IBD (Crhon's Disease, Kolitis)

KOLITIS ULSEROSA

Divisi Gastroentero-Hepatologi

FK USU / RSUP HAM.

IBD ( INFLAMMATORY BOWEL DISEASE)

ULCERATIVE COLITIS

CRHON’S DISEASE

DEFINISI : INFLAMASI KRONIK DIFUS NON SPESIFIK PD MUKOSA KOLON DGN KLINIS REMISI & EKSASERBASI.

LOKALISASI :RECTUM – SIGMOID – COLDES – COLTRANS - COLASS44% PROCTITIS - PROCTOSIGMOIDITIS

36% PROCTOCOLITIS

18% PANCOLITIS

EPIDEMIOLOGI

EROPA & USA :

INSIDENSI = 7/100.000/TAHUN

PREVALENSI = 90-170100.000

SEMUA GOL UMUR : SAMA

PUNCAK I DEKADE : 2, II : (5), III : (6).

JAHUDI >> EROPA

ASIA – AFRIKA DI ISRAEL – INTERPLAY – LINGKUNGAN - GENETIK

1875 : WILKS & MOXON (PERTAMA SEKALI)

ETIOLOGI

1940 : PSIKOSOMATIK ?

1950-1990 : AUTOIMMUN ?

> 1990a : MULTIFAKTORIAL

MULTIFAKTORIAL :

* GENETIK

* INFEKSI

* EMOSI / PSIKIS

* LINGKUNGAN

* MEROKOK

* IMMUNOLOGI

PATOLOGI / PATOGENESELAPISAN:MUKOSA-SUB MUKOSA-L PROPRIA-MUSKULARIS

GAMBARAN : ERITEMA, EDEMA, KONTAK BLIDING.

ABSES KRIPTUS PECAH

PSEUDO POLIP TUKAK PERFORASI

(FULMINAN)

PATOLOGI ANATOMI :

RADANG KRONIK NON SPECIFIK

- GOBLET SEL

- MIKROABSES

- EOSINOFIL SEL

- PMN LEUKOSIT

PATOFISIOLOGI :

STIMULUS

MULTI FAKTORIAL

ACTIVATOR CEL

MASTCELL

PHAGOCYTIC MACROPHAGE NEUTROPHIL EOSINOPHIL

T. LYMPOSYT

PROTEASE, OXYRADICALCYTOTOXIC LYMPOSYT COMPLEMEN, CYTOKININ

INTESTINAL RESPONS

EPITHEL DAMAGE & EXFOLIATION

EROSION & ULCERASI

KLINIS INITIAL SYMPTOM’S COL-ULCERATIVE PD 113 PASIEN

SYMPTOM % SYMPTOM %

DIARRHEA 96,4 LOSS OF APPETITE 15,2

BLOOD IN STOOL 89,3 OPHTHALMO PATHIES 7,1

PAIN 81,3 NAUSEA 6,3

GENERAL UNWEIL 40,2 VOMITING 4,5

WEIGHT LOSS 38,4 ABSCESSES 3,6

ARTHRALGIA 27,7 FISTULA 3,6

FEVER 20,5 LYMPH NODE SWELLING 1,8

SKIN CHANGES 15,2

INTESTINAL SIGN AWAL /TAHUNINTESTINAL BLEEDING 80% 100%

DIARRHEA 52 % 85%

ABDOMINAL PAIN 42% 35%

ANAL FISURA 4% 4%

ANAL FISTULA 0% 0%

MANIFESTASI EXTRA INTESTINAL

MATA : IRIDOCYCLITIS, UVEITIS

MULUT : STOMATITIS, APHTAE

KULIT : ERYTHEMA NO DOSUM, PYODERMA GANGGRENOSUM

HATI : PRIMARY SCLEROSING, CHOLANGITIS PERICHOLANGITIS.

PANKREAS : PANKREATITIS

SENDI : MONOARTRITIS, OLIGOARHTRITIS ANKYLOSING, SPONDILITIS.

TINGKAT KEPARAHAN

MILD MODERATE SEVERE

STOOL FREQUENCY < 4 X > 6 X > 10X

BLEEDING SLIGHT PROFUSE CONTINUOUS

FEVER ( - ) > 37,5 > 38,8

HEMOGLOBLIN > 10G/DL < 10 G/DL < 8 G/DL

BSR < 30 MM > 30 MM > 50 MM

ALBUMIN NORMAL 3 – 4 G/DL < 3 GR/DL

KRITERIA DISEASE ACTIVITY INDEX (DAI)/(CAI)

PENILAIANSCORE

0 1 2 3

Frekuensi BAB Normal Diare

1-2 x /hari

Diare

3-4 x /hari

Diare

>4 x /hari

Hematochezia (-) Darah

Bercak

Darah

Campur Feses

Darah Predominan

Perendoskopi

(Kondisi Mukosa)

Normal Kontak Bleeding Sedikit

Kontak Bleeding Banyak

Exudasi, Perdarahan

Spontan

Penilaian Dokter

Berat-Ringan

Normal Ringan Sedang Berat

Maximum CAI = DAI adalah 12

GAMBARAN ENDOSKOPIC

GRADE 0 REMISION PALE MUCOSA, TARQUET VESSEL

GRADE I SLIGHT ACTIVITY ERYTHEMA, SLIGHTY GRANULALED SURFACE, LOSS OF VASCULAR PATTERN.

