Inflammatory bowel disease (IBD) is an idiopathic and
chronic intestinal inflammation. Ulcerative colitis (UC) and Crohn's disease
(CD) are the two major types of IBD.
EPIDEMIOLOGY
The incidence of IBD varies
within different geographic areas. Northern countries, such as the United
States, United Kingdom, Norway, and Sweden, have the highest rates. The
incidence rates of UC and CD in the United States are about 11 per 100,000 and
7 per 100,000, respectively (Table 1). Countries in
southern Europe, South Africa, and Australia have lower incidence rates: 2 to
6.3 per 100,000 for UC, and 0.9 to 3.1 per 100,000 for CD. In Asia and South
America, IBD is rare; incidence rates of UC and CD are 0.5 and 0.08 per
100,000, respectively. The highest mortality in IBD patients is during the
first years of disease and in long-duration disease due to the risk of colon
cancer. In a Swedish population study, the standardized mortality ratios for CD
and UC were 1.51 and 1.37, respectively.
TABLE 1 Epidemiology of IBD
|
Ulcerative Colitis
|
Crohn's Disease
|
Incidence (U.S.)
|
11/100,000
|
7/100,000
|
Age of onset
|
15–30 & 60–80
|
15–30 & 60–80
|
Ethnicity
|
Jewish > Non-Jewish
Caucasian > African American > Hispanic > Asian
|
|
Male:female ratio
|
1:1
|
1.1–1.8:1
|
Smoking
|
May prevent disease
|
May cause disease
|
Oral contraceptives
|
No increased risk
|
Relative risk 1.9
|
Appendectomy
|
Protective
|
Not protective
|
Monozygotic twins
|
20% concordance
|
67% concordance
|
Dizygotic twins
|
0% concordance
|
8% concordance
|
The peak age of onset of UC and CD is between 15 and 30 years. A second
peak occurs between the ages of 60 and 80. The male to female ratio for UC is
1:1 and for CD is 1.1 to 1.8:1. A two- to fourfold increased frequency of UC
and CD in Jewish populations has been described in the United States, Europe,
and South Africa. Furthermore, disease frequency differs within the Jewish
populations. The prevalence of IBD in Ashkenazi Jews is about twice that of
Israeli-born, Sephardic, or Oriental Jews. The prevalence decreases
progressively in non-Jewish Caucasian, African-American, Hispanic, and Asian
populations. Urban areas have a higher prevalence of IBD than rural areas, and
high socioeconomic classes have a higher prevalence than lower socioeconomic
classes.
The effects of cigarette smoking are different in UC
and CD. The risk of UC in smokers is 40% that of nonsmokers. Additionally,
former smokers have a 1.7-fold increased risk for UC than people who have never
smoked. In contrast, smoking is associated with a twofold increased risk of CD.
Oral contraceptives are also linked to CD; the relative risk of CD for oral
contraceptive users is about 1.9. Appendectomy appears to be protective against
UC, but no studies have applied this as a preventive intervention.
IBD runs in families. If a patient has IBD, the
lifetime risk that a first-degree relative will be affected is ~10%. If two
parents have IBD, each child has a 36% chance of being affected. In twin
studies, 67% of monozygotic twins are concordant for CD and 20% are concordant for UC, whereas 8% of dizygotic twins are concordant for CD and
none are concordant for UC. Anatomic site and clinical type of CD is also
concordant within families.
Additional evidence for genetic predisposition to IBD
comes from its association with certain genetic syndromes. UC and CD are both
associated with Turner's syndrome, and Hermansky-Pudlak syndrome is associated
with a granulomatous colitis. Glycogen storage disease type 1b can present with
Crohn's-like lesions of the large and small bowel. Other immunodeficiency
disorders, such as hypogammaglobulinemia, selective IgA deficiency, and
hereditary angioedema, also exhibit an increased association with IBD.
ETIOLOGY AND PATHOGENESIS
Although IBD has been described as a clinical entity
for over 100 years, its etiology and pathogenesis have not been defined. A
consensus hypothesis is that in genetically predisposed individuals, both
exogenous factors (e.g., infectious agents, normal lumenal flora) and host
factors (e.g., intestinal epithelial cell barrier function, vascular supply,
neuronal activity) cause a chronic state of dysregulated mucosal immune
function that is further modified by specific environmental factors (e.g.,
smoking). Although it is possible that the chronic activation of the mucosal
immune system may represent an appropriate response to an unidentified infectious
agent, a search for such an agent has thus far been unrewarding. As such, IBD
is currently considered an inappropriate response to either the endogenous
microbial flora within the intestine, with or without some component of
autoimmunity. Importantly, the normal intestine contains a large number of immune
cells in a chronic state of so-called physiologic inflammation, in which the
gut is poised for, but actively restrained from, full immunologic responses.
During the course of infections in the normal host, full activation of the
gut-associated lymphoid tissue occurs but is rapidly superceded by dampening
the immune response and tissue repair. In IBD this process is not regulated
normally.
GENETIC CONSIDERATIONS
IBD is a polygenic disorder that gives rise to
multiple clinical subgroups within UC and CD. Genome-wide searches have shown
potential disease-associated loci on chromosomes 16, 12, 7, 5, 3, and 1,
although the specific gene associations are mostly undefined. The
disease-related gene on chromosome 16 is NOD-2, an intracellular
molecule that senses bacterial peptidoglycan and regulates NF-κB signaling. Homozygosity for mutant alleles confers up to a 40-fold
increased risk for fibrostenosing CD, especially in the ileum. HLA alleles may
also play a role. UC patients disproportionately express DR2-related alleles,
whereas in CD an increased use of the DR5 DQ1 haplotype or the DRB*0301 allele
has been described. In UC patients with pancolitis undergoing total proctocolectomy,
14.3% versus 3.2% of non-IBD controls express the HLA DRB1*0103 allele. This allele
is associated with extensive disease and extraintestinal manifestations such as
mouth ulcers, arthritis, and uveitis. Other associations with immunoregulatory
genes include the intercellular adhesion molecule R241 allele in UC and CD and
the interleukin (IL) 1 receptor antagonist allele 2 in UC patients that is
associated with total colonic inflammation. Patients with IBD and their
first-degree relatives may also exhibit diminished intestinal epithelial cell
barrier function.
DEFECTIVE IMMUNE REGULATION IN IBD
The normal state of the mucosal immune system is one
of inhibited immune responses to lumenal contents due to oral tolerance that
occurs in the normal individual. When soluble antigens are administered orally
rather than subcutaneously or intramuscularly, antigen-specific
non-responsiveness is induced. Multiple mechanisms are involved in the induction
of oral tolerance and include deletion or anergy of antigen-reactive T cells or
activation of CD4+ T cells that suppress gut inflammation through secretion of
inhibitory cytokines, such as IL-10 and transforming growth factor β (TGF-β). Oral tolerance may be
responsible for the lack of immune responsiveness to dietary antigens and the
commensal flora in the intestinal lumen. In IBD this suppression of
inflammation is altered, leading to uncontrolled inflammation. The mechanisms
that maintain this regulated immune suppression are unknown.
Gene knockout (-/-) or transgenic (Tg) mouse models of
colitis have revealed that deleting specific cytokines (e.g., IL-2, IL-10, TGF-β) or their receptors, deleting molecules associated with T cell antigen
recognition (e.g., T cell antigen receptors, MHC class II), or interfering with
intestinal epithelial cell barrier function (e.g., blocking N-cadherin,
deleting multidrug resistance gene 1a or trefoil factor) leads to colitis.
Thus, a variety of specific alterations can lead to autoimmunity directed at
the colon in mice.
In both UC and CD, activated CD4+ T cells in the
lamina propria and peripheral blood secrete inflammatory cytokines. Some
activate other inflammatory cells (macrophages and B cells) and others act
indirectly to recruit other lymphocytes, inflammatory leukocytes, and
mononuclear cells from the peripheral vasculature into the gut through
interactions between homing receptors on leukocytes (e.g., α4β7 integrin) and addressins on
vascular endothelium (e.g., MadCAM1). CD4+ T cells are of two major types, both
of which may be associated with colitis in animal models and humans: TH1
cells [interferon (IFN) γ,
tumor necrosis factor (TNF)] and TH2 cells (IL-4, IL-5, IL-13). TH1
cells appear to induce transmural granulomatous inflammation that resembles CD,
and TH2 cells appear to induce superficial mucosal inflammation
resembling UC. The TH1 cytokine pathway is initiated by IL-12, a key
cytokine in the pathogenesis of experimental models of mucosal inflammation.
Thus, use of antibodies to block proinflammatory cytokines (e.g., anti-TNF-α, anti-IL-12) or molecules associated with leukocyte recruitment (e.g.,
anti-α4β7) or use of cytokines that inhibit inflammation (e.g., IL-10) or promote
intestinal barrier function (e.g., IL-11) may be beneficial to humans with
colitis.
THE INFLAMMATORY CASCADE IN IBD
Once initiated in IBD, the immune inflammatory
response is perpetuated as a consequence of T cell activation. A sequential cascade
of inflammatory mediators acts to extend the response; each step is a potential
target for therapy. Inflammatory cytokines, such as IL-1, IL-6, and TNF, have
diverse effects on tissue. They promote fibrogenesis, collagen production,
activation of tissue metalloproteinases, and the production of other inflammatory
mediators; they also activate the coagulation cascade in local blood vessels
(e.g., increased production of von Willebrand's factor). These cytokines are
normally produced in response to infection, but are usually turned off or
inhibited at the appropriate time to limit tissue damage. In IBD their activity
is not regulated, resulting in an imbalance between the proinflammatory and
anti-inflammatory mediators. Therapies such as the 5-ASA (5-aminosalicylic
acid) compounds are potent inhibitors of these inflammatory mediators through inhibition
of transcription factors such as NF-κB
that regulate their expression.
EXOGENOUS FACTORS
IBD may have an as yet undefined infectious etiology.
Three specific agents have received the greatest attention, Mycobacterium paratuberculosis, Paramyxovirus, and Helicobacter species. The immune response
to a specific organism could be expressed differently, depending upon the individual's
genetic background. M. paratuberculosis does not
have a confirmed disease association, and antimycobacterial agents are not
effective in treating CD. A role for the measles virus or paramyxoviruses in
the development of CD has been suggested based on an increase in the incidence
of CD in England that paralleled use of the measles vaccine. However, studies
in the United States have not substantiated this finding. In an animal model of
IBD, H.
hepaticus has been implicated as a trigger for
the inflammatory response; evidence in humans is lacking.
