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  • Diagnostic,

    prsentation clinique et

    histoire naturelle des MICI

    Prof Yoram Bouhnik

    Gastroentrologie et Assistance Nutritive

    Universit Paris VII

    Hpital Beaujon, Clichy

    DU Mdecine interne, Novembre 2013

  • The burden of IBD

    Prevalence of IBD is 1% in North America and some European countries

    Incidence of Crohns disease is still increasing in these countries

    Rapid increases in the incidence of IBD are now being observed in Japan, South Korea, Australia, New Zealand and some regions of India and China

    IBD will emerge as a worldwide epidemic in the coming years

    Elkjaer M et al. Gut 2010;59:165261 Molodecky NA, et al. Gastroenterology 2012;142:4654

  • global map of inflammatory bowel disease

  • Worldwide IBD incidence and/or prevalence rates for countries reporting

    data (A) before 1960; (B) from 1960 to 1979; (C) after 1980.

    Before 1960

    1960-1979

    1980

    Molodecky et al. Gastroenterology 2012;142 (Jan):46-54

    UC CD

  • Molodecky et al. Gastroenterology 2012

    Temporal trends of incidence rates for studies that reported at least 10 years

    of data and with at least 3 time points for CD

  • Data from France The EPIMAD registry: Northern France

    6 million inhabitants (9.3% of french population)

    242 adult gastroenterologists, 12 pediatric gastroenterologists, 6733 GPs

    22,976cases recorded by the Registry (1988-2012)

  • 4

    5

    6

    7

    8

    9

    Total

    Femmes

    Hommes

    Incidence /105

    Incidence of Crohns disease in Northern France (1988-2008)

    Chouraki V et al. Aliment Pharmacol Ther 2011 (maj 2012)

    5,3

    4,5

    6,1

    7,6

    6,4

    8,8

  • 0

    2

    4

    6

    8

    10

    12

    0-19

    0-9

    10-19

    Age at diagnosis

    Incidence /105

    Incidence variation for CD in children and adolescents in Northern France (1988-2008)

    Chouraki V et al. Aliment Pharmacol Ther 2011 (maj 2012)

    3,5

    0,5

    6,5 7,1

    1,2

    12,9

  • Crohns Disease Incidence according to gender & age

    0

    2

    4

    6

    8

    10

    12

    14

    16

    18

    20

    0-9

    10-1

    9

    20-2

    9

    30-3

    9

    40-4

    9

    50-5

    9

    60-6

    9

    70-7

    9

    >=80

    Age

    incid

    en

    ce

    Males

    Females

    Incidence /100 000 26 years (median age at diagnosis)

  • 0%

    20%

    40%

    60%

    80%

    100%

    < 17 ans 17-39 ans 40-59 ans > 60 ans

    E3 (PANCOLITE)

    E2 (COLITE GAUCHE)

    E1 (RECTITE)

    Prsentation de la RCH selon l'ge

    tude prospective 5 253 cas incidents en population Registre EPIMAD de 1988 et 2010

    Incidence

    Localisation au diagnostic

    Symptmes au diagnostic

    0

    20

    40

    60

    80

    100

    douleurs abdominales perte de poids syndrome rectal manifestations

    extraintestinales

    < 17 ans

    17-39 ans

    40-59 ans

    > 60 ans

    ATCD Familiaux

    13 % 3 % p < 10-4 * p < 10-4

    Conclusion : Prsentations cliniques diffrentes en fonction de lge probablement reflet dune pathognie diffrente (poids des facteurs environnementaux et gntiques)

    Charpentier C et al. DDW 2012. Abstract 102

    p < 10-4

  • Facteurs environnementaux protecteurs

    RR de dvelopper une RCH :

    fumeur = 0,4

    ex-fumeur = 1,7

    Ex-fumeur :

    aggravation de la maladie

    extension des lsions

    augmentation du risque de RCH

    rfractaire et de colectomie.

  • Facteurs Causalit

    Tabac +++

    Appendicectomie +++

    Infections intestinales ++

    Antibiothrapie +

    Hygine +

    OP ou THS +

    Alimentation +

    Polluants ?

    Soleil ?

    Chane du froid ?

  • Ulcerative colitis Crohns disease

  • Crohns disease

    CD is a relapsing, transmural inflammatory disease of the GI mucosa that can affect the entire GIT from the mouth to the anus.

    Typical presentations include the discontinuous involvement

    of various portions of the GIT and the development of complications including strictures, abscesses, or fistulas.

    The clinical presentation is largely dependent on disease

    location and can include diarrhoea, abdominal pain, fever, clinical signs of bowel obstruction, as well as passage of blood or mucus or both.

  • From mouth to anus

    Rare

    Perianal fistula:

    One fourth of patients

    after 20 years

  • Small bowel and colon (30%)

    Colon (40%)

    Small bowel (30%)

    Upper GI tract (

  • Ulcerative colitis

    UC is a relapsing non-transmural inflammatory disease that is restricted to the colon

    Patients typically present with bloody diarrhoea (often nocturnal and postprandial), passage of pus, mucus, or both, and abdominal cramping during bowel movements.

