Ulcerative colitis lecture 14-11-1429

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بسم الله الرحمن الرحيم

Ulcerative colitis:

Ulcerative colitis Dr/ Waleed Fawzy Radwan MRCS Edinburgh 11-2008

Definition:

Definition Is a Non Specific Inflammatory Bowel Disease Of Unknown Etiology that affect the mucosa of the colon and Rectum Present in Both Genders 2 nd – 4 th Decades

Epidemiology:

Epidemiology Incidence of U.C 2.2-14.3 / 100000 (In N.America). The highest incidence is in Northern Europe, U.K, N.America, but now increasing in Africa and Asia. More in whites than in blacks Occur in 3 peaks of Age Early adulthood , 40-60 years and the 3 rd after 70 years. 1-2 / 100,000 in children are affected

Facts About U.C:

Facts About U.C Risk Of Cancer Is low during 1 st 8-10 years, then increased in a rate of 1-2/year Malignancy may be present in 18% of patients after 30 years of disease Relative increased risk 2.6-5.4 folds relative to G.Population 1 st Colonoscopy after 10 years will reveal dysplasia

Causes:

Causes

Risk Factors:

Risk Factors

Genetics :

Genetics 5-10 % of affected persons have +ve family history. IBD 2 Locus(12q13) may be associated with UC Chromosome 6 IBD 3 Associated with MHC Class II genes.

Relieving Factors:

Relieving Factors

Pathology:

Pathology Macroscopic : It is called (pancolitis ) when the entire colon is involved. Sometimes Terminal ileum is affected it is called (Backwash ileitis) . Largely limited to mucosa & submucosa of the colorectum . continue

Pathology:

Pathology The rectum is always involved. The disease is present in continuous fashion. Shows confluence of numerous ulcers with area of regenerating mucosa called pseudo polyps . It lacks thickening and fibrosis. continue

Post Op. Colectomy specimen:

Post Op. Colectomy specimen

Pathology:

Pathology Microscopic Appearance: -Acute inflammatory cells-Neutrophils infiltrating into Crypts Of Lieberkuhn at the base of the mucosa to form crypt abscess. -Superficial desquamation of the overlying epithelium leads to ulcers formation. -In sever inflammation , the muscularis propria may undergo myocytolysis resulting In hyperemia & wall thinning.

Clinical Picture:

Clinical Picture Bloody Diarrhea Abdominal pain Fever

Colitis Severity:

Colitis Severity

The C/P Of Proctitis:

The C/P Of Proctitis 1- Urgency 2-Tenesmus 3-Frequency 4-Blood mucoid Diarrhea Can be diagnosed by Anoproctoscopy at will demonstrate Inflamed mucosa & mucous on the gloved finger.

C/P Of Pancolitis:

C/P Of Pancolitis Anemia Inertia Anorexia Fatigue Weight Loss

Extra-Intestinal Manifestations:

Extra-Intestinal Manifestations Dermatological Ocular Musculoskeletal Hepatic

Dermatological:

Dermatological 1- Erythema Nodosum (9 %) Rash , tender,symmetric raised erythematus papules. On the external surface of arms & legs. Skin disease parallel the activity but not severity. It is rare to precede the Dx.

Skin Signs:

Skin Signs 2-Pyoderma Gangrenosum (50 %) Starts as erythematous plaques, papules or blebs In the pretibial region. Can progress to ulcerated,necrotizing,tender wound with ill defined purple-red margin

Ocular Signs:

Ocular Signs 1- Episcleritis Pain & tender eye is red w/out visual dst. 2- Iritis & Uveitis A/w blindness Joint & Skin Manif. Includes Iris , Ciliary Body , vitreous Or Retina Painful eye Blurred vision Headache

Eye Manifestation:

Eye Manifestation Diffuse Episcleritis Ant. Uveitis Ant. Uveitis

The Musculoskeletal :

The Musculoskeletal

Hepatobiliary:

Hepatobiliary

1ry Sclerosing Cholangitis:

1ry Sclerosing Cholangitis Chronic Cholestatic Syndrome characterized by Fibrosing of bile ducts . 50% of PSC patients have Ulcerative Colitis . Increased risk of Cholangiocarcinoma.

