Inflammatory Bowel Disease And Urinary Obstruction Essay

Case Study 3 & 4 (10 Points)
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Case Study 3 & 4 S Inflammatory Bowel Disease and Urinary Obstruction
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In simple mechanical obstruction, blockage occurs without vascular compromise. Ingested fluid and food, digestive secretions, and gas accumulate above the obstruction. The proximal bowel distends, and the distal segment collapses. The normal secretory and absorptive functions of the mucosa are depressed, and the bowel wall becomes edematous and congested. Severe intestinal distention is self-perpetuating and progressive, intensifying the peristaltic and secretory derangements and increasing the risks of dehydration and progression to strangulating obstruction.

Strangulating obstruction is obstruction with compromised blood flow; it occurs in nearly 25% of patients with small-bowel obstruction. It is usually associated with hernia, volvulus, and intussusception. Strangulating obstruction can progress to infarction and gangrene in as little as 6 hours. Venous obstruction occurs first, followed by arterial occlusion, resulting in rapid ischemia of the bowel wall. The ischemic bowel becomes edematous and infarcts, leading to gangrene and perforation. In large-bowel obstruction, strangulation is rare (except with volvulus). Inflammatory Bowel Disease And Urinary Obstruction Essay

Perforation may occur in an ischemic segment (typically small bowel) or when marked dilation occurs. The risk is high if the cecum is dilated to a diameter ≥ 13 cm. Perforation of a tumor or a diverticulum may also occur at the obstruction site.

Pearls & Pitfalls
Strangulating obstruction can progress to infarction and gangrene in as little as 6 hours.
Symptoms and Signs
Obstruction of the small bowel causes symptoms shortly after onset: abdominal cramps centered around the umbilicus or in the epigastrium, vomiting, and—in patients with complete obstruction—obstipation. Patients with partial obstruction may develop diarrhea. Severe, steady pain suggests that strangulation has occurred. In the absence of strangulation, the abdomen is not tender. Hyperactive, high-pitched peristalsis with rushes coinciding with cramps is typical. Sometimes, dilated loops of bowel are palpable. With infarction, the abdomen becomes tender and auscultation reveals a silent abdomen or minimal peristalsis. Shock and oliguria are serious signs that indicate either late simple obstruction or strangulation. Inflammatory Bowel Disease And Urinary Obstruction Essay

Cecal Volvulus
Cecal Volvulus
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The cecum has twisted around its mesentery, causing a dilated “coffee bean” to project toward the left upper quadrant.

Image provided by Parswa Ansari, MD.
Obstruction of the large bowel usually causes milder symptoms that develop more gradually than those caused by small-bowel obstruction. Increasing constipation leads to obstipation and abdominal distention. Vomiting may occur (usually several hours after onset of other symptoms) but is not common. Lower abdominal cramps unproductive of feces occur. Physical examination typically shows a distended abdomen with loud borborygmi. There is no tenderness, and the rectum is usually empty. A mass corresponding to the site of an obstructing tumor may be palpable. Systemic symptoms are relatively mild, and fluid and electrolyte deficits are uncommon. Inflammatory Bowel Disease And Urinary Obstruction Essay

The inflammatory bowel diseases (IBD), Crohn’s disease (CD) and ulcerative colitis (UC), are chronic inflammatory disorders of the gastrointestinal tract of unknown etiology. The diseases are thought to be the result of a disregulated mucosal immune response to commensal gut flora in genetically susceptible individuals. The impact of IBD on patients’ quality of life is substantial due to early onset, fluctuating disease course and the lack of a cure. Furthermore, CD and UC account for substantial costs to the health care system and society. Descriptive epidemiological studies are important for health care system leadership, as they provide valuable information for decision making. The aim of this review is to describe the burden of IBD in Europe by discussing the occurrence of IBD, the risk for surgery and hospitalization, mortality and cancer risks, as well as the patients’ disability and work impairment. Inflammatory Bowel Disease And Urinary Obstruction Essay

