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Inflammatory Bowel Disease Clinical essentials – Dr. Kiran Peddi MRCP(UK), FRCP(London), CCT(Gastro)

Inflammatory bowel disease (IBD) is an idiopathic chronic relapsing inflammation of the bowel that presents with recurrent episodes of abdominal pain and diarrhea. There are two sub-types of IBD: Crohn’s disease and ulcerative colitis.

Interestingly, while smoking is associated with an increased risk of Crohn’s disease, it is protective for the development of ulcerative colitis.

IBD subtypes can be differentiated based on the pattern of inflammation:
• Crohn’s disease is associated with transmural inflammation. Histopathology reveals lymphoid aggregates with noncaseating granulomas.
• Ulcerative colitis is associated with mucosal inflammation (superficial submucosa may also be affected). Histopathology reveals crypt abscesses with neutrophils, but no granulomas.

IBD subtypes can be differentiated based on the affected location within the GI tract:
• Crohn’s disease begins anywhere from the mouth to anus with “skip lesions”.The terminal ileum is most commonly involved while the rectum is rarely involved.
• Ulcerative colitis begins in the rectum (always involved) and can extend up to the cecum, with continuous involvement (and sparing of the remainder of the GI tract).

IBD subtypes can be differentiated based on gross morphological appearance:
• In Crohn disease there is “cobblestone” mucosa, strictures, and creeping fat
• In ulcerative colitis, there are pseudopolyps

IBD subtypes can be differentiated based on imaging with barium contrast:
• Crohn disease may present with “string sign” (due to narrowing of the lumen)
• Ulcerative colitis may present with “lead pipe sign” (loss of haustra)

IBD subtypes can be differentiated based on associations with certain extraintestinal disorders:
• Crohn disease is associated with calcium oxalate kidney stones and gallstones
• Ulcerative colitis is associated with primary sclerosing cholangitis (p-ANCA positive)
Both subtypes are associated (to varying degrees) with the following disorders:
• Pyoderma gangrenosum
• Erythema nodosum
• Ankylosing spondylitis
• Uveitis
• Aphthous ulcers
• Arthritis

Serologic studies for the presence of anti-Saccharomyces cerevisiae antibodies (ASCA) and perinuclear anti-neutrophil cytoplasmic antibodies (p-ANCA) can contribute to the differentiation of IBD subtypes. Helpful patterns are:
• Crohn disease: ASCA-positive, p-ANCA negative
• Ulcerative colitis: ASCA-negative, p-ANCA positive

Systemic complications of both IBD subtypes include:
• Malnutrition due to intestinal inflammation. This is particularly common in patients with Crohn’s disease (which most commonly involves the terminal ileum) since the absorption of both vitamin B12 and bile salts occurs in the terminal ileum.

• Adenocarcinoma of the large colon due to persistent inflammation. This can be seen in both inflammatory bowel diseases but is more common in ulcerative colitis since ulcerative colitis always involves the colon.

The risk of developing inflammatory bowel disease-associated adenocarcinoma is proportional to:
• Disease duration (increased risk at 8-10 years)
• Extent of colonic involvement (increased risk with pancolitis)
• Frequency and intensity of inflammation (increased risk with more intense and frequent relapses)

There are several important GI complications more closely associated with Crohn disease, most notably the following:
• Obstruction caused by stricture formation
• Fistula formation
• Perianal disease
• Cholelithiasis

There are several important GI complications more closely associated with ulcerative colitis, most notably:
• Toxic megacolon
• Sclerosing cholangitis

Cutaneous pathologies that are associated with inflammatory bowel diseases include erythema nodosum and pyoderma gangrenosum.

Pyoderma gangrenosum is a neutrophilic dermatosis that appears as a purulent ulcer with a violaceous edge. The majority of patients with pyoderma gangrenosum have an associated systemic disease, most commonly inflammatory bowel disease.

Treatments for ulcerative colitis include:
• 5-aminosalicylic acid formulations (e.g. sulfasalazine, mesalamine)
• 6-mercaptopurine (purine synthesis inhibitor)
• Infliximab (anti-TNFα antibody)
• Colectomy

Treatments for Crohn disease include:
• Corticosteroids
• Azathioprine (purine synthesis inhibitor)
• Infliximab (anti-TNFα antibody)
• Adalimumab (anti-TNFα antibody)
• Antibiotics (ciprofloxacin, metronidazole)

#inflammatoryboweldisease #clinicalessentials #gastroentrology #pathology #internalmedicine #Crohndisease #Crohnsdisease #ulcerativecolitis

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