Risk Of Cholangiocarcinoma:

Risk Of Cholangiocarcinoma

Diagnosis:

Diagnosis

History :

History Diarrhea Urgency Tenesmus Systemic symptoms Fever Arthritis Skin Mnf. Wt. Loss

Lab Workup:

Lab Workup CBC: Leucocytosis Anemia Hct . Platelets. liver enzymes continue

Lab.Workup:

Lab.Workup Stool Analysis Fecal Leucocytes Stool Culture: Campylobacter Salmonella Shigella Pathogenic E.Coli Clost.Difficile Giardia Cytomegalo virus continue To R/O

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Calprotectin : Is an abundant neutrophil protein found in both plasma and stool. 130 mg/kg stool were 68% sensitive and 67% specific in predicting relapse risk. allow for serial monitoring of the disease as well as success or failure of treatment. It is stable in faeces for several days. It allows for differentiation between organic diarrhoea and functional diarrhoea

Calprotectin:

Calprotectin

Serological tests:

Serological tests P-ANCA (Perinucliar Anti- Neutrophil Cytoplasmic Antibody) Diagnostic for U.C in 60-80%. Indicates earlier need for surgery. (Peeters, 2000; Hoffenberg, 1999). No relation to post-op. complications. Specific 94%- sensitive 57% ASCA ( a nti–Saccharomyces cerevisiae antibodies ) +ve in 12% of U.C Patients.

Endoscopy:

Endoscopy

Colonoscopy:

Colonoscopy

Important Note:

Important Note 18 Biopsies should be taken with 4 biopsies from the rectum.

Colonoscopy:

Colonoscopy Collar Button Ulcer Hyperemia & Granular texture

Colonoscopy:

Colonoscopy Mucosal Friability & Hyperemia Loss of Haustrations

colonoscopy:

colonoscopy Psuedopolyps Continuous fashion Hyperemia From the Rectum & Descending colon

Radiology:

Radiology

Air Contrast Barium:

Air Contrast Barium

Toxic Megacolon:

Toxic Megacolon Dilated Colon > 5.5 cm

Toxic Megacolon:

Toxic Megacolon

Differential Diagnosis:

Differential Diagnosis Ulcerative Colitis Crohn Disease Colon only involved Pan-intestinal Continuous inflammation extending proximally from rectum Skip-lesions with intervening normal mucosa Inflammation in mucosa and submucosa only Transmural inflammation No granulomas Non-caseating granulomas pANCA positive ASCA positive Bleeding is common Bleeding is uncommon Fistulae are rare Fistulae are common

Historical Evolution of Management of Ulcerative Colitis:

Historical Evolution of Management of Ulcerative Colitis

Management:

Management

Medical Treatment:

Medical Treatment

Medical Treatment:

Medical Treatment

I-Amino Salicylic Acid:

I-Amino Salicylic Acid Mechanism Colonic Bacteria Contain Azo-Reductase enzyme that split sulfasalazine to liberate 5-ASA, which acts topically. Drug Forms 1-Sulfasalazine = 5 ASA + sulfapyridine 2-Mesalamine (Asacol) Released at pH > 7 (Pentasa). Controlled release in Duodenum. Rowasa = pH> 6 for distal ileum and colonic exposure

II-Steroids :

II-Steroids Mechanism: used to control symptoms not to maintain long term remission. Has immunologic & Anti-inflammatory effect through 1-cytokine cascade 2- Prostaglandin production 3-Leucocyte Reaction Used for Moderate to sever U.C . Failed ASA treatment .

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Dosage : in sever cases Prednisone 40-60 mg/day in hospital 300 mg hydrocortisone or 60 mg methylprednisone Recent drug : Budesonide less side effects Great potency to glucocorticoid receptors 1 st pass hepatic metabolism

III- Immunomodulators:

III- Immunomodulators Cyclosporin Therapy Mechanism: 1-it is a lipophilic peptide w/inhibitory effect on cellular & immune system. 2-It blocks production of IL2 produced by T-Helper Lymphocytes. 3-It binds cyclophilin and inhibit Calcineurin which is cytoplasmic phosphatase enzyme, and involved in the action of T-cells and inhibit B-Cell function. Indication : For Refractory Colitis

Cyclosporin:

Cyclosporin Dosage: 4mg/kg Side effects: Renal Insufficiency HTN Seizures Paraesthesias Long term F/U Failed to demonstrate decreased Incidence of colectomy with 60-80% of patients required operation within one year.

