Inflammatory%20bowel%20disease Management

Acute Complications of IBD

Strictures

• Cross-sectional imaging preferably MRI or IUS, can be used to detect small bowel strictures
• CD: Strictures are transmural and contain variable proportions of inflammation and fibrotic tissue
• Colonic stricture should be evaluated to exclude malignancy and surgery should be considered

Fistulae and Abscesses

• Intraabdominal fistulae and abscesses can be detected with cross-sectional imaging
  • MRI is preferred because it can detect deep-seated fistulae and abscesses or pelvic fistulae
• Examination under anesthesia (EUA) with drainage is recommended if perianal abscess is suspected
• Perianal CD: Endoscopic evaluation of the rectum is necessary to determine the most appropriate management strategy

Pouch Complications

• IPAA complications may be inflammatory and non-inflammatory and include abscesses, fistulae, sinus tracts and strictures
• Cross-sectional imaging and endoscopy are complementary methods used to assess suspected structural complications after IPAA
• Pouchography can be done to assess functional disorders and other complications

Emergency Complications

• Plain abdominal radiograph is an acceptable first diagnostic modality in acute severe colitis to detect toxic megacolon
  • Toxic megacolon is defined on plane abdominal X-ray as a transverse colonic dilatation >5.5 cm
• CT is recommended when a perforation is suspected in patients with acute abdominal pain and established diagnosis of IBD

Postoperative Complications

• CT is recommended to investigate acute postoperative complications such as anastomotic leaks and abscesses
  • US may be used as an alternative but must be followed by immediate CT when results are negative or equivocal 

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

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

Vaccinations 

Ulcerative Colitis

• May consider administration of the following vaccines prior to therapy with immunosuppressants: Influenza, pneumococcal, recombinant herpes zoster, tetanus, hepatitis B and meningococcal
• Once immunosuppressants are initiated, avoid vaccinations with live vaccines

Crohn's Disease 

• May consider administration of the following vaccines prior to therapy with immunosuppressants: Influenza, pneumococcal, recombinant herpes zoster and hepatitis B
• Once immunosuppressants are initiated, avoid vaccinations with live vaccines

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

• Patients with UC and CD have increased risk of 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 CRC have a 5-fold risk of developing CRC
• Patients with concomitant PSC have an increased risk of 31% for developing CRC
• Surveillance colonoscopy should start 8 years after diagnosis in patients with UC or CD regardless of extent of disease at the time of diagnosis
• Colonoscopic surveillance is best performed when colonic disease 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 3-6 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 1-6 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
• Patients with CD and visible dysplastic lesion should undergo complete endoscopic excision 
• Patients with CD with visible dysplasia not amenable to endoscopic excision or is multifocal, or if CRC is diagnosed, are recommended for total colectomy with IRA or total proctocolectomy
• Several major societies have different recommendations on optimal surveillance strategies for colon cancer in patients with IBD