Multiple pathogens (e.g., Salmonella, Shigella sp., Campylobacter sp.) may initiate IBD by triggering an inflammatory response that the mucosal
immune system may fail to control. However, in an IBD patient the normal flora
is likely perceived as if it were a pathogen. Anaerobic organisms, particularly
Bacteroides species, may be responsible for the induction of
inflammation. Such a notion is supported by the response in patients with CD to
agents that alter the intestinal flora, such as metronidazole, ciprofloxacin,
and elemental diets. CD also responds to fecal diversion, demonstrating the
ability of lumenal contents to exacerbate disease. On the other hand, other
bacteria, so-called probiotics (Lactobacillus sp.), inhibit inflammation in animal models and humans.
Psychosocial factors can contribute to worsening of
symptoms. Major life events such as illness or death in the family, divorce or
separation, interpersonal conflict, or other major loss are associated with an
increase in IBD symptoms such as pain, bowel dysfunction, and bleeding. Acute
daily stress can worsen bowel symptoms even after controlling for major life
events. When the sickness-impact profile, a measurement of overall
psychological and physical functioning, is used, IBD patients have functional impairment
greater than that of a normal population but less than that of patients with
chronic back pain or amyotrophic lateral sclerosis. IBD patients have been hypothesized
to have a characteristic personality that renders them susceptible to emotional
stresses. However, emotional dysfunction could also be the result of chronic
illness rather than a cause.
PATHOLOGY
ULCERATIVE COLITIS: MACROSCOPIC
FEATURES
UC is a mucosal disease that usually involves the
rectum and extends proximally to involve all or part of the colon. About 40 to
50% of patients have disease limited to the rectum and rectosigmoid, 30 to 40%
have disease extending beyond the sigmoid but not involving the whole colon,
and 20% have a total colitis. Proximal spread occurs in continuity without areas
of uninvolved mucosa. When the whole colon is involved, the inflammation
extends 1 to 2 cm into the terminal ileum in 10 to 20% of patients. This is
called backwash
ileitis and is of little clinical
significance. Although variations in macroscopic activity may suggest skip
areas, biopsies from normal-appearing mucosa are usually abnormal. Thus, it is
important to obtain multiple biopsies from apparently uninvolved mucosa,
whether proximal or distal, during endoscopy.
With mild inflammation, the mucosa is erythematous and
has a fine granular surface that looks like sandpaper. In more severe disease,
the mucosa is hemorrhagic, edematous, and ulcerated (Fig. 1).
In long-standing disease, inflammatory polyps (pseudopolyps) may be present as
a result of epithelial regeneration. The mucosa may appear normal in remission,
but in patients with many years of disease it appears atrophic and featureless
and the entire colon becomes narrowed and shortened. Patients with fulminant
disease can develop a toxic colitis or megacolon where the bowel wall thins and
the mucosa is severely ulcerated; this may lead to perforation.
FIGURE 1 Pan-ulcerative
colitis. Mucosa has a lumpy, bumpy appearance because of areas of inflamed
but intact mucosa separated by ulcerated areas. (Courtesy of Dr. EK Rosado and Dr. CA Perkos,
Division of Gastrointestinal Pathology, Department of Pathology, Emory
University, Atlanta, Georgia.)
|
ULCERATIVE COLITIS: MICROSCOPIC FEATURES
Histologic findings correlate well with the endoscopic
appearance and clinical course of UC. The process is limited to the mucosa and
superficial submucosa, with deeper layers unaffected except in fulminant disease.
In UC, two major histologic features are indicative of chronicity and help distinguish
it from infectious or acute self-limited colitis. First, the crypt architecture
of the colon is distorted; crypts may be bifid and reduced in number, often
with a gap between the crypt bases and the muscularis mucosae. Second, some
patients have basal plasma cells and multiple basal lymphoid aggregates.
Mucosal vascular congestion with edema and focal hemorrhage, and an
inflammatory cell infiltrate of neutrophils, lymphocytes, plasma cells, and
macrophages may be present. The neutrophils invade the epithelium, usually in
the crypts, and give rise to cryptitis and, ultimately, to crypt abscesses (Fig. 2).
FIGURE 2 Characteristic
findings of IBD in a case of ulcerative colitis: crypt distortion, cryptitis,
and crypt abscess. (Courtesy of Dr. EK Rosado and Dr. CA Perkos, Division of Gastrointestinal
Pathology, Department of Pathology, Emory University, Atlanta, Georgia.)
|
CROHN'S DISEASE: MACROSCOPIC FEATURES
CD can affect any part of the gastrointestinal tract
from the mouth to the anus. Some 30 to 40% of patients have small-bowel disease
alone, 40 to 55% have disease involving both the small and large intestines,
and 15 to 25% have colitis alone. In the 75% of patients with small-intestinal
disease, the terminal ileum is involved in 90%. Unlike UC, which almost always
involves the rectum, the rectum is often spared in CD. CD is segmental, with
skip areas in the midst of diseased intestine (Fig. 3).
Perirectal fistulas, fissures, abscesses, and anal stenosis are present in
one-third of patients with CD, particularly those with
colonic involvement. CD may also involve the liver and the pancreas.
FIGURE 3 Portion of colon
with stricture in patient with CD. (Courtesy of Dr. EK Rosado and Dr. CA Perkos,
Division of Gastrointestinal Pathology, Department of Pathology, Emory University,
Atlanta, Georgia.)
|
Unlike UC, CD is a transmural process. Endoscopically,
aphthous or small superficial ulcerations characterize mild disease; in more
active disease, stellate ulcerations fuse longitudinally and transversely to
demarcate islands of mucosa that frequently are histologically normal. This
“cobblestone” appearance is characteristic of CD, both endoscopically and by barium
radiography. As in UC, pseudopolyps can form in CD.
Active CD is characterized by focal inflammation and
formation of fistula tracts, which resolve by fibrosis and stricturing of the
bowel. The bowel wall thickens and becomes narrowed and fibrotic, leading to
chronic, recurrent bowel obstructions. Projections of thickened mesentery encase
the bowel (“creeping fat”), and serosal and mesenteric inflammation promote
adhesions and fistula formation.
CROHN'S DISEASE: MICROSCOPIC FEATURES
The earliest lesions are aphthoid ulcerations and
focal crypt abscesses with loose aggregations of macrophages, which form
noncaseating granulomas in all layers of the bowel wall from mucosa to serosa (Fig. 4). Granulomas can be seen in lymph nodes, mesentery,
peritoneum, liver, and pancreas. Although granulomas are a pathognomonic
feature of CD, they are rarely found on mucosal biopsies. Surgical resection
reveals granulomas in about half of cases. Other histologic features of CD
include submucosal or subserosal lymphoid aggregates, particularly away from areas
of ulceration, gross and microscopic skip areas, and transmural inflammation
that is accompanied by fissures that penetrate deeply into the bowel wall and
sometimes form fistulous tracts or local abscesses.
FIGURE 4 Granulomas (arrow)
in bowel wall and serosa of colon, CD. (Courtesy of Dr. EK Rosado and Dr. CA Perkos,
Division of Gastrointestinal Pathology, Department of Pathology, Emory
University, Atlanta, Georgia.)
|
CLINICAL PRESENTATION
ULCERATIVE COLITIS
Signs and Symptoms
The major symptoms of UC are diarrhea, rectal
bleeding, tenesmus, passage of mucus, and crampy abdominal pain. The severity
of symptoms correlates with the extent of disease. Although UC can present
acutely, symptoms usually have been present for weeks to months. Occasionally,
diarrhea and bleeding are so intermittent and mild that the patient does not
seek medical attention.
Patients with proctitis usually pass fresh blood or
blood-stained mucus, either mixed with stool or streaked onto the surface of a
normal or hard stool. They also have tenesmus, or urgency with a feeling of
incomplete evacuation. They rarely have abdominal pain. With proctitis or proctosigmoiditis,
proximal transit slows, which may account for the constipation that is commonly
seen in patients with distal disease.
When the disease extends beyond the rectum, blood is
usually mixed with stool or grossly bloody diarrhea may be noted. Colonic
motility is altered by inflammation with rapid transit through the inflamed
intestine. When the disease is severe, patients pass a liquid stool containing
blood, pus, and fecal matter. Diarrhea is often nocturnal and/or postprandial.
Although severe pain is not a prominent symptom, some patients with active
disease may experience vague lower abdominal discomfort or mild central
abdominal cramping. Severe cramping and abdominal pain can occur in association
with severe attacks of the disease. Other symptoms in moderate to severe
disease include anorexia, nausea, vomiting, fever, and weight loss.
Physical signs of proctitis include a tender anal
canal and blood on rectal examination. With more extensive disease, patients
have tenderness to palpation directly over the colon. Patients with a toxic
colitis have severe pain and bleeding, and those with megacolon have hepatic
tympany. Both may have signs of peritonitis if a perforation has occurred. The
classification of disease activity is shown in Table 2.
TABLE 2 Ulcerative Colitis: Disease Presentation
|
Mild
|
Moderate
|
Severe
|
Bowel movements
|
<4 per day
|
4–6 per day
|
>6 per day
|
Blood in stool
|
Small
|
Moderate
|
Severe
|
Fever
|
None
|
<37.5°C mean
|
>37.5°C mean
|
Tachycardia
|
None
|
<90 mean pulse
|
>90 mean pulse
|
Anemia
|
Mild
|
>75%
|
≤75%
|
Sedimentation rate
|
<30 mm
|
|
>30 mm
|
Endoscopic appearance
|
Erythema, decreased
vascular pattern, fine granularity
|
Marked erythema, coarse
granularity, absent vascular markings, contact bleeding, no ulcerations
|
Spontaneous bleeding, ulcerations
|
Active disease can be associated with a rise in acute-phase
reactants (C-reactive protein, orosomucoid levels), platelet count, erythrocyte
sedimentation rate (ESR), and a decrease in hemoglobin. In severely ill patients,
the serum albumin level will fall rather quickly. Leukocytosis may be present
but is not a specific indicator of disease activity. Proctitis or
proctosigmoiditis rarely causes a rise in C-reactive protein. Diagnosis relies
upon the patient's history; clinical symptoms, negative stool examination for
bacteria, Clostridium
difficile toxin, and ova and parasites; sigmoidoscopic
appearance (see Fig. 18); and histology of rectal or colonic biopsy specimens.