IV. Biological Agents:

IV. Biological Agents

Biological Agents:

Biological Agents Anti TNF Infliximab Inhibits Production of Interferon,IL2,IL 12 Of Benefit in 88% of steroid refractory patients. In sever colitis 5mg/kg i.v at 0,2,6 weeks. Anti IL2R Daclizumab Recobinent Humanized Ig Monoclonal Ab to IL2R Produces Clinical response in 2 weeks. Continue

Biological Agents:

Biological Agents Anti CD3 Visilizumab Remission for several months. Growth Facor Epidermal growth factor.

How To treat Practically?:

How To treat Practically?

Treatment of Mild U.C:

Treatment of Mild U.C Symptomatic therapy Diet changes: incr iron, decr. Lactose, low-roughage diet Anti Diarrheal Agents : not if moderate to sever: Diphenoxylate 2.5-5 mg Loperamide 2-4 mg Deoderized tincture of opium 10-15 drops Or Codeine 15-30 mg tid. Bulk formers : psyllium. continue

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Rectal Installations :( limited proctosigmoiditis or tenesmus): Hydrocortisone enema (100 mg in 60 ml) Hydrocortisone foam 10 % or suppository 25 mg in daytime 5 ASA 4 gm in 60 ml if refractory Sulfasalazine for mild – moderate colitis: 0.5-1.5 gm, 2-4 times/day. Nicotine may improve symptoms in approx. 40 % ( transdermal 11-22 mg/day )

Treatment of moderate colitis:

Treatment of moderate colitis Prednisone 30-40 mg QD, tapering after remission. Antimetabolites : Azathioprine 2mg/kg/day or 6 mercaptopurine 1.5 mg/kg/day

Treatment of sever U.C:

Treatment of sever U.C Hospitalize I.V Hydrocortisone (300 mg qd,cont.iv infusion q 6 hr I.V Adrenocort. ACTH 120 U/ day. Electrolytes: supplement kcl in ivf 20-40 meq/l

What is the prognostic Factors in Sever Ulcerative Colitis ?:

What is the prognostic Factors in Sever Ulcerative Colitis ?

Prognostic Factors in Sever Ulcerative Colitis:

Prognostic Factors in Sever Ulcerative Colitis Clinical Laboratory Altered Consciousness Jalan 1969. Pulse > 120/min Fever > 38 C Intestinal sound < 5/ min Albumin <3 gm/100 ml Lennard-Jones 1975 Ca++ < 4.0 meq/L Cl < 95 K+ < 2.5 HCO3 > 32 pH > 7.5 Caprilli 1976 CRP > 45 mg/L Travis 1990 Bowel Motion > 8 stools/day .

Toxic megacolon:

Toxic megacolon Pathophysiology toxic fulminant colitis due to deep transmural dissection of ulcerating inflammatory process. Generalized paralysis of bowel wall Systemic toxicity Diagnosis: By Plain X-ray 1- bowel sounds 2- painful ,distended ,tender abdomen 3-systemic: fever, tachycardia , leukocytosis

Treatment of Toxicmegacolon:

Treatment of Toxicmegacolon 1-NPO, NG to intermittent suction 2-discontinue antidiarrheal drugs. 3-IVF , Frequent electrolytes, transfuse as necessary 4- IV Hydrocortisone or IV ACTH. 5- B/S Abx : triple therapy metronidazole (500mg q8hr) gentamicin (5 mg/kg 1 st dose) Clindamycin (900 mg iv q8h) Continue

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6- Rotate patient to prone position every few hours to redistribute colonic gas. 7-frequent abd.exam. For fear of peritonitis or perforation. 8- KUB upright/supine BID for colonic dilatation or free air.

Surgical Treatment:

Surgical Treatment

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Surgical Treatment Emergency Elective

Indications:

Indications

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Historical sequence of Operations Total Proctocolectomy Colectomy with ileorectal anastmosis TPC WITH Brooke Ileostomy Restorative Proctocolectomy

Emergency Surgery:

Emergency Surgery

What type of Operation? In Emergency :

What type of Operati o n? In Emergency Total Abdominal Colectomy With Management Of Rectal Stump. The Rectum is preserved to decrease Chance of Presacral Bleeding. The stump either : 1-Sutured 2-Stapled 3- left w/ enough sigmoid to create mucus fistula Before : Colostomy & Ileostomy had been advocated. Now : Total Abdominal colectomy & End Ileostomy is the safest procedure

Is any procedure needed later?:

Is any procedure needed later? A 2 nd procedure is needed for Completion poctectomy, Pouch Formation & Diverting loop ileostomy .( After 6 months) A 3 rd Procedure is needed for Ileostomy Closure

