inflammatory%20bowel%20disease
INFLAMMATORY BOWEL DISEASE
Treatment Guideline Chart
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

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
  • Surveillance colonoscopy is recommended:
    • At the time of diagnosis and then yearly in patients with PSC 
    • More frequently in patients with ongoing endoscopic or histologic inflammation, anatomic abnormality (foreshortened colon, stricture or multiple inflammatory pseudopolyps) or 1st-degree relative with CRC 
    • Within 1-2 years after the initial screening endoscopy in patients with extensive or left-sided colitis 
    • Every 1-3 years after 2 negative examinations
  • Same guideline for UC also applies to CD
American College of Gastroenterology (ACG) 2019
  • Patients with UC and PSC should undergo a screening colonoscopy at the time of diagnosis of UC and surveillance yearly thereafter 
  • Surveillance colonoscopies should be performed at 1- to 3-year intervals based on the findings of previous colonoscopies and combined risk factors for CRC (younger age at diagnosis, duration of disease, greater extent of inflammation, 1st-degree relative with CRC)
  • Optimal surveillance interval has not been clearly defined
American Society for Gastrointestinal Endoscopy (ASGE) 2015
  • Surveillance colonoscopy is recommended:
    • Yearly in patients with PSC, active inflammation or history of dysplasia, anatomic abnormality (stricture, multiple pseudopolyps), or family history of CRC in a 1st-degree relative 
    • Every 1-3 years in patients with average risk 
    • Beyond every 3 years in patients with ≥2 surveillance colonoscopies which are endoscopically and histologically normal
  • Same guideline for UC also applies to CD
British Society of Gastroenterology (BSG) 2010
  • Surveillance colonoscopy is recommended:
    • Yearly in patients with high-risk features (extensive colitis with moderate to severe active endoscopic or histologic inflammation, stricture or dysplasia within the past 5 years without surgery, PSC, or family history of CRC in a 1st-degree relative diagnosed at <50 years old) 
    • Every 3 years in patients with intermediate-risk features (extensive colitis with mild active endoscopic or histologic inflammation, post-inflammatory polyps, or family history of CRC in a 1st-degree relative diagnosed at ≥50 years old) 
    • Every 5 years in patients with low-risk features (extensive colitis without active endoscopic or histologic inflammation or left-sided colitis or Crohn's colitis with <50% involvement)
  • 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) 2017
  • 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, or family history of CRC in a 1st-degree relative diagnosed at <50 years old) 
    • Every 2-3 years in patients with intermediate-risk features (extensive colitis with mild to moderate active inflammation, post-inflammatory polyps, or family history of CRC in a 1st-degree relative diagnosed at ≥50 years old) 
    • Every 5 years in patients with low-risk features (without intermediate or high-risk features) 
  • Same guideline for UC also applies to CD
National Comprehensive Cancer Network (NCCN) 2022
  • Surveillance colonoscopy is recommended 8 years after onset of symptoms  
    • Initiated at the time of PSC diagnosis and then yearly in patients with PSC independent from time of onset of symptoms
    • Annually in patients with high-risk features (PSC, active inflammation, family history of CRC diagnosed at <50 years old)  
    • Every 2-3 years in patients with low-risk features (no endoscopic/histologic active inflammation)
  • High-definition white light endoscopy or dye-spray or high-definition virtual chromoendoscopy with targeted biopsies including samples from strictures or masses may be performed
  • Standard-definition white light endoscopy may be performed but must be in conjunction with chromoendoscopy
  • Same guideline for UC also applies to CD 
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