Sigmoidoscopy is used to assess disease activity and
is often performed before treatment. If the patient is not having an acute
flare, colonoscopy is used to assess disease extent and activity. Histologic
features change more slowly than clinical features but can also be used to
grade disease activity.
FIGURE 5 Barium enema in a
patient with acute ulcerative colitis: inflammation of the entire colon. (Courtesy of Dr. JM Braver,
Gastrointestinal Radiology, Department of Radiology, Brigham and Women's
Hospital, Boston, Massachusetts.)
|
Patients with a severe attack of UC should have a
plain, supine film of the abdomen. In the presence of severe disease, the
margin of the colon becomes edematous and irregular. Colon thickening and toxic
dilation can both be seen on a plain radiograph.
The earliest radiologic change of UC seen on
single-contrast barium enema is a fine mucosal granularity (Fig.
5). With increasing severity, the mucosa becomes thickened and superficial
ulcers are seen. Deep ulcerations can appear as “collar-button” ulcers, which
indicate that the ulceration has penetrated the mucosa. Haustral folds may be
normal in mild disease, but as activity progresses they become edematous and
thickened. Loss of haustration can occur, especially in patients with
long-standing disease. In addition, the colon becomes shortened and narrowed.
Polyps in the colon may be postinflammatory polyps or pseudopolyps, adenomatous
polyps, or carcinoma.
Computed
tomography (CT) scanning is not as helpful as endoscopy and barium enema in
making the diagnosis of UC, but typical findings include mild mural thickening
(<1.5 cm), inhomogeneous, increased perirectal and presacral fat, target
appearance of the rectum, and adenopathy.
COMPLICATIONS
Only 15% of patients with UC present initially with
catastrophic illness. Massive hemorrhage occurs with severe attacks of disease
in 1% of patients, and treatment for the disease usually stops the bleeding. However,
if a patient requires 6 to 8 units of blood within 24 to 48 h, colectomy is
indicated. Toxic megacolon is defined as a transverse colon with a diameter of
>5 to 6 cm, with loss of haustration in patients with severe attacks of UC.
It occurs in about 5% of attacks and can be triggered by electrolyte abnormalities
and narcotics. About 50% of acute dilations will resolve with medical therapy
alone, but urgent colectomy is required for those that do not improve.
Perforation is the most dangerous of the local complications, and the physical
signs of peritonitis may not be obvious, especially if the patient is receiving
glucocorticoids. Although perforation is rare, the mortality rate for
perforation complicating a toxic megacolon is about 15%. In addition, patients
can develop a toxic colitis and such severe ulcerations that the bowel may
perforate without first dilating.
Obstructions caused by benign stricture formation
occur in 10% of patients, with one-third of the strictures occurring in the rectum.
These should be surveyed endoscopically for carcinoma. UC patients occasionally
develop anal fissures, perianal abscesses, or hemorrhoids, but the occurrence
of extensive perianal lesions should suggest CD.
CROHN'S DISEASE
Signs and Symptoms
Although CD usually presents as acute or chronic
bowel inflammation, the inflammatory process evolves toward one of two patterns
of disease: a fibrostenotic-obstructing pattern or a penetrating-fistulous
pattern, each with different treatments and prognoses. The site of disease influences
the clinical manifestations.
ILEOCOLITIS
Because the most common site of inflammation is the terminal ileum, the
usual presentation of ileocolitis is a chronic history of recurrent episodes of
right lower quadrant pain and diarrhea. Sometimes the initial presentation
mimics acute appendicitis with pronounced right lower quadrant pain, a palpable
mass, fever, and leukocytosis. Pain is usually colicky; it precedes and is
relieved by defecation. A low-grade fever is usually noted. High-spiking fever
suggests intraabdominal abscess formation. Weight loss is common—typically 10
to 20% of body weight—and develops as a consequence of diarrhea, anorexia, and
fear of eating.
An inflammatory mass may be palpated in the right
lower quadrant of the abdomen. The mass is composed of inflamed bowel, adherent
and indurated mesentery, and enlarged abdominal lymph nodes. Extension of the
mass can cause obstruction of the right ureter or bladder inflammation,
manifested by dysuria and fever. Edema, bowel wall thickening, and fibrosis of
the bowel wall within the mass account for the radiographic “string sign” of a
narrowed intestinal lumen.
Bowel obstruction may take several forms. In the early
stages of disease, bowel wall edema and spasm produce intermittent obstructive
manifestations and increasing symptoms of postprandial pain. Over several
years, persistent inflammation gradually progresses to fibrostenotic narrowing
and stricture. Diarrhea will decrease and be replaced by chronic bowel obstruction.
Acute episodes of obstruction occur as well, precipitated by bowel inflammation
and spasm or sometimes by impaction of undigested food or medication. These
episodes usually resolve with intravenous fluids and gastric decompression.
Severe inflammation of the ileocecal region may lead
to localized wall thinning, with microperforation and fistula formation to the
adjacent bowel, the skin, the urinary bladder, or to an abscess cavity in the
mesentery. Enterovesical fistulas typically present as dysuria or recurrent
bladder infections or less commonly as pneumaturia or fecaluria. Enterocutaneous
fistulas follow tissue planes of least resistance, usually draining through
abdominal surgical scars. Enterovaginal fistulas are rare and present as
dyspareunia or as a feculent or foul-smelling, often painful vaginal discharge.
They are unlikely to develop without a prior hysterectomy.
JEJUNOILEITIS
Extensive inflammatory disease is associated with a
loss of digestive and absorptive surface, resulting in malabsorption and
steatorrhea. Nutritional deficiencies can also result from poor intake and
enteric losses of protein and other nutrients. Intestinal malabsorption can
cause hypoalbuminemia, hypocalcemia, hypomagnesemia, coagulopathy, and
hyperoxaluria with nephrolithiasis. Vertebral fractures are caused by a
combination of vitamin D deficiency, hypocalcemia, and prolonged glucocorticoid
use. Pellagra from niacin deficiency can occur in extensive small-bowel disease,
and malabsorption of vitamin B12 can lead to a megaloblastic anemia
and neurologic symptoms.
Diarrhea is characteristic of active disease; its
causes include: (1) bacterial overgrowth in obstructive stasis or
fistulization, (2) bile-acid malabsorption due to a diseased or resected
terminal ileum, and (3) intestinal inflammation with decreased water absorption
and increased secretion of electrolytes.
COLITIS AND PERIANAL DISEASE
Patients with colitis present with low-grade fevers,
malaise, diarrhea, crampy abdominal pain, and sometimes hematochezia. Gross
bleeding is not as common as in UC and appears in about half of patients with
exclusively colonic disease. Only 1 to 2% bleed massively. Pain is caused by
passage of fecal material through narrowed and inflamed segments of large
bowel. Decreased rectal compliance is another cause for diarrhea in Crohn's
colitis patients. Toxic megacolon is rare but may be seen with severe
inflammation and short-duration disease.
Stricturing can occur in the colon and produce
symptoms of bowel obstruction. Also, colonic disease may fistulize into the
stomach or duodenum, causing feculent vomiting, or to the proximal or mid small
bowel, causing malabsorption by “short circuiting” and bacterial overgrowth.
Ten percent of women with Crohn's colitis will develop a rectovaginal fistula.
Perianal disease affects about one-third of patients with Crohn's colitis
and is manifested by incontinence, large hemorrhoidal tags, anal strictures,
anorectal fistulae, and perirectal abscesses. Not all patients with perianal
fistula will have endoscopic evidence of colonic inflammation.
GASTRODUODENAL DISEASE
Symptoms and signs of upper gastrointestinal tract
disease include nausea, vomiting, and epigastric pain. Patients usually have a H. pylori –negative gastritis. The second portion of the duodenum is more
commonly involved than the bulb. Fistulas involving the stomach or duodenum
arise from the small or large bowel and do not necessarily signify the presence
of upper gastrointestinal tract involvement. Patients with advanced gastroduodenal
CD may develop a chronic gastric outlet obstruction.
Laboratory, Endoscopic, and Radiographic Features
Laboratory abnormalities include elevated ESR and
C-reactive protein. In more severe disease, findings include hypoalbuminemia,
anemia, and leukocytosis.
Endoscopic features of CD include rectal sparing,
aphthous ulcerations, fistulas, and skip lesions. Endoscopy is useful for
biopsy of mass lesions or strictures, or for visualization of filling defects
seen on barium enema. Colonoscopy allows examination and biopsy of the terminal
ileum, and upper endoscopy is useful in diagnosing gastroduodenal involvement
in patients with upper tract symptoms. Ileal or colonic strictures may be dilated
with balloons introduced through the colonoscope. Endoscopic appearance
correlates poorly with clinical remission; thus, repeated endoscopy is not used
to monitor the inflammation.
In CD early radiographic findings in the small bowel
include thickened folds and aphthous ulcerations. “Cobblestoning” from
longitudinal and transverse ulcerations most frequently involves the small
bowel (Fig. 6). In more advanced disease, strictures,
fistulas (Fig. 7), inflammatory masses, and abscesses may
be detected. The earliest macroscopic findings of colonic CD are aphthous
ulcers. These small ulcers are often multiple and separated by normal
intervening mucosa. As disease progresses, aphthous ulcers become enlarged,
deeper, and occasionally connected to one another, forming longitudinal
stellate, serpiginous, and linear ulcers (see Fig. 17).
FIGURE 6 Crohn's disease:
small bowel series demonstrating “cobblestoning” of the terminal ileum (arrows).
(Courtesy of
Dr. JM Braver, Gastrointestinal Radiology, Department of Radiology, Brigham
and Women's Hospital, Boston, Massachusetts.)
|
|
|
|
The transmural inflammation of CD leads to decreased
luminal diameter and limited distensibility. As ulcers progress deeper, they
can lead to fistula formation. The radiographic “string sign” represents long
areas of circumferential inflammation and fibrosis, resulting in long segments
of luminal narrowing. The segmental nature of CD results in wide gaps of normal
or dilated bowel between involved segments.
CT findings include mural thickening >2 cm,
homogeneous wall density, mural thickening of small bowel, mesenteric fat
stranding, perianal disease, and adenopathy. CT scanning can help identify
abscesses, fistulas, and sinus tracts. Magnetic resonance imaging (MRI) may
prove superior for demonstrating pelvic lesions such as ischiorectal abscesses.
