:
– Proctitis may present with constipation
– A small area of inflammation surrounding the appendiceal orifice
(cecal patch) can be identified in patients with left sided colitis,
proctosigmoiditis, or proctitis.
– Cancer: up to 20-30% after 30 years
• CD:
– Video capsule endoscopy
– Single balloon enteroscopy
– Double balloon enteroscopy
Pillcam SB capsule (originally named the M2A capsule)
• Indication for surgery:
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Failure of medical therapy
Intractable fulminant colitis
Toxic megacolon
Perforation
Uncontrollable bleeding
Intolerable side effects of medication
Stricture that are not amenable to endoscopic therapy
Unresectable high-grade or multifocal dysplasia
DALM (Dysplasia associated lesion or mass)
Cancer
Growth retardation in children
• Unlike CD, UC may respond to probiotics:
– Escherichia coli strain Nissle 1917 (200 mg/day)
– VSL#3 (3600 colony-forming units/day/for 8 weeks)
• Pouchitis:
– An inflammation caused by an immune response to the newly established
microbiota in the ileal pouch (dysbiosis).
– Metronidazole, ciprofloxacin, rifaximin.
– Probiotics can be effective for preventing recurrence.
– Pouch failure is a condition requiring pouch excision or permanent diversion.
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Suppository: Rectum
Foam enema: Proximal sigmoid
Liquid enema: Splenic flexure
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Rectal 5-ASA induces earlier & better results than oral mesalazine in the
treatment of active proctitis. In active left-sided colitis there is proximal
colonic stasis & fast colonic transit through the inflamed colon. This results in
reduced exposure of the distal colon to the oral agent. The combination of both
oral & rectally delivered 5-ASA has greater efficacy & speed of response in
patients with distal colitis than either administration route used alone.
• Cyclosporine is only a bridge.
• The expanding use of anti-TNFa agents has not
decreased the need for colectomy for UC patients.
• Do not forget these etiologies of acute pancreatitis in a patient with
IBD:
– AZA
– 6-MP
– 5-ASA
– Sulfasalazine
– Steroid
• Granuloma may be seen:
– CD
– TB
– Lymphoma
– Behcet's disease
– Yersinia
• Toxic megacolon:
– Colonic distension (supine
film >6 cm)
– Plus at least 3 of the following:
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Systemic toxicity
T >38ºC
HR >120
Neutrophilic leukocytosis >10,500
Anemia
– PLUS at least 1 of the following:
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Dehydration
Altered sensorium
Electrolyte disturbances
Hypotension
Smooth muscle inflammation
 paralyzes  dilatation
Decreased incidence
Hydrocortisone 100 mg/tid-qid
Third generation + Metronidazole