Inflammatory bowel disease

Inflammatory bowel disease include several condition most commonly being
1. Ulcerative colitis.
2. Crohn's disease .
Other uncommon inflammatory bowel disease include
1 microscopic ulcerative colitis
2microscopic lymphocytic colitis
3.microscopic collagenous colitis

ULCERATIVE COLITIS
DEF.
    #ulcerative colitis is an inflammatory disease affecting mainly the large intestine characterised clinicaly by recurrent attack of bloody diarrhoea and pathologically diffuse inflammation of colonic mucosa.
 # Disease extent can be broadly divide into distal and more extensive disease
 -distal disease refer to colitis confined  to rectum or rectum or sigmoid colon.
 -more extensive disease include "left side colitis" (up to the splenic flexure). Extensive colitis (upto the hepatia flexor ) and pancolitis)
.
AETIOLOGY
1. Familial or genetic
  a. Strong family history
  b. Occupance in monozygotic twins
2.infection
 a. Mycobacterium
 b. Measles virus
 c. Listeria monocytogens  .
 d yeast
 e. Endogenous bacteria
  bacteroides
  E-coli.
3. DIETARY FACTORS
 Deficiency of certain nutrients (butyric  
 acid. Sulphides. L - arginine glutamine.)
4.SMOKING
 -Can exacerbate Crohn's disease
 -increased risk of ulcerative colitis in non smokers
5.PSYCHOLOGICAL
 Characterised personality and major psychologica stresses are related to flare ups and ppt symptoms 6.DEFECTIVE IMMUNE REGULATION
 MANY Immunological ABNORMALITIES LIKE punt of macrophages leading to excessive production of cytokine (interlukin.1 interlukin 6 and tunn necrosis factor alpha ) also activation of other cells like eosinophills mast cells fibroblast
-immune complexes  are responsible for extra intestinal menifestatiom.
-

PATHOLOGY
1. Primarily involves the colonic mucosa
2. Mucosa involvement is uniform and continuous  with no intervening areas of normal mucosa
3.rectum is involved in 95 percent cases 4. From the rectum the disease extend proximally into the colon in a continuous fashion
5.Back wash ileitis in involvement of a few centimeter of ileum when the entire colon is involved
6. Macroscopically the mucosa appears hyperaemic haemorrhagic of ulcerated. Ulcer do not usually extend deeper beyond the sub mucosa .
7.Pseudopolyps are regenerationi island of mucosa surrounde by areas of ulcerative and denuded mucosa .they protrude into the lumen of colon like polyps.
8.microscopically the lamina propria is infiltered with lymphocytes and plasma cells . There is loss of goblet cell also .
9.crypts absess are characterised wits infiltration with neutrophills.
10. In toxic meghacolon , transverse colon is dilated ,walls are thin , mucosa denuded and inflammation extend to serosa. It may rupture.
11. In the chronic variety there is fibrosis and shortening of colon with loss of normal haustral pattern . The surface epithelium may show features and coal abscesses are uncommon.
,
CLINICAL FEATURES
A. General
 1.severity of symptoms reflects the extent the extent of colonic involvement and the intensity of inflammation .
2.Exacerbation and remission are characteristic.    
.3. Bloody diarrhoea with mucosa  and pus .
4 abdominal pain ,especially lower abdominal .
5.fever ,weight loss , loss of apetite.
6.symptoms and signs of dehydration and anemia
7. Extraintestinal manifestation
8.tenderness on palpation over the left iliac fossa .
9. Incidence of carcinoma
,
B. Acute variety
1. Systemic symptoms like fever ,weight loss and loss of apetite .
2. Diarrhoea and dehydration
3. Tachycardia and postural hypotentsion
4. Tenesmus .lower abdominal . Pain , left iliac fossa
5.rupture of colon ,,
,
CHRONIC VARIETY ,
1. Bowel is damaged  by fibrosis . It behaves like rigid tube incapable of absorbing fluids action like faecal reserviour
2.chronic diarrhoea
,
DISEASE CONFINED TO RECTUM
1.SYSTEMIC SYMPTOMS ARE ABSENT.
2. Loose motions and blood streaking of stools
3.bleeding and ovat per rectum
,,
Distal colitis
1. Constipation rather than diarrhoea
2 Retention of faeces in the proximal colon and small hard stools.
,
INVESTIGATION
1. Anaemia ,raised ESR AND leucocytosis
2.electrolyte imbalance
3hypoproteinaemia
4.abnormal liver function
5.blood culture in septicaemia
6.stool examination and culture
7.plain radiography abdomen
8.Barium enema
_irritability and incomplete filling
_ulceration
_pseudopolyps and strictures.
_bowel has assymetrica ,ahustral, tubular(pipe stem appearance).
9.sigmoidoscopy
_uniform continuous involvement of mucosa
_loss of mucosal vascularity
_diffuse hyperaemia
_exudate of mucus, pus and blood.
_,shallow but small or confluent ulcer .
_pseudopolyps
11. Colonoscopy
ht is preferable to flexible sigmoidscopy,
since there is high risk of bowel perforatin and flexible sigmoidoscopy .
12. Rectal biopsy shows mucosal inflammation.
13Serogical markers
_ pANCA :Perinuclear anti neutrophilc cytoplasmic antibody
_ASCA ANti-Saccharomyces cerevisiae antibody.
_ANTI-GOBLET cell auto antibodies in 30-40percent . Cases of ulcerative
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TREATMENT
GENERAL MEASURES
1.Parental nutrition
2. High protein diet, low residue diet.
3.blood and plasma infusion .
4. Correction of dehydration and electrolyte imbalance .
5. Codeine phosphate and loperamide for diarrhoea .

CORTICOSTEROIDS
local treatment
_HYDROCORTISONE or PREDNISOLONE enemas, suppositors or foam.
_duration of treatment is 3to 6 weeks.
SYSTEMIC TREATMENT
_Prednisolone 40 to 60 mg orally daily for 3 to 6 weeks
_increase hydrocortisone 100-200 Mg.
-steroids  are gradually tapered and withdrawn.
-
AMINOSALICYLATES
-it includes 5aminosalicylic acid or mesalazin alone os combination of 5ASA carrier which release 5-ASA after splitting an bacteria in colon (sulphasalazine,osalazine, basalazide).
Side effect include nausea ,headache ,rashes,sterility in males ,haemolytic anaemia ,steven johnsen syndrome and agranulocytosis.
DOSE : 2 to 4 gm/day in mile to moderate attack and 0.5gm QID to prevent relapse .

IMMUNOSUPPRESSIVE AGENTS
-Azathioprine and 6-mercartopurine both are useful in inducing and maintaining remission and have steroid sparing activities
-useful in patient who require two or more corticosteroid within a balcodes year .
-methotrexate
-cyclosporine- an inhibitor of calcineurin- preventing expansion of T cell subset .
-Surgical management
emergency surgical procedure is colectomy with ileostomy, the rectum and distal colon being removed at a later stage.

Indication of emergency surgeries
severe forms of disease
toxic dilation of colon
perforatin
severe haemorrhage
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indication of elective surgeries
acute disease which fails to respond to medical treatment
-frequent relapse in spite of adequate treatment
-chronic disease with permancouly damaged bowel.