Complications
Because CD is a transmural process, serosal adhesions
develop that provide direct pathways for fistula formation and reduce the
incidence of free perforation. Free perforation occurs in 1 to 2% of patients,
usually in the ileum but occasionally in the jejunum or as a complication of
toxic megacolon. The peritonitis of free perforation, especially colonic, may
be fatal. Generalized peritonitis may also result from the rupture of an intraabdominal
abscess. Other complications include intestinal obstruction in 40%, massive
hemorrhage, malabsorption, and severe perianal disease.
Serologic Markers
Several serologic markers may be used to differentiate
between CD and UC and help to predict the course of disease. Two antibodies
that can be detected in the serum of IBD patients are perinuclear
antineutrophil cytoplasmic antibodies (pANCAs) and anti-Saccharomyces cerevisiae antibodies (ASCAs). A distinct set of antineutrophil cytoplasmic antibodies
with perinuclear staining by indirect immunofluorescence is associated with UC.
The antigens to which these antibodies are directed have not been identified,
but they are distinct from those associated with vasculitis and may be a marker
for reactivity to enteric bacteria. pANCA positivity is found in about 60 to
70% of UC patients and 5 to 10% of CD patients; 5 to 15% of first-degree
relatives of UC patients are pANCA positive, whereas only 2 to 3% of the
general population is pANCA positive. pANCA may also identify specific disease
phenotypes. pANCA positivity is more often associated with pancolitis, early
surgery, pouchitis, or inflammation of the pouch after ileal pouch–anal
anastamosis (IPAA) and primary sclerosing cholangitis. pANCA in CD is
associated with colonic disease that resembles UC.
ASCA antibodies recognize mannose sequences in the cell wall mannan of S. cerevisiae; 60 to 70% of CD patients, 10
to 15% of UC patients, and up to 5% of non-IBD controls are ASCA positive.
About 55% of CD patients are seroreactive to outer-membrane porin C (OMPC), a
bacterial antigen. The combined measurement of pANCA and ASCA has been
advocated as a valuable diagnostic approach to IBD. In one report, pANCA+ with
ASCA- results showed a 57% sensitivity and 97% specificity for UC, whereas
pANCA- with ASCA+ results showed a 49% sensitivity and 97% specificity for CD.
ASCA was associated with small-bowel CD. These antibody tests may help decide
whether a patient with indeterminate colitis should undergo an IPAA, because
patients with predominant features of CD often have a more difficult postoperative
course.
Other serologic markers in IBD patients include
anti-goblet cell autoantibodies, pancreatic autoantibodies, and an autoantibody
against tropomyosin isoform 5 found in colon epithelial cells. Antibodies to
red cell membrane antigens that cross-react with enteropathogens such as Campylobacter sp. may be associated with hemolytic anemia in CD. None of these
antibodies are useful in the diagnosis and management of patients with IBD.
DIFFERENTIAL DIAGNOSIS OF UC AND CD
UC and CD have similar features to many other
diseases. In the absence of a key diagnostic test, a combination of clinical,
laboratory, histopathologic, radiographic, and therapeutic observations is
required (Table 3). Once a diagnosis of IBD is made,
distinguishing between UC and CD is impossible in 10 to 15% of cases. These are
termed indeterminate
colitis.
TABLE 3 Different Clinical, Endoscopic, and Radiographic Features
|
Ulcerative Colitis
|
Crohn's Disease
|
CLINICAL
|
||
Gross blood in stool
|
Yes
|
Occasionally
|
Mucus
|
Yes
|
Occasionally
|
Systemic symptoms
|
Occasionally
|
Frequently
|
Pain
|
Occasionally
|
Frequently
|
Abdominal mass
|
Rarely
|
Yes
|
Significant perineal
disease
|
No
|
Frequently
|
Fistulas
|
No
|
Yes
|
Small-intestinal
obstruction
|
No
|
Frequently
|
Colonic obstruction
|
Rarely
|
Frequently
|
Response to antibiotics
|
No
|
Yes
|
Recurrence after surgery
|
No
|
Yes
|
ANCA-positive
|
Frequently
|
Rarely
|
ASCA-positive
|
Rarely
|
Frequently
|
ENDOSCOPIC
|
||
Rectal sparing
|
Rarely
|
Frequently
|
Continuous disease
|
Yes
|
Occasionally
|
“Cobblestoning”
|
No
|
Yes
|
Granuloma on biopsy
|
No
|
Occasionally
|
RADIOGRAPHIC
|
||
Small bowel significantly
abnormal
|
No
|
Yes
|
Abnormal terminal ileum
|
Occasionally
|
Yes
|
Segmental colitis
|
No
|
Yes
|
Asymmetric colitis
|
No
|
Yes
|
Stricture
|
Occasionally
|
Frequently
|
Note:
ANCA, antineutrophil cytoplasm antibody; ASCA, anti-Saccharomyces cerevisiae
antibody.
|
Infections of the small intestines and colon can mimic
CD or UC. They may be bacterial, fungal, viral, or protozoal in origin (Table
4). Campylobacter colitis can mimic the endoscopic appearance of severe UC and can cause
a relapse of established UC. Salmonella can cause watery or bloody diarrhea,
nausea, and vomiting. Shigellosis causes watery diarrhea, abdominal pain, and
fever followed by rectal tenesmus and by the passage of blood and mucus per
rectum. All three are usually self-limited, but 1% of patients infected with Salmonella become asymptomatic carriers.
Yersinia
enterocolitica infection occurs mainly in
the terminal ileum and causes mucosal ulceration, neutrophil invasion, and
thickening of the ileal wall. Other bacterial infections that may mimic IBD
include C. difficile, which presents with watery diarrhea, tenesmus, nausea, and vomiting;
and Escherichia
coli, three categories of which can cause
colitis. These are enterohemorrhagic, enteroinvasive, and enteroadherent E. coli, all of which can cause bloody diarrhea and abdominal tenderness. Diagnosis
of bacterial colitis is made by sending stool specimens for bacterial culture
and C. difficile toxin analysis. Gonorrhea, Chlamydia,
and syphilis can also cause proctitis.
Although most of the patients with viral colitis are
immunosuppressed, cytomegalovirus (CMV) and herpes simplex proctitis may occur
in immunocompetent individuals. CMV occurs most commonly in the esophagus, colon,
and rectum but may also involve the small intestine. Symptoms include abdominal
pain, bloody diarrhea, fever, and weight loss. With severe disease, necrosis
and perforation can occur. Diagnosis is made by identification of intranuclear
inclusions in mucosal cells on biopsy. Herpes simplex infection of the
gastrointestinal tract is limited to the oropharynx, anorectum, and perianal
areas. Symptoms include anorectal pain, tenesmus, constipation, inguinal adenopathy, difficulty with urinary voiding, and sacral
paresthesias. Diagnosis is made by rectal biopsy. HIV itself can cause
diarrhea, nausea, vomiting, and anorexia. Small-intestinal biopsies show
partial villus atrophy; small-bowel bacterial overgrowth and fat malabsorption
may also be noted.
TABLE 4 Diseases that Mimic IBD
Infectious Etiologies |
||
Bacterial
Salmonella Shigella Toxigenic Escherichia coli Campylobacter Yersinia Clostridium difficile Gonorrhea Chlamydia trachomatis |
Mycobacterial
Tuberculosis Mycobacterium avium Parasitic Amebiasis Isospora Trichuris trichura Hookworm Strongyloides |
Viral
Cytomegalovirus Herpes simplex HIV Fungal Histoplasmosis Candida Aspergillus |
NONINFECTIOUS
ETIOLOGIES
|
||
Inflammatory
Appendicitis Diverticulitis Diversion colitis Collagenous/lymphocytic colitis Ischemic colitis Radiation colitis/enteritis Solitary rectal ulcer Eosinophilc gastroenteritis Neutropenic colitis Beçhet's syndrome Graft-versus-host disease |
Neoplastic
Lymphoma Metastatic carcinoma Carcinoma of the ileum Carcinoid Familial polyposis |
Drugs and Chemicals
NSAIDs Phosphasoda Cathartic colon Gold Oral contraceptives Cocaine Chemotherapy |
Note:
NSAIDs, nonsteroidal anti-inflammatory drugs.
|
Protozoan parasites include Isospora belli, which can cause a self-limited infection in healthy hosts but causes a
chronic profuse, watery diarrhea and weight loss in AIDS patients. Entamoeba histolytica or related species infect about 10% of the world's population; symptoms
include abdominal pain, tenesmus, frequent loose stools containing blood and mucus,
and abdominal tenderness. Colonoscopy reveals focal punctate ulcers with normal
intervening mucosa; diagnosis is made by biopsy or serum amebic antibodies.
Fulminant amebic colitis is rare but has a mortality rate of >50%.
Other parasitic infections that may mimic IBD include
hookworm (Necator
americanus), whipworm (Trichuris trichiura), and Strongyloides
stercoralis. In severely immunocompromised
patients Candida or Aspergillus can be identified in the submucosa. Disseminated histoplasmosis can involve
the ileocecal area.
NONINFECTIOUS DISEASE
Many diseases may mimic IBD (Table 4).
Diverticulitis can be confused with CD clinically and radiographically. Both diseases
cause fever, abdominal pain, tender abdominal mass, leukocytosis, elevated ESR,
partial obstruction, and fistulas. Perianal disease or ileitis on small-bowel series
favors the diagnosis of CD. Significant endoscopic mucosal abnormalities are
more likely in CD than in diverticulitis. Endoscopic or clinical recurrence following
segmental resection favors CD. Diverticular-associated colitis is similar to
CD, but mucosal abnormalities are limited to the sigmoid and descending colon.
Ischemic colitis is commonly confused with IBD. The
ischemic process can be chronic and diffuse as in UC, or segmental as in CD.
Colonic inflammation due to ischemia may resolve quickly or may persist and result
in transmural scarring and stricture formation. Ischemic bowel disease should
be considered in the elderly following abdominal aortic aneurysm repair or when
a patient has a hypercoagulable state or a severe cardiac or peripheral
vascular disorder. Patients usually present with sudden onset of left lower
quadrant pain, urgency to defecate, and the passage of bright red blood per
rectum. Endoscopic examination often demonstrates a normal-appearing rectum and
a sharp transition to an area of inflammation in the descending colon and splenic
flexure.
