IBD

Inflammatory Bowel Diseases is a group of inflammatory conditions which affect the colon and the small bowel: Crohn's disease, ulcerative colitis and indeterminate colitis


1) Crohn's disease: its incidence is rising in industrialized countries. It is generally observed in adolescents and young adults but can start from the age of 10 years. Early forms often caue more severe impairment. Before puberty, Crohn's disease affects more boys than girls. Its likely cause is an inappropriate immune response to the intestinal microbiota, particularly the invasive bacteria among which E Coli AIEC. Genetic  [mutation of NOD2 (16q12), ATG16L1 (chr 2), IRGM (ch 5) or IL23R (ch 1) genes] and environmental factors have a promoting role. It is characterized by segmental inflammatory damage (sometimes multiple zones but separated by healthy areas) involving the three tissue layers of the digestive tube and even the meso's. At the histological examination, there is an inflammatory granulomatous reaction with giant cells. The primary location is the terminal ileum and right colon, but all levels of the digestive tract can be involved, including the esophagus, and the perineum. The initial symptoms are often unspecific: asthenia, abdominal pain, mucous diarrhea. In case of ileocolic involvement, an occlusive or pseudoappendicular syndrome can be observed. Rectal involvement is characterized by tenesmus and incontinence. In children, the diagnosis is sometimes made on the basis of perianal involvement (anal fistulae). Extra-digestive manifestations are sometimes present: arthritis, erythema nodosum or pyoderma gangrenosum (phagedenic ulceration), hepatic steatosis, urinary lithiasis, sometimes ocular involvement.

       Treatments :
-        a) at the acute stage: exclusively enteral diet (stomach tube or gastrostomy)
          based on a casein-rich solute;
-        b) short periods of corticosteroids by mouth in case of major attack;
-        c) in case of corticodependance, immunomodulators: methotrexate, azathioprine.
-        d) biotherapy: infliximab (anti-TNF antibodies) IV or adalimunab subcutaneously;
-        e) fecal  transplantation to modify the intestinal microbiota;

     -        f) surgery is reserved for complications: perforations, fistulae, stenoses.

2) ulcerative colitis: frequency peak is between 11 and 15 years of age; it is very rare before the age of 10. It  is limited to the mucosa and submucosa of the colon and rectum. The histological lesions are unspecific. Clinically, the disease is characterized by muco-bloody diarrhea and abdominal cramps, with a succession of remissions and relapses. The major complication is toxic megacolon with fever and abdominal distention, that may lead to perforation, bleeding or sepsis. It is often an urgent indication of colectomy. Possible extra-intestinal manifestations: arthritis, erythema nodosum and sclerosing cholangitis  with early portal hypertension.

       Treatments:

a)        5 - aminosalicylates in suppositories or corticosteroids by enemas;

b) 5-aminosalicylates orally;

c) short periods of corticosteroids orally in case of major attack;

d) in case of corticodependance immunomodulators: methotrexate, azathioprine.

e) in case of failure: total colectomy with or without preservation of the rectum (bowel neoreservoir or pouch)


Anesthetic implications:

check the nutritional status (weight, protein and albumin plasma levels); often, presence of latent depression; side effects of the treatments (date of the last intake of corticoids ?)


References :


Updated: May 2017