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Epidemiology
both occur at the highest incidence in Europe, the United Kingdom, and North America. In North America, incidence rates range from 2.2 to 14.3 cases per 100,000 person-years for UC and from 3.1 to 14.6 cases per 100,000 person-years for CD
Epidemiology
The peak age of onset of UC and CD is between 15 and 30 years. A second peak occurs between the ages of 60 and 80. The male to female ratio for UC is 1:1 and for CD is 1.11.8:1. UC and CD have two- to fourfold increased frequency in Jewish populations in the United States, Europe, and South Africa
Epidemiology
Urban areas have a higher prevalence of IBD than rural areas high socioeconomic classes have a higher prevalence than lower socioeconomic classes.
Epidemiology
The risk of UC in smokers is 40% that of nonsmokers. Additionally, former smokers have a 1.7-fold increased risk for UC than people who have never smoked. In contrast, smoking is associated with a twofold increased risk of CD. Oral contraceptives are also linked to CD; the odds ratio of CD for oral contraceptive users is about 1.4. Appendectomy is protective against UC but increases the risk of CD.
Epidemiology
If a patient has IBD, the lifetime risk that a first-degree relative will be affected is ~10%. If two parents have IBD, each child has a 36% chance of being affected. In twin studies, 58% of monozygotic twins are concordant for CD and 6% are concordant for UC, whereas 4% of dizygotic twins are concordant for CD and none are concordant for UC. The risks of developing IBD are higher in first-degree relatives of Jewish versus nonJewish patients: 7.8% versus 5.2% for CD and 4.5% versus 1.6% for UC. Anatomic site and clinical type of CD is also concordant within families.
Epidemiology
UC and CD are both associated with Turner's syndrome, and Hermansky-Pudlak syndrome is associated with granulomatous colitis. Glycogen storage disease type 1b can present with Crohn's-like lesions of the large and small bowel. Other immunodeficiency disorders, such as hypogammaglobulinemia, selective IgA deficiency, and hereditary angioedema, also exhibit an increased association with IBD.
Genetic Considerations
IBD is a polygenic disorder that gives rise to multiple clinical subgroups within UC and CD. Genome-wide searches have shown diseaseassociated loci on many chromosomes. Some loci are associated with both UC and CD, suggesting some overlap in pathogenesis. Specific gene associations are mostly undefined; however, several predisposing genes have been identified
Genetic Considerations
CARD15 (caspase-associated recruitment domain containing protein 15) on chromosome 16 is a cytosolic molecule that senses bacterial muramyl dipeptide and regulates intracellular signaling. CARD15 protein is expressed by intestinal epithelial cells, including Paneth cells, monocytes, macrophages, and dendritic cells.
Genetic Considerations
Loss-of-function mutations in CARD15 are highly associated with CD and may account for up to 10% of CD risk. CD-associated CARD15 alleles either allow excess NF- B activation or decreased intestinal antimicrobial activity by diminishing defense in production by Paneth cells. Homozygosity for these mutant alleles confers up to a fortyfold increased risk for fibrostenosing CD, especially in the ileum.
Genetic Considerations
IBD has also been associated with polymorphisms in DLG5 and the IL-23 receptor. Indeed, patients with IBD and their firstdegree relatives may exhibit diminished intestinal epithelial cell barrier function.
Exogenous Factors
multiple pathogens (e.g., Salmonella sp., Shigella sp., Campylobacter sp., Clostridium difficile) may initiate IBD by triggering an inflammatory response that the mucosal immune system may fail to control
Exogenous Factors
Anaerobic organisms, particularly Bacteroides and Clostridia species, and some aerobic species such as Escherichia may be responsible for the induction of inflammation. Agents that alter the intestinal flora, such as metronidazole, ciprofloxacin, and elemental diets, may improve CD.
Exogenous Factors
CD also responds to fecal diversion, demonstrating the ability of luminal contents to exacerbate disease. On the other hand, other organisms, so-called probiotics (e.g., Lactobacillus sp., Bifidobacterium sp., Taenia suis, and Saccharomyces boulardii), may inhibit inflammation in animal models and humans. Psychosocial factors can contribute to worsening of symptoms
Role of infection
The role of infection in the pathogenesis of IBD has been evaluated in two ways: the correlation between specific microorganisms and IBD; and the possible association between acute gastroenteritis and IBD
Role of infection
an association between CD susceptibility and specific infectious agents (eg, measles virus, Mycobacterium paratuberculosis, paramyxovirus) has been suggested but remains unproven
Role of infection
Normal intestinal microflora may contribute to the development of IBD in susceptible individuals. Consistent with this hypothesis is the observation that animals which are genetically altered to be susceptible to IBD do not develop the disease when raised in a germ-free environment
Role of infection
After excluding patients who had acute gastroenteritis within six months of IBD diagnosis and adjusting for potential confounders, the risk of IBD was significantly increased after an episode of acute gastroenteritis (odds ratio 1.4; 95% CI 1.2-1.7). In addition, there was an approximate 5-fold increase in IBD risk in persons with a previous diagnosis of irritable bowel syndrome
Role of infection
An increased risk of developing IBD, both CD and UC, was also found in a population-based cohort study of 13,148 patients with documented Salmonella or Campylobacter gastroenteritis when compared to a matched control group (1.2 versus 0.5 percent, hazard ratio 2.9, 95% CI 2.23.9) . This increased risk was highest during the first year after infection, but was observed throughout 15 years of observation.