The effects of radiation therapy on the
gastrointestinal tract can be difficult to distinguish from IBD. Acute symptoms
can occur within 1 to 2 weeks of starting radiotherapy. When the rectum and
sigmoid are irradiated, patients develop bloody, mucoid diarrhea and tenesmus,
as in distal UC. With small-bowel involvement, diarrhea is common. Late symptoms
include malabsorption and weight loss. Stricturing with obstruction and
bacterial overgrowth may occur. Fistulas can penetrate the bladder, vagina, or
abdominal wall. Flexible sigmoidoscopy reveals mucosal granularity, friability,
numerous telangiectasias, and occasionally discrete ulcerations. Biopsy can be
diagnostic.
Solitary rectal ulcer syndrome is uncommon and can be
confused with IBD. It occurs in persons of all ages and may be caused by
impaired evacuation and failure of relaxation of the puborectalis muscle.
Ulceration may arise from anal sphincter overactivity, higher intrarectal
pressures during defecation, and digital removal of stool. Patients complain of
constipation with straining and pass blood and mucus per rectum. Other symptoms
include abdominal pain, diarrhea, tenesmus, and perineal pain. The ulceration,
which can be as large as 5 cm in diameter, is usually seen anteriorly or anteriorlaterally
3 to 15 cm from the anal verge. Biopsies can be diagnostic.
Several types of colitis have been associated with
nonsteroidal anti-inflammatory drugs (NSAIDs), including de novo colitis,
reactivation of IBD, and proctitis caused by use of suppositories. Most
patients with NSAID-related colitis present with diarrhea and abdominal pain
and complications include stricture, bleeding, obstruction, perforation, and
fistulization. Withdrawal of these agents is crucial, and in cases of reactivated
IBD, standard therapies are indicated.
INDETERMINATE COLITIS
Cases of IBD that cannot be categorized as UC or CD
are called indeterminate
colitis. Long-term follow-up reduces the
number of cases labeled indeterminate to about 10%. The disease course of indeterminate
colitis is unclear and surgical recommendations are difficult, especially since
up to 20% of pouches fail, requiring ileosotomy. A multistage IPAA (the initial
stage consisting of a subtotal colectomy with Hartmann pouch) with careful
histologic evaluation of the resected specimen to exclude CD is advised.
Medical therapy is similar to that for UC and CD; most clinicians use 5-ASA
drugs, glucocorticoids, and immunomodulators as necessary.
THE ATYPICAL COLITIDIES
Two atypical colitides—collagenous colitis and
lymphocytic colitis—have completely normal endoscopic appearances. Collagenous
colitis has two main histologic components: increased subepithelial collagen deposition
and colitis with increased intraepithelial lymphocytes. Female to male ratio is
9:1, and most patients present in the sixth or seventh decades of life. The
main symptom is chronic watery diarrhea. Treatments range from sulfasalazine or
mesalamine and Lomotil to bismuth to glucocorticoids for refractory disease.
Lymphocytic colitis has features similar to
collagenous colitis including age at onset and clinical presentation, but it
has almost equal incidence in men and women and no subepithelial collagen
deposition on pathologic section. However, intraepithelial lymphocytes are
increased. Diarrhea stops in most patients treated with 5-ASA or prednisone.
Diversion colitis is an inflammatory process that
arises in segments of the large intestine that are excluded from the fecal
stream. It usually occurs in patients with ileostomy or colostomy when a mucus
fistula or a Hartmann's pouch has been created. Diversion colitis is reversible
by surgical reanastamosis. Clinically, patients have mucus or bloody discharge
from the rectum. Erythema, granularity, friability, and, in more severe cases, ulceration
can be seen on endoscopy. Histopathology shows areas of active inflammation
with foci of cryptitis and crypt abscesses. Crypt architecture is normal and
this differentiates it from UC. It may be impossible to distinguish it from CD.
Short-chain fatty acid enemas will help in diversion colitis, but the
definitive therapy is surgical reanastamosis.
EXTRAINTESTINAL MANIFESTATIONS
IBD is associated with a variety of extraintestinal
manifestations; up to one-third of patients have at least one. Patients with
perianal CD are at higher risk for developing extraintestinal manifestations
than other IBD patients.
DERMATOLOGIC
Erythema nodosum (EN) occurs in up to 15% of CD
patients and 10% of UC patients. Attacks usually correlate with bowel activity;
skin lesions develop after the onset of bowel symptoms, and patients frequently
have concomitant active peripheral arthritis. The lesions of EN are hot, red,
tender nodules measuring 1 to 5 cm in diameter and are found on the anterior
surface of the lower legs, ankles, calves, thighs, and arms. Therapy is directed
toward the underlying bowel disease.
Pyoderma gangrenosum (PG) is seen in 1 to 12% of UC patients and less
commonly in Crohn's colitis. Although it usually presents after the diagnosis
of IBD, PG may occur years before the onset of bowel symptoms, run a course
independent of the bowel disease, respond poorly to colectomy, and even develop
years after proctocolectomy. It is usually associated with severe disease.
Lesions are commonly found on the dorsal surface of the feet and legs but may
occur on the arms, chest, stoma, and even the face. PG usually begins as a
pustule and then spreads concentrically to rapidly undermine healthy skin.
Lesions then ulcerate, with violaceous edges surrounded by a
margin of erythema. Centrally, they contain necrotic tissue with blood and
exudates. Lesions may be single or multiple and grow as large as 30 cm. They
are sometimes very difficult to treat and often require intravenous
antibiotics, intravenous glucocorticoids, dapsone, azathioprine, thalidomide,
intravenous cyclosporine, or infliximab.
Other dermatologic manifestations include pyoderma
vegetans that occurs in intertriginous areas, pyostomatitis vegetans that
involves the mucous membranes, Sweet's syndrome, a neutrophilic dermatosis, and
metastatic CD, a rare disorder defined by cutaneous granuloma formation. Psoriasis
affects 5 to 10% of patients with IBD and is unrelated to bowel activity.
Perianal skin tags are found in 75 to 80% of patients with CD, especially those
with colon involvement. Oral mucosal lesions are seen often in CD and rarely in
UC and include aphthous stomatitis and “cobblestone” lesions of the buccal
mucosa.
RHEUMATOLOGIC
Peripheral arthritis develops in 15 to 20% of IBD
patients, is more common in CD, and worsens with exacerbations of bowel
activity. It is asymmetric, polyarticular, and migratory and most often affects
large joints of the upper and lower extremities. Treatment is directed at
reducing bowel inflammation. In severe UC, colectomy frequently cures the arthritis.
Ankylosing spondylitis (AS) occurs in about 10% of IBD
patients and is more common in CD than UC. About two-thirds of IBD patients
with AS test positive for the HLA-B27 antigen. The activity of AS is not
related to bowel activity and does not remit with glucocorticoids or colectomy.
It most often affects the spine and pelvis, producing symptoms of diffuse
low-back pain, buttock pain, and morning stiffness. The course is continuous
and progressive, leading to permanent skeletal damage and deformity.
Sacroiliitis is symmetric, occurs equally in UC and
CD, is often asymptomatic, does not correlate with bowel activity, and does not
always progress to AS. Other rheumatic manifestations include hypertrophic osteoarthropathy,
pelvic/femoral osteomyelitis, and relapsing polychondritis.
OCULAR
The incidence of ocular complications in IBD patients
is 1 to 10%. The most common are conjunctivitis, anterior uveitis/iritis, and
episcleritis. Uveitis is associated with both UC and Crohn's colitis, may be
found during periods of remission, and may develop in patients following bowel
resection. Symptoms include ocular pain, photophobia, blurred vision, and
headache. Prompt intervention, sometimes with systemic glucocorticoids, is
required to prevent scarring and visual impairment. Episcleritis is a benign
disorder that presents with symptoms of mild ocular burning. It occurs in 3 to
4% of IBD patients, more commonly in Crohn's colitis, and is treated with
topical glucocorticoids.
HEPATOBILIARY
Hepatic steatosis is detectable in about half of the
abnormal liver biopsies from patients with CD and UC; patients usually present
with hepatomegaly. Fatty liver usually results from a combination of chronic
debilitating illness, malnutrition, and glucocorticoid therapy. Cholelithiasis
is more common in CD than UC and occurs in 10 to 35% of patients with ileitis
or ileal resection. Gallstone formation is caused by malabsorption of bile
acids resulting in depletion of the bile salt pool and the secretion of lithogenic
bile.
Primary sclerosing cholangitis (PSC) is characterized
by both intrahepatic and extrahepatic bile duct inflammation and fibrosis,
frequently leading to biliary cirrhosis and hepatic failure; 1 to 5% of
patients with IBD have PSC, but 50 to 75% of patients with PSC have IBD.
Although it can be recognized after the diagnosis of IBD, PSC can be detected
earlier or even years after proctocolectomy. Most patients have no symptoms at
the time of diagnosis; when symptoms are present they consist of fatigue,
jaundice, abdominal pain, fever, anorexia, and malaise. Diagnosis is made by
endoscopic retrograde cholangiopancreatography (ERCP), which demonstrates
multiple bile duct strictures alternating with relatively normal segments. The
bile acid ursodeoxycholic acid (ursodiol) may reduce alkaline phosphatase and
serum aminotransferase levels, but histologic improvement has been marginal.
High doses (25 to 30 mg/kg per day) may have long-term benefit. Endoscopic
stenting may be palliative for cholestasis secondary to bile duct obstruction.
Patients with symptomatic disease develop cirrhosis and liver failure over 5 to
10 years and eventually require liver transplantation. Ten percent of PSC
patients develop cholangiocarcinoma and cannot be transplanted. Pericholangitis
is a subset of PSC found in about 30% of IBD patients; it is confined to small
bile ducts and is usually benign.
UROLOGIC
The most frequent genitourinary complications are
calculi, ureteral obstruction, and fistulas. The highest frequency of nephrolithiasis
(10 to 20%) occurs in patients with CD following small-bowel resection. Calcium
oxalate stones develop secondary to hyperoxaluria, which results from increased
absorption of dietary oxalate. Normally, dietary calcium combines with luminal
oxalate to form insoluble calcium oxalate, which is eliminated in the stool. In
patients with ileal dysfunction, however, nonabsorbed fatty acids bind calcium
and leave oxalate unbound. The unbound oxalate is then delivered to the colon,
where it is readily absorbed, especially in the presence of colonic inflammation.
