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Inflammatory Bowel Disease
KidsHealth>Teens>Diseases & Conditions> Digestive System> Inflammatory Bowel Disease
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What Is IBD? Who Gets IBD? What 6uuhyhigrs Do? How Is IBD Treated?
Listen
Digestive problems are among the most common conditions affecting Americans today. Thereare many different types of digestive problems, from gastrointestinal infections that make a
person miserable but pass quickly to long-term illnesses like inflammatory bowel disease (IBD).IBD is a general term that refers to illnesses that cause chronic inflammation in the intestines.
If you're having diarrhea, stomach cramps, and other symptoms that make you question yourdigestion, you might want to learn more about the digestive system and IBD, as well as other
digestive conditions.
What Is IBD?
Thedigestive systemis the set of organs that digest food and absorb the important nutrients yourbody needs to stay healthy and grow. Two of the major parts of the digestive system are the
small and large intestines. Just like other organs in your body, the intestines can develop
problems or diseases.
IBD (which is not the same thing as irritable bowel syndrome, or IBS), can cause more serious
problems than just diarrhea and pain. IBD may also cause adelay in pubertyor growth problemsfor some teens with the condition, because it can interfere with a person getting nutrients from
the foods he or she eats.
The two major types of IBD are Crohn's disease and ulcerative colitis.
Crohn's disease occurs when the lining and wall of the intestines become inflamed and ulcersdevelop. Although Crohn's disease can occur in any part of the digestive system, it often occurs
in the lower part of the small intestine where it joins the colon.
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The intestine becomes inflamed, meaning the lining of the intestinal wall reddens and swells. It
can become irritated, causing it to bleed and preventing it from properly absorbing the nutrients
from digested food.
People with Crohn's disease usually have these symptoms:
abdominal cramps or pain diarrhea, sometimes with blood in the stool (bowel movements) fever weight loss
These symptoms often cause people with Crohn's disease to feel tired and lose their appetites.
Some people with Crohn's disease have minor symptoms and hardly any discomfort or pain.
Their symptoms may only flare a few times. But others may experience frequent diarrhea,
intestinal ulcers, and problems in other parts of their bodies, such as inflammation of the joints,skin rashes, and eye problems.
Crohn's disease can cause the intestines to become blocked by swelling and scar tissue. Peoplewith the condition may also be more susceptible to infections and developing abscesses in and
around their intestines.
In ulcerative colitis, the large intestine becomes inflamed and ulcers may develop. Ulcerative
colitis affects only the large intestine. The inflammation begins in the rectum (the last few inches
of the large intestine where feces are stored before they leave the body) and can affect only therectum or the part of the large intestine that joins it. However, most kids and teens who have
ulcerative colitis have the condition throughout their large intestines.
The most common symptoms of ulcerative colitis are abdominal pain and bloody diarrhea. But
some people also experience these symptoms:
tiredness weight loss loss of appetite nausea
Some people with ulcerative colitis may have periods of time when they are free of symptoms
(this is called remission) and other times when they feel sick (called relapse).
Like Crohn's disease, ulcerative colitis can be associated with problems in other parts of the
body. These problems may include inflammation of the joints, eye problems, andanemiadue toblood loss.
Continue
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endoscopecolonoscopyupper endoscopybiopsybarium
studybariumcorticosteroidsimmunosuppressantsimmunomodulators 123
For Teens
Inflammatory Bowel DiseaseWhat is inflammatory bowel disease?
Inflammatory bowel disease is the name of a group of disorders that cause the intestines to become
inflamed (red and swollen). The inflammation lasts a long time and usually comes back over and over
again. More than 600,000 Americans have some kind of inflammatory bowel disease every year.
If you have inflammatory bowel disease, you may have abdominal cramps and pain, diarrhea, weight
loss and bleeding from your intestines. Two kinds of inflammatory bowel disease are Crohn's disease
and ulcerative colitis. Crohn's disease usually causes ulcers (open sores) along the length of the small
and large intestines. Crohn's disease either spares the rectum, or causes inflammation or infection with
drainage around the rectum. Ulcerative colitis usually causes ulcers in the lower part of the large
intestine, often starting at the rectum.
