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) may be used in patients with symptomatic small bowel disease
  • It is complementary to phenotype assessment 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
• Biomarker-based monitoring strategy, which includes monitoring of symptoms and biomarkers of inflammation, is recommended in UC patients with symptomatic remission and patients with symptomatically active UC to determine response to therapy
  • Has the advantage of giving a more accurate prognosis compared to symptoms alone resulting in optimal treatment determination and decreased risk of disease complications
  • Biomarker monitoring may be performed every 6-12 months in patients with UC in symptomatic remission
• Fecal biomarkers (eg fecal calprotectin or fecal lactoferrin) may be used for monitoring especially in patients where biomarkers have been previously correlated with endoscopic disease activity
  • Studies have shown good correlation between fecal calprotectin and endoscopic disease activity in both CD and UC
  • Fecal calprotectin >150 μg/g, elevated fecal lactoferrin, or elevated CRP may be used to rule in active inflammation in patients with UC with moderate to severe symptoms suggestive of flare
    • Treatment adjustment should be done and routine endoscopic assessment of disease activity can be avoided
  • Fecal calprotectin value of <150 μg/g, normal fecal lactoferrin or normal CRP rules out active inflammation and does not necessitate routine performance of endoscopic assessment of disease activity
  • Fecal calprotectin cutoff of <50 μg/g may be used to detect endoscopic improvement in patients who achieved symptomatic remission after treatment adjustment in the last 1-3 months
• Endoscopic assessment of disease activity is recommended in patients with:
  • UC in symptomatic remission with elevated stool or serum markers of inflammation (eg fecal calprotectin >150 μg/g, elevated fecal lactoferrin, elevated CRP)
    • Repeat biomarker measurement may be done within 3-6 months as an alternative to endoscopic assessment but endoscopic assessment is recommended in the presence of elevated biomarkers on repeat evaluation
  • UC with mild symptoms with normal stool or serum markers of inflammation (fecal calprotectin <150 μg/g, normal fecal lactoferrin, normal CRP)
• 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 8-10 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