2 Incidence and prevalence in Europe
The incidence and prevalence of IBD is subject to considerable variation, both between and within geographic regions, with IBD being more common in industrialized than in non-industrialized countries. Traditionally, the highest occurrence of both UC and CD is found in the developed countries of North America1,2 and Europe. Within Europe, the highest incidence and prevalence rates are found in Scandinavia3–15 and the United Kingdom16–19 while the diseases remain rare in Eastern Europe.20–22 However, the occurrence of IBD is a dynamic process as increasing incidence rates being reported from previously low incidence areas, including not only Asia,23 for instance, but also Eastern Europe.24,25 Inflammatory Bowel Disease And Urinary Obstruction Essay

The comparison of incidence and prevalence rates in IBD across multiple studies is challenging. Detection rates and diagnostic criteria differ between studies, just as access to diagnostic procedures, such as endoscopy, may vary over time and between centers. Furthermore, methods of case assessment, as well as physicians’ disease awareness, vary considerably and complete case assessment is dependent on the ability to identify all cases in the population. As such, prospective population-based studies are preferable in descriptive epidemiology compared to studies using secondary data that depend on existing hospital or public health registry systems; however such prospective population-based studies are both expensive and time consuming, and therefore rare. It is thus essential to bear in mind that observed differences between regions might either be attributed to real differences in environmental factors, lifestyle, and genetic susceptibility or simply be due to differences in methodology. Inflammatory Bowel Disease And Urinary Obstruction Essay

2.1 Incidence and prevalence rates
Incidence and prevalence rates from selected countries in Europe are shown in Tables 1 and 2. The incidence of CD in Europe ranges from 0.5 to 10.6 cases per 100,000 person-years while the estimates for UC range from 0.9 to 24.3 per 100,000 person-years. The highest incidence rates are observed in Scandinavia and the United Kingdom, while the lowest rates are seen in southern and Eastern Europe — suggesting a north-west/south-east gradient in IBD incidence. The European Collaborative Study on Inflammatory Bowel Disease (EC-IBD) assessed the north–south gradient in a prospective population-based cohort using uniformed diagnostic criteria and case ascertainment methods. The total incidence rates in northern Europe were 6.3 for CD and 11.4 for UC per 100,000 person-years, while in southern Europe they were for 3.6 and 8.0 per 100,000 person-years, respectively. Inflammatory Bowel Disease And Urinary Obstruction Essay

Extrapolation of the incidence figures on the total European population (app. 731 million in 2006,27) despite the challenges of heterogeneous health care systems and differences in study methodology between countries and centers, would indicate a maximal estimate of 78,000 new cases of CD and 178,000 new cases of UC each year — for a combined estimate of 256,000 new cases of IBD per year. Previous reviews28 have used the population of the European Union (27 countries, approximately 500 million in 201229) which would yield 53,000 new cases of CD and 123,000 new cases of UC each year, with a combined estimate of 176,000 new cases of IBD each year.

The prevalence of CD in Europe varies from 1.522 to 21312 cases per 100,000 persons, whereas the prevalence of UC in Europe varies from 2.422 to 2946 cases per 100,000 persons. As for the incidence of IBD, the highest prevalence rates are found in Northern Europe. Extrapolating these numbers for the total European population indicates that there may be up to 1.6 million persons with CD and 2.1 million persons with UC in Europe, meaning a combined total of 3.7 million persons with IBD. Using the population of the European Union yields maximal estimates of 1.1 million persons with CD and 1.5 million persons with UC in Europe, for a combined total of 2.6 million persons with IBD. Inflammatory Bowel Disease And Urinary Obstruction Essay

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Since the incidence of both CD and UC is increasing or stable in virtually every region of the world,30 the prevalence of IBD is expected to increase further due to the early age of onset and low mortality of IBD patients. The emergence of IBD in traditionally low-prevalence regions (i.e. Eastern Europe) will further contribute to this increase. A current inception cohort study by the Epidemiological Committee (EpiCom) is investigating the East–west gradient in the incidence of IBD, as well as differences in potential environmental risk factors between Eastern and Western Europe.31

The incidence and prevalence of CD and UC is increasing in Europe.

Estimated 0.3% of the European population suffers from IBD equalling 2.5–3 million persons.

