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inflammatory bowel disease

A term used in reference to: 1) ulcerative colitis 2) Crohn's disease 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: 1) commonly classified as autoimmune disease 2) role for Mycobacterium avium paratuberculosis? 3) childhood anti-anaerobic antibiotic exposure [7] 4) gliptin use as risk factor ? [27] Epidemiology: 1) combined prevalence of 200 to 300 per 100,000 2) prevalence is increased in individuals with other autoimmune diseases, particularly ankylosing spondylitis, psoriasis, sclerosing cholangitis, & multiple sclerosis Pathology: 1) chronic relapsing intestinal inflammation 2) both diseases include extraintestinal inflammation of the skin, eyes, or joints 3) up-regulation inflammatory molecules: REG4 4) 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] - hepatitis A serology - hepatitis B serology - hepatitis C serology - HIV1 serology - Epstein-Barr virus serology - cytomegalovirus serology - varicella-zoster virus serology - measles virus serology - papillomavirus DNA in urine - 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 - 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] Special laboratory: - colonoscopy a) advised within 8-10 years of IBD onset; b) high-definition colonoscopy favored over standard definition [14] c) routine performance of chromoendoscopy during IBD surveillance is recommended as an adjunct to high-definition colonoscopy [14] d) narrowband imaging is not a replacement for high-definition, white-light colonoscopy or chromoendoscopy [14] e) no specific recommendation on performance of random biopsies [14] f) after 2 negative scopes, screening intervals of 1-3 years g) 1-2 years after initial endoscopy for more extensive or left-sided colitis h) 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] i) 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] i) reduces colorecal cancer risk by 35% [13] Radiology: - radiographs of LS spine for back pain - MRI of sacroiliac joints if radiograph normal Complications: 1) increased risk of colon cancer - additional risk factors - disease duration - extensive disease - primary sclerosing cholangitis - family history of colorectal cancer [3] 2) increased risk of oral cancer (9-12 fold) [15] 3) increased risk for cervical cancer [1] 4) 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] 5) increased risk of venous thromboembolism [1,4] - LMW for DVT prophylaxis despite active bleeding [1] - risk for DVT is highest at the time of flare [1] 6) C difficile colitis (without recent antibiotics) [1] 7) enteropathic arthritis - sacroiliitis (20%) affected more often than lumbar spine - ankylosing spondylitis - peripheral arthritis 8) increased risk for cardiovascular events [29] 9) increased risk for type 2 diabetes mellitus (RR=1.54) [29] 10) 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: - sulfasalazine, azathioprine, methotrexate, TNF-alpha inhibitors, glucocorticoids [1,36] - 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]

Interactions

disease interactions

Related

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)

Specific

Crohn's disease; terminal ileitis; regional enteritis; granulomatous enteritis; chronic cicatrizing enteritis inflammatory bowel disease in pregnancy ulcerative colitis (UC)

General

autoimmune disease chronic gastrointestinal disease chronic inflammation intestinal disease

Database Correlations

OMIM correlations

References

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  2. Prescriber's Letter 12(9): 2005 Drug Therapy for Ulcerative colitis Detail-Document#: 211112 (subscription needed) http://www.prescribersletter.com
  3. 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 PMID: 20141809 http://www.gastrojournal.org/article/S0016-5085(09)02202-1/fulltext corresponding NGC guideline withdrawn Dec 2015
  4. 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: 20149425 - Nguyen GC and Yeo EL. Prophylaxis of venous thromboembolism in IBD. Lancet 2010 Feb 20; 375:616. PMID: 20149426
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