2.6.3.7 Irritable Bowel Syndrom &kolitis

dr. Muhammad Sayuti, Sp.
B (K) BD
Bedah Digestif RSUD Cut Meutia/
FK UNIMAL
Irritabel Bowel Disease
• IBS is defined as “abdominal pain or discomfort that
occurs in association with altered bowel habits over a
periods of at least three months.
Pathophysiology
• IBS is characterized by changes in motility in response to

environmental or enteric stimuli
• Visceral hypersensitivity is well documented in IBS patients
• Serotonin, which has both motility and sensory modulating
properties, could represent a common factor linking the
symptoms of IBS
• Mucosal inflammatory process
3
28
Symptoms
• Loose stool
• Constipation
• Alternating Diarrhea and Constipation
• Urges to move bowel again immediately following a
bowel movement
• Mucus in stool
5
2
Subtypes
• Diarrhoea predominant (IBS-D)

• Constipation predominant (IBS-C)
• Pain predominant (IBS-P)
7
Differential Diagnoses
• Dietary – e.g. lactose intolerance, ↑ caffeine etc.

• Infections – Giardia, Bacterial Overgrowth Syndrome
• Inflammatory Bowel Disease – UC, CD,
• Microscopic Colitis
• Malabsorption syndrome – Celiac Disease
• Pancreatic Insufficiency
• Psychological – Depression Anxiety, Somatization
• Other - Neuroses
13
“Red Flags’” - Alarm Symptoms/Signs
• Onset after 55 years

• Persistent anorexia & weight loss > 10 lbs
• Persistent “fever” in the evening
• Pain – changing pattern or increasing after food
and persisting for a few hours
• Awakened by pain &/or diarrhea at night
• Rectal bleeding, not just on wiping
• Stools “like malabsorption syndrome”
• P/E: palpable mass in the abdomen
14
Diagnosis Summary
• IBS remains a clinical diagnosis
• In those below 55 years and in the absence

of alarm symptoms, Rome II Criteria (Clinical)
has:
- Sensitivity → 65%
- Specificity → 100%
- PPV → 100%
Vanner et al (1999) Amer J Gast 94:2912 15

Traditional therapies focused on
individual symptoms of IBS with constipation
Bloating and distention
 Dietary modifications
Abdominal pain / discomfort  Antispasmodics
 Antispasmodics  Antiflatulants
 Tricyclics Abdominal  Digestive enzymes
 Analgesics pain / Bloating /  Antibiotics
discomfort distention
Constipation
Irregular Bowel or Diarrhea
Habit
 Fiber
 Laxatives
 Imodium
 None of these medications effectively treat the multiple symptoms of IBS.
May exacerbate individual symptoms e.g., fiber and bloating; antispasmodics and constipation
IBS: Symptomatic Therapy
Smooth muscle relaxants Smooth muscle relaxants

5-HT agonists/antagonists 5-HT agonists/antagonists
TCAs, SSRIs Antiflatulents
Abdominal
pain/ Bloating
discomfort
Altered bowel
function
CONSTIPATION
Fibres DIARRHEA
Osmotic agents Loperamide
5-HT4 agonists Cholestyramine
Prokinetics 5-HT3 antagonists
17
Alternative/Complementary Approach
1. Herbal
– Peppermint oil capsule
– Turmeric Extract
– Artichoke leaf Extract
2. Mind-Body Therapies
– Hypnotherapy
– Cognitive-behavioral Therapy (CBT)
3. Relaxation Technique
4. Acupuncture and Moxibustion
5. Diet, lifestyle
6. Probiotics
Yoon et al, Altern Med Rev, 2011; 16(2): 134-151
Inflammatory Bowel Disease
• Inflammatory Bowel Disease (IBD) is an idiophatic
disease caused by a dysregulated immune response to
host intestinal microflora
• Two major type :
• Ulcerative Colitis (UC) only colon
• Crohn Disease (CD) can involve any segment of
GIT from the mouth to anus
• Medical research hasn’t determined yet what causes IBD but
researchers believe that a number of factors may be involved
such: environment, diet and possibly genetics
• Current evidence suggest that likely a genetic defect that

affects immune system works
• Often the most severe in the rectal area, which can cause
frequent diarrhea
• 40-50% of patients have disease limited to the rectum &
rectosigmoid
• 30-40% extending beyond sigmoid
• 20% of patients have total colitis
• Proximal spread occur in continuity without areas of uninvolved
mucosa
• Mucosa :
• Mild disease :
• Erythematous,
• granular surface that looks like a sand paper
• Friability & loss of vascular pattern
• Severe diseases :
• Hemorrhagic, edematous and ulcerated
• In ptnt with cycle inflammation & healing
• Pseudopolyps or mucosal bridging
• > 8 years : biopsy
• Surveillance of dysplasia
• Fulminant disease :
A toxic colitis / toxic megacolon may develop (wall become
very thin and mucosa is severely ulcerated)
• Process is limited to the mucosa and sub mucosa with deeper
layer unaffected
• Two or three major histologic features :