3 Disease phenotype, overall disease course and relapse rates
One of the most important parameter associated with long-term outcomes is the disease phenotype. Current practice guidelines advocate the use of the Montreal classification in both CD and UC.32 The most important variables are age at onset and disease location (terminal ileum (L1), colon (L2) and ileocolon (L3) and upper GI (L4) as modifier), behavior (non-stricturing non-penetrating (B1), structuring (B2) and penetrating (B3)) and presence of perianal disease in CD and disease extent (proctitis (E1), left-sided (E2) and extensive (E3)) in UC. Yet, there are still limited data available on the natural history of IBD in Europe. Inflammatory Bowel Disease And Urinary Obstruction Essay

In CD, the distribution of location is relatively homogeneous and stable with the exception of the reported variance in the frequency of the upper GI location, especially in pediatric— versus adult-onset populations. In addition, the proportion of isolated colonic disease is increasing in the last decade. An example may be the recent IBSEN cohort33 with 27% of patients with L1, 48% L2 and 23% L3 and only 2% L4 disease at presentation. Somewhat lower rates of isolated colonic disease were reported from Denmark (L2: 30%, 43% and 37% in 1962–1987, 1991–1993 and 2003–2004).34 Similar data were recently reported also from Eastern Europe (L1: 20%; L2: 35%, L3: 44% and all L4: 2.4%)24 in 2002–2006. Inflammatory Bowel Disease And Urinary Obstruction Essay

Up to one-third of European patients may present with complicated disease phenotype at diagnosis, e.g. in the IBSEN cohort 36%, 49% and 53% of patients had presented with or developed stricturing or penetrating disease at diagnosis or after 5- or 10-years. In contrast, in previous cohorts by Cosnes et al.,35 up to 70% of CD patients developed either penetrating or stricturing disease. Similar results were published in a Belgian study.36 45.9% of patients had a change in disease behavior during 10 years of follow-up, from non-stricturing, non-penetrating disease to either stricturing (27.1%) or penetrating (29.4%) disease. In contrast, disease location remained relatively stable during follow-up, with only 15.9% of patients exhibiting a change in disease location during the first 10 years. The rate of perianal complication may vary between 10 and 20% at presentation. Inflammatory Bowel Disease And Urinary Obstruction Essay

In UC, the distribution of the disease extent at diagnosis is variable among the different cohorts with increasing rates of proctitis. In the IBSEN cohort37 the distribution of the disease extent was E1 in 32%, E2 in 35% and E3 in 33%. Of the patients initially diagnosed with proctitis, 28% had progressed during the observation period, 10% to extensive colitis over the next 5-years. Similar distribution of the initial disease extent was observed in a population-based cohort from Eastern Europe (E1: 27%, E2: 51% and E3: 22%),24 while the 5-year probability of proximal disease extension in patients with initial proctitis or left-sided colitis was 12.7%. The rate of proctitis was more variable in Denmark,34 with 44%, 60% and 31% at diagnosis reported in 1962–1987, 1991–1993 and 2003–2004. Little data are available on the relapse rates and overall disease course in IBD from Europe. Most data were published from the Nordic countries. Inflammatory Bowel Disease And Urinary Obstruction Essay

In one of the early publications, the long-term disease course was reported in 185 CD patients followed-up regularly between 1960 and 78 in Copenhagen, Denmark.38 About 45% of patients were without clinical symptoms for all the observation years. The disease activity was low in app. 30% of patients and moderate-to high in app. 25%. Continuous disease activity was observed in about 20% and intermittent symptoms were reported in 35% of patients with active disease in a given year. However, the cumulative relapse rate after 5-years was already as high as 93.1%. Similar disease course was reported in a follow-up cohort from the same region in 1991–1993. Inflammatory Bowel Disease And Urinary Obstruction Essay

