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DISEASES OF SMALL INTESTINE

Small Intestine Diseases

Diarrhea
Intolerance

to specific foods Acute food poisoning Viral infections

Small Intestine Diseases

Malabsorption
Maldigestion

problems Intestinal mucosal changes Genetic disease Intestinal enzyme deficiency Cancer and its treatment Metabolic defects

Small Intestine Diseases

Celiac sprue
Hypersensitivity

certain grains Steatorrhea and progressive malnutrition are secondary effects to gluten reaction Nutrition management controls dietary gluten intake and prevents malnutrition

to the protein gluten in

Small Intestine Diseases

Cystic fibrosis
Genetic

disease of childhood Inhibits movement of chloride and sodium ions in the body tissue fluids

Small Intestine Diseases

Cystic fibrosis
Treated

with pancreatic replacement products Children with CF require 105% - 150% of recommended nutrients for their age Nutritionally adequate high-protein, normalto-high fat diet recommended

Small Intestine Diseases

Inflammatory bowel disease


Applies

disease Short-bowel syndrome results from repeated surgical removal of parts of the small intestine as disease progresses Reduces absorption of nutrients

to both ulcerative colitis and Crohns

Large Intestine Diseases

Diverticular disease
Diverticulosis:

formation of many small pouches (diverticula) along muscular mucosal lining Diverticulitis caused by pockets becoming infected

Inflammatory bowel disease..


Inflammatory bowel diseases (IBD) include a group of chronic disorders that cause inflammation or ulceration in the small and large intestines. Most often IBD is classified as:Ulcerative colitisUlcerative colitis--causes ulceration and inflammation of the inner lining of the colon and rectum.Crohn'sCrohn'sdiseasedisease--an inflammation that extends into the deeper layers of the intestinal wall, and also may affect other parts olayers of the f digestive tract, including the mouth, esophagus, stomach, and smdigestive small all intestine.

Ulcerative colitis and Crohn's disease

cause similar symptoms that often resemble other conditions, such as irritable bowel syndrome. The correct diagnosis may take some time. Inflammatory bowel disease may also be referred to as colitis, enteritis, ileitis, and proctitis

PLAN

CROHNS DISEASE (CD) Etiology and Epidemiology of CROHNS DISEASE Pathology of CROHNS DISEASE Clinical picture of CROHNS DISEASE Diagnosis of CROHNS DISEASE Differential Diagnosis of CROHNS DISEASE Prognosis of CROHNS DISEASE Treatment of CROHNS DISEASE

Traditional view

Crohns disease

is characterized by acute and chronic inflammation of the small and large intestine and structures apart from the bowel (BA Lashner in
Inflammatory Bowel Diseases, J Kirsner ed. 5the ed WB Saunders, 2000)

Ulcerative colitis

is an inflammatory disease of the colon of unknown etiology (PB Miner in Inflammatory Bowel Diseases, J
Kirsner ed. 5the ed WB Saunders, 2000)

Exceptions

backwash ileitis Postcolectomy pouchitis

Porto criteria for the diagnosis of Pediatric IBD

Indeterminate colitis can only be diagnosed after a full diagnostic work-up. This must include colonoscopy with intubation of the terminal ileum, upper gastrointestinal endoscopy and small bowel follow through. Diagnosis of indeterminate colitis is suggested by histology showing acute and chronic inflammation with architectural changes confined to the colon, absence of abnormalities suggesting lymphocytic or allergic colitis, or CD, a normal small bowel follow through or enteroclysis and no definite classification of CD or UC possible with histology.

(IBD Working Group of the European Society for Paediatric Gastroenterology, Hepatology and Nutrition.. Inflammatory bowel disease in children and adolescents: recommendations for diagnosis--the Porto criteria. J Ped Gastroenterol Nutr 2005; 41: 1-7)

Upper GI involvement and IBD

The difference in distribution between CD and UC is a feature which is used for the differential diagnosis! Upper GI Involvement is considered as an argument against a diagnosis of UC But? Is UC confined to the colon

Ulcerative colitis and upper GI disease


Ulcerative small bowel lesions in pts with ulcerative colitis Diffuse, confined to mucosa, no granulomas

Ulcerative colitis and Upper GI involvement

Ectors N, Rutgeerts P, Geboes K, Penninckx F, Desmet V. Ulcerative jejunitis in patients with established ulcerative colitis. Gastroenterology 1994; 106: A676. Sasaki M et al; Ulcerative colitis complicated by gastroduodenal lesions. J Gastroenterol 1996; 31: 585 Annese V et al Fatal ulcerative panenteritis following colectomy in a patient with ulcerative colitis. Dig Dis Sci 1999; 44: 1189 Valdez et al. Diffuse duodenitis associated with ulcerative colitis. Am J Surg Pathol 2000; 24: 1407 Terashima et al. Ulcerative duodenitis accompanying ulcerative colitis. J Clin Gastroenterol 2001; 32: 172 Rubenstein J et al; Ulcerative colitis associated enteritis : is ulcerative colitis always confied to the colon J Clin Gastroenterol 2004; 38: 46

Upper GI involvement and ulcerative colitis Duodenum : Friability

Upper GI involvement and ulcerative colitis Duodenum : Friability & Granularity

Gastritis and Ulcerative colitis


B -1390258

Gastritis and Ulcerative colitis


B -1390258

Focally Enhanced gastritis


B-1412032

Focally Enhanced gastritis

Upper GI involvement and ulcerative colitis Aphthous gastritis : Crohn or UC

Conclusions

Upper GI lesions in ulcerative colitis are different in children and adults Gastritis is common in children with ulcerative colitis The diagnostic value of gastritis in ulcerative colitis has not yet been established; the predictive value is low in adults Two patterns have been recognized

Diffuse gastritis Focally enhanced gastritis

Severe upper small intestinal inflammation can complicate severe ulcerative colitis

Definition
CROHNS DISEASE A nonspecific chronic transmural inflammatory disease that most commonly affects the distal ileum and colon but may occur in any part of the GI tract.

