Transcript IBD 9/9/11 Morning Report

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.
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