inflammatory bowel disease
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Introduction
A term used in reference to:
In approximately 10% of cases confined to the rectum & colon, definitive classification of Crohn disease or ulcerative colitis cannot be made & are designated 'indeterminate colitis.'
Etiology
- commonly classified as autoimmune disease
- role for Mycobacterium avium paratuberculosis?
- childhood anti-anaerobic antibiotic exposure[7]
- gliptin use as risk factor ?[27]
Epidemiology
- combined prevalence of 200 to 300 per 100,000
- prevalence is increased in individuals with other autoimmune diseases, particularly ankylosing spondylitis, psoriasis, sclerosing cholangitis, & multiple sclerosis
Pathology
- chronic relapsing intestinal inflammation
- both diseases include extraintestinal inflammation of the skin, eyes, or joints
- up-regulation inflammatory molecules: REG4
- when dysplasia is detected, it should be characterized as endoscopically resectable or nonendoscopically resectable[14]
Genetics
- genetic loci for IBD include:
- IBD1 (266600) chromosome 16p12-q13, SLC22A4, NOD2
- IBD2 (601458) chromosome 12p13.2-q24.1
- IBD3 (604519) chromosome 6p
- IBD4 (606675) chromosome 14q11-q12
- IBD5 (606348) chromosome 5q31
- IBD6 (606674) chromosome 19p13
- IBD7 (605225) chromosome 1p36
- IBD8 (606668) chromosome 16p
- IBD10 (611081) ATG16L1
Laboratory
- complete blood count (CBC)
- mild anemia
- thrombocytosis
- serum albumin may be low
- erythrocyte sedimentation rate elevated
- screening for viral infection & before or during immunosuppressive therapy[31]
- screening for tuberculosis
- low serum 25-OH vitamin D common & associated with higher morbidity & disease severity[23]
- intensive monitoring of drug levels has not been shown to improve patient outcomes compared with empiric dosage adjustments[24]
- despite this many authors recommend monitoring plasma drug & drug antibody levels[24]
- consider therapeutic drug monitoring for patients on TNF-alpha inhibitor[25]
- suggested through levels
- infliximab in serum: >= 5 ug/mL
- adalimumab in serum: >= 7.5 ug/mL
- certolizumab in serum: >= 20 ug/mL
- suggested through levels
- no recommendations for patients with quiescent disease on TNF-alpha inhibitor[25]
- routine testing for thiopurine methyltransferase in blood vs thiopurine methyltransferase in erythrocytes prior to initiation of thiopurine
- monitor complete blood count when thiopurine used[25]
- target 6-thioguanine in erythrocytes 230-450 (units not specified)[25]
- no need to meausure in quiescent disease[25]
- see ARUP consult[5]
Diagnostic procedures
- colonoscopy
- advised within 8-10 years of IBD onset;
- high-definition colonoscopy favored over standard definition[14]
- routine performance of chromoendoscopy during IBD surveillance is recommended as an adjunct to high-definition colonoscopy[14]
- narrowband imaging is not a replacement for high-definition, white-light colonoscopy or chromoendoscopy[14]
- no specific recommendation on performance of random biopsies[14]
- after 2 negative scopes, screening intervals of 1-3 years
- 1-2 years after initial endoscopy for more extensive or left-sided colitis
- polypectomy & continued surveillance recommended for adenoma-like dysplasia-associated lesion or mass with no evidence of other flat dysplasia
- after complete removal of endoscopically resectable polypoid or nonpolypoid dysplasia, surveillance colonoscopy is recommended rather than colectomy[14]
