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IBD encompasses ulcerative colitis (UC) & Crohn's disease (CD)

  • UC: inflammation of colonic mucosa; rectum (proctitis) → may extend contiguously as far as colon; unknown etiology; usual onset in mid-20s, ↑ risk Caucasians, Ashkenazi Jews, genetic link, association with isotretinoin use (Am J Gastroenterol 2010;105:1986); tobacco use protective (N Engl J Med 1987;316:707); colon cancer risk highest with pancolitis
    • Inflammation may penetrate colonic musculature → toxic megacolon → colonic perforation → peritonitis
  • CD: transmural inflammation; can encompass entire GI tract, not always contiguous; ↑ risk Caucasians, Ashkenazi Jews, smoking; colon has “cobblestone” appearance, ulcers & fissures
    • Perianal fissures, perirectal abscess in up to 33% of patients; fistulas → perianal, enteroenteric, enterocutaneous, rectovaginal, enterovesicular
    • Ileitis in 30% of pts → ↑ risk for B12 deficiency

  • Labs: acute phase reactants (ESR, CRP, platelets) typically ↑; anemia & hypoalbuminemia common; ASCA & pANCA have very low sensitivity, high specificity for IBD; in combination may differentiate between UC & CD: pANCA+/ASCA– 98% specific for UC (Am J Gastroenterol 2001;96:730); ASCA+/pANCA- 93% specific for CD (J Gastroenterol 2006;101:2410)
  • Because of overlapping characteristics, a definitive diagnosis of UC or CD is not always possible

Table 13-1 Signs/Symptoms of Inflammatory Bowel Disease

Two distinctly different approaches to therapy; step-up → begin with most benign therapy, then intensify if no results; step-down strategy → initiate potent therapies with the goal of quick disease control/remission, then step-down once disease is under control

  • UC—distal disease (below splenic flexure) is accessible by topical therapies; proximal disease requires systemic treatment
    • Proctitis & left-sided UC: topical steroids ± PO aminosalicylate, topical mesalamine → better response & remission vs topical steroids or PO therapy (Inflamm Bowel Dis 2006;12:979), topical + oral mesalamine superior (faster response, remission) than either alone (Am J Gastroenterol 1997;92:1867)
    • Colitis (above splenic flexure): PO sulfasalazine or 5-ASA; PO steroids if ...

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