Inflammatory Bowel Disease

Published on 21/03/2015 by admin

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Chapter 43 Inflammatory Bowel Disease

PATHOPHYSIOLOGY

Ulcerative colitis (UC) and Crohn’s disease (CD) are two major idiopathic inflammatory bowel disease (IBD) in children, with 15% falling in the indeterminate IBD category. They share many common characteristics such as diarrhea, pain, fever, and blood loss. The etiologies of both diseases are unknown, although recent research has focused on genetic (IBD disease gene on chromosome 16 [CARD15]), immunologic, dietary, and infectious causes. Some research implicates the presence in IBD of specific infectious agents such as Bacteroides fragilis, Mycobacterium paratuberculosis, paramyxoviruses, and Listeria monocytogenes; Campylobacter jejuni, Salmonella, Shigella, Yersinia, and Eschericia coli have also been associated with relapses of IBD. The single greatest risk factor for IBD is a positive family history (found in 15% to 30% of IBD patients). To date, there is no indication that emotional factors are the primary cause. The goal of therapy includes control of inflammation and associated signs and symptoms, improving nutritional status to allow optimal growth and sexual maturation, and good quality of life—both emotionally and physically.

An association between ankylosing spondylitis and the histocompatibility of human leukocyte antigen (HLA-B27) and inflammatory bowel disease is a possibility. Ulcerative colitis and Crohn’s disease have similar initial signs, including diarrhea, rectal bleeding, abdominal pain, fever, malaise, anorexia, weight loss, and anemia. Children may initially be seen with vague symptoms such as growth failure, anorexia, fever, and joint pains with or without gastrointestinal symptoms. Both conditions are characterized by remissions and exacerbations. Extracolonic manifestations such as joint problems, hepatobiliary conditions, skin rashes, and eye irritation can occur. Although the peak incidence of inflammatory bowel disease is between 15 and 25 years of age, 15% of all cases occur at age 15 years and younger. Prognosis is dependent on the following factors: (1) age at onset and rapidity of onset; (2) response to medical treatment; and (3) extent of involvement.

Ulcerative colitis is a recurrent inflammatory and ulcerative disease affecting primarily the large intestine. Lesions are continuous and involve the superficial mucosa, causing vascular congestion, capillary dilation, edema, hemorrhage, and ulceration. Muscular hypertrophy and deposition of fibrous tissue and fat result, which gives the bowel a “lead pipe” appearance because of narrowing of the bowel itself.

Crohn’s disease is an inflammatory and ulcerative disease affecting any part of the alimentary tract from the mouth to the anus. Rectal pain and bleeding from fissures and fistulas occurs in 25% of CD patients. Of CD patients, 10% have proctitis, and 70% of these patients will develop more extensive disease. The CD affects the deep walls of the bowel. The lesions are discontinuous, resulting in a “skipping” effect, with the diseased portions of the bowel separated by normal tissue. Fissures, fistulas, and thickened intestinal walls result. Granulomas occur in approximately 50% of cases.