OTHER
The risk of thromboembolic disease increases when IBD
becomes active, and patients may present with deep vein thrombosis, pulmonary
embolism, cerebrovascular accidents, and arterial emboli. Factors responsible
for the hypercoagulable state include reactive thrombocytosis; increased levels
of fibrinopeptide A, factor V, factor VIII, and fibrinogen; accelerated
thromboplastin generation; antithrombin III deficiency secondary to increased
gut losses or increased catabolism; and free protein S deficiency. A spectrum
of vasculitidies involving small, medium, and large vessels has also been
observed in IBD patients.
Patients with IBD have an increased prevalence of
osteoporosis and osteomalacia from vitamin D deficiency, calcium malabsorption,
malnutrition, glucocorticoid use, and the intestinal inflammation itself.
Deficiencies of vitamin B12 and fat-soluble vitamins may occur after
ileal resection or with ileal disease.
More common cardiopulmonary manifestations include
endocarditis, myocarditis, pleuropericarditis, and interstitial lung disease. A
secondary or reactive amyloidosis can occur in patients with long-standing IBD,
especially in patients with CD. Amyloid material is deposited systemically and
can cause diarrhea, constipation, and renal failure. The renal disease can be
successfully treated with colchicine. Pancreatitis is a rare extraintestinal
manifestation of IBD and results from duodenal fistulas, ampullary CD,
gallstones, PSC, drugs such as 6-mercaptopurine, azathioprine, or very rarely,
5-ASA agents, autoimmune pancreatitis, and primary CD of the pancreas.
TREATMENT
5-ASA AGENTS
The mainstay of therapy for mild to moderate UC and
Crohn's colitis is sulfasalazine and the other 5-ASA agents. These agents are
effective at inducing remission in both UC and CD and in maintaining remission
in UC; it remains unclear whether they have a role in remission maintenance in
CD.
Sulfasalazine was originally developed to deliver both antibacterial (sulfapyridine)
and anti-inflammatory (5-ASA) therapy into the connective tissues of joints and
the colonic mucosa. The molecular structure provides a convenient delivery
system to the colon by allowing the intact molecule to pass through the small
intestine after only partial absorption, and to be broken down in the colon by
bacterial azo reductases that cleave the azo bond linking the sulfa and 5-ASA
moieties. Sulfasalazine is effective treatment for mild to moderate UC and
Crohn's ileocolitis and colitis, but its high rate of side effects limits its
use. Although sulfasalazine is more effective at higher doses, at 6 or 8 g/d up
to 30% of patients experience allergic reactions or intolerable side effects
such as headache, anorexia, nausea, and vomiting that are attributable to the
sulfapyridine moiety. Hypersensitivity reactions, independent of sulfapyridine
levels, include rash, fever, hepatitis, agranulocytosis, hypersensitivity
pneumonitis, pancreatitis, worsening of colitis, and reversible sperm abnormalities.
Sulfasalazine can also impair folate absorption, and
patients should be given folic acid supplements.
Newer sulfa-free aminosalicylate preparations deliver
increased amounts of the pharmacologically active ingredient of sulfasalazine
(5-ASA, mesalamine) to the site of active bowel disease while limiting systemic
toxicity. 5-ASA may function through inhibition of NF-κB activity. Sulfa-free aminosalicylate formulations include alternative
azo-bonded carriers, 5-ASA dimers, pH-dependent tablets, and continuous-release
preparations. Each has the same efficacy as sulfasalazine when equimolar
concentrations are used. Olsalazine is composed of two 5-ASA radicals linked by
an azo bond, which is split in the colon by bacterial reduction and two 5-ASA
molecules are released. Olsalazine is similar in effectiveness to sulfasalazine
in treating CD and UC, but up to 17% of patients experience non-bloody diarrhea
caused by increased secretion of fluid in the small bowel. Balsalazide contains
an azo bond binding mesalamine to the carrier molecule 4-aminobenzoyl-β-alanine; it is effective in the colon. Claversal is an enteric-coated
form of 5-ASA that consists of mesalamine surrounded by an acrylic-based
polymer resin and a cellulose coating that releases mesalamine at pH > 6.0,
a level that is present from the mid-jejunum continuously to the distal colon.
The most commonly used drugs besides sulfasalazine in
the United States are Asacol and Pentasa. Asacol is also an enteric-coated form
of mesalamine, but it has a slightly different release pattern, with 5-ASA liberated
at pH > 7.0. The disintegration of Asacol is variable, with complete breakup
of the tablet occurring in many different parts of the gut ranging from the
small intestine to the splenic flexure; it has increased gastric residence when
taken with a meal. Asacol is used to induce and maintain remission in UC and to
induce remission in CD ileitis, ileocolitis, and colitis. Appropriate doses of
Asacol and the other 5-ASA compounds are shown in Table 5.
Some 50 to 75% of patients with mild to moderate UC and CD improve when treated
with 2 g/d of 5-ASA; the dose response continues up to at least 4.8 g/d. Doses
of 1.5 to 4 g/d maintain remission in 50 to 75% of patients with UC.
TABLE 5 Oral 5-ASA Preparations
Preparation
|
Formulation
|
Delivery
|
Dosing, g/d
|
AZO-BOND
|
|||
Sulfasalazine (500 mg)
|
Sulfapyridine-5-ASA
|
Colon
|
4–8 (acute)
2–6 (maintenance) |
Olsalazine (250 mg)
|
5-ASA-5-ASA
|
Colon |
1–3
|
Balsalazide (500–750 mg)
|
Aminobenzoyl-alanine-5-ASA
|
Colon
|
2.25–6.75
|
DELAYED-RELEASE
|
|||
Asacol (400 mg)
|
Eudragit S (pH 7)
|
Distal ileum-colon
|
2.4–4.8 (acute)
1.6–4.8 (maintenance) |
Claversal (250–500 mg)
|
Eudragit L (pH 6)
|
Ileum-colon
|
1.5–3 (acute)
0.75–3 (maintenance) |
SUSTAINED-RELEASE
|
|||
Pentasa (250 mg)
|
Ethylcellulose microgranules
|
Stomach-colon
|
2–4 (acute)
1.5–4 (maintenance) |
Pentasa is another mesalamine formulation that uses an ethylcellulose
coating to allow water absorption into small beads containing the mesalamine.
Water dissolves the 5-ASA, which then diffuses out of the bead into the lumen.
Disintegration of the capsule occurs in the stomach. The microspheres then disperse
throughout the entire gastrointestinal tract from the small intestine through
the distal colon in both fasted or fed conditions. Controlled trials of Pentasa
and Asacol in active CD demonstrate a 40 to 60% clinical improvement or
remission, but the data are not conclusive that these agents maintain remission
in CD. 5-ASA agents may be effective in postoperative prophylaxis of CD.
Topical mesalamine enemas are effective in
mild-to-moderate distal UC and CD. Clinical response occurs in up to 80% of UC
patients with colitis distal to the splenic flexure. Mesalamine suppositories
are effective in treating proctitis.
Glucocorticoids
The majority of patients with moderate to severe UC
benefit from oral or parenteral glucocorticoids. Prednisone is usually started
at doses of 40 to 60 mg/d for active UC that is unresponsive to 5-ASA therapy.
Parenteral glucocorticoids may be administered as intravenous hydrocortisone,
300 mg/d, or methylprednisolone, 40 to 60 mg/d. Adrenocorticotropic hormone
(ACTH) is occasionally preferred for glucocorticoid-naïve patients despite a
risk of adrenal hemorrhage. ACTH has equivalent efficacy to intravenous
hydrocortisone in both glucocorticoid-naïve and -experienced CD patients.
Topically applied glucocorticoids are also beneficial
for distal colitis and may serve as an adjunct in those who have rectal involvement
plus more proximal disease. Hydrocortisone enemas or foam may control active disease,
although they have no proven role as maintenance therapy. These glucocorticoids
are significantly absorbed from the rectum and can lead to adrenal suppression
with prolonged administration.
Glucocorticoids are also effective for treatment of
moderate-to-severe CD and induce a 60 to 70% remission rate compared to a 30%
placebo response. The systemic effects of standard glucocorticoid formulations
have led to the development of more potent formulations that are less well absorbed
and have increased first-pass metabolism. Controlled ileal-release budesonide
has been nearly equal to prednisone for ileocolonic CD with fewer glucocorticoid
side effects. Budesonide is used for 2 to 3 months at a dose of 9 mg/d, then
tapered.
Glucocorticoids play no role in maintenance therapy in
either UC or CD. Once clinical remission has been induced, they should be
tapered according to the clinical activity, normally at a rate of no more than
5 mg per week. They can usually be tapered to 20 mg/d within 4 to 5 weeks but often
take several months to be discontinued altogether. The side effects are
numerous, including fluid retention, abdominal striae, fat redistribution,
hyperglycemia, subcapsular cataracts, osteonecrosis, myopathy, emotional
disturbances, and withdrawal symptoms. Most of these side effects, aside from
osteonecrosis, are related to the dose and duration of therapy.
ANTIBIOTICS
Antibiotics have no role in the treatment of active or
quiescent UC. However, pouchitis, which occurs in about a third of UC patients
after colectomy and IPAA, usually responds to treatment with metronidazole or
ciprofloxacin.
Metronidazole is effective in active inflammatory,
fistulous, and perianal CD and may prevent recurrence after ileal resection.
The most effective dose is 15 to 20 mg/kg per day in three divided doses; it is
usually continued for several months. Common side effects include nausea, metallic
taste, and disulfiram-like reaction. Peripheral neuropathy can occur with
prolonged administration (several months) and on rare occasions is permanent
despite discontinuation. Ciprofloxacin (500 mg bid) is also beneficial for
inflammatory, perianal, and fistulous CD. These two antibiotics should be used
as second-line drugs in active CD after 5-ASA agents and as first-line drugs in
perianal and fistulous CD.
