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KEY CONCEPTS

KEY CONCEPTS

  • imageThe exact cause of inflammatory bowel disease (IBD) is unknown. Proposed causes include infectious, genetic, and environmental factors, as well as immune dysregulation.

  • imageUlcerative colitis (UC) is confined to the rectum and colon, causes continuous lesions, and affects primarily the mucosa and the submucosa. Crohn’s disease (CD) can involve any part of the GI tract, often causes discontinuous (skip) lesions, and is a transmural process that can result in fistulas, perforations, or strictures.

  • imageCommon GI complications of IBD include rectal fissures, fistulas (CD), perirectal abscess (UC), toxic megacolon (UC), and colon cancer. Extraintestinal manifestations include hepatobiliary complications, arthritis, uveitis, skin lesions (including erythema nodosum and pyoderma gangrenosum), osteoporosis, anemia, and aphthous ulcerations of the mouth.

  • imageThe severity of UC may be assessed by stool frequency, presence of blood in stool, fever, pulse, hemoglobin, erythrocyte sedimentation rate (ESR), C-reactive protein (CRP), abdominal tenderness, and radiologic or endoscopic findings. The severity of CD can be assessed using similar parameters, in addition to the CD Activity Index, which includes stool frequency, presence of blood in stool, endoscopic appearance, and physician’s global assessment.

  • imageThe goals of IBD treatment are resolution of acute inflammation and complications, alleviation of systemic manifestations, maintenance of remission, and improvement in quality of life (QOL).

  • imageThe first line of treatment for mild to moderate extensive UC consists of oral aminosalicylates (ASAs) with oral controlled release budesonide or prednisone as an alternative. Mesalamine enemas or suppositories are preferred for distal disease. Mesalamine is less effective for CD. Controlled-release budesonide or a tapering course of prednisone with or without azathioprine is preferred as a first-line agent for mild to moderate CD confined to the terminal ileum and/or ascending colon. Patients with more diffuse disease can be managed by a tapering course of prednisone with or with azathioprine.

  • imageSystemic corticosteroids are often required for acute UC or CD. The duration of steroid use should be minimized and the dose tapered gradually over 3 to 4 weeks if possible.

  • imageInfliximab, adalimumab, golimumab, and vedolizumab are treatment options for high risk or moderate to severe active UC in outpatients and for those patients with UC who are corticosteroid dependent. Azathioprine or mercaptopurine may be used for maintenance of remission in UC as an alternative to or in combination with tumor necrosis factor-alpha (TNF-α) inhibitors, and in patients failing ASAs or with corticosteroid dependency. Vedolizumab with or without an immunomodulator may also be used as intial therapy or for patients failing TNF-α inhibitors. Tofacitinib is used for patients with moderate to severe UC who have failed TNF-α inhibitors.

  • imageIV continuous infusion of cyclosporine or infliximab may be effective in treating severe colitis that is refractory to corticosteroids as an option to delay or prevent the need for surgery.

  • imageAminosalicylates may prevent recurrence of acute UC in many patients, while corticosteroids are ineffective for this purpose.

  • imageTreatments for for high risk or moderate to severe CD include infliximab, adalimumab, certolizumab, and vedolizumab. Methotrexate, ...

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