- for patients with endoscopically invisible dysplasia (confirmed by a GI pathologist), referral is suggested to an endoscopist with expertise in IBD surveillance using chromoendoscopy with high-definition colonoscopy[14]
- reduces colorecal cancer risk by 35%[13]
Radiology
- radiographs of LS spine for back pain
- MRI of sacroiliac joints if radiograph normal
Complications
- increased risk of colon cancer
- additional risk factors
- disease duration
- extensive disease
- primary sclerosing cholangitis
- family history of colorectal cancer[3]
- additional risk factors
- increased risk of oral cancer (9-12 fold)[15]
- increased risk for cervical cancer[1]
- children with inflammatory bowel disease have increased risk of cancer in childhood & adulthood[26]
- risk highest for liver cancer, colorectal cancer, small intestinal cancer, nonmelanoma skin cancer, & lymphoma/lymphocytic leukemia[26]
- therapy has not reduced risk of cancer[26]
- increased risk of venous thromboembolism[1][4]
- C difficile colitis (without recent antibiotics)[1]
- enteropathic arthritis
- sacroiliitis (20%) affected more often than lumbar spine
- ankylosing spondylitis
- peripheral arthritis
- increased risk for cardiovascular events[29]
- increased risk for type 2 diabetes mellitus (RR=1.54)[29]
- increased risk of shingles[32]
Differential diagnosis
- irritable bowel syndrome: non-bloody diarrhea, no anemia, no weight loss
- Meckel's diverticulum: generally painless rectal bleeding
- microscopic colitis: non-bloody diarrhea
- celiac disease: diarrhea & anemia, but rectal bleeding is uncommon[33]
Management
- see ulcerative colitis &/or Crohn's disease
- colectomy is advised for patients with non-adenoma-like dysplasia-associated lesion or mass[3]
- extraintestinal manifestations of inflammatory bowel disease typically resolve with treatment of the underlying inflammatory bowel disease[1]
- pharmaceuticals that treat both inflammatory bowel disease & enteropathic arthritis include:
- vaccines
- pneumococcal vaccine prior to immunosuppressive therapy if possible
- seasonal influenza vaccine
- avoid live virus vaccines with immunosuppressive therapy
- delay live virus vaccination 1-6 months after discontinuation of immunosuppressive therapy
- Shingrix vaccine recommended
- infectious diseases
- discontinue immunosuppressive therapy if disseminated CMV infection[31]
- chemoprophylaxis after Pneumocystis jirovecii infection[31]
- dietary recommendations:[30]
- avoid emulsifiers & thickeners (carrageenan & processed foods containing titanium dioxide & sulfites
- avoid trans fats
- avoid foods containing maltodextrin & artificial sweeteners
- avoid unpasteurized dairy products
- see recommendations specific for ulcerative colitis & Crohn's disease[30]
More general terms
More specific terms
- Crohn's disease; terminal ileitis; regional enteritis; granulomatous enteritis; chronic cicatrizing enteritis
- inflammatory bowel disease in pregnancy
- ulcerative colitis (UC)
Additional terms
- distinguishing features of ulcerative colitis vs Crohn's disease
- enteropathic arthritis; inflammatory bowel-associated arthritis
- solute carrier family 22 member 4 (SLC22A4, organic cation/carnitine transporter 1, ergothioneine transporter, ET transporter, ETT, OCTN1, UT2H)
References
- ↑ 1.0 1.1 1.2 1.3 1.4 1.5 1.6 1.7 Medical Knowledge Self Assessment Program (MKSAP) 15, 16, 17, 18, 19. American College of Physicians, Philadelphia 2009, 2012, 2015, 2018, 2021.