AZATHIOPRINE AND 6-MERCAPTOPURINE
Azathioprine and 6-mercaptopurine (6-MP) are purine analogues commonly
employed in the management of glucocorticoid-dependent IBD. Azathioprine is
rapidly absorbed and converted to 6-MP, which is then metabolized to the active
end product, thioinosinic acid, an inhibitor of purine ribonucleotide synthesis
and cell proliferation. These agents also inhibit the immune response. Efficacy
is seen at 3 to 4 weeks. Compliance can be monitored by
measuring the levels of 6-thioguanine and 6-methyl-mercaptopurine, end products
of 6-MP metabolism. Azathioprine (2.0 to 2.5 mg/kg per day) or 6-MP (1.0 to 1.5
mg/kg per day) have been employed successfully as glucocorticoid-sparing agents
in up to two-thirds of UC and CD patients previously unable to be weaned from
glucocorticoids. The role of these immunomodulators as maintenance therapy in
UC and CD and for treating active perianal disease and fistulas in CD appears
promising. In addition, 6-MP or azathioprine may be effective for postoperative
prophylaxis of CD.
Although azathioprine and 6-MP are usually well
tolerated, pancreatitis occurs in 3 to 4% of patients, typically presents
within the first few weeks of therapy, and is completely reversible when the
drug is stopped. Other side effects include nausea, fever, rash, and hepatitis.
Bone marrow suppression (particularly leukopenia) is dose-related and often delayed,
necessitating regular monitoring of the complete blood count. Additionally, 1
in 300 individuals lacks thiopurine methyltransferase, the enzyme responsible
for drug metabolism; an additional 11% of the population are heterozygotes with
intermediate enzyme activity. Both are at increased risk of toxicity because of
increased accumulation of thioguanine metabolites. No increased risk of cancer
has been documented in IBD patients chronically taking these medications.
METHOTREXATE
Methotrexate (MTX) inhibits dihydrofolate reductase,
resulting in impaired DNA synthesis. Additional anti-inflammatory properties
may be related to decreased IL-1 production. Intramuscular or subcutaneous MTX
(25 mg per week) is effective in inducing remission and reducing glucocorticoid
dosage, and 15 mg per week is effective in maintaining remission in active CD.
Potential toxicities include leukopenia and hepatic fibrosis, necessitating
periodic evaluation of complete blood counts and liver enzymes. The role of
liver biopsy in patients on long-term MTX is uncertain. Hypersensitivity
pneumonitis is a rare but serious complication of therapy.
CYCLOSPORINE
Cyclosporine (CSA) alters the immune response by
acting as a potent inhibitor of T cell–mediated responses. Although CSA acts
primarily via inhibition of IL-2 production from T helper cells, it also
decreases recruitment of cytotoxic T cells and blocks other cytokines,
including IL-3, IL-4, IFN-γ,
and TNF. It has a more rapid onset of action than 6-MP and azathioprine.
CSA is most effective given at 2 to 4 mg/kg per day
intravenously in severe UC that is refractory to intravenous glucocorticoids,
with 82% of patients responding. CSA can be an alternative to colectomy. The
long-term success of oral CSA is not as dramatic, but if patients are started
on 6-MP or azathioprine at the time of hospital discharge, remission can be
maintained. Intravenous CSA is effective in 80% of patients with refractory fistulas,
but 6-MP or azathioprine must be used to maintain remission. Oral CSA alone is
effective only at a higher dose (7.5 mg/kg per day) in active disease but is
not effective in maintaining remission without 6-MP/azathioprine. Serum levels
should be monitored and kept in the range of 200 to 400 ng/mL.
CSA may cause significant toxicity; renal function
should be monitored frequently. Hypertension, gingival hyperplasia, hypertrichosis,
paresthesias, tremors, headaches, and electrolyte abnormalities are common side
effects. Creatinine elevation calls for dose reduction or discontinuation.
Seizures may also complicate therapy, especially if the patient is hypomagnesemic
or if serum cholesterol levels are <3.1 mmol/L (<120 mg/dL).
Opportunistic infections, most notably Pneumocystis carinii pneumonia, may occur with combination immunosuppressive treatment;
prophylaxis should be given.
NUTRITIONAL THERAPIES
Dietary antigens may stimulate the mucosal immune
response. Patients with active CD respond to bowel rest, along with total enteral
or total parenteral nutrition (TPN). Bowel rest and TPN are as effective as glucocorticoids
at inducing remission of active CD but are not effective as maintenance
therapy. Enteral nutrition in the form of elemental or peptide-based
preparations are also as effective as glucocorticiods or TPN, but these diets
are not palatable. Enteral diets may provide the small intestine with nutrients
vital to cell growth and do not have the complications of TPN. In contrast to
CD, active UC is not effectively treated with either elemental diets or TPN.
Standard medical management of UC and CD is reviewed in Table
6.
TABLE 276-6 Medical Management of IBD
Ulcerative Colitis:
Active Disease
|
||||||||||||
|
Mild
|
Moderate
|
Severe
|
Fulminant
|
||||||||
Distal
|
5-ASA oral and/or enema
|
5-ASA oral and/or enema
Glucocorticoid enema Oral glucocorticoid |
5-ASA oral and/or enema
Glucocorticoid enema Oral or IV glucocorticoid |
Intravenous glucocorticoid
Intravenous CSA |
||||||||
Extensive
|
5-ASA oral and/or enema
|
5-ASA oral and/or enema
Glucocorticoid enema Oral glucocorticoid |
5-ASA oral and/or enema
Glucocorticoid enema Oral or IV glucocorticoid |
Intravenous glucocorticoid
Intravenous CSA |
||||||||
|
||||||||||||
|
||||||||||||
|
||||||||||||
Note:
CSA, cyclosporine; 6-MP, 6-mercaptopurine; TPN, total parenteral nutrition.
|
NEWER MEDICAL THERAPIES
Anti-Tumor Necrosis Factor
Antibody
TNF is a key inflammatory cytokine and mediator of
intestinal inflammation. The expression of TNF is increased in IBD. Infliximab
is a chimeric mouse-human monoclonal antibody against TNF that is extremely
effective in CD. It blocks TNF in the serum and at the cell
surface and likely lyses TNF-producing macrophages and T cells through complement
fixation and antibody-dependent cytotoxicity. Of active CD patients refractory
to glucocorticoids, 6-MP, or 5-ASA, 65% will respond to intravenous infliximab
(5 mg/kg); one-third will enter complete remission. Of the patients who
experience an initial response, 40% will maintain remission for at least 1 year
with repeated infusions of infliximab every 8 weeks.
Infliximab is also effective in CD patients with
refractory perianal and enterocutaneous fistulas, with a 68% response rate (50%
reduction in fistula drainage) and a 50% complete remission rate. Reinfusion,
typically every 8 weeks, is necessary to continue therapeutic benefits in many
patients.
The development of antibodies to infliximab (ATI) is
associated with an increased risk of infusion reactions and a decreased
response to treatment. Patients who receive on-demand or episodic infusions
rather than periodic (every 8 weeks) infusions are more likely to develop ATI.
A humanized antibody to TNF also shows some promise in early clinical testing.
Among 120,000 patients treated with infliximab, 8
developed lymphoma: 5 patients with CD and 3 with rheumatoid arthritis. As the
risk of lymphoma is already increased in these conditions, it is unclear
whether infliximab is the cause. Thus, infliximab is extremely effective in
refractory inflammatory and fistulous CD but should be used only when necessary.
Results on the efficacy of infliximab in UC are mixed.
Newer Immunosuppressive Agents
Tacrolimus has a mechanism of action similar to
cyclosporine. It has shown efficacy in children with refractory IBD and in
adults with extensive involvement of the small bowel.
Mycophenolate mofetil is another immunomodulator that
may be effective in CD patients resistant to or intolerant of 6-MP
azathioprine. Patients with CD who received 15 mg/kg per day have tolerated the
drug well and have experienced benefit with reduction of glucocorticoid requirements.
6-Thioguanine is the active metabolite
of 6-MP and has shown activity in patients resistant to or intolerant of
6-MP/azathioprine.
Thalidomide has been shown to inhibit TNF production
by monocytes and other cells. Thalidomide is effective in glucocorticoid-refractory
and fistulous CD, but randomized controlled trials still need to be performed.
The α4
integrin-specific humanized monoclonal antibody, natalizumab, prevents the
migration of leukocytes into the parenchyma and blocks their activation in inflammatory
sites. It seems to be effective in CD, but more trials are needed.
SURGICAL THERAPY
Ulcerative Colitis
Nearly half of patients with extensive chronic UC undergo surgery within
the first 10 years of their illness. The indications for surgery are listed in
Table 7. Morbidity is about 20% in elective, 30% for urgent, and 40% for
emergency proctocolectomy. The risks are primarily hemorrhage, contamination
and sepsis, and neural injury. Although single-stage total proctocolectomy with
ileostomy has been the operation of choice, newer operations maintain continence
while surgically removing the involved rectal mucosa.
TABLE 276-7 Indications for Surgery
Ulcerative Colitis
Intractable disease Fulminant disease Toxic megacolon Colonic perforation Massive colonic hemorrhage Extracolonic disease Colonic obstruction Colon cancer prophylaxis Colon dysplasia or cancer Crohn's Disease CD of Small Intestine Stricture and obstruction unresponsive to medical therapy Massive hemorrhage Refractory fistula Abscess CD of Colon and Rectum Intractable disease Fulminant disease Perianal disease unresponsive to medical therapy Refractory fistula Colonic obstruction Cancer prophylaxis Colon dysplasia or cancer |
The IPAA is the most frequent
continence-preserving operation performed. Because UC is a
mucosal disease, the rectal mucosa can be dissected out and removed down to the
dentate line of the anus or about 2 cm proximal to it. The ileum is fashioned
into a pouch that serves as a neorectum. This ileal pouch is then sutured
circumferentially to the anus in an end-to-end fashion. If performed carefully,
this operation preserves the anal sphincter and maintains continence. The
overall operative morbidity is 10%, with the major complication being bowel
obstruction. Pouch failure necessitating conversion to permanent ileostomy occurs
in 5 to 10% of patients. Some inflamed rectal mucosa is usually left behind,
and thus endoscopic surveillance is necessary. Primary dysplasia of the ileal
mucosa of the pouch has occurred rarely.
Patients with IPAAs usually have about six to eight
bowel movements a day. On validated quality-of-life indices, they report better
performance in sports and sexual activities than ileostomy patients. The most
frequent late complication of IPAA is pouchitis in about one-third of patients
with UC. This syndrome consists of increased stool frequency, watery stools,
cramping, urgency, nocturnal leakage of stool, arthralgias, malaise, and fever.
