Transcript 炎 症 性 肠 病 inflammatory bowel disease IBD

Case
A
25-year-old woman
 A 4-m history of abdominal pain in the
left lower quadrant and bloody diarrhea
Case
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Stool Examination: WBC + ,RBC ++
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Microbiologic cultures of stools : negative
Colonoscopy
Colonoscopy
Continuous ulcers begin in the rectum
Colonoscopy biopsy
Pathology
crypt abscesses
(H/E, 4x)
(H/E, 10x)
Ulcerative Colitis
Yan Chen 陈焰
Second Affiliated Hospital
Concept
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Idiopathic Inflammatory Bowel Disease
(
 Ulcerative
 Crohn’s
colitis(UC)
disease (CD)
IBD)
IBD 有关内容
Learning Objectives
• Understand the current theories of IBD pathogenesis
• Understand the clinical presentation, and
management of ulcerative colitis and Crohn’s disease
• Understand the fundamental differences between
ulcerative colitis and Crohn’s
commendatory websites and books
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commendatory websites
 http://content.nejm.org/
 http://www.ccfa.org
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http://www.gastrolab.net/show.html
http://wwwmedlib.med.utah.edu/WebPath/TUTORIAL/IBD/IBD.html
commendatory books

Harrison’s principles of internal medicine
15th Edition

Goldman: Cecil Medicine, 23rd ed
Chapter 144
Ulcerative Colitis (UC)
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Concept
Etiology
Pathology
Clinical presentation
Diagnosis and differential diagnosis
Complications
Treatment
Concept
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Ulcerative Colitis
An idiopathic inflammatory
disorder involving primarily the
mucosa and submucosa of the
colon
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especially the rectum
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often with mucosal erosions
and ulcers
Concept
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colitis confined
rectum
(proctitis)
 rectum and sigmoid colon (proctosigmoiditis)
 splenic flexure
(left sided colitis)
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colitis up to
the hepatic flexure
 the whole colon
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(extensive colitis)
(pancolitis)
Concept
Ulcerative Colitis (UC)
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Concept
Etiology
Pathology
Clinical presentation
Diagnosis and differential diagnosis
Complications
Treatment
Etiologic Theories in IBD
Genetic
Predisposition
IBD
Mucosal Immune
System
(Immuno-regulatory
Defect)
Environmental
Triggers
(Lumenal Bacteria,
Infection)
Ulcerative Colitis (UC)
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Concept
Etiology
Pathology
Clinical presentation
Diagnosis and differential diagnosis
Complications
Treatment
Pathology
Tends to begin in the rectum and be
continuous
 Limited inflammation
 Mucosa and submucosa
 Crypt abscess
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Pathology
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Tends to be
continuous along
the mucosal surface;
Tends to begin in
the rectum.
Pathology
Tends to begin in the rectum and be
continuous
 Limited inflammation
 Mucosa and submucosa
 Crypt abscess
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Normal colon
Ulcerative colitis
Pathology
Tends to begin in the rectum and be
continuous
 Limited inflammation
 Mucosa and submucosa
 Crypt abscess:
Characteristic finding
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Characteristic finding
Crypt abscess
Pathology
Tends to begin in the rectum and be
continuous
 Limited inflammation
 Mucosa and submucosa
 Crypt abscess
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Ulcerative Colitis (UC)
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Concept
Etiology
Pathology
Clinical presentation
Diagnosis and differential diagnosis
Complications
Treatment
Clinical presentation
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variable
 Bloody
diarrhea
 Abdominal
 Fecal
pain
urgency
 Tenesmus
hallmark
U C
Mild
Moderate
Bowel movements
<4/d
4-6/d
Blood in stool
Small
Moderate
Fever
None
<37.5℃
Tachycardia
None
<90
Anemia
Mild
Moderate
ESR
<30mm
Endoscopic
Erythema
Marked Erythema
appearance
contract bleeding
Severe
>6/d
Severe
>37.5℃
>90
Severe
>30mm
Spontaneous
bleeding,
ulcerations
extraintestinal manifestation
Pyoderma gangrenosum
Erythema nodosum
Episcleritis
Ulcerative Colitis (UC)
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Concept
Etiology
Pathology
Clinical presentation
Diagnosis and differential diagnosis
Complications
Treatment
Diagnosis
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Essentials of Diagnosis
Bloody diarrhea
 Lower abdominal pain and
fecal urgency
 Anemia,low serum albumin
 Negative stool cultures
 Colonoscopy is key to
diagnosis
 Imaging is helpful sometimes
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Laboratory finding
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Negative stool cultures
