Inflammatory Bowel Disease

Emily Poellinger

Krissie Lobon

Background

  • Ulcerative colitis (UC): colon only (can have backwash ileitis) and almost always involves the rectum; contiguous lesions; mucosal inflammation
  • Crohn’s disease (CD): any part of the GI tract; “skip lesions”; transmural inflammation
  • Important historical considerations to include in your documentation and presentation:
    • Location of disease (CD: LB/SB, LB only, SB only; UC: proctitis, left-sided or pancolitis)
    • Complications: Fistulas, sinus tracts, strictures, perianal disease, microperforation (more commonly in CD)
    • Include previous endoscopy and imaging findings; current and prior IBD treatment and reason for transition (SEs, failure), primary IBD provider

Genetics and Epidemiology

  • First-degree relatives of people with IBD are 20x more likely to be diagnosed with the condition; however, only 15% of patients with IBD have a first-degree relative with the disease
  • Genetic predisposition: CD > UC
  • The number of individuals affected by IBD across the globe has increased from 3.7 mil (1990) to 6.8 mil (2017)
  • Age of onset 15-30, though can present at any age. A bimodal age distribution with second peak between 50-80 is also seen
  • Smoking is a risk factor for CD and increases risk of complications of CD. Does not increase risk for UC.

Presentation

  • UC: frequent diarrhea (often bloody), tenesmus, urgency, abdominal pain; may have fever, malaise, symptomatic anemia, and weight loss
    • Complications: severe bleeding/anemia, fulminant colitis, toxic megacolon, perforation, colorectal cancer
  • CD: abdominal pain, nausea/vomiting, fever, malaise, weight loss; May also have diarrhea (± bloody depending on CD location)
    • Complications: fistulas (entero-enteric, entero-vesicular, entero-cutaneous, rectovaginal, perianal, retroperitoneal), abscesses, strictures, obstruction
    • Small bowel involvement (>100 cm of terminal ileum) can lead to fat malabsorption 2/2 impaired enterohepatic circulation of bile salts
  • Extra-intestinal (EI): arthritis, sacro-iliitis, uveitis, episcleritis, aphthous ulcers, erythema nodosum, pyoderma gangrenosum, PSC (esp. UC), nephrolithiasis (calcium oxalate), thromboembolism, metabolic bone disease
  • Disease severity (mild, moderate, severe) can be objectively measured using different indices, for example the Montreal classification of severity of UC is one such index that stratifies UC and CD. Crohn’s Disease Activity Index (CDAI) is also used as a grading system to describe disease activity. The frequency and severity of diarrhea, systemic symptoms, and lab abnormalities are also considerations of classification of IBD.

Ulcerative Colitis

Crohn’s Disease
Site Colon only, can have ileitis Any part of the GI tract
Distribution Diffusely throughout colon; mucosa and submucosa inflammation only Focal, “skip lesions”, transmural inflammation
Histology Crypt abscess Non-caseating granulomas
Complications Toxic megacolon, colorectal cancer Fistulas, strictures,abscesses, obstruction
Perianal disease Rare Common
Extraintestinal Manifestations Common Common

Evaluation

  • CBC w/diff, CMP, CRP, ESR, ± CMV PCR
  • If diarrhea: rule out infection with GI Pathogen panel and C. diff, consider stool cultures, O&P, CMV PCR
  • If anemic: obtain iron studies and type & screen
  • If weight loss or concern for malnutrition: albumin, pre-albumin, Vitamin D, B12, folate - Imaging:
    • CT Enterography (oral contrast) preferred in CD, for luminal/extra-luminal complications
    • How to order CTE: “CT abdomen pelvis enterography”, order barium (Volumen) 0.1% oral suspension x2, 1st dose to be given by nurse 60 min before study, 2nd study to be given 30 min before (nurse should be in contact with CT tech)
  • Endoscopy: If CD, will depend on the situation, but if acute severe UC, patient will need flex sig/colonoscopy asap (can be unprepped)