Medical Knowledge Self Assessment Program (MKSAP) 19 Board Basics. An Enhancement to MKSAP19. American College of Physicians, Philadelphia 2022 - ↑ Prescriber's Letter 12(9): 2005 Drug Therapy for Ulcerative colitis Detail-Document#: http://prescribersletter.com/(5bhgn1a4ni4cyp2tvybwfh55)/pl/ArticleDD.aspx?li=1&st=1&cs=&s=PRL&pt=3&fpt=25&dd=211112&pb=PRL (subscription needed) http://www.prescribersletter.com
- ↑ 3.0 3.1 3.2 Farraye FA et al AGA Medical Position Statement on the Diagnosis and Management of Colorectal Neoplasia in Inflammatory Bowel Disease. Gastroenterology 2010, 138(2):738-745 <PubMed> PMID: https://www.ncbi.nlm.nih.gov/pubmed/20141809 <Internet> http://www.gastrojournal.org/article/S0016-5085(09)02202-1/fulltext corresponding NGC guideline withdrawn Dec 2015
- ↑ 4.0 4.1 Grainge MJ et al. Venous thromboembolism during active disease and remission in inflammatory bowel disease: A cohort study. Lancet 2010 Feb 20; 375:657. PMID: https://www.ncbi.nlm.nih.gov/pubmed/20149425
Nguyen GC and Yeo EL. Prophylaxis of venous thromboembolism in IBD. Lancet 2010 Feb 20; 375:616. PMID: https://www.ncbi.nlm.nih.gov/pubmed/20149426 - ↑ 5.0 5.1 ARUP Consult: Inflammatory Bowel Disease - IBD The Physician's Guide to Laboratory Test Selection & Interpretation https://www.arupconsult.com/content/inflammatory-bowel-disease
- ↑ Medical position statement on corticosteroids, immunomodulators, and infliximab in inflammatory bowel disease. American Gastroenterological Association Institute (AGAI) http://www.gastrojournal.org/content/aga
- ↑ 7.0 7.1 Kronman MP et al. Antibiotic exposure and IBD development among children: A population-based cohort study. Pediatrics 2012 Oct; 130:e794 PMID: https://www.ncbi.nlm.nih.gov/pubmed/23008454
Shaw SY et al. Association between early childhood otitis media and pediatric inflammatory bowel disease: An exploratory population-based analysis. J Pediatr 2012 Oct 19 <PubMed> PMID: https://www.ncbi.nlm.nih.gov/pubmed/23084703 <Internet> http://www.jpeds.com/article/S0022-3476(12)00995-X/abstract - ↑ Melmed GY. Vaccination strategies for patients with inflammatory bowel disease on immunomodulators and biologics. Inflamm Bowel Dis. 2009 Sep;15(9):1410-6. PMID: https://www.ncbi.nlm.nih.gov/pubmed/19462435
- ↑ Farraye FA, Odze RD, Eaden J, Itzkowitz SH. AGA technical review on the diagnosis and management of colorectal neoplasia in inflammatory bowel disease. Gastroenterology. 2010 Feb;138(2):746-74, 774.e1-4 PMID: https://www.ncbi.nlm.nih.gov/pubmed/20141809
- ↑ Ardizzone S, Puttini PS, Cassinotti A, Porro GB. Extraintestinal manifestations of inflammatory bowel disease. Dig Liver Dis. 2008 Jul;40 Suppl 2:S253-9 PMID: https://www.ncbi.nlm.nih.gov/pubmed/18598997
- ↑ Farraye FA, Odze RD, Eaden J et al AGA medical position statement on the diagnosis and management of colorectal neoplasia in inflammatory bowel disease. Gastroenterology. 2010 Feb;138(2):738-45. PMID: https://www.ncbi.nlm.nih.gov/pubmed/20141808 corresponding NGC guideline withdrawn Dec 2015
- ↑ Larsen S, Bendtzen K, Nielsen OH. Extraintestinal manifestations of inflammatory bowel disease: epidemiology, diagnosis, and management. Ann Med. 2010 Mar;42(2):97-114 PMID: https://www.ncbi.nlm.nih.gov/pubmed/20166813
