Inflammatory Bowel Disease
Author: William A Rowe, MD; Chief Editor: Julian Katz, MD more...
Inflammatory bowel disease (IBD) is an idiopathic disease caused by a dysregulated immune response to host intestinal microflora. The 2 major types of inflammatory bowel disease are ulcerative colitis (UC), which is limited to the colon, and Crohn disease (CD), which can involve any segment of the gastrointestinal tract from the mouth to the anus, involves "skip lesions," and is transmural. There is a genetic predisposition for IBD, and patients with this condition are more prone to the development of malignancy.
Essential update: Mercaptopurine a safe alternative in azathioprine-intolerant patients
Mercaptopurine is a safe treatment alternative for the majority of patients with IBD who are azathioprine intolerant, according to an observational study and meta-analysis by Kennedy et al. The observational study was conducted retrospectively on 149 patients with IBD (including 82 patients with Crohn disease and 67 patients with ulcerative colitis) who had been switched from azathioprine to mercaptopurine after demonstrating azathioprine intolerance. The investigators found that 58% of these patients tolerated mercaptopurine. In the meta-analysis, which included 11 studies and a total of 455 azathioprine-intolerant patients who had been switched to mercaptopurine, 68% of patients tolerated the replacement drug. The investigators also found that mercaptopurine tolerance was more prevalent among patients who had experienced gastrointestinal toxicity (62%) or hepatotoxicity (81%) than among those who had suffered a flu-like illness (36%).
Signs and symptoms
Generally, the manifestations of IBD depend on the area of the intestinal tract involved. The symptoms, however, are not specific for this disease, as follows:
Cramping Irregular bowel habits, passage of mucus without blood or pus Weight loss Fever, sweats Malaise, fatigue Arthralgias Growth retardation and delayed or failed sexual maturation in children Extraintestinal manifestations (10-20%): Arthritis, uveitis, or liver disease Grossly bloody stools, occasionally with tenesmus: Typical of UC, less common in CD Perianal disease (eg, fistulas, abscesses): Fifty percent of patients with CD
tenesmus Abdominal cramping and pain: Commonly present in the right lower quadrant in CD. no laboratory test is specific enough to adequately and definitively establish the diagnosis. may proceed to bowel obstruction Bowel movement abnormalities: Possible presence of pain or rectal bleeding. which are directly related to the severity of the attack:
Fever Tachycardia Dehydration Toxicity Pallor. iron studies. ova and parasite studies. antiSaccharomyces cerevisiae antibodies Stool studies: Stool culture. lethargy. and tachycardia. distention Mass in the right lower abdominal quadrant: May be present in CD Perianal complications: May be observed in up to 90% of cases of CD
Testing Although several laboratory studies may aid in the management of IBD and provide supporting information. anemia Toxic megacolon: Medical emergency. as well as have increasing abdominal pain. bacterial pathogens culture. including the following:
Complete blood count Nutritional evaluation: Vitamin B12 evaluation. red blood cell folate. tenderness. have high fever. occurs at night. obstipation may occur.The World Gastroenterology Organization indicates the following symptoms may be associated with inflammatory damage in the digestive tract :
Diarrhea: Possible presence of mucus/blood in stool.
Examination in patients with IBD may include the following findings. nutritional markers Erythrocyte sedimentation rate and C-reactive protein levels Fecal calprotectin level Serologic studies: Perinuclear antineutrophil cytoplasmic antibodies. severe urgency. chills. incontinence Constipation: May be the primary symptom in UC and limited to rectum. and evaluation for Clostridium difficile infection
Imaging studies The following imaging studies may be used to assess patients with IBD:
. occur periumbilically or in the left lower quadrant in moderate to severe UC Nausea and vomiting: More often in CD than in UC
See Clinical Presentation for more detail. patients appear septic.
methotrexate. omeprazole. enema. topical. certolizumab pegol) Monoclonal antibodies (eg. natalizumab) H2-receptor antagonists (eg. such as the following:
Step I – Aminosalicylates (oral. diphenoxylate and atropine. nizatidine) Proton pump inhibitors (eg. an agent works for CD but not for UC. rectal): For acute disease flares only Step III – Immunomodulators: Effective for steroid-sparing action in refractory disease. relief of symptoms) and mucosal healing following a stepwise approach to medication. prednisone. balsalazide. esomeprazole magnesium. ranitidine. rifaximin) Corticosteroid agents (eg. fistulas. rabeprazole sodium. dexamethasone) Immunosuppressant agents (eg. hydrocortisone. azathioprine.
The medical approach for patients with IBD is symptomatic care (ie. adalimumab. most commonly used for perianal disease. cholestyramine) Anticholinergic antispasmodic agents (eg. lansoprazole. methylprednisolone. suppository formulations): For treating flares and maintaining remission. budesonide. or vice versa)
Pharmacotherapy The following medications may be used in patients with IBD:
5-Aminosalicylic acid derivatives (eg. cyclosporine) Tumor necrosis factor inhibitors (eg. pantoprazole) Antidiarrheal agents (eg. metronidazole. in CD. intra-abdominal inflammatory masses Step II – Corticosteroids (intravenous. sulfasalazine. ciprofloxacin. increased risk for antibiotic-associated pseudomembranous colitis). prednisolone. primary treatment for fistulas and maintenance of remission in patients intolerant of or not responsive to aminosalicylates Step IV – Clinical trial agents: Tend to be disease-specific (ie. olsalazine) Antibiotics (eg. more effective in UC than in CD Step IA – Antibiotics: Used sparingly in UC (limited efficacy. with escalation of the medical regimen until a response is achieved (“step-up” or “stepwise” approach). mesalamine. dicyclomine. hyoscyamine)
. with biopsies of tissue/lesions Flexible sigmoidoscopy Upper gastrointestinal endoscopy Capsule enteroscopy/double balloon enteroscopy
See Workup for more detail. oral. 6-mercaptopurine. cimetidine. famotidine. loperamide.
Upright chest and abdominal radiography Barium double-contrast enema radiographic studies Abdominal ultrasonography Abdominal/pelvic computed tomography scanning/magnetic resonance imaging Computed tomography enterography Colonoscopy. infliximab.
generally. total proctocolectomy with ileoanal anastomosis Fulminant colitis: Surgical procedure of choice is subtotal colectomy with end ileostomy and creation of a Hartmann pouch CD: Surgery (not curative) most commonly performed in cases of disease complications of the disease. Consider early consultation with a surgeon in the setting of severe colitis or bowel obstruction and in cases of suspected toxic megacolon.Surgery UC is surgically curable. The mucosa is grossly denuded. potential stricturoplasty vs resective surgery) to preserve bowel length in case future additional surgery needed Selected patients with distal ileal or proximal colonic disease: Option for ileorectal or ileocolonic anastomosis Severe perianal fistulas: Option for diverting ileostomy. with active bleeding noted. generally consists of conservative resection (eg. with recurrence being the norm. resection for symptomatic enteroenteric fistulas
Severe colitis noted during colonoscopy in a patient with inflammatory bowel disease.
. The patient had her colon resected very shortly after this view was obtained. Surgical intervention in IBD includes the following:
UC: Proctocolectomy with ileostomy. However. surgical resection is not curative in CD.