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.

Inflammatory%20bowel%20disease Management

Colorectal Cancer (CRC) Surveillance

  • Patients with UC and CD have increased risk of colorectal cancer (CRC), 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
  • Patients with concomitant primary sclerosing cholangitis (PSC) have an increased risk of 31% for developing CRC
  • Colonoscopic surveillance is best performed when UC is in remission
  • Pancolonic dye spraying with targeted biopsy of abnormal areas is recommended
    • Chromoendoscopy with targeted biopsies has been shown to increase detection rate of dysplasia and is superior to white-light endoscopy
  • White-light endoscopy may be used but random biopsies (quadrantic biopsies every 10 cm) and targeted biopsies of any visible lesion should be performed
  • A repeat chromoendoscopic colonoscopy with random biopsies is recommended within 3 months in patients with confirmed low-grade dysplasia in mucosa without an associated endoscopically visible lesion
  • If a dysplastic polyp is detected within an area of inflammation and can be removed, colectomy is not routinely recommended
    • Patients who underwent endoscopic resection for polypoid lesions have approximately 10-fold risk of developing further dysplasia; monitoring with chromoendoscopy is recommended after 3-6 months, then yearly thereafter
  • Patients with UC and with endoscopically unresectable non-polypoid dysplasia are recommended for immediate colectomy, regardless of rate of dysplasia detected by biopsy
  • 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 8 years of symptom onset and yearly from diagnosis in patients with PSC
  • Surveillance colonoscopy every 5 years for patients at low risk, every 3 years for intermediate risk, every year for high risk
  • Colonoscopy targeted biopsies are recommended over random biopsies; 2-4 random biopsies every 10 cm is done if taking random biopsy
  • 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
European Crohn's and Colitis Organisation (ECCO)
  • Screening colonoscopy is recommended after 8 years of onset of symptoms in all patients to reassess disease extent and exclude dysplasia
  • Annual surveillance colonoscopy is recommended in patients with concurrent PSC, irrespective of disease activity, extent and duration
  • Surveillance colonoscopy is recommended yearly in patients with high-risk features (stricture or dysplasia detected within the past 5 years, PSC, extensive colitis with severe active inflammation)
  • Surveillance colonoscopy is recommended every 2-3 years in patients with intermediate-risk factors (extensive colitis with mild to moderate active inflammation, post-inflammatory polyps, family history of CRC in a 1st-degree relative diagnosed at 50 years and above)
  • Surveillance colonoscopy is recommended every 5 years in patients with low-risk features
  •  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
  • Response to treatment should be evaluated with a combination of clinical parameters, endoscopy, and laboratory markers eg CRP and fecal calprotectin
  • In patients with clinical response to medical therapy, mucosal healing should be determined by endoscopy or through fecal calprotectin 3-6 months after initiation of treatment
  • In patients with persistent disease activity, new unexplained symptoms, or severe relapse, and before switching to another therapy, endoscopic reassessment is recommended
  • Monitor frequency of relapse (pattern of disease) which is defined during the first 3 years as to:
    • Continuous: Characterized by persistent symptoms without remission
    • Frequent: Characterized by ≥2 relapses/year
    • Infrequent: Characterized by ≤1 relapse/year
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; for adults, monitor the weight
  • Vitamin B12 status should be monitored especially if there is ileal resection
  • Clinical and biochemical response to therapy should be evaluated within 12 weeks after treatment initiation
  • Endoscopic or transmural response (by IUS, MR enterography or SBCE) to therapy should be determined within 6 months after treatment initiation
  • In patients with persistent disease activity, new unexplained symptoms or relapse, and before switching to another therapy, endoscopic or cross-sectional reassessment may be considered
  • Extramural complications eg fistulae and abscesses, should be monitored by cross-sectional imaging (IUS or MRI) together with clinical and laboratory parameters
  • Evaluation of perianal CD and fistula closure should be done with clinical evaluation in combination with endoscopic examination of the rectum and MRI

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

Follow Up

Monitoring of Clinically Asymptomatic Patients

  • Monitoring is recommended every 3-6 months in IBD patients with clinical and biochemical remission to detect disease flare
  • Fecal calprotectin can detect relapses before clinical symptoms
  • Endoscopic evaluation or cross-sectional imaging is recommended in asymptomatic patients with abnormal biochemical parameters after infection has been ruled-out
  • Disease activity should be assessed using a combination of clinical and biochemical markers, and endoscopic and/or cross-sectional imaging, before de-escalation or withdrawal of maintenance therapy for IBD
    • Evaluation of endoscopic activity in patients with quiescent CD is recommended before discontinuation of therapy
    • A meta-analysis has shown that discontinuation of immunomodulatory monotherapy after remission was associated with approximately 75% of patients having a relapse within 5 years after discontinuation

Monitoring of Clinically Symptomatic Patients

  • Patients with suspected new flare of IBD should be investigated for infection including exclusion of C difficile infection
    • C difficile infection is associated with poorer outcomes in UC, including increased colectomy rates and increased postoperative complications
    • Testing for CMV is reserved for steroid-resistant disease
      • A meta-analysis has shown that CMV infection in IBD is associated with longer disease duration, reduced efficacy of corticosteroids, and increased colectomy rate
    • Stool examination for ova cysts and parasites and Strongyloides serology is recommended before therapy is escalated if travel history is suggestive
  • Ileocolonoscopy is the gold standard for investigating large bowel disease activity of symptomatic CD or UC
    • Provides direct mucosal visualization of the colon and terminal ileum and allows for histological assessment and therapeutic intervention
  • Cross-sectional imaging (IUS, MR enterography, and/or SBCE) is complementary to assess phenotype and may be used as an alternative to ileocolonoscopy in assessing large bowel disease activity of symptomatic CD or UC
  • Flexible sigmoidoscopy should be considered if symptoms suggest an acute severe flare of UC
  • Cross-sectional imaging (IUS, MR enterography, and/or SBCE) may be used in patients with symptomatic small bowel disease
  • Fecal calprotectin can be used to evaluated disease activity from the colon to the small bowel
    • Studies have shown good correlation between fecal calprotectin and endoscopic disease activity in both CD and UC
  • Malabsorption parameters should be evaluated at regular intervals in all patients with IBD
    • Weight should be taken and recorded every clinic visit
    • Patients should be screened for anemia
      • Patients with symptoms suggestive of active disease should be screened for anemia every 3 months
    • Vitamin B12 and folic acid measurement should be done every 3-6 months in patients with small bowel disease or previous resection
    • Measurement of vitamin D is recommended in symptomatic patients and re-evaluation after treatment to check if levels are back to normal

Monitoring Post-surgery

  • Ileocolonoscopy is the reference standard for the diagnosis of postoperative recurrence after ileocolonic surgery and is recommended within the first 6-12 months after surgery
    • Postoperative recurrence rate after resection of ileocecal disease has been shown to be approximately 65-90% within 12 months, in the absence of treatment
  • Fecal calprotectin, IUS, MR enterography, and SBCE may be considered as non-invasive alternatives to evaluate for postoperative recurrence especially after small bowel resection
  • Pouch-related symptoms can be assessed with endoscopy with biopsies
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