Transcript Slide 1
• 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: – – – – – – • 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: – – – – – – – – – – – 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. • • • Suppository: Rectum Foam enema: Proximal sigmoid Liquid enema: Splenic flexure • 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: • • • • Systemic toxicity T >38ºC HR >120 Neutrophilic leukocytosis >10,500 Anemia – PLUS at least 1 of the following: • • • • Dehydration Altered sensorium Electrolyte disturbances Hypotension Smooth muscle inflammation paralyzes dilatation Decreased incidence Hydrocortisone 100 mg/tid-qid Third generation + Metronidazole