Return to top
What causes inflammatory bowel disease?
The exact causes are unknown. The disease may be caused by a germ or by an immune system problem.
You don't have to worry about your family members catching the disease from you, because it isn't
contagious. However, inflammatory bowel disease does seem to be hereditary (runs in your family).
Return to top
How is inflammatory bowel disease diagnosed?
Based on your symptoms, your doctor may suspect that you have Crohn's disease or ulcerative colitis.
Your bowel movements may be tested for germs and the presence of blood. Your doctor will probably
look inside your intestines with a sigmoidoscope or a colonoscope. In these procedures, the doctor uses
a narrow flexible tube to look directly inside your intestines. Special x-rays may be helpful in diagnosing
this illness.
Return to top
How is inflammatory bowel disease treated?
The best thing you can do is take good care of yourself. It's important to eat a healthy diet. Depending
on your symptoms, your doctor may ask you to cut down on the amount of fiber or dairy products in
your diet. In addition to eating well, you need to get enough rest. It's also important that you learn to
manage the stress in your life. When you become overly upset by things that happen at home or at
work, your intestinal problems can get worse.
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You will most likely be treated by a team of doctors. This team may include your family physician, a
gastroenterologist (a specialist in stomach and intestinal disorders) and, possibly, a surgeon.
The goal of treatment is to get rid of the inflammation. Many types of medicine can reduce
inflammation, including anti-inflammatory drugs such as sulfasalazine, corticosteroids such as
prednisone, and immune system suppressors such as azathioprine and mercaptopurine. An antibiotic,
such as metronidazole, may also be helpful for killing germs in the intestines, especially if you have
Crohn's disease.
To help treat your symptoms, your doctor may recommend anti-diarrheals, laxatives, pain relievers or
other over-the-counter (OTC) drugs. It is important to talk to your doctor before taking any OTC
medicine on your own. Your body may not be able to handle the effects of medicine. If you have severe
symptoms, such as diarrhea, fever or vomiting, you may need to go to the hospital to be treated with
special fluids and medicines that must be given intravenously (in your veins).
If your ulcerative colitis becomes so severe that it can't be helped by medicines, it may be necessary to
remove part or all of your colon surgically. Crohn's disease usually isn't helped with surgery.
Because Crohn's disease and ulcerative colitis keep coming back and their symptoms cannot be
predicted ahead of time, patients with these illnesses can become depressed. If you feel depressed, talk
with your family doctor. An antidepressant medicine could help you feel better.
Return to top
How can I get more information?By asking questions, reading informational materials and discussing your treatments with your doctor,
you'll be able to understand your illness and manage it better. Patient support groups are helpful,
especially if you have severe disease.
Return to top
Inflammatory Bowel Disease
Author: Sarvotham Kini, MD, Associate Professor of Emergency Medicine, MedicalUniversity of South Carolina, Charleston.
Contributor Information and Disclosures
Updated: Nov 20, 2009
Print This
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Overview Differential Diagnoses & Workup
Treatment & Medication Follow-up Multimedia References Keywords
Information from Industry
Bacterial RTIs: View S pneumoniae resistance mapClick on your state Consider the growing problem
of antibacterial resistance. What is the S pneumoniae resistance rate in your state? Read more
Introduction
Background
The term inflammatory bowel disease (IBD) refers to primarilyulcerative colitis(UC) andCrohn's disease(CD). These are chronic conditions of uncertain etiology, characterized by
recurrent episodes of abdominal pain, often with diarrhea. Although both ulcerative colitis and
Crohn's disease have distinct pathologic findings, a significant percentage of patients with
inflammatory bowel disease (IBD) have indeterminate findings. Crohn's disease is also referredto a regional enteritis, terminal ileitis, or granulomatous ileocolitis.
