Inflammatory Bowel Disease
Clinically we cannot differentiate between ulcerative colitis and Crohn's unless
Presentation: mainly diarrhea.
I- Ulcerative Colitis
1- Intestine: diarrhea (bloody) - pain - malabsorption - tenesmus
2- Skin: erythema nodosum, pyoderma gangrnosum
5- Thromboembolic disease
6- Both: ant. Uveitis, conjectivitis, episcleritis, iritis, ankylosing spondylitis,
sacroilitis, sclerosing cholangitis
7- Fatty liver, autoimmune hepatitis.
1- Toxic megacolon (most severe complication)
Tachycardia, anemia, hypotension, dilated transverse colon more than 6cm
If not improved in 24 to 48 hours -> total Colonectomy should be preformed
More with Ulcerative Colitis
A patient with Ulcerative Colitis for more than 10 years must have an annual
3- Amylodosis (in both)
Terminal ilium B12 deficiency
Intestinal obstruction - stricture
Fistula (entero - enteric or vesical).
Perianal (abscess - tags)
Diarrhea > 5/day
Diarrhea > 10/day
I- Salphasalazine (Paraaminosalicylic acid)
II- Steroids (Pridnisolone)
If the patient suffers Chron’s:
Add metronidazole (antibiotic covers anaerobes)
4- Barium enema
5- Endoscopy (Chron's skiplesion) coplet stones
7- Stool (to exclude infections)
8- Abdominal x-ray
* Vitamin deficiency (B12) numbness.
* Gallstone (both).
* Exudates stones Crohn's (Child)
1- Bloody diarrhea.
3- Abdominal pain (lower).
- More frequent diarrhea more than 10 times per day
5- Weight loss.
6- Signs of anemia, hypoalbuminemia.
If only rectum (proctitis).
2- Blood in stool.
1- Clubbing, leukonychia.
2- If fulminant: diarrhea mixed with blood & mucus.
3- Abdominal tenderness , distention (toxic megacolon)
1- Skin: erythema nodosum, Pyoderma gangrinosum.
2- Eye: uvitis, conjunctivitis, iritis, episcleitis.
3- Mouth: aphtous ulcer.
6- Thromboembolic disease.
Other unrelated to disease activity:
1- Sclerosing cholangitis.
2- Fatty liver, autoimmune hepatitis.
3- Ankylosing spondylitis, sacroilitus.
1- Toxic megacolon.
4- Bleeding dehydration.
Granulomatous – transmural – skip lesion.
Terminal ilium (any where)
Diarrhea, malabsorption, abdominal pain, right iliac fossa pain, rectal
bleeding (less than U C), weight loss, fever.
2- Perianal skin tags, fistula, stricture, abscess.
3- Weight loss.
Abdomen: tender, mass.
Extra-intestinal: as in Ulcerative Colitis
1- Stricture (intestinal obstruction).
2- Fistula (enteroenteric , vescal or vaginal).
3- Renal disease due to ureteric compression.
4- Fe- folate- B12 deficiency.
Relapsing of Crohn's
Session with Dr. Faiza Qari (5th year tutor)
► A known case of Crohn's dis. presents to the ER with vomiting &
abdominal distention, what might be the causes of his complains?
1- Intestinal obstruction:
vomiting (repeated attacks)
2- Relapsing of Crohn's
3- Gastric or duodenal ulcer heart burn
4- Peritonitis severe abdominal pain
5- Colon cancer weight loss
► Relapsing of Crohn's other important history:
* Past history since the time of 1st diagnosis
- Times admitted to hospital
- Procedures (what happened?)
- Any relapses
- Any ICU admissions
* Last colonoscopy
* Abdominal pain, bleeding diarrhea, bleeding/rectum, abdominal distension,
repeated mouth ulcer, loss of appetite, weight loss, repeated fissures & fistulae
* Intestinal manifestations of Crohn's:
- Anemia (iron deficiency) chronic illness
- Appendicitis (Right Iliac mass)
* Extra-intestinal manifestations of Crohn's:
- Arthritis sacroiliac joint back pain
- Liver hepatitis, gall stone …
- Phlebitis DVT…
- Renal stones
- Skin rash Erythema Nodosum
► Crohn's affect small intestine > large intestine
► Most important investigations:
Hb ↓ microcytic hypochromic anemia
Platelet ↑↑↑ (1) postsplenectomy (↑)
(2) Relapse of Crohn's
- ESR activity of disease
When a patient presents with hepatic symptoms, 1st search for acute causes of
illness then ask about chronic.