About 4050% limited to the rectum and rectosigmoid, 3040% extending beyond the sigmoid but not involving the whole colon, and 20% have a total colitis. When the whole colon is involved, the inflammation extends 12 cm into the terminal ileum in 1020% of patients. This is called backwash ileitis and is of little clinical significance. normal.
Although variations in macroscopic activity may suggest skip areas, biopsies from normal-appearing mucosa are usually abnormal.
Thus, it is important to obtain multiple biopsies from apparently uninvolved mucosa, whether proximal or distal, during endoscopy.
Effective medical therapy can change the appearance of the mucosa such that either skip areas or the entire colon can be microscopically normal
Pathology
mild inflammation, the mucosa is erythematous and has a fine granular surface that resembles sandpaper. In more severe disease, the mucosa is hemorrhagic, edematous, and ulcerated In long-standing disease, inflammatory polyps (pseudopolyps) may be present as a result of epithelial regeneration.
Pathology
The mucosa may appear normal in remission, but in patients with many years of disease it appears atrophic and featureless, and the entire colon becomes narrowed and shortened. Patients with fulminant disease can develop a toxic colitis or megacolon where the bowel wall thins and the mucosa is severely ulcerated; this may lead to perforation.
Clinical Presentation
Diagnosis
Patient's history Clinical symptoms Negative stool examination for bacteria, C. difficile toxin, and ova and parasites; sigmoidoscopic appearance Histology of rectal or colonic biopsy specimens
Sigmoidoscopy
Assess disease activity and is usually performed before treatment. If the patient is not having an acute flare, colonoscopy is used to assess disease extent and activity Mild disease is :erythema, decreased vascular pattern, and mild friability.
Sigmoidoscopy
Moderate disease :marked erythema, absent vascular pattern, friability and erosions, Severe disease by spontaneous bleeding and ulcerations. Histologic features change more slowly than clinical features but can also be used to grade disease activity.
radiologic change
The earliest of UC seen on single-contrast barium enema is a fine mucosal granularity. Haustral folds may be normal With increasing severity, the mucosa becomes thickened, and superficial ulcers are seen. Deep ulcerations can appear as "collar-button" ulcers, which indicate that the ulceration has penetrated the mucosa. Haustral folds as activity progresses become edematous and thickened.
radiologic change
Loss of haustration can occur, especially in patients with long-standing disease. In addition, the colon becomes shortened and narrowed. Polyps in the colon may be postinflammatory polyps or pseudopolyps, adenomatous polyps, or carcinoma
CT
not as helpful as endoscopy and barium enema in making the diagnosis of UC, but typical findings include : mild mural thickening (<1.5 cm), inhomogeneous wall density, Absence of small bowel thickening, increased perirectal and presacral fat, target appearance of the rectum, and adenopathy.
Complications UC
Only 15% of patients with UC present initially with catastrophic illness. Massive hemorrhage occurs with severe attacks of disease in 1% of patients, and treatment for the disease usually stops the bleeding. If a patient requires 68 units of blood within 2448 hours, colectomy is indicated.
Toxic megacolon UC
Toxic megacolon is defined as a transverse or right colon with a diameter of >6 cm, with loss of haustration in patients with severe attacks of UC. It occurs in about 5% of attacks and can be triggered by electrolyte abnormalities and narcotics. About 50% of acute dilations will resolve with medical therapy alone, but urgent colectomy is required for those that do not improve.
Perforation UC
Perforation is the most dangerous of the local complications, and the physical signs of peritonitis may not be obvious, especially if the patient is receiving glucocorticoids. Although perforation is rare, the mortality rate for perforation complicating a toxic megacolon is about 15%. In addition, patients can develop a toxic colitis and such severe ulcerations that the bowel may perforate without first dilating.