Pathophysiology
Multiple etiologies have been proposed for inflammatory bowel disease (IBD), but the precisecause is unknown. However, considerable evidence suggests that inflammatory mediators play
an important role in the pathologic and clinical characteristic of these disorders. Cytokines,
released by macrophages in response to various antigenic stimuli, bind to different receptors andproduce autocrine, paracrine, and endocrine effects. Cytokines differentiate lymphocytes into
different types of T cells. Helper T cells, type 1 (Th-1), are associated principally with Crohn's
disease, whereas Th-2 cells are associated principally with ulcerative colitis. The immune
response disrupts the intestinal mucosa and leads to a chronic inflammatory process.1
In ulcerative colitis (UC), inflammation begins in the rectum and extends proximally in an
uninterrupted fashion to the proximal colon, eventually involving the entire length of the largeintestine. The rectum is always involved in ulcerative colitis, and no "skip areas" (ie, normal
areas of the bowel interspersed with diseased areas) are present. Ulcerative colitis primarily
involves the mucosa and the submucosa, with formation of crypt abscesses and mucosalulceration. The mucosa typically appears granular and friable. In more severe cases,
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pseudopolyps form, consisting of areas of hyperplastic growth with swollen mucosa surrounded
by inflamed mucosa with shallow ulcers. In severe ulcerative colitis, inflammation and necrosis
can extend below the lamina propria to involve the submucosa and the circular and longitudinalmuscles, although this is very unusual.
Ulcerative colitis remains confined to the rectum in approximately 25% of cases. In theremainder of cases, ulcerative colitis spreads proximally and contiguously. Pancolitis occurs in10% of patients. The small intestine is never involved, except when the distal terminal ileum is
inflamed in a superficial manner, referred to as backwash ileitis. Even with less than total colonic
involvement, the disease is strikingly and uniformly continuous. As the disease becomes chronic,the colon becomes a rigid foreshortened tube that lacks its usual haustral markings, leading to the
lead pipe appearance observed on barium enema. The skip areas observed in the colon in Crohn's
disease do not occur in ulcerative colitis.
Crohn's disease, on the other hand, consists of segmental involvement by a nonspecific
granulomatous inflammatory process. The most important pathologic feature is that Crohn's
disease is transmural, involving all layers of the bowel, not just the mucosa and the submucosa,which is characteristic of ulcerative colitis. Crohn's disease can affect any portion of the
gastrointestinal tract from the mouth to the anus. Furthermore, Crohn's disease is discontinuous,with skip areas interspersed between one or more involved areas.
Late in the disease, the mucosa develops a cobblestone appearance, which results from deep
longitudinal ulcerations interlaced with intervening normal mucosa. The 3 major patterns ofinvolvement in Crohn's disease are (1) disease in the ileum and cecum (occurring in 40% of
patients), (2) disease confined to the small intestine (occurring in 30% of patients), and (3)
disease confined to the colon (occurring in 25% of patients). Rectal sparing is a typical but not
constant feature of Crohn's disease. However, anorectal complications (eg, fistulas, abscesses)are common. Much less commonly, Crohn's disease involves the more proximal parts of the
gastrointestinal (GI) tract, including the mouth, tongue, esophagus, stomach, and duodenum.
Crohn's disease causes 3 patterns of involvement: inflammatory disease, strictures, and fistulas.
Ulcerative colitis and Crohn's disease are generally diagnosed using clinical, endoscopic, and
histologic criteria. Histologically, transmural non-necrotizing lymphoid granulomas arecharacteristic of Crohn's disease. However, they may not be found in a given case of Crohn's
disease, and no single finding is absolutely diagnostic for one disease or the other. Furthermore,
approximately 20% of patients have a clinical picture that falls between Crohn's disease andulcerative colitis; they are said to have indeterminate colitis.
