Inflammatory Bowel Disease (IBD)

Notes

## Basic introduction

  • IBD is a group of idiopathic chronic inflammatory intestinal conditions.
  • The pathogenesis of IBD is not fully understood.
  • Crohn's disease (CD) and ulcerative colitis are (UC) the most common and important members of IBD.
  • Other forms of IBD that occur generally in very few incidences include collagenous colitis, lymphocytic colitis, Diversion colitis, Behçet's disease, and indeterminate colitis.
  • Ulcerative colitis mainly affects the colon and the rectum while Crohn's disease affects the small intestine, large intestine, mouth, esophagus, stomach, and the anus areas.

## Predisposing factors to IBD include:

  • Genetic disorder (affecting immune system).
  • Immune system disorder
  • Environmental factors such as human gut microbiota, foods, smoke, and chemical contamination

## Statistics

  • In the USA 1-1.3 million people suffer from IBD
  • The prevalence of IBD in industrialized countries is > in developing countries.
Symptoms

## Intestinal presentations

  • Diarrhea with blood and/or mucus
  • Nausea and vomiting (in CD > UC)
  • Pain or rectal bleeding with bowel movement
  • Abdominal pain

## General symptoms

  • Fever
  • Weight loss
  • Fatigue
  • Night sweats
  • Growth retardation
  • Primary amenorrhea
  • Ulcers

## Extraintestinal presentations

  • Peripheral or axial arthropathy
  • Erythema nodosum
  • Pyoderma gangrenosum
  • Scleritis
  • Episcleritis
  • Uveitis

## Complications of IBD

  • Fistulas and perianal disease
  • Hemorrhage
  • Bowel perforation
  • Proximal gastrointestinal involvement
  • Malignancy
  • Toxic megacolon
Diagnosis
  • Clinical review
  • Stool examination - routine tests but the following can be included: occult blood or fecal leukocytes, lactoferrin and α1-antitrypsin (to rule out inflammation), and when resources are available, rapid fecal calprotectin tests (diagnostic)
  • CBC
  • ESR
  • TB test (for exclusion)
  • HIV testing
  • Endoscopy & biopsy
  • Abdominal X-ray
  • Sigmoidoscopy/colonoscopy
Differential
  • Complications of AIDS
  • Irritable Bowel Syndrome
  • Lactose Intolerance
  • Anorexia Nervosa
  • Intestinal tuberculosis
  • Salmonellosis
  • Viral Gastroenteritis
  • Appendicitis
  • Bacterial Gastroenteritis
  • Bulimia Nervosa
  • Malignancy
  • NSAID enteropathy
  • Celiac Disease (Sprue)
  • Clostridium Difficile Colitis
  • Collagenous and Lymphocytic Colitis
  • Ischemic colitis
  • Cytomegalovirus Colitis
  • Diverticulitis
  • Giardiasis
  • Intestinal Motility Disorders
Prevention
  • None is known so far
Reference

1. Kenyan Ministry of Health. Clinical guidelines for management and referral of common conditions at levels 4-6. Hospitals. 2009; 3:259-261.http://apps.who.int/medicinedocs/documents/s21000en/s21000en.pdf

2. Ministry of Health, Kenya. Kenya Essential Medicine List (2016). http://publications.universalhealth2030.org/uploads/KEML-2016Final-1.pdf

3. Kappelman MD, Rifas-Shiman SL, Kleinman K, Ollendorf D, Bousvaros A, Grand RJ, Finkelstein JA. The prevalence and geographic distribution of Crohn's disease and ulcerative colitis in the United States. Clin Gastroenterol Hepatol. 2007; 5:1424-9

4. World Gastroenterology Organisation Global Guidelines.(2017). Inflammatory Bowel Disease. http://www.worldgastroenterology.org/guidelines/global-guidelines/inflammatory-bowel-disease-ibd/inflammatory-bowel-disease-ibd-english

Management

## Patient education

  • To educate the patient about the diseases and its management

## Diet and lifestyle

  • Decrease the fiber intake when the disease is active (diarrhea) and increase in case of constipation
  • Low FODMAP diet (diet low in fermentable oligosaccharides, disaccharides, and monosaccharides and polyols)
  • Smoking cessation
  • Stress management

## Aminosalicylates

  • These have anti-inflammatory effects
  • They include the following: sulfasalazine, mesalamine, olsalazine, and mesalazine
  • They are beneficial in treatment of colitis flare-ups and maintenance of remission
  • Patients on sulfasalazine will need folic acid.
  • The dose range for aminosalicylates is 2.0 - 4.8 g/day for active disease, ≥ 2 g/day for maintenance.

## Corticosteroids

  • They include the following: methylprednisolone (IV), hydrocortisone (IV), prednisone (oral), prednisolone (oral), budesonide (oral), and dexamethasone (oral). Suppository and enema are also available for UC.
  • They are useful for suppression of inflammation and rapid relief of symptoms of IBD but they should not be used for maintenance of remission (due to their side effects).
  • They should be used with calcium and vitamin D supplement

## Immune Modifiers

  • Thiopurines (azathioprine and mercaptopurine) are NOT by themselves useful in inducing remission of IBD but are effective for maintenance of remission induced by corticosteroids. Azathioprine is the most affordable immune modifiers. Thiopurines are contraindicated in patients with deficiency of Thiopurine Methyltransferase Activity (TPMT).
  • Calcineurin inhibitors (cyclosporine A and tacrolimus) are reserved for the severe IBD that is resistant to other treatments. Both cyclosporine A and tacrolimus are useful in UC while tacrolimus is useful in CD.
  • Methotrexate is indicated for induction of remission of CD and for maintenance of remission induced by corticosteroids especially in patients who cannot tolerate azathioprine or mercaptopurine or those in whom TPMT activity is deficient.
  • Anti-tumor necrosis factor (anti-TNF) agents (such as infliximab and adalimumab) may be a preferred first-line therapy in patients with severe disease and in those with perianal CD.
  • Adhesion molecule antagonists such as vedolizumab are expected to play a key role in the management of IBD in future.
  • Antimicrobials, mainly metronidazole and ciprofloxacin, are used to treat CD complications such as perianal disease, fistulas and bacterial overgrowth in the setting of strictures).
  • Symptomatic therapy and supplements such as loperamide, cholestyramine, paracetamol, and routine vitamin D and calcium supplements (for corticosteroid users)
  • Surgery will be required by 70–75% of CD patients to relieve symptoms if drug treatment fails, or to correct complications.
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