• B sexually
• C blood transfusion / vertical from mother to child
- Schistosomiasis (Bilharziasis)
- Hydatid cyst by compression, not hepatocellular.
- TB most common in KSA.
- HIV usually acute, but chronic if patient lives long enough.
(2) Alcohol always take History of alcohol.
* Most likely jobs to be alcoholic & drug abusers:
- Cops & Army.
- People working at port of entry.
REMEMBER! These infections are causes of acute, not chronic liver
(3) Autoimmune all CTD: SLE, RA, Wegner's Granulomatosis.
• Wilson's disease autosomal recessive.
Low ceruloplasmin (serum).
High 24 hr urine cupper.
• hemochromatosis autosomal recessive.
Serum iron, ferretin.
Liver biopsy diagnostic.
(5) Drugs remember 1 or 2 only
• Anti-epileptics sodium valporate, phenytoin, tegretol.
(6) Primary biliary cirrhosis:
Classically pt present with:
Young female .
Itching 1 or 2 years before any liver involvement.
All these 3 are raised in these patients.
(7) Malignancy metastasis.
budd chiare syndrome:
Hepatic vein thrombosis.
Causes: all causes of DVT
90% of pt
acute abdominal distention main
Do liver scan find uptake in caudate lobe.
(9) Cardiac cirrhosis.
(11) fatty liver NEVER say it, because it is TOO RARE, & if you mentioned it in the
exam ( في البداية ) you will lose marks
Dr Maimoona says "don't remember it".
Decompensation of CLD shows up by Complications:
(1) Portal Hypertension:
• variceal Hrg.
(2) Hepatocellular Ca. this is #1
(3) Hypersplenism. pancytopenia.
(4) Bleeding tendency.
(5) Hepatic encephalopathy.
(6) SBP. (spontaneous bacterial peritonitis)
(7) Hepatorenal syndrome if you mentioned this, Dr Maimoona will tell you
to talk about something that is more important.
50 years old lady admitted through ER, who is known case of CLD secondary to
C/O: altered level of conciseness (complaint & HPI)
How do you manage?
(1) Take History of what ppt. of a patient to have an encephalopathy:
History of precipitating factor:
• SBP: spontaneous bacterial peritonitis
• Sore throat, respiratory, UTI, leg ulcer…etc.
- Hemorrhage (bleeding):
Upper/Lower GI bleeding globulin high urea.
- High protein diet high urea.
- Drugs: analgesics, sedatives & tranquilizers.
- Causes of electrolytes imbalance:
• Overuse of diuretics.
• Gastroenteritis vomiting & diarrhea.
- Dehydration: vomiting, diarrhea, burn.
- Excess alcohol.
- Heart failure.
- Hepatoma (hcc).
(2) Examination of pt who already has CLD & came with hepatic
1- Glasgow coma scale (1st) consciousness.
2- Vital signs:
-Blood Pressure look for postural hypotension (Ascites).
-Pulse tachycardia due to infection or loss of fluid.
3- Fluid status: (2nd)
• Fluid overload (from liver failure) pleural effusion, Ascites, lower limb
• Dehydration mucus membrane, auxiliary sweating, postural
4- PR = per rectum Ex (digital rectal Ex) (3rd) bleeding: 'melena' in all hepatic
5- Evidence of infection: (4th)
• SBP (spontaneous bacterial peritonitis) abdominal tenderness.
6- Hepatic bruit 'hepatoma'.
+ CLD stigma.
(3) Everyday follows up:
1- Glasgow-coma scale.
2- Flapping tremor (asterixis).
3- Constructional apraxia: draw a 5 pointed star (better) or draw a square.
That should be done to all patients:
- Leukocytosis infection.
- Cytopenia hypersplenism & vasculitis (CTD).
In cirrhotic liver: cells are distorted enzymes not secreted = normal LFT.
1- Hepatocellular Ca enzymes.
2- Obstructive (primary biliary cirrhosis) ALP.
4- PT, PTT (coagulation profile) clotting factors.
5- Albumin level if <13 pt is prone to develop SBP.
(3) Urea & electrolytes:
1- Low K diuretic.
2- Low Na dilutional or diuretic.
3- prerenal failure increase urea & creatinine.
(4) Blood glucose hypoglycemic, because there is no gluconeogenesis in liver.
(5) Hepatitis B & C serology most common in KSA.
(6) α-fetoprotein (AFP) & abdominal US every 6 months for hepatoma.
If all these didn't help you, then you'll do the other tests if symptoms are suggestive (but
in a written exam, you have to write them all)
(7) Abdominal US/CT (only 1, if US didn't help: do CT)
1st size of liver? If shrunken order a biopsy.