The incidence of gallstones andkidney stonesis increased in Crohn's disease because of
malabsorption of fat and bile salts.Gallstonesare formed because of increased cholesterolconcentration in the bile, caused by a reduced bile salt pool. Patients who have Crohn's disease
with ileal disease or resection also are likely to form calcium oxalate kidney stones. With the fat
malabsorption, unabsorbed long-chain fatty acids bind calcium in the lumen. Oxalate in thelumen normally is bound to calcium. Calcium oxalate is poorly soluble and poorly absorbed;
however, if calcium is bound to malabsorbed fatty acids, oxalate combines with sodium to form
sodium oxalate, which is soluble and is absorbed in the colon (enteric hyperoxaluria). The
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development of calcium oxalate stones in Crohn's disease requires an intact colon to absorb
oxalate. Patients with ileostomies do not develop calcium oxalate stones.
Extraintestinal manifestations of inflammatory bowel disease (IBD) includeiritis, episcleritis,
arthritis, and skin involvement, as well aspericholangitisand sclerosing cholangitis. These
extraintestinal manifestations (EIM) are observed in up to 20-40% of patients with IBD.
2
Frequency
United States
The incidence is 70-150 cases per 100,000 individuals.
The incidence of inflammatory bowel disease (IBD) varies within different geographic areas.
Crohn's disease (CD) and ulcerative colitis (UC) both occur at the highest incidence in Europe,the United Kingdom, and North America.
International
The incidence of inflammatory bowel disease (IBD) ranges from 2.2-14.3 cases per 100,000person-years for ulcerative colitis and from 3.1-14.6 cases per 100,000 person-years for Crohn's
disease. Overall, the combined incidence for inflammatory bowel disease is 10 cases per 100,000
annually.3,4
Mortality/Morbidity
The quality of life generally is lower in those with Crohn's disease than in those with ulcerative
colitis, in part because of recurrences after surgery performed for Crohn's disease.
The most common causes of death in inflammatory bowel disease (IBD) areperitonitis withsepsis, malignancy, thromboembolic disease, and complications of surgery.
Toxic megacolon, one of the most dreaded complications of ulcerative colitis, can lead toperforation, sepsis, and death.
Malnutrition and chronic anemia are observed in long-standing Crohn's disease. Children with Crohn's disease or ulcerative colitis can exhibit growth retardation.
Race
Incidence among whites is approximately 4 times that of other races. IBD is observed most commonly in Northern Europe and North America. It is a disease of
industrialized nations.
Incidence is higher in Ashkenazi Jews (ie, those who have immigrated from Northern Europe)than in other groups.
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Sex
Incidence is slightly greater in females than in males.Age
Incidence peaks in the second and third decades of life. A second smaller peak occurs in patients aged 55-65 years. Crohn's disease and ulcerative colitis can occur in childhood, although the incidence is much
lower in children younger than 15 years.
Clinical
History
Patients with ulcerative colitis (UC) most commonly present with bloody diarrhea, whereaspatients with Crohn's disease (CD) usually present with nonbloody diarrhea.
o Abdominal pain and cramping, fever, and weight loss occur in more severe cases.o The greater the extent of colon involvement, the more likely the patient is to have
diarrhea.
o Rectal urgency or tenesmus reflects reduced compliance of the inflamed rectum.o Patients might have formed stools if their disease is confined to the rectum.o As the degree of inflammation increases, systemic symptoms develop, including low-
grade fever, malaise, nausea, vomiting, sweats, and arthralgias.
o Fever, dehydration, and abdominal tenderness develop in severe ulcerative colitis,reflecting progressive inflammation into deeper layers of the colon.
The presentation of Crohn's disease is generally more insidious than that of ulcerative colitis,with ongoing abdominal pain, anorexia, diarrhea, weight loss, and fatigue.
o Grossly bloody stools, while typical of ulcerative colitis, are less common in Crohn'sdisease.
o Stools may be formed, but loose stools predominate if the colon or the terminal ileum isinvolved extensively.
o One half of patients with Crohn's disease present with perianal disease (eg, fistulas,abscesses).
o Occasionally, acute right lower quadrant pain and fever, mimicking appendicitis, may benoted.
o Commonly, the diagnosis is established only after several years of recurrent abdominalpain, fever, and diarrhea.
