Transcript Crohn,s disease

Crohn,s disease
DEFINITION.
• IBD>
RESULT FROM AN ABNORMAL LOCAL IMMUNE
RESPONSE AGAINST THE NORMAL FLORA OF THE
GUT.
CROHN’S DISEASE is a systemic non-caseating
granulomatous inflammatory disease with
predominant GI-involvement.
>may affect any part of GIT from lips to anal margin
but most commonly affects terminal ileum.
AETIOLOGY
• 1- idiopathic
• 2-some proposed risk factors are
• >DNA of M.PARATUBERCULOSIS has been found
in the intestine of 60%pts but of no value.
• >focal ischemia
• >dietary habit--------in conclusive
• >smoking
• >genetic factors
PATHOGENESIS
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Pathogenesis of IBD involves 3 components.
1)Genetic Predisposition,
HLA DR7 and DQ4 alleles.
NON-HLA genes NOD2(CARD15).
(NOD2 protein is an intracellular receptor for
muramyl dipeptide, a component of cell wall
of many bacteria.Mutation in this gene leads
to defective host response to bacteria and
thus allowing chroinc inflammation.)
2)Immunological Factors,
• Primary damaging agents appear to b CD4+
cells.
• produce IL-17 and TNF which result in chronic
immunological response and tissue
inflammation.
3)Microbial Factors,
Organisms just provide the antigenic trigger to
already dysregulated immune system.
PATHOLOGY
• Fibrotic thickening of intestinal wall with a
narrow lumen.
• Creeping fat
• Stricture with deep mucosal ulcers(snake-like
pattern)
• Oedema in the mucosa b/w ulcers
(cobblestone appearance)
• Skip lesions
CLINICAL FEATURES
A)ACUTE CD:
-mimic the C/F of appendicitis with severe
diarrhoea
-local or diffuse peritonitis
-acute colitis with or without toxic megacolon
B)CHRONIC CD:
1-1st stage– mild diarrhoea, colicky pain, anemia,
mass in the RIF9tender,firm and non mobile) and
perianal fissure or abscess.
• 2-2ND stage---acute or chronic I.O due to
fibrosing lead to narrowing.
• 3-3RD Stage---adhesions, fissures,intra
abdominal abscesses and fistlae formation.
• >enteroenteric fistula.
• >enterovesical fistula-----recurrent UTI and
pneumaturia.
• >enterocutaneous fistula.
• C)ANAL DISEASE,
-bluish perianal skin
-painless superficial ulcers with undermined edges
-deep ulcers in upper anal canal ass/with perianal
abscess and fistula.
-sepsis
-thick,nodular and irregular rectal mucosa if
involved---------rare
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D)EXTRAINTESTINAL MENIFESTATIONS:
Skin----erythema nodosum
Eye----iritis, uveitis
Joints---arthritis,
Sclerosing cholangitis
Nephrotic syndrome
Pancreatitis
amyloidosis
INVESTIGATIONS
• 1-Laboratory;
• -CBC------anemia ,FALL IN
ALBUMIN.MAGNESIUM,Zn
• -CRP
• 2-ENDOSCOPY;
• Sigmoidoscopy----ulceration in anal canal
• Aphthoid like ulcers surrounded by a rim of
erythematous mucosa
• strictures
Crohn,s disease
• 3)Imaging;
a)Barium enema-->narrowed and irregular involved area
>string sign of kantor
b)sinograms----enterocutaneous fistula
c)CT scan-----fistula, intra-abd. Abscesses
d)MRI
MANAGEMENT
• LIFESTYLE MODIFICATION…
• Stop smoking
• Eating small meal frequently instead of big
meal
• Low fiber diet when fiberious food cause
symptoms
MANAGEMENT
a)MEDICAL THERAPY.
>STEROIDS-------------mainstay of therapy
>antibiotics---------meteronidazole especially in
perianal disese
>immunomodulatory agents----azathioprin,
ciclosporin
>monoclonal antibody----infliximab
>nutritional support----anemia,electrolytes, vitamins
etc.
MANAGEMENT
b)SURGICAL THERAPY.
>Indications
-failure of medical treatment
-recurrent I.O
-fistula formation
-bleeding
-perforation
-malignant changes
Perianal disease
MANAGEMENT
*PROCEDURES*
1-ileocaecal resection
2-Segmental resection
3-colectomy and ileorectal anastomosis----wide
spread colonic disease wd rectal sparing.
4-emegency colectomy
5-laparoscopic surgery
6-temporary loop ileostomy
MANAGEMENT-------7-proctocolectomy
8-strictureplasty
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PROGNOSIS
• Small bowel and colorectal carcinoma