Elective Surgery For U.C.:

Elective Surgery For U.C. Advantage Disadvantage Total Proctocolectomy + Ileostomy Single Operation Permanent Ileostomy Kock Pouch Continent Abdominal Reconstruction Frequent complications Rec. Multiple procedures Total Abdominal colectomy + Ileorectal Anastmosis Single operation Native Continence The Remaining rectum is diseased Total Proctocolectomy + Ileal Pouch Anal Anastmosis All diseased areas are removed Anastmotic Leak Pouchitis Frequent Bowel Movement & soiling

Diagrammatic steps of Laparoscopic Total Proctocolectomy & Ileo-Anal Pouch Anastmosis (TPC+IAPA):

Diagrammatic steps of Laparoscopic Total Proctocolectomy & Ileo-Anal Pouch Anastmosis (TPC+IAPA)

Right colon Dissection:

Right colon Dissection

Hepatic Flexure Dissection:

Hepatic Flexure Dissection

Splenic Flexure Dissection:

Splenic Flexure Dissection

Left Colon Dissection:

Left Colon Dissection

Rectal Dissection:

Rectal Dissection

Resection:

Resection

J-Pouch Creation:

J-Pouch Creation

Ileo-Anal Anastmosis:

Ileo-Anal Anastmosis

Completion of Anastmosis:

Completion of Anastmosis

J Pouch Reconstructed:

J Pouch Reconstructed

Surgical details:

Surgical details A total proctocolectomy is performed through a midline abdominal section. The ileum is divided close to the ileocecal valve with a stapler to save maximal ileal length. The ileal branch of the ileocolic artery is preserved, if possible, to provide optimal blood supply to the distal ileum. The rectum is stapled and divided, within 1 cm proximal to the dentate line. Rectal mucosectomy may be performed and the ileum brought through a short seromuscular sleeve of rectum.

The Pouch Technique:

The Pouch Technique The dimensions of the pouch depend on the size of the patent. In adolescents, as in adults, a 9-12-cm long pouch is created by folding the distal ileum on itself in a J configuration and by using a linear cutting stapler to place staples longitudinally along the antimesenteric boarder between the two limbs of the J to create a reservoir . Limb lengths of 8-10 cm are used in small children. The bowel at the lower end (ie, curve) of the J is then used to create an anastomosis to the anus with a circular stapling device or sutures. Because of the increased incidence of cancer in patients with UC and PSC complete mucosectomy to the dentate line and creation of a hand-sewn pouch-anal anastomosis has been recommended in these patients (Marchesa, 1997).

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To ensure a tension-free anastmosis at the anus, a number of techniques may be used to gain length in the small bowel. First, the ligament of Treitz may be opened to allow the proximal jejunum to turn toward the pelvis is a more gradual manner. The peritoneum overlying the small bowel mesentery may be sequentially opened in an orientation perpendicular to the superior mesenteric artery ("stair stepping") to release tension and provide length. Finally, the superior mesenteric artery may be divided just distal to the origin of the first or second arterial arcade. This proximal division preserves distal collateral flow and provides length.

Is Fecal Diversion needed?:

Is Fecal Diversion needed? The need for fecal diversion after ileal pouch-anal anastmosis is controversial in the adult patients. Usually, the need to operate on young patients is due to the severity of illness. Thus, most surgeons prefer to proximally divert the fecal stream in young patients. During the procedure, the distal vascular arcades of the ileum often are divided to gain length to reach the pelvis; this division predisposes the patient to ischemia. Therefore, many surgeons opt for an end ileostomy or loop ileostomy as the means of diversion. Many use loop ileostomy because of the widely held belief that takedown of a loop ileostomy is technically easier.

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Recent data refute this assumption. On average, the operating time with loop ileostomy takedown is 54 minutes less than that of end ileostomy. However, loop ileostomy takedown lengthens the hospital stay, increases the time to oral feeding, and has a 2-fold higher wound infection rate compared with that of end-ileostomy takedown. In addition, loop ileostomy requires significantly more outpatient stoma care and is associated with more frequent anal complications (Fonkalsrud, 2000).

Notice for the patient:

Notice for the patient Every patient who undergoes an ileal pouch-anal anastomotic procedure, as currently performed, must be able to accept the possibilities of stool seepage or incontinence and frequent bowel movements, with a minimum of 4-6 per day. Although the procedure results in removal of the diseased organ and although it is more technically advanced than end ileostomy, it is not a perfect solution.

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Thank you