inflammatory%20bowel%20disease
INFLAMMATORY BOWEL DISEASE
Inflammatory bowel disease consists of ulcerative colitis and Crohn's disease.
Ulcerative colitis is a diffuse mucosal inflammation limited to the colon while Crohn's disease is a patchy, transmural inflammation that occurs in any part of the gastrointestinal tract.
The ileum and colon are the most frequently affected sites.

Colorectal Cancer Surveillance

  • Patients with UC and CD have increased risk of colorectal cancer, but there is much more known data about the risk in UC than in CD
    • The risk for IBD is related to both the duration and extent of the disease, and to the degree of histologic inflammation over time
  • Patients with UC who have family history of colorectal cancer have a 5-fold risk of developing colorectal cancer
  • Pancolonic dye spraying with targeted biopsy of abnormal areas is recommended
  • If a dysplastic polyp is detected within an area of inflammation and can be removed, colectomy is not routinely recommended
  • Several major societies have different recommendations on optimal surveillance strategies for colon cancer in patients with IBD

Society

Ulcerative Colitis

Crohn’s Disease

American Gastroenterological Association
  • Surveillance colonoscopy after 8 years in pancolitis
  • Surveillance colonoscopy after 15 years in left-sided colitis
  • Repeat colonoscopy every 1-2 years
  • Same guideline for UC also applies to CD
American College of Gastroenterology
  • Yearly surveillance colonoscopy after 8-10 years in patients who are surgical candidates
  • Multiple biopsies at regular intervals
  • Repeat surveillance colonoscopy at a shorter interval for patients with indefinite dysplasia
  • No guideline for surveillance due to insufficient evidence
American Society for Gastrointestinal Endoscopy
  • Surveillance colonoscopy after 8 years in pancolitis
  • 4 biopsies every 10 cm from cecum to rectum. Any suspicious lesions or masses should be biopsied
  • Repeat colonoscopy every 1-3 years
  • Surveillance colonoscopy after 15 years for left-sided colitis
  • Surveillance is not warranted in ulcerative proctitis
  • Patients with longstanding Crohn colitis should be offered surveillance colonoscopy and biopsy for dysplasia but data to guide the surveillance/screening intervals as well as procedure for biopsies are limited
British Society of Gastroenterology
  • Surveillance colonoscopy should be performed during remission
  • Surveillance colonoscopy in all patients after 10 years of symptom onset
  • Surveillance colonoscopy every 5 years for patients at low risk, every 3 years for intermediate risk, every year for high risk
  • 2-4 random biopsies every 10 cm from entire colon if chemoendoscopy is not used. Any suspicious area should be biopsied
  • Surveillance flexible sigmoidoscopy of pouch/rectal mucosa every year for postcolectomy patients at high risk; if without risk factors every 5 years
  • Same guideline for UC also applies to CD

Monitoring

Patient Monitoring for Ulcerative Colitis
  • Assessment of body mass index (BMI) and nutritional status should occur at diagnosis
  • For children, monitor height and weight; for adults, monitor the weight
Hospitalized Patient Monitoring for Severe Ulcerative Colitis
  • Physical exam daily to evaluate abdominal tenderness and rebound tenderness
  • Stool chart to record number and character of bowel movements
  • Daily abdominal radiography if colonic dilatation is detected at presentation
  • Immediate surgical referral if there is evidence of toxic megacolon
  • Objective re-evaluation on the 3rd day of intensive treatment
    • Consideration of colectomy or treatment with IV Ciclosporin or Infliximab
Patient Monitoring for Crohn's Disease
  • Assessment of BMI and nutritional status should occur at diagnosis
  • For children, monitor height and weight in children; for adults, monitor the weight
  • Vit B12 status should be monitored especially if there is ileal resection

Prevention

Vaccination for Ulcerative Colitis
  • May consider administration of the following vaccines prior to therapy of immunosuppressants: Influenza, pneumococcal, tetanus, hepatitis B, and meningococcal
  • Once immunosuppressants are initiated, avoid vaccinations with live vaccines
Vaccinations for Crohn's Disease
  • May consider administration of the following vaccines prior to therapy of immunosuppressants: Influenza, pneumococcal and hepatitis B
  • Once immunosuppressants are initiated, avoid vaccinations with live vaccines
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