Crohn's disease with gastroduodenal involvement may mimic peptic ulcer disease and canprogress to gastric outlet obstruction.
Many patients with inflammatory bowel disease (IBD) haveirritable bowel syndrome, which canproduce occasional cramping, irregular bowel habits, and passage of mucus without blood or
pus.
Weight loss is observed more commonly in Crohn's disease than in ulcerative colitis because ofthe malabsorption associated with small bowel disease. Patients may reduce their food intake in
an effort to control their symptoms.
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Systemic symptoms are common and include fever, sweats, malaise, and arthralgias. A low-grade fever may be the first warning sign of a flare.
Recurrences may occur with emotional stress, infections or other acute illnesses, pregnancy,dietary indiscretions, use of cathartics or antibiotics, or withdrawal of anti-inflammatory or
steroid medications.
Children may present with growth retardation and delayed or failed sexual maturation. In 10-20% of cases, patients present with extraintestinal manifestations, including arthritis,
uveitis, or liver disease.
Physical
Fever, tachycardia, dehydration, and toxicity may occur. Pallor may be noted, reflecting anemia.The magnitude of these factors is related directly to the severity of the attack.
Evaluate for signs of localized peritonitis, although abdominal tenderness is common. Patientswith toxic megacolon appear septic. They have high fever; lethargy; chills; tachycardia; and
increasing abdominal pain, tenderness, and distention.
Patients with Crohn's disease may develop a mass in the right lower quadrant. The rectal examination often reveals bloody stool on gross or Hemoccult examination. Complications (eg, perianal fissures or fistulas, abscesses,rectal prolapse) may be observed in
up to 90% of patients with Crohn's disease.
The physical examination should include a search for extraintestinal manifestations, such asiritis, episcleritis, arthritis, and dermatologic involvement.
Distinguishing Features of Crohn's Disease Versus Ulcerative Colitis
Opentable in new window
[CLOSE WINDOW]
Table
Features Crohns DiseaseUlcerative Colitis
Skip areas Common Never
Cobblestone mucosa Common Rare
Transmural involvementCommon Occasional
Rectal sparing Common Never
Perianal involvement Common Never
Fistulas Common Never
Strictures Common Occasional
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Granulomas Common Occasional
Features Crohns DiseaseUlcerative Colitis
Skip areas Common Never
Cobblestone mucosa Common Rare
Transmural involvementCommon Occasional
Rectal sparing Common Never
Perianal involvement Common Never
Fistulas Common Never
Strictures Common Occasional
Granulomas Common Occasional
Causes
The etiology of inflammatory bowel disease (IBD) is unknown. Environmental, infectious,genetic, autoimmune, and host factors have been suspected. Interactions among these factors
may be more important.
o Inflammatory mediators Interleukin-1 Tumor necrosis factoralpha (TNF-alpha)
o Aggravation by bacterial infection and inflammatory cascadeo Positive family history: The most important risk factor for developing IBD is a positive
family history.
The risk of developing ulcerative colitis is higher in nonsmokers and former smokers than incurrent smokers. The onset of ulcerative colitis occasionally appears to coincide with smoking
cessation. This does not imply that smoking would improve the symptoms of ulcerative colitis.
Interestingly, some success in the use of nicotine patches has been reported. On the contrary,
patients with Crohn's disease have a higher incidence of smoking than the general population,
and those patients with Crohn's disease who continue to smoke appear to be less likely to
respond to medical therapy.
More on Inflammatory Bowel Disease
Overview: Inflammatory Bowel Disease
Differential Diagnoses & Workup: Inflammatory Bowel Disease
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Treatment & Medication: Inflammatory Bowel Disease
Follow-up: Inflammatory Bowel Disease
Multimedia: Inflammatory Bowel Disease
References
Inflammatory Bowel Disease: Differential
Diagnoses & Workup
Author: Sarvotham Kini, MD, Associate Professor of Emergency Medicine, Medical
University of South Carolina, Charleston.
