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Inflammatory Bowel Disease

It includes ulcerative colitis and Crohn’s disease. It has two peaks-one between 15-30 years and second between 60-80 years. High prevalence in urban and high socioeconomic class.
Ulcerative Colitis (Ref. Hari. 18th ed., Pg - 2477)
Definition – It is a chronic, recurrent disease characterized by diffuse mucosal inflammation involving the rectum and large intestine


Ulcerative Colitis is more common in NON SMOKERS !!!.


Pathological features-
  1. UC is a disease of large intestine, rectum is the most common site. 
  2. Backwash ileitis- Inflammation involving 1-2 cm of ileum.
  3. Mucosa has fine granular surface like sand paper in mild Inflammation. In more severe inflammation mucosa is hemorrhagic, edematous and ulcerated.
  4. The disease process is limited to mucosa and superficial sub mucosa except in fulminant disease.
  5. Pseudopolyp- due to epithelial regeneration in long standing disease.
  6. Toxic mega colon- Bowel wall become very thin and the mucosa is severely ulcerated.
  7. Cryptitis is present leading to crypt abscess, and crypt distortion.
Clinical features- Clinical features depend on the site and severity of involvement.
  1. Rectum involvement - It pass fresh blood or blood stained mucus. Tenesmus, and fecal urgency are common. No abdominal pain is present.
  2. Sigmoid colon involvement - It result in slowness of proximal transit leading to constipation.
  3. Colon involvement - Bloody diarrhea as transit through inflamed colon increased. Pus may be present. Diarrhea is often nocturnal and post prandial. Abdominal pain and tenderness are frequent.
Laboratory investigations-
  1. Anemia
  2. Raised ESR, CRP levels.
  3. Increased platelet count
  4. Low serum albumin
  5. Leukocytosis.
Serological markers:
  1. P-ANCA (60-70%)
  2. Anti-saccharomyces cerevisiae antibody(10-15%)
  3. Anti goblet cell antibody (40%)
  4. Anti colon antibody (36%)
  5. Pancreatic autoantibody (41%)
Endoscopic features-
  1. Sigmoidoscopy - to assess disease activity.
  2. Colonoscopy - To determine extend of disease and subsequent need for cancer surveillance. But it should not be performed in severe disease due to risk of perforation.
Radiological features:
  1. Plain abdominal X-ray- colonic dilation can be seen in severe disease.
  2. Barium enema – 
    1. Earliest change is fine mucosal granularity   
    2. Deep ulceration appear as ‘ collar-button’ Q ulcers. 
    3. Loss of haustration Q in long standing disease colon become shortened and narrowed. 
    4. Polyp can be seen which may be due to post inflammatory polyp, pseudopolyp, adenomatous polyps or carcinoma.
  3. U/S-
    1. Mild mural thickening
    2. Inhomogeneous wall density  
    3. Increased perirectal and pre sacral fat,
    4. Target appearance of rectum and adenopathy.
Extra colonic manifestations:
  1. Constitutional symptoms- Anorexia, nausea, vomiting, fever, weight loss.
  2. Arthritis (Sacroiliitis) 
  3. Anterior uveitis (LQ 2012)
  4. Ankylosing spondylitis. (LQ 2012)
  5. Erythema nodosum
  6. Sclerosing cholangitis (ANCA positive). (LQ 2012)
  7. Thromboembolic events.
  8. Cholestasis


  1. Massive hemorrhage.
  2. Toxic mega colon with perforation
  3. Colonic epithelial dysplasia and carcinoma. The risk of neoplasia increased with duration and extend of the disease.
Mild Mod-Severe Fulminant Maintenance
(a) Sulfasalazine (3-6g/d) (a) 5-ASA I.V.Glucocorticoid 5-ASA
(b) Olsalazine (1-3 g/d) (b) Glucocorticoids
(oral/ enema)
I.V.Cyclosporine 6-Mercaptopurine
Indication of surgery:
  1. Perforation
  2. Massive hemorrhage
  3. Toxic megacolon (diameter of transverse colon more than 6 cm in X-ray abdomen)
  4. Failure to respond to medical therapy
Extra Edge
Annual or biennial colonoscopy with multiple biopsies is recommended for patients with >8–10 years of pancolitis or 12–15 years of left-sided colitis


Crohn’s disease- (Ref. Hari. 18th ed., Pg - 2483)
Definition- It is a recurrent, chronic disease process involving trans mural part of GIT anywhere from mouth to the anus.
Pathological features:
  1. Most patients have involvement of both small and large intestine ( 40-55%).
  2. 30-40% have involvement of small intestine alone.
  3. 15-25% have involvement of large intestine alone.
  4. Rectum is often spared in CD.
  5. The most common site of inflammation is terminal ileum.
  6. Involvement is segmental with skip areas.
  7. CD is a trans mural process. (LQ 2012)
  8. ‘Cobblestone’ appearance is characteristic of CD.
  9. Pseudo polyps can occur in CD. But much less frequent than ulcerative colitis.
  10. Bowel wall thickens, fibrosed leading to recurrent bowel obstruction.
  11. Creeping fat’- Projections of thickened mesentery encase the intestine.
  12. Perirectal fistula, abscesses, fissures and stenosis is common.
  13. Liver and pancreas are also involved.
  14. Non caseating granuloma in all layers of intestinal wall from mucosa to serosa. Granuloma are also seen in lymph nodes, mesentery, peritoneum, liver and pancreas.
  15. Aphthoid ulcers and focal crypt abscesses are earliest lesion.

