1 Wednesday Feb. 25 th 2015 8:15 – 9:00 Master's Course in Gastroenterology Universitätsklinik für Viszerale Chirurgie und Medizin Inselspital, Bern Source: MGH Crohn’s and colitis center Inflammatory Bowel Diseases Dr. med. P. Juillerat, MSc Oberarzt I Head of IBD clinical studies Source: medicaldaily.com
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Inflammatory Bowel Diseases - Mucosal Immunology...2 Definition of Inflammatory Bowel Diseases (IBD) Chronic relapsing inflammatory diseases involving : - The whole GI tract Crohn‘s
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Wednesday Feb. 25th 2015 8:15 – 9:00 Master's Course in Gastroenterology Universitätsklinik für Viszerale Chirurgie und Medizin Inselspital, Bern
Source: MGH Crohn’s and colitis center
Inflammatory Bowel Diseases
Dr. med. P. Juillerat, MSc Oberarzt I Head of IBD clinical studies
Source: medicaldaily.com
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Definition of Inflammatory Bowel Diseases (IBD) Chronic relapsing inflammatory diseases involving : - The whole GI tract
• ↓ „good“ bacteries („Symbionts“ e.g. F. prausnitzii)
R. Navus F.Nucleatus Ecoli AIEC
F. prausznitzii R. intestinalis A. muciniphyla
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HOW FREQUENT ?? Do you know people with IBD???
?
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One Study on prevalence in Canton de Vaud � 1/500 individual has inflammatory bowel disease (IBD) In Switzerland : (Vaud is very similar to Switzerland for age and gender)
12’000 IBD patients (6100 CD; 5900 UC)
Juillerat et al. Journal of Crohn's and Colitis (2008) 2, 131–141
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Switzerland compared to Europe
USA + Canada
Sud de l’Europe et Europe de l’Est
Nord de l’Europe
et Grande-Bretagne
Juillerat et al. Journal of Crohn's and Colitis (2008) 2, 131–141
Cosnes J et al. Clin Gastroenterol Hepatol 2004; 2: 41-48
N= 1784 IBD, 1096 UC , 688 Crohn
279 (61%)
52 (12%)
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Crohn’s Disease
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Crohn‘s disease ILEITIS and COLITIS
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Diagnosis: Endoscopy Æ HISTOLOGY
Hoffmann JC et al. DGVS Leitlinien Z Gastroenterol 2008; 46: 1094–1146 Sands BE et al. Gastroenterology 2004;126:1518–1532
Segmental focal inflammation of the whole intestinal wall : 1) Destruction / modification of the architectures oft the crypts 2) Infiltration of Lymphocytes and Plasmocytes 3) epitheloid Granuloma (20–40 %) 4) Reduction of gobelet cells Macroscopically : microerosions, fissures, ulcerations
Crohn‘s disease Normal
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Crohn‘s disease lesions
• Most frequent : terminal ileum & caecum
• Upper GI : rare
• rectum : rare and mostly associated with fistula
Harrisons Gastroenterologie und Hepatologie, 1. Auflage; Martin Zeitz, Hartmut H.-J. Schmidt, Christian Bojarski (Hrsg.); ABW Wissenschaftsverlag, 2011.
Upper GI : 4% Ileum & colon 40-55% Ileum only 30-40% Colon only 15-25%
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Silverberg MS, et al. Can J Gastroenterol 2005; 19:5–36. Quelle: Baumgart et al. Lancet 2012
Montréal classification of Crohn‘s disease
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MRI-example : inflammation type B1
1 year later
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Complication of the behavior of Crohn‘s disease: ulcerations Æ Stenosis – stricturing Type -
Courtesy of Prof. Dr. med. R. Ehehalt
ulcerations stenosis
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Crohn disease after resection
Wall thickening Stricture
– stricturing type - B2 -
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Complication of the behavior of Crohn‘s disease: Perforations Æ Fistula – penetrating type - B3 - fistulizing perianal - +P -
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Crohn disease : evolution
Cosnes J, et al. Gastroenterology 2011 ;140 (6):1785–1794
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Progression of digestive damage and inflammatory activity in a theoretical patient with CD Pre-clinical Clinical
Inflamm
atory Activity
(CD
AI, CD
EIS, PCR)
Surgery
Stricture
Stricture
Fistula/abscess
Disease onset
Diagnosis Early disease
Dig
estiv
e D
amag
e
Progression of digestive disease damage (Lémann score) and inflammation
Pariente B et al. Inflamm Bowel Dis 2011;17(6):1415-22
Typ B1
Typ B2 Typ B3
TREATMENT
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Therapeutical Arsenal
« Optimizing» therapy means currently: Æ An « accelerated» step –up ! OR …
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Evolution of the need for surgery in CD since the 1930's and impact of medications
Recommendations for colitis (Crohn or UC) colorectal cancer screening
• Based on disease duration and extension: 8–10 Jahre (pancolitis) 15-20 Jahre (left –sided colitis) • then, controls (in particular with pancolitis)
every 2–3 years after 20 y. dis. duration every 1-2 years after 30 y., 40 y., ...
• CAVE: every year with the diag. of primary sclerosing cholangitis
Farraye AGA Technical review GE 2010, Josh Korzenik MGH , Boston
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! !
Wang, Loftus et al. Am J Gastro 2013; 108:444-9
47 Farray. AGA Medical Position Statement and Technical Review, Gastroenterology 2010
High grade Dysplasia
DALM: Dysplasia-Associated Lesion or Mass Adenoma-like DALM Non-Adenoma-like DALM
Low grade Dysplasia
3-6 Mo
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Chromoendoscopy • Dye: Indigocarmin (or methylen blue) vial of 5 ml, with 20 ml NaCl [Spritze] (or 10 ml/50 ml) Æ Spray – catheter => use oft at least 40 ml