Contributor Information and Disclosures
Updated: Nov 20, 2009
Print This Email This
Overview Differential Diagnoses & Workup Treatment & Medication Follow-up Multimedia References Keywords
Information from Industry
Bacterial RTIs: Consider the importance of broad-spectrum coverage See coverage in community-
acquired pneumonia (CAP) Read more
Differential DiagnosesAppendicitis, AcuteDiverticular Disease
Endometriosis
Pelvic Inflammatory Disease
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icine.medscape.com/article/774566-mediahttp://emedicine.medscape.com/article/774566-followuphttp://emedicine.medscape.com/article/774566-treatmenthttp://emedicine.medscape.com/article/774566-overviewmailto:enter%20email%20address%20here?Subject=eMedicine%20Article%20-%20Inflammatory%20Bowel%20Disease&Body=I%20thought%20you%20might%20be%20interested%20in%20this%20article%20from%20eMedicine.%20You%20may%20either%20click%20on%20the%20following%20link%20or%20copy%20and%20paste%20it%20into%20your%20browser.%0Dhttp://emedicine.medscape.com/article/774566-overview%0D%0A%0D%0AeMedicine%20is%20the%20leading%20provider%20of%20clinical%20medical%20information%20for%20medical%20professionals%20and%20consumers.%20To%20explore%20eMedicine%20today,%20visit%20http://emedicine.medscape.comhttp://emedicine.medscape.com/article/774566-printhttp://emedicine.medscape.com/article/774566-mediahttp://emedicine.medscape.com/article/774566-followuphttp://emedicine.medscape.com/article/774566-treatment 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Other Problems to Be Considered
AIDS (The chronic diarrhea and diffuse colonic involvement of Kaposi sarcoma may mimicchronic UC.)
Antibiotic-associated colitis
Arteriovenous malformationsCollagenous colitis
Colon cancer
Fever of unknown originInfectious colitis (if confined to the rectum, rule out "gay bowel syndrome")
Intestinal lymphoma
Irritable bowel syndrome (can be present along with IBD): In IBS, diarrhea often alternates with
constipation. In contrast to IBD, IBS is not associated with blood in the stool, nocturnal diarrhea,weight loss, or other inflammatory sequelae (eg, fever, arthritis, skin or eye lesions, perianal
disease). Fecal WBCs are not observed in IBS.
Ischemic colitis
Pseudomembranous colitisRadiation-induced colitis
Workup
Laboratory Studies
CBC with differentialo Anemia may result from acute or chronic blood loss or malabsorption (iron, folate,
vitamin B-12) or may reflect the chronic disease state.
o Leukocytosis, anemia, and thrombocytosis are common. A modestly elevated WBC isobserved in active disease, but a marked elevation suggests the presence of an abscessor other suppurative complication.
Erythrocyte sedimentation rate: The sedimentation rate is typically elevated and has been usedto monitor disease activity.
Serum chemistryo Hypokalemiareflects the severity of the diarrhea.o Abnormal liver function test results may represent pericholangitis or sclerosing
cholangitis, which are complications of inflammatory bowel disease .
o Hypoalbuminemia, resulting fromprotein-losing enteropathy, suggests extensive colitis.o Decreased serum calcium level may reflect reduced serum albumin level.
Type and crossmatch: Consider obtaining a type and crossmatch, especially in patientspresenting with bloody diarrhea .
Stool examination: Send stool for fecal leukocytes, ova and parasite studies, bacterial pathogensculture, and Clostridium difficile titer.
o Amebiasis can be difficult to identify from the stool. Consider serologic testing in thisregard.
o As many as 50-80% of cases of acute terminal ileitis are due to Yersinia enterocolitisinfections. This produces a picture of pseudoappendicitis. Yersiniosis also has a high
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frequency of secondary manifestations, such as erythema nodosum and monarticular
arthritis, similar to IBD.