- ↑ 13.0 13.1 Ananthakrishnan AN et al. Colonoscopy is associated with a reduced risk for colon cancer and mortality in patients with inflammatory bowel diseases. Clin Gastroenterol Hepatol 2014 Jul 17 <PubMed> PMID: https://www.ncbi.nlm.nih.gov/pubmed/25041865 <Internet> http://www.cghjournal.org/article/S1542-3565%2814%2901047-7/abstract
- ↑ 14.0 14.1 14.2 14.3 14.4 14.5 14.6 14.7 Laine L et al. SCENIC international consensus statement on surveillance and management of dysplasia in inflammatory bowel disease. Gastrointest Endosc 2015 Mar; 81:489 <PubMed> PMID: https://www.ncbi.nlm.nih.gov/pubmed/25708752 <Internet> http://www.giejournal.org/article/S0016-5107%2814%2902578-4/abstract
- ↑ 15.0 15.1 Katsanos KH et al. Increased risk of oral cancer in patients with inflammatory bowel diseases. Clin Gastroenterol Hepatol 2015 Oct 20; S1542-3565(15)01417-2 PMID: https://www.ncbi.nlm.nih.gov/pubmed/26499929
- ↑ Ng SW, Mahadevan U Management of inflammatory bowel disease in pregnancy. Expert Rev Clin Immunol. 2013 Feb;9(2):161-73 PMID: https://www.ncbi.nlm.nih.gov/pubmed/23390947
- ↑ Lakatos PL, Lakatos L, Kiss LS et al Treatment of extraintestinal manifestations in inflammatory bowel disease. Digestion. 2012;86 Suppl 1:28-35 PMID: https://www.ncbi.nlm.nih.gov/pubmed/23051724
- ↑ Collins PD Strategies for detecting colon cancer and dysplasia in patients with inflammatory bowel disease. Inflamm Bowel Dis. 2013 Mar-Apr;19(4):860-3. PMID: https://www.ncbi.nlm.nih.gov/pubmed/23446340
- ↑ Talley NJ, Abreu MT, Achkar JP et al An evidence-based systematic review on medical therapies for inflammatory bowel disease. Am J Gastroenterol. 2011 Apr;106 Suppl 1:S2-25; Review. PMID: https://www.ncbi.nlm.nih.gov/pubmed/21472012
- ↑ Perez-Alamino R, Maldonado-Ficco H, Maldonado-Cocco JA. Rheumatic manifestations in inflammatory bowel diseases: a link between GI and rheumatology. Clin Rheumatol. 2016 Feb;35(2):291-6. PMID: https://www.ncbi.nlm.nih.gov/pubmed/26573206
- ↑ Bandinelli F, Manetti M, Ibba-Manneschi L. Occult spondyloarthritis in inflammatory bowel disease. Clin Rheumatol. 2016 Feb;35(2):281-9. PMID: https://www.ncbi.nlm.nih.gov/pubmed/26354428
- ↑ Oikonomou KA, Kapsoritakis AN, Stefanidis I, Potamianos SP. Drug-induced nephrotoxicity in inflammatory bowel disease. Nephron Clin Pract. 2011;119(2):c89-94; Review. PMID: https://www.ncbi.nlm.nih.gov/pubmed/21677443 Free Article
- ↑ 23.0 23.1 Kabbani TA, Koutroubakis IE, Schoen RE et al Association of Vitamin D Level With Clinical Status in Inflammatory Bowel Disease: A 5-Year Longitudinal Study. Am J Gastroenterol. 2016 May;111(5):712-9. PMID: https://www.ncbi.nlm.nih.gov/pubmed/26952579
- ↑ 24.0 24.1 24.2 Colombel JF, Narula N, Peyrin-Biroulet L. Management Strategies to Improve Outcomes of Patients with Inflammatory Bowel Diseases. Gastroenterology. 2016 Oct 5. PMID: https://www.ncbi.nlm.nih.gov/pubmed/27720840
- ↑ 25.0 25.1 25.2 25.3 25.4 25.5 Feuerstein JD, Nguyen GC, Kupfer SS, Falck-Ytter Y, Singh S; American Gastroenterological Association Clinical Guidelines Committee. Therapeutic drug monitoring in inflammatory bowel disease. Gastroenterology 2017 Aug 02 PMID: https://www.ncbi.nlm.nih.gov/pubmed/28780013