    Severe symptoms are less common in left-sided colitis and proctitis.

  • Left sided

    colitis

    (20%) Extensive

    colitis

    (30%)

    Proctitis (50%)

  • Differential diagnosis of UC and CD

  • Up to 25% patients with CD and UC will develop EIM

  • Ileocolonoscopy with biopsies is the 1st

    line investigation to diagnose IBD

  • Le diagnostic repose sur lendoscopie et les biopsies

    http://www.sciencephoto.com/image/415157/large/C0103581-Ulcerative_colitis-SPL.jpg

  • Small intestinal Crohns disease

    as seen by capsule endoscopy

    Detects erosions in suspected Crohns disease with negative SBFT /

    colonoscopy

  • Recent imaging to explore the SB in IBD

    CT-based (left) and MRI-based (right) enterography showing an ileocaecal-sigmoid fistula in patient with Crohns disease

  • Histoire naturelle RCH

  • Reprsentation de lhistoire naturelle

    de la rectocolite hmorragique

    Torres J et al. Inflamm Bowel Dis 2012 ; 18 : 1356-63

    Ac

    tivit

    infla

    mm

    ato

    ire

    (Ma

    yo

    sco

    re, U

    CEIS

    )

    Premiers

    Symptmes

    Diagnostic RCH

    prcoce

    RCH

    tardive

    De

    stru

    ctio

    n in

    test

    ina

    le

    Atteinte

    Epithliale

    Dysplasie

    /Cancer

    Extension

    Perte de

    compliance

    Chirurgie

    Pousses

    svres

  • Profil volutif de la RCH

    Solberg, Scand J Gastro 2009; 44: 431

    amlioration

    progressive

    aggravation

    progressive

    chronique

    continu

    chronique

    intermittent

    55% 1% 37% 6%

    Cohorte d'inclusion danoise (IBSEN study), n=423/519, suivi 10 ans

  • Principales complications

    associes la RCH

    Complications Commentaires

    Colite grave 15%

    Hmorragie 10%, cause frquente danmie

    Mgaclon toxique,

    perforation

    5%

    Stnose colique 2 -10%, avec risque tumoral +++

    Hpatobiliaires CSP avec risque de cholangiocarcinome (X

    100-800)

    Thrombovasculaires FDR indpendant accident + rcidive (x 3,5

    vs population gnrale (veineuses+++)

  • Risque de complications/mgacolon toxique,

    pritonite, hmorragie

    Risque de chirurgie / Risque morbimortalit

    Risque de cancer colorectal

    Qualit de vie / handicap fonctionnel

    Risques particuliers des formes

    svres/compliques de RCH

    (E3 > E1-E2)

  • Cu

    mu

    lati

    ve p

    rob

    abili

    ty (

    %)

    Cohorte de 1161 patients au Danemark (196287)

    Langholz E et al. Scand J Gastroenterol 1996;31:2606

    Recto-sigmoidite

    Ltendue des lsions progresse avec le temps

    chez 50% des patients atteints de RCH

    0

    20

    40

    60

    80

    100

    0 2 4 6 8 10 12 14 16 18 20 22 24

    Annes aprs le diagnostic

    Progression

  • Une maladie destructrice au cours du temps

    Relation entre augmentation de la largeur de

    lespace prsacr et la dure de la maladie :

    augmentation du dpt de graisse en avant

    du sacrum

    rtrecissement de la lumire rectale

    paississement de la paroi rectale

    affaissement de la graisse prirectale

    Torres J et al. Gut 2011;Jul 11:Epub ahead of print

  • % cumul de CCR

    Risque lev de cancer colorectal

    dans la RCH

    Double mta-analyse : CCR et RCH

    Lutgens et al. Gut 2008 ; 57 :A131. Eaden et al. Gut 2001;48:526-35

    1% 10 ans 4% 20 ans 14% 30 ans

  • Adherence to endoscopy guidelines

    CESAME cohort: prevalence of colonoscopic surveillance of IBD in patients with longstanding (>7 years) extensive colitis

    0

    20

    40

    60

    80

    100

    Pro

    po

    rtio

    n o

    f p

    atie

    nts

    su

    rvey

    ed

    (%

    )

    Study centre (academic)

    All UC + IBDU Crohns colitis

    1 2 3 4 5 6 7 8 All 9

    Vienne A, et al. Aliment Pharmacol Ther 2011;34:18895

  • Vingt et 30% des patients RCH ont une

    colectomie aprs 10 et 25 ans dvolution

    Langholz E et al. Gastroenterology. 1994

    0%

    10%

    20%

    30%

    40%

    50%

    60%

    70%

    80%

    90%

    100%

    0 2 4 6 8 10 12