BII

Boli inflamatorii intestinale

 Epidemiologie

• Risc similar femei/barbati

• Debut in adolescenta/adulti tineri

• Varfuri de varsta : 15-25 , 55-65

• Europa N si SUA N : incidenta s-a dublat in anii

1960 si 1970 apoi a ramas constanta

• Mortalitatea celor cu BII este > populatia

generala
 Etiopatogeneza

• Factori genetici

• Factori de mediu

• Factori imuni
 Factori genetici

• Implicarea genetica este sustinuta de :

– Concordanta de apartitie a bolii la gemenii monozigoti este
de 50% BC si 5-14% CU

– Variatiile rasiale si etnice : albi>afro/americani, evrei >

– Istoric familial pozitiv : 6-37%

– Asocieri cu Ac : pANCA 59-84% CU , ASCA 50-60 % IN BC

– Implicarea unor gene : NOD2 (CARD 15 ),DLG5,NOD 1, HLA

 Factori de mediu

• INFECTIOSI

• ALERGENE

• FACTORI EXTERNI
 Factori infectiosi
• CU : tulpina de E.Coli
• BC : micobacterii : M.paratuberculosis
• Virusul rujeolic , Pseudomonas , reovirusuri ,
paramixovirusuri
In BII – bariera intestinala este afectata difuz
determinand o permeabilitate crescuta pentru
antigenele endoluminale
 Factori externi

• Efectul protector al nicotinei in CU

• Efectul nociv al nicotinei in BC

• Alaptatul la san protectiv fata de BII

• Contraceptive orale – declansarea CU

• AINS – aparitia BII si exacerbare

• Alimente procesate
 COLITA ULCERATIVA (RCUH)

• DEFINITIE :
– Este o boala inflamatorie neinfectioasa a colonului
caracterizata prin :
• recaderi si remisiuni , care afecteaza mucoasa colonului

• Afectarea obligatorie a rectului cu ascensiune

progresiva, continua

• Complicatii dg si extradg.
 Clinic

• Diaree +rectoragie

• Debut acut sau insidios

• Evolutie ondulanta : remisiuni /recaderi

• Diaree : 4-20, si nocturne

– Mecanism : exudativ , ca rezultat al secretiei
intestinale +reducerea ariei de absorbtie a H2O,
decolarea mucoasei
 Clinic

• Alte semne :
– Febra

– Adinamie

– Scaderea in greutate
 Clinic

• Durere abdominala, tenesme , produse

patologice in scaun

• Constipatia : proctite ( spasm rectal ), stenoze

 Examen obiectiv

• In f-tie de gravitate

• Normal

• Inspectie : paloare , distensie abdominala (

importanata: megacolon toxic )

• Palpare : coarda colica dureroasa flanc stg

 Forme clinico-topografice

• Proctita

• Proctosigmoidita

• Colita stg

• Pancolita
 Explorari diagnostice
• Endoscopic

• Histologic

• Laborator- markeri serologici

• Radiologie

• CT

• RMN
 Dg. endoscopic
• Leziuni distribuite continuu, demarcatia intre
mucoasa afectata si ce normala este precisa.

• Hiperemie mucosala , fara luciu

• Granularitate , friabilitate

• Stergerea desenului vascular

• Eroziuni / ulceratii superficiale

• Polipi inflamatori
 Indicatii endoscopie

• Stabilirea Dg.poz si diferential

• Prelevare biopsie

• Stabilirea extensiei bolii , gravitatii

• Urmarirea displaziei
 Contraindicatii endoscopie

• Megacolon toxic

• Perforatie intestinala

• Forme severe/fulminante
 Markeri serologici

• pANCA : pozitivi la 2/3 din pacientii cu CU si 1/3

din pacientii cu BC

• ASCA : pozitivi la 2/3 BC si 1/3 CU

• Utili in dg. Diferential intre CU si BC

 Biochimic
• VSH – se coreleaza cu severitatea si gravitatea
bolii
• Anemia
• Leucocitoza – infectie
• Trombocitoza – risc de complicatii
tromboembolice
• Proteine de faza acuta : PCR , Calprotectina
• Gama GT , FA - CSP
 Coprocultura

• Pentru excluderea infectiei

• Salmonella , Schigella , Campylobacter ,

Clostridium Difficile , Yersinia
 Radiologia

• Rx.pe gol:
– Dilatatia acuta toxica ( colon transvers >6 cm )