- ↑ 26.0 26.1 26.2 26.3 Olen O, Askling J, Sachs MC et al Childhood onset inflammatory bowel disease and risk of cancer: a Swedish nationwide cohort study 1964-2014. BMJ 2017;358:j3951 <PubMed> PMID: https://www.ncbi.nlm.nih.gov/pubmed/28931512 <Internet> http://www.bmj.com/content/358/bmj.j3951
Editorial Increased risk of cancer in children with inflammatory bowel disease. BMJ 2017;358:j4285 <PubMed> PMID: https://www.ncbi.nlm.nih.gov/pubmed/28931516 <Internet> http://www.bmj.com/content/358/bmj.j4285 - ↑ 27.0 27.1 Abrahami D, Douros A, Yin H, et al Dipeptidyl peptidase-4 inhibitors and incidence of inflammatory bowel disease among patients with type 2 diabetes: population based cohort study. BMJ 2018;360:k872 <PubMed> PMID: https://www.ncbi.nlm.nih.gov/pubmed/29563098 <Internet> http://www.bmj.com/content/360/bmj.k872
- ↑ Lee JM, Lee KM. Endoscopic Diagnosis and Differentiation of Inflammatory Bowel Disease. Clin Endosc. 2016 Jul;49(4):370-5. Review. PMID: https://www.ncbi.nlm.nih.gov/pubmed/27484813 Free PMC Article
- ↑ 29.0 29.1 29.2 Jess T, Jensen BW, Andersson M, Villumsen M, Allin KH. Inflammatory bowel disease increases risk of type 2 diabetes in a nationwide cohort study. Clin Gastroenterol Hepatol 2019 Aug 5 PMID: https://www.ncbi.nlm.nih.gov/pubmed/31394285 https://www.cghjournal.org/article/S1542-3565(19)30841-9/pdf
- ↑ 30.0 30.1 Levine A, Rhodes JM, Lindsay JO et al. Dietary guidance for patients with inflammatory bowel disease from the international organization for the study of inflammatory bowel disease. Clin Gastroenterol Hepatol 2020 Feb 14 PMID: https://www.ncbi.nlm.nih.gov/pubmed/32068150 https://www.cghjournal.org/article/S1542-3565(20)30185-3/pdf
- ↑ 31.0 31.1 31.2 31.3 European Crohn's and Colitis Organisation Infections in Inflammatory Bowel Disease Clinical Practice Guidelines (ECCO, 2021). Medscape. August 10, 2021 https://reference.medscape.com/viewarticle/956233
- ↑ 32.0 32.1 Rowe WA, Anand BS Inflammatory Bowel Disease. Medscape. April 10, 2020 https://emedicine.medscape.com/article/179037-overview
- ↑ 33.0 33.1 NEJM Knowledge+ Gastroenterology
- ↑ Mozdiak E, O'Malley J, Arasaradnam R. Inflammatory bowel disease. BMJ. 2015 Sep 24;351:h4416. PMID: https://www.ncbi.nlm.nih.gov/pubmed/26403642
- ↑ Rogler G, Singh A, Kavanaugh A, Rubin DT. Extraintestinal Manifestations of Inflammatory Bowel Disease: Current Concepts, Treatment, and Implications for Disease Management. Gastroenterology. 2021 Oct;161(4):1118-1132 PMID: https://www.ncbi.nlm.nih.gov/pubmed/34358489 PMCID: PMC8564770 Free PMC article
- ↑ 36.0 36.1 NEJM Knowledge+ Complex Medical Care
Ananthakrishnan AN, Nguyen GC, Bernstein CN AGA Clinical Practice Update on Management of Inflammatory Bowel Disease in Elderly Patients: Expert Review. Gastroenterology. 2021 Jan;160(1):445-451. PMID: https://www.ncbi.nlm.nih.gov/pubmed/33011177 Review.
Patient information
inflammatory bowel disease patient information
Database
- OMIM: https://mirror.omim.org/entry/266600
- OMIM: https://mirror.omim.org/entry/601458
- OMIM: https://mirror.omim.org/entry/604519
- OMIM: https://mirror.omim.org/entry/606675
- OMIM: https://mirror.omim.org/entry/606348
- OMIM: https://mirror.omim.org/entry/606674
- OMIM: https://mirror.omim.org/entry/605225
- OMIM: https://mirror.omim.org/entry/606668
- OMIM: https://mirror.omim.org/entry/611081