Pouch biopsies and pANCA/ASCA/OMPC serologies can distinguish true pouchitis
from underlying CD. Although it usually responds to antibiotics, in 3 to 5% of
patients it is refractory and requires pouch take-down.
Most patients with CD require at least one operation in their lifetime.
The need for surgery is related to duration of disease and the site of involvement.
Patients with small-bowel disease have an 80% chance of requiring surgery.
Those with colitis alone have a 50% chance. The indications for surgery are
shown in Table 7.
SMALL INTESTINAL DISEASE
Because CD is chronic and recurrent with no clear
surgical cure, as little intestine as possible is resected. Current surgical
alternatives for treatment of obstructing CD include resection of the diseased
segment and strictureplasty. Surgical resection of the diseased segment is the
most frequently performed operation, and in most cases primary anastomosis can
be done to restore continuity. If much of the small bowel has already been
resected and the strictures are short with intervening areas of normal mucosa,
strictureplasties should be done to avoid a functionally insufficient length of
bowel. The strictured area of intestine is incised longitudinally and the
incision sutured transversely, thus widening the narrowed area. Complications
of strictureplasty include prolonged ileus, hemorrhage, fistula, abscess, leak,
and restricture.
COLORECTAL DISEASE
A greater percentage of patients with Crohn's colitis
require surgery for intractability, fulminant disease, and anorectal disease.
Several alternatives are available, ranging from the use of a temporary loop
ileostomy to resection of segments of diseased colon or even the entire colon
and rectum. For patients with segmental involvement, segmental colon resection
with primary anastomosis can be performed. In 20 to 25% of patients with
extensive colitis, the rectum is spared sufficiently to consider rectal preservation.
Most surgeons believe that an IPAA is contraindicated in CD due to the high
incidence of pouch failure. A diverting colostomy may help heal severe perianal
disease or rectovaginal fistulas, but disease almost always recurs with
reanastomosis. Often, these patients require a total proctocolectomy and
ileostomy.
INFLAMMATORY BOWEL DISEASE AND PREGNANCY
Patients with quiescent UC and CD have normal fertility rates; the fallopian
tubes can be scarred by the inflammatory process of CD, especially on the right
side because of the proximity of the terminal ileum. In addition, perirectal,
perineal, and rectovaginal abscesses and fistulae can result in dyspareunia.
Infertility in men can be caused by sulfasalazine but reverses when treatment
is stopped.
In mild or quiescent UC and CD, fetal outcome is
nearly normal. Spontaneous abortions, stillbirths, and developmental defects
are increased with increased disease activity, not medications. The courses of
CD and UC during pregnancy mostly correlate with disease activity at the time
of conception. Patients should be in remission for 6 months before conceiving.
Most CD patients can deliver vaginally, but cesarean section may be the
preferred route of delivery for patients with anorectal and perirectal abscesses
and fistulas to reduce the likelihood of fistulas developing or extending into
the episiotomy scar.
Sulfasalazine, mesalamine, and balsalazide are safe
for use in pregnancy and nursing, but folate supplementation must be given with
sulfasalazine. Topical 5-ASA agents are also safe during pregnancy and nursing.
Glucocorticoids are generally safe for use during pregnancy and are indicated
for patients with moderate to severe disease activity. The amount of
glucocorticoids received by the nursing infant is minimal. The safest antibiotics
to use for CD in pregnancy for short periods of time (weeks, not months) are
ampicillin, cephalosporin, or flagyl. Ciprofloxacin causes cartilage lesions in
immature animals and should be avoided because of the absence of data on its
effects on growth and development in humans.
6-MP and azathioprine pose minimal or no risk during pregnancy, but experience
is limited. If the patient cannot be weaned from the drug or has an
exacerbation that requires 6-MP/azathioprine during pregnancy, she should
continue the drug with informed consent. Their effects during nursing are
unknown.
Little data exist on cyclosporine in pregnancy. In a
small number of patients with severe IBD treated with intravenous cyclosporine
during pregnancy, 80% of pregnancies were successfully completed without development
of renal toxicity, congenital malformations, or developmental defects. However,
because of the lack of data, cyclosporine should probably be avoided unless the
patient would otherwise require surgery. Methotrexate is contraindicated in
pregnancy and nursing. Based on 35 reported pregnancies, infliximab does not
appear to present a risk to the mother or baby.
Surgery in UC should be performed only for emergency indications,
including severe hemorrhage, perforation, and megacolon refractory to medical
therapy. Total colectomy and ileostomy carry a 60% risk of postoperative spontaneous
abortion. Fetal mortality is also high in CD requiring surgery. Patients with
IPAAs have increased nighttime stool frequency during pregnancy that resolves
post-partum. Transient small-bowel obstruction or ileus has been noted in up to
8% of patients with ileostomies.
INFLAMMATORY BOWEL DISEASE IN THE ELDERLY
The most common presenting symptoms in the elderly are
diarrhea, weight loss, and abdominal pain. CD in the elderly mostly affects the
colon with a distal distribution and occurs predominantly in women. Proctitis
has been documented in 50% of elderly patients, and the diagnosis is often delayed.
Diseases that can mimic CD in the elderly are ischemic colitis, diverticular disease,
irritable bowel, infectious colitides, and malignancies, including carcinoma,
lymphoma, and carcinoid. The incidence of surgery is high in elderly patients,
with up to 50% of patients with ileitis, ileocolitis, or extensive colitis
requiring urgent or early surgery for first-time disease. In addition, surgery
has a much higher morbidity than in younger patients, although the rate of
postoperative recurrence is less. Most elderly patients respond as well as
younger individuals to medical management.
UC in the elderly is more common in men, presents
usually with diarrhea and weight loss, and may have a more distal distribution
than in younger patients. Most elderly patients have a favorable response to
medical therapy, especially 5-ASA agents, and immunosuppressives used in
conjunction with low doses of glucocorticoids. Cyclosporine has been used more
frequently in the elderly, but the age-related decreases in renal clearance may
affect dosing. Glucocorticoid complications such as osteoporosis and
hyperglycemia are also increased in the elderly. 6-MP and azathioprine are well
tolerated in the elderly. Surgery also has a higher morbidity and mortality in
UC, and elderly patients have a longer hospital stay than younger patients. The
risk of colon cancer in UC and Crohn's colitis is no greater than that in the
general population since the duration of disease is short and the extent of
disease is often distal.
CANCER IN INFLAMMATORY BOWEL DISEASE
ULCERATIVE COLITIS
Patients with long-standing UC are at increased risk for developing
colonic epithelial dysplasia and carcinoma (Fig. 8).
Several features distinguish sporadic colon cancer (SCC) and colitis-associated
colon cancer (CAC). First, SCCs usually arise from an adenomatous polyp; CACs
typically arise from either flat dysplasia or a dysplasia-associated lesion or
mass (DALM). Second, multiple synchronous colon cancers occur in 3 to 5% of SCC
but in 12% of CAC. Third, the mean age of individuals with SCC is in the sixties;
the mean age of those with CAC is in the thirties. Fourth, SCC exhibits a
left-sided predominance, whereas CAC is distributed more uniformly throughout
the colon. Fifth, mucinous and anaplastic cancers are more common in CAC than
SCC. At the molecular level, p53 mutations occur much earlier and APC gene mutations much later in CAC than in SCC.
|
FIGURE 276-8
Low-power transition between dysplasia (D) and nondysplastic (N) mucosa in a
case of ulcerative colitis. (Courtesy of Dr. EK Rosado and Dr. CA Perkos, Division of
Gastrointestinal Pathology, Department of Pathology, Emory University,
Atlanta, Georgia.)
|
The risk of neoplasia in chronic UC increases with
duration and extent of disease. For patients with pancolitis, the
risk of cancer rises 0.5 to 1% per year after 8 to 10 years of disease. This
observed increase in cancer rates has led to the endorsement of surveillance
colonoscopy with biopsies for patients with chronic UC as the standard of care.
Annual or biennial colonoscopy with multiple biopsies has been advocated for
patients with >8 to 10 years of pancolitis or 12 to 15 years of left-sided
colitis and has been widely employed to screen and survey for subsequent
dysplasia and carcinoma.
CROHN'S DISEASE
Risk factors for developing colorectal cancer in CD are a history of
colonic (or ileocolonic) involvement and long disease duration. The cancer
risks in CD and UC are probably equivalent for similar extent and duration of
disease. In patients with extensive.
Crohn's colitis, 22% developed dysplasia or cancer by
the fourth surveillance exam after a negative screening colonoscopy. Thus, the
same endoscopic surveillance strategy used for UC is recommended for patients
with chronic Crohn's colitis. A pediatric colonoscope can be used to pass
narrow strictures in CD patients, but surgery should be considered in
symptomatic patients with impassable strictures.
MANAGEMENT OF DYSPLASIA AND CANCER
Dysplasia can be flat or polypoid. If flat high-grade
dysplasia (HGD) is encountered on colonoscopic surveillance, the usual
treatment for UC is colectomy and for CD is either colectomy or segmental resection.
If flat low-grade dysplasia (LGD) is found, most investigators recommend immediate
colectomy. Adenomas may occur coincidently in UC and CD patients with chronic
colitis and can be removed endoscopically provided that biopsies of the
surrounding mucosa are free of dysplasia.
IBD patients are also at greater risk for other
malignancies. Patients with CD may have an increased risk of developing
non-Hodgkin's lymphoma and squamous cell carcinoma of the skin. Although CD
patients have a twelvefold increased risk of developing small-bowel cancer,
this type of carcinoma is extremely rare.
QUALITY OF LIFE IN INFLAMMATORY BOWEL DISEASE
The assessment of health-related quality of life plays
an important role in the evaluation and treatment of IBD patients. Although
clinical trials have generally relied upon traditional disease activity indices
such as the Crohn's Disease Activity Index (CDAI) to measure therapeutic efficacy,
these measures do not reflect quality of life. The Inflammatory Bowel Disease
Questionnaire (IBDQ) is a validated, disease-specific instrument that has been
used to measure quality of life. It is a 32-item questionnaire that measures
global function, systemic and bowel symptoms, functional and social impairment,
and emotional function. When compared to the general population, IBD patients
have an impaired quality of life in all six categories. The most frequent
concerns of UC patients are having an ostomy bag, developing cancer, effects of
medication, the uncertain nature of the disease, and having surgery. The most
frequent concerns of CD patients are the uncertain nature of the disease,
energy level, effects of medication, having surgery, and having an ostomy bag.