2nd macronodular (alcohol) or micronodular.
3rd lesion (masses) metastasis, tumor, hydatid cyst.
2- Dilatation of biliary tract obstruction stones … etc.
4- Spleen enlarged hypersplenism.
5- Any other masses LN / metastasis.
• Evidence of infection.
• Fluids overload pulmonary edema.
• Malignancy metastasis, 1° tumor.
(9) UGI endoscopy: to know source of bleeding.
- Oesophageal varices.
- Peptic ulcer because liver can't metabolize. endogenous gastrin
ttt: PPI (proton pump inhibitor).
(10) Liver biopsy: (invasive procedure, keep it at last).
Only in patient with non-shrunken liver & he has Hepatitis B or C.
To know activity of the virus, & treatment.
(11) ascitic tap: diagnostic/relief for gram stain , culture & sensitivity,
cytology, protein, glucose "see below".
(12) If Pt. not known to have CLD, presented with hepatic encephalopathy, do:
-Young Pt: metabolic causes.
- Blood culture.
- Urine analysis.
- Urine culture & sensitivity.
- ECG in electrolytes disturbance.
- Patient should have Ascites to develop it
- Abdominal pain
Abdominal pain, distention, fever, decrease bowel sounds, worsening hepatic
Or in the absence of signs:
1- WBC >500, neutrophil >250 neutrophils/ μl diagnostic.
2- Gram staining.
3- Culture E. coli most common.
After tap, pt. will be on antibiotic empirically, then if +ve SBP (SBP is
documented) life-long prophylactic antibiotic.
- Bed rest.
- Low salt/low protein diet.
- Intake/output chart.
- Daily weighting: the goal of diuretic therapy is daily weight loss of 0.5-1
- Daily examination of 2 signs: constructional apraxia, flapping tremor asterixis:
see if improver with ttt.
- Daily urea & electrolytes if disturbed.
1- laxative: lactulose.
Aim: 2-3 bowel motion daily, lactic acid lactose disaccharide change pH of colon
flora no overgrowth of bacteria.
2- Antibiotic 3rd generation cephalosporin SBP.
3- Fluid status management:
o Dehydration give fluid.
o Fluid overload diuretic:
• loop diuretic, quick action till spironolactone takeover.
• spironolactone, aldactone, antialdosteron (aldosterone cause Na &
water retention) take 3 days to work.
4- Proton pump inhibitor 'prophylaxis'.
5- β-blocker inderal decrease portal pressure.
If patient out of encephalopathy:
3- Proton pumps inhibitor.
If it is not diuretic albumin.
& the following investigation:
1- Urea & electrolytes.
2- Alpha-fetoprotein Q 6 months.
3- Abdominal U/S Q 6 months.
- Salt restriction.
- Diuretic: loop diuretic & spironolactone.
- Diagnostic paracentesis.
- In refractory ascites: fluid overload that is none responsive to a sodiumrestricted
diet & high-dose diuretic: -TIPS -shunt - therapeutic paracentesis Q
2/52. If child C >>liver transplant.
- In large volume paracentesis: concomitant administration of IV colloid (5-8g
albumin/L ascites removed).
-ttt: empiric IV antibiotic therapy 3rd generation cephalosporin (ceftriaxone or
cefotaxime) depending on renal function, or quinolone( ciprofloxacin).
- Then long life/2ry prophylaxis: norfloxacin 400 mg PO qd.
- If total protein < 10g give antibiotic as prophylaxis even if no SBP.
- In GI bleeding start antibiotic prophylaxis 2nd generation cephalosporin or
- Vit. K IV 10mg/day for 3 consecutive days.
- In active bleeding or invasive procedure: fresh frozen plasma & platelets
GI bleeding management:
- ICU admission.
- ABC resuscitation with IV fluid fast drip till blood available.
- Lab tests CBC, U & E, coagulation profile, cross matching.
- Octreotide infusion, bolus then infusion acutely reduces portal pressures &
controls variceal bleeding with very few side effects, improving the diagnostic &
therapeutic success of subsequent endoscopy.
- Vasopressin: cardiovascular risk in ICU w. cardiac monitoring, + nitroglycerin.
- Endoscopy for variceal ligation banding, sclerotherapy.
- TIPS, shunt surgery: if child B not responding to therapeutic endoscopy to
relief portal hypertension, then liver transplant.
- Balloon tamponade: dangerous esophageal rupture.
- Discharge on b-blocker Propranolol : reduce portal pressure & lower the risk of
- Endoscopy every year.