Etiology
The

fundamental cause of Crohn's disease is unknown

The spectrum of CROHN DISEASE presentations includes gastroduodenitis, jejunoileitis and ileitis, ileocolitis, colitis

7%

33%

45%

15%

CROHNS DISEASE Clinical picture

Abdominal pain (77%) Chronic diarrhea (73%) Bleeding (22%) Anal Fistulas (16%) Anorexia A right lower quadrant mass or fullness

CROHNS DISEASE Extraintestinal manifestations

Weight loss (54%) Fever (35%) Anemia (27%)

Peripheral arthritis (16%) Ophtalmic diseases (Episcleritis,


10%)

Aphthous stomatitis Erythema nodosum (2%) Pyoderma gangrenosum

Endoscopic spectrum of includes

CD

a) aphthous ulcerations amid normal colonic mucosal vasculature; b) deeper, punchedout ulcers in ileal mucosa; c) a single colonic linear ulcer; d) deep colonic ulcerations forming a stricture.

CROHNS DISEASE DIAGNOSIS

x-ray: Barium enema x-ray may show reflux of barium into the terminal ileum with irregularity, nodularity, stiffness, wall thickening, and a narrowed lumen. A small-bowel series with spot x-rays of the terminal ileum usually most clearly shows the nature and extent of the lesion. An upper GI series without small-bowel follow-through usually misses the diagnosis.

X-ray showing abnormal terminal ileum in Crohn's disease

Laboratory findings

Laboratory findings are nonspecific: -anemia, -leukocytosis, -hypoalbuminemia, - ESR, C-reactive proteins.

Elevated alkaline phosphatase and glutamyltranspeptidase accompanying colonic disease often reflect primary sclerosing cholangitis.

Sigmoidoscopy An internal examination of the rectum, distal sigmoid colon, and large bowel using a type of small camera (flexible sigmoidoscope sigmoidoscope). ). This test can help diagnose: 1.Inflammatory bowel disease 2.Bowel obstruction 3.Colon cancer 4.Colon polyps 5.Diverticulosis 6.Causes of diarrhea 7.causes of abdominal pain This test can also be used to: 1.Determine the cause of blood, mucus, or pus in the stool 2.Confirm findings of another test or X-rays 3.Take a biopsy of a growth

Sigmoidoscopy with biopsy showed: - Non Non-specific inflammation of the rectal mucosa with some granulomas but without necrosis. Differential diagnosis of Granulomas Granulomas: Crohn Crohns disease Mycobacterial Tuberculosis On the suspicion of tuberculosis anti antituberculous medication was given for four months

CROHNS DISEASE DIFFERENTIAL DIAGNOSIS


Ulcerative colitis Acute appendicitis Pelvic inflammatory disease Ectopic pregnancy Ovarian cysts

Cancer of the cecum Lymphosarcoma Systemic vasculitis Radiation enteritis Ileocecal TB AIDS-related opportunistic infections (cytomegalovirus)

DIFFERENTIAL DIAGNOSIS
Crohn's Disease Small bowel is involved in 80% of cases Rectosigmoid is often spared; colonic involvement is usually right-sided. Gross rectal bleeding is absent in 15-25% of cases. Fistula, mass, and abscess development is common. Perianal lesions are significant in 25-35%. Ulcerative Colitis Disease is confined to the colon. Rectosigmoid is invariably involved; colonic involvement is usually leftsided. Gross rectal bleeding is always present. Fistulas do not occur. Significant perianal lesions never occur.

The typical perianal skin tag of Crohn's Disease

DIFFERENTIAL DIAGNOSIS
Crohn's Disease
On x-ray, bowel wall is affected asymmetrically and segmentally, with "skip areas" between diseased segments. Endoscopic appearance is patchy, with discrete ulcerations separated by segments of normalappearing mucosa.

Ulcerative Colitis
Bowel wall is affected symmetrically and uninterruptedly from rectum proximally (ahaustral Colon). Inflammation is uniform and diffuse (continuous superficial inflammation with granular)

DIFFERENTIAL DIAGNOSIS
Crohn's Disease
Microscopic inflammation and fissuring extend transmurally; lesions are often highly focal in distribution.

Ulcerative Colitis
Inflammation is confined to mucosa (diffuse, continuous, superficial inflammation) except In severe cases.

Epithelioid (sarcoid-like) Typical epithelial granulomas detected in granulomas do not occur. bowel wall or lymph nodes in 25-50% of cases (pathognomonic).

Enterocutaneous fistulae in Chrohn's disease

CROHNS DISEASE Treatment


Diet 4 Aminosalicilates (Sulfasalazine, Salofalk) Corticosteroid therapy (Budesonid, Prednizolon) Immunosuppressive drugs (Azathioprine) Symptomatic treatment (antidiarrheal drugs - loperamide, Anticholinergics)