GRADE 2 MODERATE ACTIVITY SINGLE ULCER, VELVETY MUCOSA, CONTACT DAN SPONTANEUS BLEEDING

GRADE 3 HIGHT ACTIVITY PUS, SPONTANEUS BLEEDING, LARGER ULCERACE.

DIAGNOSTIK

KLINIK : DIARRHEA, BLOOD, PAIN

HISTORY : GENETIK ?

PHISIC DIAGNOSTIC : ABD PAIN, EXTRAINTESTINAL

L A B : BSR ,CRP , LEUCYTE , TROMBOCYTE , SPE

RADIOLOGY :

AWAL : GRANULATED MUCOSA, EROSION & ULCER

LANJUT : “SHIRT STUD” ULCER, HAUSTRA DAN

PEMENDEKAN COLON.

KRONIK : HIATUS (-)/PIPE LINE,SHRINKAGE, PSUDOPOLIP

USG : PENEBALAN DDG USUS/KOLON OK PERADANGAN.

ENDOSKOPI : KLASIFIKASI ENDOSKOPI 0/1/2/3PA : RADANG KRONIK NON SPESIFIK : SEL GOBLET MUKOSA

MIKROABSES EOSINOFIL CEL PMN LEUKOSIT

DIFRENSIAL DIAGNOSTIK

DD

INFEKSI

NON INFEKSI

KOLITIS ACUTT BAKTERIAL

KOLITIS AMUBA

AB - KOLITIS

IBS – DIVERTIKULOSIS

CROHN’S DISEASE

KOLITIS ISKEMIK

RADIASI

KEGANASAN

PERBEDAAN KOLITIS ULSEROSA & CROHN’S

KOLITIS ULSEROSA CROHN’S DISEASE

TINJA DARAH (+) /LENDIR DARAH (-)/STEATERHOE

PAIN ( + ) ( ++ )BB (+)/SEDANG (++)MASSA ABD

JARANG SERING

LESI PERIANAL

RINGAN BERAT

LOKASI KOLON KOLON/USUS HALUS

BA-ENEMA DIFUS, KOLON DISTAL /REKTUM.

SEGMENTAL,STRIKTUR, KOLON

PROXIMAL ILEUM.

1. KLINIS

KOLITIS ULSEROSA

CROHN’S DISEASE

GOBLESTONE ( - ) ( + + + )

INVOLVEMENT CONTINOUS DISCOTINOUS

RECTAL INVOLMENT ALWAYS 20%

VESSEL ABNORMAL NORMAL

ERYTHEMA/EDEMA (+++) (+)

VULNERABILITY (+++) (+)

BLEEDING (+++) (+)

PUS/MUCOSA (+++) (+)

LOCAL ULCER (+) (+++)

FISSURA ULCER (+) (+++)GRANULARITY ( + ) (+++)STRIKTURA (+) (+++)PSUDOPOLIP (+++) (++)

2. ENDOSKOPI

KOLITIS ULSEROSA

CROHN’S DISEASE

CRYPT INJURY (++) (++)GRANULANS ( - ) (++)TRANSMURAL INFLAMATION

( - ) (+++)

MUCOSAL INFLAMATION (+++) ( - )LYMPHOID HYPERPLASIA

( - ) (++)

DEEP ULCER (+) (++)MICROSCOPIC FOCALITY ( - ) (+++)CRYPT ABSCESES (+++) (+)GOBLET CELL DEPLETION

(+++) (+)

FLAT ULCER (++) (+)

3. HISTOLOGY

KLASIFIKASI CROHN MENURUT VIENNA

A1 A2 L1 L2 L3 L4 B1 B2 B3

Umur <40 >40

Lokasi Terminal Ileum

Kolon Ilio

Kolon

Upper GI

Perilaku Penyakit

Strik

tura (-)

Striktura (+)

Perforasi (+)

LABEL ALB

SEVERE ACUTE COLITIS

PARENTERAL GSC

MILD/MODERATE COLITIS

5-ASA/SASP,(ORALLY)OR RECTALLY ACCORDING TO EXTENT

NO IMPROVMENT

IMPROVMENT IMPROVMENT NO IMPROVMENT

ORAL GCS+5-ASA REMISIONGCS, ORALLY OR

RECTALLY

CHRONICALLY ACTIVE DISEASE

MAINTENANCE WITH 5-ASA

RELAPSE

GCS ORALLY

REPEATED RELAPSE

REMISION

AZATHIOPRINE

CYCLOSPORINE INTRAVENOUSLY

COLECTOMY

ALGORITMA : PENANGANAN KOLITIS ULSEROSA

Berat

Algoritma : PENATALAKSANAAN PENYAKIT CHROHN

Sedang-Ringan

Kortikosteroid IV antibiotik

Respons (-)

Sisklosporin IV

Surgikal

Respons (+)Respons (-)

Kortikosteroid oral Diet polimerik atau

elemental

Respons (+)

Respons (+)

Tappering dose

Kortikosteroid Dosis normal

Azatioprin/ 6MP

Respons (+)

Respons (-)

Dosis pemeliharaan

azatioprin/6MPMetotrets

atSurgikal

PRIMARY ATTACK

WRONG DIAGNOSIS

(“SELF-LIMITING”)

REMISSION CHRONIC ACTIVITY

CARCINOMA

RELAPSE

POSSIBLE COURSES OF ULCERATIVE

COLITIS

KOMPLIKASI :

- PERDARAHAN MASIF

- PERFORASI USUS

- ISCHIORECTAL ABSES.