Recent Advances Mutations in NOD2 gene have been associated with Crohn's disease (LQ 2012)


Clinical Features – Clinical features depend on the site and pathological process involved.
Ileocolitis – Initially it presents with, recurrent right lower quadrant colicky pain and diarrhea.
  1. Low grade fever is usually seen.
  2. Weight loss is common due to diarrhea and anorexia.
  3. An inflammatory mass is palpable in right lower quadrant of abdomen composed of inflamed bowel, adherent and indurate mesentery and enlarged abdominal lymph node.
  4. Later diarrhea decrease and chronic bowel obstruction and constipation occur due to fibro stenotic narrowing and stricture.
  5. Fistula formation to adjacent bowel, skin (Enterocutaneous fistula), and vagina (Enterovaginal fistula) Q occur due to localized wall thinning with micro perforation.
  1. Malabsorption and steatorrhea due to loss of digestive and absorptive surface.
  2. Nutritional deficiency due to poor intake and enteric looser leading to hypoalbuminemia, hypocalcaemia, vitamin D deficiency (Causing vertebral fracture), megaloblastic anemia, pellagra. (Hyperoxaluria leading to renal stone) 
Colitis and perianal disease-
  1. Fever, hematochezia (Bright red blood per rectum), diarrhea are common with colitis.
  2. Crampy abdominal pain caused by passage of fecal material through narrowed and inflamed segments of large bowel.
  3. Stricture leading to bowel obstruction can occur.
  4. Fistula into stomach or duodenum causes vomiting of fecal material.
  5. Bacterial over growth due to enterocolic fistula..
  6. Rectovaginal fistula, enterocutaneous fistula, Perianal fistula.  
  7. Perianal disease causes incontinence, large hemorrhoidal tags and strictures, anorectal fistula and perirectal abscesses.
Gastro duodenal disease
  1. Nausea vomiting, epigastric pain..
  2. H. Pylori negative gastritis.
  3. Chronic gastric outlet obstruction in patients with advanced gastro duodenal CD.
Laboratory Features:
  1. Anemia, Leucocytosis.
  2. Increased ESR, CRP level.
  3. Hypoalbuminemia
  4. ASCA antibodies (60-70%)
  5. p-ANCA (5-10%)
  6. Anti goblet antibodies (30%)
  7. Anti colon antibodies (13%)
  8. Pancreatic auto antibodies (30%)
Infectious etiologies of chron disease (AIIMS May 12)
Endoscopic features:
  1. Rectal sparing
  2. Aphthous ulceration
  3. Fistula
  4. Skip lesions.
Radiological features.
  1. Thickened folds.
  2. Aphthous ulcer.
  3. Cobble stoning of small intestine.
  4. Stricture, fistula in advanced disease.
  5. ‘String sign’ represents long areas of circumferential inflammation and fibrosis.
  6. CT findings include mural thickening > 2cm, perianal disease and adenopathy.
  1. Fistula formation.
  2. Perforation leading to peritonitis.
  3. Intestinal obstruction.
  4. Massive hemorrhage.
  5. Malabsorption.
  6. Carcinoma especially with colonic involvement.
Extra Edge
Condition predisposing to colo rectal carcinoma
  1. UC
  2. CD
  3. Uretero sigmoid anastomosis
  4. Familial adenomatous polyposis


Recent Advances
  1. Capecitabine: This is an antipyrimidine drug that could be given orally for breast and colorectal cancer.
  2. Cetuximab is used in treatment of metastatic colorectal cancer and head and neck cancer.


Newer drugs for the treatment of IBD
  1. Tacrolimus
  2. Mycophenolate
  3. 6 Thioguanine
  4. Thalidomide
  5. Natalizumab
  6. Adalimumab
Table 295-8 Indications for Surgery (Ref. Hari. 18th ed., Pg- 2493)
Ulcerative Colitis Crohn's Disease
1.  Intractable disease
2.  Fulminant disease
3.  Toxic megacolon
4.  Colonic perforation
5.  Massive colonic hemorrhage
6.  Extracolonic disease
7.  Colonic obstruction
8.  Colon cancer prophylaxis
9.  Colon dysplasia or cancer
A. Small Intestine
    1. Stricture and obstruction unresponsive to medical therapy
    2. Massive hemorrhage
    3. Refractory fistula
    4. Abscess
B. Colon and rectum
    1. Intractable disease
    2. Fulminant disease
    3. Perianal disease unresponsive to medical therapy
    4. Refractory fistula
    5. Colonic obstruction

The differences between ulcerative colitis and Crohn’s disease (Ref. Hari. 18th ed., Pg - 2486, Table - 295.5)
Features Ulcerative colitis Crohn’s disease
Monozygotic twins 8%concordance 67%concordance
Gross blood in stools present rare
Systemic symptoms rare present
Pain rare present
Abdominal mass rare present
Perineal disease absent present
Fistula absent present
Small int. obstruction absent present
Colonic obstruction rare present
Response to antibiotic absent present
Recurrence after surgery- absent present
ANCA positivity 60-70% 5-10%
Rectal sparing rare present
Continuous disease present rare
Cobblestone appearance- absent present
Granuloma absent present
Abnormal small int. absent present
Abnormal terminal ileum- rare present
Segmental colitis absent present
Asymmetrical colitis absent present
Stricture rare present


Extra Edge: ASCA are also positive in Behcet Syndrome

Thalidomide is used for the following conditions: (Ref. Hari. 18th ed., Pg - 2141, 2148)

  1. Amyloidosis
  2. Beh|et’s syndrome
  3. Chronic idiopathic myelofibrosis
  4. Inflammatory bowel disease
  5. Lepra reactions
  6. Leprosy
  7. Multiple myeloma
  8. Myelodysplasia
  9. Sarcoidosis

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