– Suspiciunea de ocluzie intestinala

– Suspiciunea de perforatie intestinala

• Rx.in dublu contrast contrast : extensia,

stenoze
 Alte examinari

• Echografia abdomianala

• ERCP

• Colangio-RMN

• RMN
42
43
 Examen histologic

• Inflamatie acuta

• Inflamatie cronica

• Criptita+abcese criptice

• Pseudopolipi inflamatori

• Displazie
 Complicatii

• C. intestinale

• C.extraintestinale
 Complicatii intestinale

• HDI severa- rara

• Megacolonul toxic

• Perforatia

• Displazia/cancerul colonic
 Megacolon toxic
• Urgenta !
• 5% din formele severe
• Factori favorizanti : hipoK,manopere invazive
• Clinic : alterarea starii generale , febra, dureri
abdominale , constipatie , timpanism la
percutie
• 50%: interv.ch daca in 48-72 h nu se
amelioreaza
50
• Dysplasia is the best and most reliable marker of an
increased risk of malignancy in patients with IBD
Complicatii extraintestinale
CU
 CCR

• Incidenta de 26 % fata de 2-3% in populatia

generala

• GRUPE DE RISC
da
Complicatii extraintestinale
 Dg.Diferential

• Cauze infectioase

• Cauze neinfectioase
 Tratament

• Dietetic

• Medicamentos

• Chirurgical
 Obiectivele tratamentului

• Inducerea remisiunii

• Mentinerea remisiunii

• Cresterea calitatii vietii

• Vindecarea mucosala
 Tratament

• Produsi 5-ASA

• Corticosteroizi

• Terapia imunomodulatoare

• Terapia biologica
 Terapia chirurgicala

• Colectomie +ileostomie

• Colectomie cu pouch ileal

• Rezectie segmentara
76
Boala Crohn
 Definitie

• Boala inflamatorie neinfectioasa :

- Localizare la nivelul tractului dg de la nivelul

gurii pana la anus

- Afectarea transmurala a peretelui

 Clinic
• In f-tie de localizarea anatomica:
– ILEO-CECALA : durere abdominala , febra ,
diaree/constipatie
– COLONICA : diaree , emisii de sange, febra
– GASTRODUODENALA : dispepsie , pirozis ,
disfagie
– PERIANALA – abcese perianale , hemoroizi ,
fistule entero-vezicale(pneumaturie),recto-
vaginale
 Ex.clinic

• Ulceratii /ulcere buze , gingie, mucoasa bucala

• Examinarea rectala si a regiunii perianale :

– fisuri

– Fistule

– Abcese perianale

– hemoroizi
 Ex.clinic

• Normal

• Febra

• Stare generala alterata , deshidratare , dureri

abdominale cu masa palpabila in FID/flanc
drept
 Dg.pozitiv

• Endoscopic

• Histologic

• Imagistic ( CT , RMN, Echo)

 Endoscopic

• Ulcere liniare adanci

• Granularitate

• Leziuni “pe sarite”

 Dg.Histologic

• Inflamatie transmurala

• Granuloame
 Tratament

• Corticosteriozi
– PREDNISON

– PREDINSOLONE

– BUDESONID

– Cai de administrare : orala/iv/clisme

 Intestinal Complications
Anal and perianal complications
•Fissure in ano or fistula in ano
•Haemorrhoids
•Skin tags
•Perianal or ischiorectal abscess
•Anorectal fistulae

Undernutrition
•Caused by reduced food intake, malabsorption, increased protein loss from
inflamed bowel and the increased metabolic demands of being sick.

Short bowel syndrome

•Develops when extensive bowel resection leads to excessive malabsorption
of fluids, electrolytes and nutrients.

Cancer
•With Crohn’s colitis, there is a increased risk of colorectal carcinoma
•There is an small increased risk of rarer small intestinal and anal cancers
occurring in cites of prolonged inflammation.
99
 Extra-intestinal complications
There are many systemic associations and complications of CD, most affecting the
liver and biliary tree, joints, skin and eyes:

Sclerosing Cholangitis – occurs in a small

proportion of patients. The pathogenesis is
unknown and the condition is characterised by
an inflammatory obliterative fibrosis of the
biliary tree (the white in the diagram->). It
progresses slowly and a liver transplant is the
only cure.

Ankylosing spondylitis – affects about 5% of patients

with Crohn’s colitis. The patient presents with back
pain and stiffness and the diagnosis can come years
before the CD.
 Extra-intestinal complications
Erythema nodosum – occurs in ~8% of Crohn’s
colitis patients when disease is active. Hot, red
tender nodules appear on the arms and legs and
subside after a few days.

Pyoderma gangrenosum – occurs in ~2% of CD

patients, starting as a small pustule, then developing
into a painful, enlarging ulcer, most commonly on
the leg.

In addition to these conditions, other complications and associations include

episcleritis and uveitis (occuring in 5% of patients with active disease), osteoporosis
(as a consequence of chronic inflammation, malabsortion and treatment with
corticosteroids) and arthropathy.