• Infiltrates : lymphocytes, plasma cells & granulocytes
• Crypt architecture of colon is distorted
• Goblet cell depletion
• Diminished crypt density
• Ulceration
• Some patients have basal plasma cells and multiple basal
lymphoid aggregates
• Majority (80%) :
• mild,
• predominantly distal disease
• Proctitis (40%)
• Left sided colitis (35%) : distal to splenic plexura
• Urgency, frequency, tenesmus
• Pass fresh blood
• inflamed mucosa on anuscopy / proctoscopy
• Minority (20%) Pancolitis
• Anemia, fatique, anorexia, weight loss
• Chronic colitis loss of mucosal folds, haustra lead pipe
apperance on radiologist
• Toxic megacolon fever, abdominal pain, tachycardia,
local tenderness, leucocytosis, “Ro” dilatation > 6 cm, and
risk of gangren, perforation
• Arthritis (20%) at knees, ankles, hips & shoulders
• Ankylosing spondylitis (3-5%)
• Erythema nodosum (10-15%) often in conjunction with
arthropathy
• Pyoderma gangrenosum (rare)
• Primary sclerosing cholangitis (5-8%)
• Fine mucosa granularity
• Mucosa become thickenned and superficial ulcers are
seen/collar button ulcers
• Loss of haustration
• Hemorrhage
• Perforation
• Stricture
• Toxic megacolon
• Disease duration : 25% at 25 years
35% at 30 years
45% at 35 years
• Pancolonic disease
• Continously active disease
65% at 40 years
• Severity of inflammation colonic stricture must be
considered to be cancer into proven other wise
Therapeutic Pyramid for Active UC
Severe Surgery
Cyclosporine
Infliximab
Moderate
Systemic Corticosteroids
AZA/6-MP
Oral Steroids
Mild
Aminosalicylates
• Aminosalicylates (sulfasalazine, mesalamine)
• Corticosteroid (prednisone, budesonide)
• Immuno modulatory agents
• 6-MP/ Azathioprine
• Cyclosporine
• Infliximab
• Cyclosporin
• Inducing remission
• Maintaining remission
• Restoring and maintaining nutrition
• Maintaining patient’s quality of life
• Surgical intervention
• selection of optimal time for surgery :
• CRP > 45 mg/ml
• Has 3 – 8 stools / day
• on day 3 after treatment with iv glucocorticoid /
cyclosporin
• Intractability (most common indication)
• Dysplasia – Carcinoma
• Massive bleeding (<5% requiring operation)
• Toxic Megacolon
• Segmental colectomy
• Abdominal colectomy + ileorectal anastomosis
• Total proctocolectomy + end ileostomy
• Total proctocolectomy + continent ileostomy
• Total proctocolectomy + ileal pouch anal anastomosis
• Crohn's disease differs from ulcerative colitis in the
areas of the bowel it involves. It most commonly affects
the last part of the small intestine and parts of the
large intestine.
• Crohn's disease isn't limited to these areas and can

attack any part of the digestive tract
• Crohn's disease generally tends to involve the entire

bowel wall
• Three prevalent theories include :
• Response to a specific infections agent
• A detective mucosal barrier allowing an increased exposure
to antigens
• An abnormal host respons to dietary antigens
• One infections agent (Myobacterium para tuberculosis isolated
up to 65% of tissue samples from Crohn’s patients)
• Smoking appears to be risk factor for CD (the risk of recurrence
is greatly increased in smokers)
• Can affect any part of GI tract from the mouth to anus
• 40 – 55% of patients have small bowel + large bowel
• 30 – 40% of patients have small bowel disease alone
• the terminal ileum involved 90%.
• 15 – 25% of patients have colitis alone
• CD is a transmural process
• CD is segmental with skip areas in the midst of

diseased intestine
• In one –third of patients with CD perirectal fistulas,

fissures, abscesses, anal stenosis are present
• Active CD is characterized by focal inflammation and formation
of fistula tracts
• Cobblestone appearance by barium radiolography and
endoscopically
• The bowel wall thickens and becomes narrowed and fibrotic
and recurrent bowel obstruction
• Characteristic triad :
- abdominal pain
- diarrhea
- weight loss
• Anorexia, fever, mimics viral gastroenteritis
• Only half of pts with CD → rectal involvement, ⅔ pts have
involvement entire colon.
• Anal disease
• Ileo colitis
• Jejunoileitis
• Gastroduodenal disease
• Colitis and perianal disease
• Dermatologic (Erythema nodosum 15% of CD and pyoderma
gangrenosum less common compared UC)
• Rheumatologic more common in CD
• Conjuctivitis , anterior uveitis, episcleritis
• Urologic → Nephrolithiasis ± 10 – 20% with CD.
• Skip lesions
• Cobblestone like mucosal pattern
• Strictures
• Thickening of haustral margin
• Irregular nodular defect
• Aminosalicylates (salfasalazine, mesalamine)
• Antibiotics
• Corticosteroids (prednisone, budesonide)
• Immuno modulatory agents (Azathioprine, 6-MP, cyclosporine)
• Infliximab → monoclonal anti TNF alpha anti antibody
Surgery
Severe
Immunomodulators
Infliximab
(Prednisone)
Moderate ?
Corticosteroids
(Budesonide)
Mild
Aminosalicylates/Antibiotics
• Intractibility
• Intestinal Obstruction
• Intra Abdominal Abscess
• Fistulas
• Fulminant Colitis and Toxic Megacolon
• Massive beeding less common UC
• Cancer at small intestinal 0,3% and large
intestinal ± 1,8%
• In general : conservative resection
• stricturoplasty,
• as opposed to resective surgery
• Ileocecal resection
• Segmental Resections
• Colostomy
• Severe perianal fistula

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dr. Muhammad Sayuti, Sp.

• IBS is characterized by changes in motility in response to

• Diarrhoea predominant (IBS-D)

• Dietary – e.g. lactose intolerance, ↑ caffeine etc.

• Onset after 55 years

• IBS remains a clinical diagnosis

• In those below 55 years and in the absence

Vanner et al (1999) Amer J Gast 94:2912 15

Smooth muscle relaxants Smooth muscle relaxants

• Current evidence suggest that likely a genetic defect that

• Two or three major histologic features :

• Crohn's disease isn't limited to these areas and can

• Crohn's disease generally tends to involve the entire

• CD is segmental with skip areas in the midst of

• In one –third of patients with CD perirectal fistulas,

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