A better disease course was reported in UC during the same observation period from the Danish group39 in 1161 patients diagnosed and followed between 1962 and 1987. After the initial one to two years, approximately 50% of UC patients were in remission in each year of follow-up, while the proportion of patients with active disease fell gradually to about 30% parallel with an increasing proportion of patients treated by colectomy. The proportion of patients in remission increased with increasing disease duration. The cumulative probability of clinical relapse was 81.6% after 5-years’ disease duration, while only 1% of patients experienced continuously active disease. Interestingly, in the 1991–1993 Copenhagen cohort34 the probability of aggressive disease during the first 5-years fell from 23.8% to 13.2%. Inflammatory Bowel Disease And Urinary Obstruction Essay

Somewhat different rates were published in the EC-IBD study.40 First all types of cumulative recurrence rates were 34%, 69.2%, and 77.5% after 1, 5, and 10 years of follow-up in 358 CD patients, with similar second and third all type relapse rates (40.2%, 76.9% and 82.6% vs. 45.9 and 76.4% after 1, 5, and 10 years). Upper gastrointestinal location and 5-ASA therapy were associated with increased risk of relapses. Interestingly, relapse rates were associated to the geographic region. Higher relapse rates were reported from Copenhagen, while lower rates were observed in Greece, Italy and Norway. Relapse rates and disease course were reported more recently from the IBSEN group from Norway.37 Of the 454 UC patients, 78% experienced at least one relapse during the first 5-years. Relapse rates were higher in females (p = 0.01) and relapsing patients were younger (p < 0.001), but it was not associated to disease extent. In addition, when patients were asked to self-assess their disease course, 59% experienced a decline in the severity of intestinal symptoms during the follow-up period. In contrast, only 1% of patients experienced an increase in severity, while chronic continuous symptoms were present in 9%. A relapsing course was observed in 31%, respectively. In a follow-up study of the same cohort,41 48% of the UC patients were in clinical remission between 5 and 10-years after diagnosis. Inflammatory Bowel Disease And Urinary Obstruction Essay

Similar to earlier reports, a high cumulative relapse rate (53%, 85% and 90% after 1, 5, and 10 years) was reported in 237 CD patients from the same group33 associated with early need for steroids but not with disease phenotype or smoking habits. In contrast, approximately 44% of patients were in clinical remission during the second 5-year period and 43% experienced a decrease in the severity of disease (according to predefined disease patterns), during the follow-up period. In contrast, 3% patients experienced an increase in severity, 19% experienced chronic continuous symptoms, and 32% experienced a relapsing course.

Effects of Crohn’s disease and ulcerative colitis
Every person responds differently to IBD. The severity of symptoms will vary from time to time and from person to person. IBD is not a progressive disease (it does not necessarily get worse over time). Rather, flare-ups can range from mild to severe and back to mild again. Some people will experience periods of relief from symptoms in between flare-ups. Inflammatory Bowel Disease And Urinary Obstruction Essay

We cannot predict how long a person will stay free from symptoms, or when their next flare-up will occur. Some flare-ups settle down quite quickly with treatment. Other times, it may take months for a person’s symptoms to respond to treatment.

IBD interferes with a person’s normal body functions. Signs and symptoms can include:
pain in the abdomen
weight loss
diarrhoea (sometimes with blood and mucus)
tiredness
constipation
malnutrition
nausea
delayed or impaired growth in children. Inflammatory Bowel Disease And Urinary Obstruction Essay
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Causes of Crohn’s disease and ulcerative colitis
The causes of these diseases are unknown. Some scientists believe the cause might be a defect in the body’s immune system. Infection by a bacterium or virus may be important. Researchers do not think that stress or diet cause IBD.

