Inflammatory bowel diseases (IBDs) are chronic inflammatory disorders of unknown etiology involving the gastrointestinal (GI) tract. Peak occurrence is between ages 15 and 30 and between ages 60 and 80, but onset may occur at any age. Epidemiologic features are shown in Table 151-1. Pathogenesis of IBD involves activation of immune cells by unknown inciting agent (? microorganism, dietary component, bacterial or self-antigen) leading to release of cytokines and inflammatory mediators. Genetic component suggested by increased risk in first-degree relatives of pts with IBD and concurrence of type of IBD, location of Crohn’s disease (CD), and clinical course. Reported associations include HLA-DR2 in Japanese pts with ulcerative colitis (UC) and a CD-related gene called CARD15 on chromosome 16p. CARD15 mutations may account for 10% of CD risk. Other potential pathogenic factors include serum antineutrophil cytoplasmic antibodies (ANCA) in 70% of pts with UC (also in 5–10% of CD pts) and antibodies to Saccharomyces cerevisiae (ASCA) in 60–70% of CD pts (also in 10–15% of UC pts and 5% of normal controls). Granulomatous angiitis (vasculitis) may occur in CD. Acute flares may be precipitated by infections, nonsteroidal anti-inflammatory drugs (NSAIDs), and stress. Onset of UC often follows cessation of smoking.
TABLE 151-1Epidemiology of IBD ||Download (.pdf) TABLE 151-1 Epidemiology of IBD
| ||ULCERATIVE COLITIS ||CROHN’S DISEASE |
|Incidence (North America) per person-years ||0–19.2 per 100,000 ||0–20.2 per 100,000 |
|Age of onset ||15–30 and 60–80 ||15–30 and 60–80 |
|Ethnicity ||Jewish > non-Jewish white > African American > Hispanic > Asian |
|Male/female ratio ||0.51–1.58 ||0.34–1.65 |
|Smoking ||May prevent disease (OR 0.58) ||May cause disease (OR 1.76) |
|Oral contraceptives ||No increased risk ||OR 2.82 |
|Appendectomy ||Protective (risk 13–26% lower) ||Not protective |
|Monozygotic twins ||6–18% concordance ||38–58% concordance |
|Dizygotic twins ||0–2% concordance ||4% concordance |
|Antibiotic use in the first year of life ||2.9× the risk of developing childhood IBD || |
Colonic mucosal inflammation; rectum almost always involved, with inflammation extending continuously (no skip areas) proximally for a variable extent; histologic features include epithelial damage, inflammation, crypt abscesses, loss of goblet cells.
Bloody diarrhea, mucus, fever, abdominal pain, tenesmus, weight loss; spectrum of severity (majority of cases are mild, limited to rectosigmoid). In severe cases, dehydration, anemia, hypokalemia, hypoalbuminemia.
Toxic megacolon, colonic perforation; cancer risk related to extent and duration of colitis; often preceded by or coincident with dysplasia, which may be detected on surveillance colonoscopic biopsies.
Sigmoidoscopy/colonoscopy: mucosal erythema, granularity, friability, exudate, hemorrhage, ulcers, inflammatory polyps (pseudopolyps). Barium enema: loss of haustrations, mucosal irregularity, ulcerations.
Any part of GI tract, usually ...