- PSEUDOPOLIP

- KEGANASAN

- STRIKTURA

- TOXIC MEGACOLON.

DIAGNOSTIK TOXIC MEGA COLONRADIOLOGIK : DISTENSI KOLON (> 5 CM)

KLINIS : SEKURANGNYA 3 DARI

- FEVER > 380 C

- HR > 120 /MNT

- NEUTRPHOHILIC LEUCOCYTOSIS > 10,5X109.

- ANEMIA

SEKURANGNYA 1 DARI

- DEHYDRATION

- HYPOTENTION

- ELECTROLITE DISTURBANCE

- ALTERED CONSCIOUSNESS

INDICATION SURGICAL RESECTION

REFRACTORY CONSERVATIVE THERAPY : 76,5%

TOXIC COLITIS : 8,8%

COLORECTAL CANCER : 8,2%

DYSPLASIA : 6,4%

PENATALAKSANAAN KOLITIS ULSEROSA

UMUM :

1. SUPPORTIV : * - TIRAH BARING, IVFD, - TRANSFUSI, DIET

TKTP.

SYMPTOMATIS : * TRANSQULIARE * ANTI SPASME

2. MEDICAMEN

CAUSAL* SULFASALAZINE/SALAZOPIRIN

* KORTIKOSTEROID

* IMMUNOSUP : - AZATHIPRINE

- 6-MP

- SIKLOSPORIN

3. OPERASI : : * COLOPROTECTOMY

* ILEORECTAL ANASTOMOSIS

* ILEO CANAL POUCH OPERATION

MILD & MODERATE : (RECTUM/SIGMOID)

1. 5 ASA SUPPOSITORIA 500 MG

ENEMA 4 GR1 X 1 / 2 X 1 (2 MGG)

100 MG MG HYDROCORTISON (ENEMA) + 5 ASA

PREDNISON ORAL 40 - 60 MG/HR

REFRACTORY

IMMUNOSUPPRESIV DRUG

FAIL

FAILTOF

FAIL

DOSIS

TUJUAN : - MENGHILANGKAN & SERANGAN AKUT

- MENCEGAH RELAPSE / KAMBUH

- PERSIAPAN TINDAKAN OPERASI

2. SEVERE CU. (ILEN & COLON )

500 MG 5 ASA (2X1) 3-4 GR/HARI (>1 MGG)

PREDNISON ORAL 40-60 MG/HR

MELHYL PREDNISOLON 60-100MG/HR

REFRACTORY

IMMUNOSUPPRESIV DRUG

FAIL

FAIL

FAIL

Jenis obat dan dosis lazim yang dipakai pada pengobatan

Nama Obat Cara Pemakaian

Dosis Harian

Indikasi

5-ASA Supositoria 3x500 mg Terapi KU Distal/proktitis

5-ASA Supositoria 3x250 mg Dosis pemeliharaan KU distal

5-ASA Enema 1-4 g Terapi left side KU

5-ASA Tablet 2-4 g Terapi pan kolitis KU

5-ASA Tablet 1-1,5 g Dosis pemeliharaan KU

Sulfasalazin Tablet 3 g Terapi pan kolitis KU

Sulfasalazin Tablet 1-2 g Dosis pemeliharaan KU

Nama Obat Cara Pemakaian

Dosis Harian

Indikasi

Budesonid Enema 2 mg Terapi KU distal/proktitis

Hidrokortison Foam 100-200 mg Terapi KU distal/proktitis

Glukortikoid (ekuivalen prednisolon)

Oral 40-100 mg Terapi pan kolitis KU dan PC (ringan-sedang)

Glukortikoid (ekuivalen prednisolon)

IV 1 mg/kg KU dan PC Berat

Sisklosporin IV 1 mg/kg KU dan PC Berat

Siklosporin IV 2,5-4 mg/kg KU refrakter dan PC

Azatioprin IV 2,5-4 mg/kg KU refrakter dan PC

6-Mercaptopurin IV 1-2 mg/kg KU refrakter dan PC

Metroteksat Im 25 mg/mgg PC

PROGNOSA

TERGANTUNG KEPADA :

* SERANGAN AWAL

* USIA

* LUASNYA LESI

USIA : BAYI JELEK

>60 TAHUN PROGNOSA JELEK

LUASNYA LESI : MINIMAL DAN TERLOKALISIR : BAIK

MENYELURUH JELEK