These diseases are not contagious.
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Diagnosis of Crohn’s disease and ulcerative colitis
Doctors use a variety of tests to diagnose IBD. These include blood tests, faecal (bowel motion) examination, x-rays, colonoscopy and gastroscopy. In some cases, computed tomography (CT) scanning, magnetic resonance imaging (MRI) and ultrasound many be used.
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Treatment for Crohn’s disease and ulcerative colitis
The type of treatment for IBD depends on whether you have ulcerative colitis or Crohn’s disease. Treatments may include:
medication to reduce the chances of flare-ups
steroid (cortisone) medication
medication to reduce the activity of the immune system
corrective surgery for complications. Inflammatory Bowel Disease And Urinary Obstruction Essay
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Crohn’s disease and ulcerative colitis and diet
Diet and food allergies do not cause IBD, and long-term special diets are not effective in treating IBD. However, adjusting your diet can help manage some of your symptoms, and can help IBD medications work better. A person with IBD has to pay close attention to their diet, since they may have malnutrition.
Crohn’s disease and ulcerative colitis and digesting food
Your mouth and stomach break down food by mechanical and chemical means. When the food has reached a pulp-like consistency, it is slowly released into the first part of the small intestine (duodenum). The food is then massaged along the length of the small intestine. Organs like the pancreas and the gall bladder make digestive enzymes to further break down the food into its simpler components. Inflammatory Bowel Disease And Urinary Obstruction Essay

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The small intestine is lined with microscopic (very small), finger-like projections (villi) that lie close to tiny blood vessels (capillaries). Nutrients pass into the bloodstream through these villi. The rest of the food is pushed into the large bowel, which absorbs excess water. The waste is then temporarily stored in the colon before it is eliminated from the anus.

The two ways in which Crohn’s disease and ulcerative colitis disturb the digestion and absorption processes are:
Crohn’s disease – an inflamed ileum impairs (reduces) absorption of vitamin B12 and bile salts. Inflammation along the length of the small intestine impairs absorption of all food nutrients. Inflammation of the large bowel impairs water absorption, causing diarrhoea. Inflammatory Bowel Disease And Urinary Obstruction Essay
Ulcerative colitis – digestion and absorption are generally not affected. Inflammation of the large bowel impairs water absorption, causing diarrhoea.
Other factors that may affect your nutritional status include:
Medication – some medication used to treat IBD may lessen your appetite and interfere with the absorption of certain nutrients, such as folic acid.
Inflammation – your body needs greater amounts of nutrients in order to cope with inflammation and fever.
Surgery – some people with IBD need surgery to remove parts of their small intestine. This lessens nutrient absorption.
Problems caused by inadequate nutrition
Over the long term, reduced absorption of food nutrients can cause a number of problems, including:
anaemia
weight loss
impaired growth and development (in children). Inflammatory Bowel Disease And Urinary Obstruction Essay
IBD and changing your diet
Some dietary changes that may help a person with IBD include:
Low-fibre diet – when IBD is active, most people find a bland (non-spicy), low-fibre diet helps to ease diarrhoea and abdominal cramping. People with Crohn’s disease who have a narrowed small intestine may need to eat a low-fibre diet most of the time.
Low-fat diet – people with Crohn’s disease who experience steatorrhoea (diarrhoea that contains undigested dietary fats) may benefit from a low-fat diet.
Low-lactose diet – the milk sugar lactose is broken down by the enzyme lactase, commonly found in the lining of the small intestine. Some people with Crohn’s disease lack this enzyme, so should avoid milk and other dairy products. Lactose intolerance can be diagnosed with a simple test – ask your doctor.
Liquid diet – a person with severe Crohn’s disease may need a nutritionally balanced liquid diet.
Plenty of water – people with IBD need to drink plenty of fluids to prevent dehydration.
Vitamin and mineral supplements for IBD
A person with IBD who eats a healthy, varied diet does not usually need to take vitamin supplements. But if they have a dietary deficiency, they may need tablets or occasional vitamin B12 injections. For example, a person on a low-fibre diet may need extra vitamin C and folic acid because they don’t eat enough fruit and vegetables. Inflammatory Bowel Disease And Urinary Obstruction Essay

