Inflammatory%20bowel%20disease Management
Monitoring
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
Prevention
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
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
Colorectal Cancer (CRC) Surveillance
- 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
Society |
Ulcerative Colitis |
Crohn’s Disease |
American Gastroenterological Association (AGA) 2010 |
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American College of Gastroenterology (ACG) 2019 |
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American Society for Gastrointestinal Endoscopy (ASGE) 2015 |
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British Society of Gastroenterology (BSG) 2010 |
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European Crohn's and Colitis Organisation (ECCO) 2017 |
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National Comprehensive Cancer Network (NCCN) 2022 |
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