Management

Acute Flare

  • Check for infectious etiology for acute flare: Send stool for C.diff and GI pathogen panel
  • Pain control: usually a major component of hospital course
    • Avoid NSAIDs, oral pain medications are preferred
    • If pain is difficult to control, consider Acute Pain Service consult
    • Narcotics and Imodium are contraindicated in toxic megacolon
  • Antibiotics: appropriately treat infections (intra-abdominal or perianal abscess) with antibiotics (consider prior culture data, often use cipro/flagyl), but empiric antibiotics not routinely recommended otherwise
  • VTE Prophylaxis: All IBD patients, even if having blood in stool (unless requiring transfusion) as they are at much higher risk of VTE
  • Nutrition: Nutrition consult for all IBD patients; For severe malnutrition or if prolonged bowel rest is needed, TPN is sometimes initiated
  • Anemia: Ferritin <100 or iron sat <20 with ferritin <300, consider iron infusions (if no bacteremia) or transfuse for severe anemia o Smoking Cessation (esp. with CD): discuss smoking cessation & consult tobacco cessation
  • Consult Colorectal Surgery (not EGS): SBO, toxic megacolon, bowel perforation, peritonitis, fistulizing disease
  • Ensure consideration of other causes of colitis as above evaluation suggests (infectious, vascular, drug-induced)
  • of colitis as above evaluation suggests (infectious, vascular, drug-induced)

Immunosuppression

(Infections must be ruled out and/or treated before starting)

  • Steroids:
    • IV methylprednisolone (solumedrol) 30 mg BID or hydrocortisone 100 mg TID/QID for 3-5 days
    • If multiple days without improvement, IBD providers will often consider initiation of biologics/immunomodulators
    • Budesonide (Entocort): non-systemic steroid released during intestinal transit
    • Transition to oral (40 mg prednisone daily) once clinically improved/tolerating PO; typically prescribe a prolonged taper on discharge (often down by 5 mg every week)
    • If severe proctitis: consider rectal steroids (hydrocortisone enema/foam)
  • If lack of response to steroids: rescue therapy with advanced therapies (Infliximab, Cyclosporine, JAK) or surgical intervention (colectomy for UC)
    • Infliximab (Inflectra) is available at VUMC
    • If patient fails to respond to steroids, consider possibility of CMV colitis (usually evaluated by biopsy on flex sig or colonoscopy), serum CMV PCR is part of initial workup but if negative it does not rule out CMV colitis
    • Prior to initiating a biologic, all patients must have the following negative studies within the last year: Quantiferon Gold and CXR, Hepatitis B serologies, HIV, urine histoplasma Ag (some providers)
    • Colon cancer screening: IBD that involves at least 1/3 of the colon (UC or CD) is associated with increased colon cancer. Usually not doing CRC screening as an inpatient but important consideration for outpatient care

Induction and Maintenance Therapies for Remission

Mild-Moderate UC

  • Induction of Remission: Multiple agents approved – advanced therapies preferred for mild/moderate disease. PO budesonide MMX, PO steroids, anti-TNF (adalimumab, golimumab, infliximab), Anti-integrin (Vedolizumab), IL 12/23 (Ustekinumab), IL-12 (Risankizumab, mirikizumab, guselkumab), JAK inhibitors (tofacinitib, upadacinitib), S1P (ozanimod, etrazimod). Avoid monotherapy with thiopurines or methotrexate
    • When infliximab is used for induction often best to pursue combination induction with thiopurine like azathioprine
  • Maintenance Therapy:
    • If remission achieved with advanced therapy, continue for maintenance
    • Corticosteroids are not used for maintenance therapy. The goal is steroid free remission

Moderate-Severe UC

  • Induction of Remission: multiple agents approved – advanced therapies are preferred for moderate to severe disease. Anti-TNF (adalimumab, infliximab, certolizumab pegol) ± immunomodulator (azathioprine, 6-MP, methotrexate) to prevent antibody development; anti-IL 12/23 (Ustekinumab), anti-IL23 (Risankiaumb, mirikizumab, guselkumab), anti-integrin antibodies (vedolizumab, natalizumab), JAK inhibitor (Upadacitinib)
    • PO steroids for short term use to alleviate symptoms during induction
  • Maintenance Therapy: typically use the same medication used to achieve induction for maintenance and decision to discontinue immunomodulator is individualized based on disease history/complications but often it is discontinued after 12-24 months specifically for younger males, patients >60, or patients with history of recurrent nonmelanoma skin cancer
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