Wednesday, 27 June 2012

Clinical Manifestation

Clinical Manifestations

As IBD is a chronic intermittent disease, symptoms can range from mild to severe during relapses and may decrease or even disappear during remissions. Symptoms generally depend on the section of the bowel involved.

Ulcerative Colitis

UC consists of chronic intermittent periods of exacerbation and remission that occur unpredictably, but it can also appear as an acute crisis. The major symptoms are bloody diarrhea and abdominal cramping pain. In mild UC, less mucosa is involved so the frequency of bleeding, bowel movements and pain, is minimal. In moderate UC, there is an increase in stool output (4-5 per day), increased amount of bleeding, and increased systemic symptoms such as fever, malaise, and anorexia. Severe forms of UC can involve the entire colon and are characterized by frequent bloody stools containing mucus (10-20 stools per day), urgency, tachycardia, and continuous and cramping pain. In addition, weight loss of more than 10% of total body weight, dehydration, fever, and anemia are present, resulting from fluid loss, bleeding, and inflammation.
Complications can include hemorrhoids, anal fissures, and perirectal abscess. Hemorrhage can result from inflamed, ulcerated mucosa, but severe hemorrhage is rare. The most common complications are fulminant colitis, bleeding, and toxic megacolon, which is extensive dilation and paralysis of the colon. Edema, fibrosis, and strictures can obstruct the colon. Perforation is possible although it is unusual, mostly occurring in the left side of the colon. Having UC for more than 10 years puts an individual at a greater risk of developing colorectal cancer. Extraintestinal manifestations include alterations in coagulation, hepatobiliary disease, and polyarthritis. The most common extraintestinal complications are skin lesions such as erythema nodosum and pyoderma gangrenosum.

Crohns Disease

Clinical manifestations of CD vary according to the anatomic site involved, the extent of the disease process, and the presence of complications. Onset of symptoms is usually insidious with nonspecific complaints. The major symptoms are diarrhea and abdominal pain, and occasionally, rectal bleeding if the colon is involved. The diarrhea is usually non-bloody and results from inflammation or malabsorption. The pain can be severe and intermittent, or constant. Weight loss, fatigue, and fever can accompany CD. Other manifestations include abdominal cramping, tenderness, and distension. Malabsorption of vitamin B12 (leading to anemia) and vitamin D can occur. Folic acid can be deficient and proteins may be lost (leading to hypoalbuminemia). Extraintestinal manifestations can include arthritis and finger clubbing. As the disease progresses, malnutrition, weight loss, electrolyte imbalances, dehydration, anemia, increased peristalsis, right lower quadrant and umbilical pain, and perianal disease can occur.
Complications include strictures and obstruction, fistulas between segments of the bowel, cutaneous fistulas, and urinary tract infections from fistulas that communicate with the urinary tract. Perforations, peritonitis, and formation of intra-abdominal abscesses can occur as a result of the inflammation of the bowels that may involve all layers. Damage to the intestinal mucosa causes the impaired absorption that leads to nutritional abnormalities. Extraintestinal complications are similar to those of UC and include renal disorders such as nephrolithiasis, ankylosing spondylitis, pyoderma gangrenosum and erythema nodosum, uveitis, liver disease cholelithiasis, and arthritis.
Clinical manifestations and complications of IBD are summarized in the following chart:
Ulceraterive ColitisCrohn's Disease
Clinical Manifestations
DiarrheaCommon; 4 times/ dayCommon(May or may not be present)
Blood stoolsCommonLess common
Abdominal painMild to severeModerate to severe
Rectal BleedingCommonFairly common
Abdominal massRareCommon
Weight lossCommonCommon/Severe
Fever(intermittent)During acute episodesCommon
Malabsorption and Nutritional deficiencesNone/Minimal incidenceCommon
Co-MorbitiesExtraintestinal manifestationsExtraintestinal manifestations
Clinical CourseExacerbations and remissionsExacerbations and remissions
Anal abcessesRareCommon
Toxic megacolonCommonRare
CarcinomaIncreased incidence after 10 yearsSlightly greater than the general population
Recurrence after surgeryCure with Colectomy40 - 60% or more recurrence after segmental resection of the small or large bowel
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