A person with Crohn’s disease who experiences steatorrhoea may need calcium and magnesium supplements. Most children with IBD should take supplements to help them grow and develop normally.
Medical advice and dietary changes for IBD
Always speak with your doctor, healthcare specialist or dietitian before making any changes to your diet. This is particularly important for children with IBD. Self-imposed restrictive diets of any kind often lead to nutritional deficiencies.
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Complications of Crohn’s disease and ulcerative colitis
Other complications of the digestive tract include fistulas and intestinal obstruction. Sometimes, a person with IBD experiences symptoms in other areas of the body. These are often referred to as ‘extra-intestinal manifestations’.
Complications caused by nutritional deficiencies
Some of the complications of malnutrition include:
Dehydration – diarrhoea causes your body to lose fluid, which can lead to dehydration. Severe dehydration can damage your kidneys.
Anaemia – reduced iron in the diet combined with losing blood from the bowel can lead to anaemia (the blood does not carry enough oxygen).
Weight loss – reduced appetite and poor absorption of food nutrients can cause weight loss.
Reduced growth (in children) – inadequate nutrition during childhood and adolescence can impair a child’s growth and physical development. Inflammatory Bowel Disease And Urinary Obstruction Essay
Inflammation in other areas
Some people with IBD have painful inflammation in other areas of the body, including:
joints of the fingers, hands, feet, ankles and knees
joints of the spine, including vertebrae and sacroiliac joints (located at the pelvis)
eyes
skin.
Skin problems
Two specific skin problems that can occur as a result of IBD are:
pyoderma gangrenosum – small, sunken ulcers on the skin
erythema nodosum – painful, small, reddened nodules on the skin (usually on the legs).
Fistulas
Fistulas are abnormal openings in the body. People with Crohn’s disease are more likely to develop fistulas than people with ulcerative colitis. The surface of the chronically inflamed bowel can become rough and sticky, causing it to ‘glue’ to a nearby structure, such as a neighbouring loop of intestine or an abdominal organ. This triggers more inflammation, and may lead to small holes (fistulas) between the structures. Sometimes, a fistula becomes blocked, causing an abscess (local infection and inflammation).
Intestinal obstruction Inflammatory Bowel Disease And Urinary Obstruction Essay
Some people with Crohn’s disease may experience intestinal obstruction. Food can no longer move through the person’s intestine, causing severe abdominal pain, bloating and sometimes vomiting.
Toxic megacolon
Toxic megacolon is a rare complication. Mild abdominal distension (bloating) is common and harmless, even in people without IBD. However, the irritated and inflamed large intestine (large bowel) of a person with IBD can suddenly and severely distend. A section of the intestinal wall may balloon until it ruptures (bursts). The ruptured bowel spills its contents into the abdominal cavity, causing infection (peritonitis).

Toxic megacolon is a life-threatening emergency. Seek urgent medical attention if you experience symptoms, which include:
hard, swollen abdomen
severe abdominal pain
fever
bloody diarrhoea
accelerated heart rate.
Treatment of IBD complications
Treatment depends on the particular complication, but may include:
complications caused by nutritional deficiencies – vitamin and mineral supplements (by mouth or injection), changes to diet (such as a low-fibre diet) or a liquid diet in severe cases
inflammation in other body areas – usually ease when the bowel inflammation is controlled with medication Inflammatory Bowel Disease And Urinary Obstruction Essay
fistulas – small openings that often heal by themselves, with treatment to ease the inflammation. A person may need surgery to close a larger fistula. Abscesses may need antibiotics and surgical drainage
intestinal obstruction – in some cases, medical treatment to ease the inflammation will clear the obstruction. In severe cases, the person will need surgery
toxic megacolon – the person goes to hospital, and receives fluids and nutrients intravenously (through a tube and needle into their bloodstream) instead of by mouth, plus antibiotics and steroids to reduce inflammation. Sometimes, the doctor will remove the contents of the person’s stomach with a slender tube (gastric suctioning). A ruptured bowel needs surgical repair or removal. In severe cases, the whole of the large bowel may need to be surgically removed.
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Daily life for people with IBD
People with IBD lead useful and productive lives, even though they need to take medications. When they are not experiencing a flare-up of their disease, they feel quite well and are often free of symptoms. Inflammatory Bowel Disease And Urinary Obstruction Essay

People with IBD can marry, enjoy sexual activity and have children. They can hold down jobs, care for families and enjoy sport and recreational activities.

Even though there is currently no cure for IBD, medical therapy has improved the health and quality of life of most people with Crohn’s disease and ulcerative colitis. Research underway today may lead to further improvements in medical and surgical treatment, and even a cure. Inflammatory Bowel Disease And Urinary Obstruction Essay