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Anemia, ESR,CRP
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low serum albumin
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p-ANCA:
70% positive
Negative stool cultures
 Very
important
Imaging
 Plain abdominal
 Barium enemas
Plain abdominal
Severe patients
colonic dilation
Toxic megacolon
Diagnosis
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Essentials of Diagnosis
Bloody diarrhea
 Lower abdominal pain and
fecal urgency
 Anemia,low serum albumin
 Negative stool cultures
 Colonoscopy is key to
diagnosis
 Imaging is helpful sometimes
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Concept
 Etiology
 Pathology
 Clinical presentation
 Diagnosis and differential
diagnosis
 Complications
 Treatment
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Differential diagnosis
Infectious disease：ameba, dysentery…
CD
Colon cancer
IBS
Tub
Ischemic colitis
amebiasis
HE stain
PAS ：
trophozoite
amebiasis
colonscopy
amebiasis
amebiasis
Ulcerative Colitis
Crohn Disease
Colon only involved
Continuous inflammation
extending proximally from
rectum
Inflammation in mucosa and
submucosa only
No granulomas, crypt
abscess
pANCA positive
Bleeding is common
Fistulae are rare
Pan-intestinal
Skip-lesions with intervening
normal mucosa
Transmural inflammation
Non-caseating granulomas
pASCA negetive
Bleeding is uncommon
Fistulae are common
UC
Colon only, proximally from
rectum
CD
Pan-intestinal,
Skip-lesions
UC
mucosa and submucosa
crypt abscess
CD
Transmural
granulomas
CD
Fistulae
Ulcerative Colitis (UC)
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Concept
Etiology
Pathology
Clinical presentation
Diagnosis and differential diagnosis
Complications
Treatment
Complications
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Toxic megacolon
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Bleeding
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Perforation
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Risk of colon cancer
Toxic megacolon
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< 2% of cases
particularly severe UC
Defined as a severe
episode of colitis with
segmental or total dilation
of the colon (colonic
dilation of > 5cm)
Mortality rate : 20%
Toxic megacolon
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An acute transmural fulminant colitis with
the neurogenic loss of motor tone.
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The rapid development of colonic dilatation
due to damage to the entire wall of the colon
associated with neuromuscular degeneration.
Toxic megacolon
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Diagnosis
 Clinical
findings
 Symptoms
 Signs
 Laboratory
finding
 abdominal plain
Clinical findings
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Symptoms
 Abdominal pain
 Abdominal distention
 Fever
 Rapid heart rate
 Dehydration
Signs
 Abdominal tenderness
 May be signs of septic
shock
 Possible loss of bowel
sounds
Lab finding
 Elevated
white blood cell
 Low potassium level
 Abdominal plain shows colonic dilation
Toxic megacolon
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Causes
 Lower
potassium level
 Barium enema
 Anticholinergics
 Drugs used for pain relief
Case 1
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A 72-year-old woman
 Vomiting
 Abdominal
distention
 History of hypertension and ulcerative
colitis
Case 1
erect
supine
Toxic megacolon
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Cause
Toxic megacolon
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Cause
 Lower
potassium level after taking
diuretics for hypertension
Case 2
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a 44-year-old man
 Long
history of ulcerative colitis
 Double-contrast barium enema
Case 2
Double-contrast
barium enema
Case 2
2 days later
Toxic megacolon
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Causes
 Lower
potassium level
 Barium enema
 Anticholinergics
 Drugs used for pain relief
Complications
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Toxic megacolon
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Bleeding
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Perforation
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Risk of colon cancer
Cumulative Risk of CRC in UC
0.5-1.0%
per year after 10 years of disease
Eaden
et al. Gut 48:526, 2001
Treatment
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Dependent on the extent of colonic
involvement and severity of illness
2 objectives
Inducing remission (periods of time that are
symptom-free)
 Maintaining remission (preventing flare-ups of
disease)
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Sulfasalazine (SASP)
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Made up of
5-aminosalicylic acid (5-ASA): functionally
active moiety of SASP
 sulfur molecule: related to the side effects
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Newer 5-ASA drugs avoid the side effects
Any other questions?
陈焰
13757118653
[email protected]