Strictures UC
occur in 510% of patients and are always a concern in UC because of the possibility of underlying neoplasia. Although benign strictures can form from the inflammation and fibrosis of UC, strictures that are impassable with the colonoscope should be presumed malignant until proven otherwise. A stricture that prevents passage of the colonoscope is an indication for surgery.
Perianal complication UC
UC patients occasionally develop anal fissures, perianal abscesses, or hemorrhoids, but the occurrence of extensive perianal lesions should suggest CD.
Ileocolitis
The most common site of inflammation is the terminal ileum : chronic history of recurrent episodes of right lower quadrant pain and diarrhea. Sometimes the initial presentation mimics acute appendicitis with pronounced right lower quadrant pain, a palpable mass, fever, and leukocytosis. Pain is usually colicky; it precedes and is relieved by defecation. A low-grade fever is usually noted. High-spiking fever suggests intraabdominal abscess formation. Weight loss is commontypically 1020% of body weightand develops as a consequence of diarrhea, anorexia, and fear of eating.
Fistula Chrons
Severe inflammation of the ileocecal region may lead to localized wall thinning, with microperforation and fistula formation to the adjacent bowel, the skin, or the urinary bladder, or to an abscess cavity in the mesentery. Enterovesical fistulas typically present as dysuria or recurrent bladder infections or, less commonly, as pneumaturia or fecaluria. Enterocutaneous fistulas follow tissue planes of least resistance, usually draining through abdominal surgical scars. Enterovaginal fistulas are rare and present as dyspareunia or as a feculent or foul-smelling, often painful vaginal discharge. They are unlikely to develop without a prior hysterectomy
Jejunoileitis
Extensive inflammatory disease is associated with a loss of digestive and absorptive surface, resulting in malabsorption and steatorrhea. Nutritional deficiencies can also result from poor intake and enteric losses of protein and other nutrients. Intestinal malabsorption can cause anemia, hypoalbuminemia, hypocalcemia, hypomagnesemia, coagulopathy, and hyperoxaluria with nephrolithiasis in patients with an intact colon. Many patients need to take oral and often intravenous iron. Vertebral fractures are caused by a combination of vitamin D deficiency, hypocalcemia, and prolonged glucocorticoid use.
Jejunoileitis
Pellagra from niacin deficiency can occur in extensive small bowel disease, and malabsorption of vitamin B12 can lead to megaloblastic anemia and neurologic symptoms. Other important nutrients to measure and replete if low are folate and vitamins A, E, and K. Levels of minerals such as zinc, selenium, copper, and magnesium are often low in patients with extensive small bowel inflammation or resections and these should be repleted as well. Most patients should take a daily multivitamin, calcium, and vitamin D supplements.
Jejunoileitis Diarrhea
(1) bacterial overgrowth in obstructive stasis or fistulization, (2) bile-acid malabsorption due to a diseased or resected terminal ileum, (3) intestinal inflammation with decreased water absorption and increased secretion of electrolytes
Laboratory Chrons
elevated ESR and CRP. In more severe disease:hypoalbuminemia, anemia, and leukocytosis
CT enterography Chrons
large volumes of ingested neutral enteric contrast material permit visualization of the entire small bowel and lumen. Unlike routine CT, which is used to detect the extraenteric complications of CD such as fistula and abscess, CT enterography clearly depicts the small bowel inflammation associated with CD by displaying mural hyperenhancement, stratification, and thickening; engorged vasa recta; and perienteric inflammatory changes. CT enterography is the first-line test for the evaluation of suspected CD and its complications.
MR Chrons
As an initial test in children or in adults with multiple radiation exposures, MR enterography is comparable to CT in diagnostic accuracy. Pelvic MRI is superior to CT for demonstrating pelvic lesions such as ischiorectal abscesses and perianal fistulae
Complications Chrons
Because CD is a transmural process, serosal adhesions develop that provide direct pathways for fistula formation and reduce the incidence of free perforation. Perforation occurs in 12% of patients, usually in the ileum but occasionally in the jejunum or as a complication of toxic megacolon. The peritonitis of free perforation, especially colonic, may be fatal.
Complications Chrons
Intraabdominal and pelvic abscesses occur in 1030% of patients with Crohn's disease at some time in the course of their illness. CT-guided percutaneous drainage of the abscess is standard therapy. Despite adequate drainage, most patients need resection of the offending bowel segment. Percutaneous drainage has an especially high failure rate in abdominal wall abscesses.
Complications Chrons
Systemic glucocorticoid therapy increases the risk of intraabdominal and pelvic abscesses in CD patients who have never had an operation. Other complications include intestinal obstruction in 40%, massive hemorrhage, malabsorption, and severe perianal disease.