Blood culture: Cultures may be positive if peritonitis or fulminant colitis is present. Serologic tests: Serologic tests have become available to aid in the diagnosis of inflammatory
bowel disease (IBD) and differentiate between Crohn's disease and ulcerative colitis. Perinuclear
antineutrophil cytoplasmic antibodies (pANCA) have been identified in some patients with
ulcerative colitis, and anti-Saccharomyces cerevisiae antibodies (ASCA) have been found in
patients with Crohn's disease. Furthermore, those patients with inflammatory bowel disease
who are seronegative appear to have a lower incidence of resistant disease. Currently, these
markers are not sensitive enough to be used as screening tests for inflammatory bowel disease.5
Imaging Studies
Upright chest radiography and abdominal serieso Evaluate for an edematous irregular colon with "thumb printing." Occasionally,
pneumatosis coli (air in the colonic wall) may be present.
o Look for free air and especially for evidence of toxic megacolon, depicted in the imagebelow, which appears as a long continuous segment of air-filled colon greater than 6 cm
in diameter.
o
Inflammatory bowel disease. Toxic megacolon. Courtesy of Dr Pauline Chu.
[CLOSE WINDOW]
Inflammatory bowel disease. Toxic megacolon. Courtesy of Dr Pauline Chu.
o In the supine position, dilatation is predominantly noted in the transverse colonsecondary to air collection.
o Repeat radiographs at 12- to 24-hour intervals to monitor the course of dilatation and toassess the need for emergency colectomy.
o Associated findings includenephrolithiasis,cholelithiasis, or arthritis of the spine or thesacroiliac joints.
Barium enema
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o In ulcerative colitis, a barium enema (BE) may reveal a shortened colon, with loss ofhaustrations and destruction of the mucosal pattern (ie, lead pipe colon).
o Skip areas and rectal sparing are noted in Crohn's disease.o Barium enema is contraindicated in patients with moderate-to-severe colitis because it
risks perforation or precipitation of a toxic megacolon.
Upper GI with small bowel follow-througho In Crohn's disease, areas of segmental narrowing with loss of normal mucosa, fistula
formation, and the string sign (a narrow band of barium flowing through an inflamed or
scarred area) in the terminal ileum are typically observed.
o Some patients with ulcerative colitis also demonstrate inflammatory changes in theterminal ileum (ileitis), but they lack the skip pattern characteristic of Crohn's disease.
CT scanning and ultrasonography: CT scanning and ultrasonography are best for demonstratingintra-abdominal abscesses, mesenteric inflammation, and fistulas.
MRI may be of help in detecting fistulas and abscesses. More recently, wireless capsule endoscopy, used most often to investigate the source of GI
bleeding, has been found useful in diagnosing mucosal lesions in Crohn's disease. The detection
rate of abnormalities was 70.5% for patients with suspected small bowel disease, and the
diagnostic yield for patients with obscure gastrointestinal bleeding was higher than that forpatients with abdominal pain or diarrhea (85.7% vs 53.3%, P
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Overview Differential Diagnoses & Workup Treatment & Medication Follow-up Multimedia References Keywords
Information from Industry
Bacterial RTIs: View S pneumoniae resistance mapClick on your state Consider the growing problem
of antibacterial resistance. What is the S pneumoniae resistance rate in your state? Read more
Treatment
Emergency Department Care
Initiate supportive care with bowel rest, nasogastric suction, and intravenous (IV) fluidscontaining electrolytes.
Admit for toxicity, obstruction, hemorrhage, or localized peritonitis. Monitor severe cases for fat malabsorption. Treat perirectal disease.
o Sitz bathso Soap and water after stoolingo Surgical drainage of perirectal abscesseso Surgical treatment of recurrent fistulas if medical management fails
Administer folate supplementation as needed.Consultations
Consult a surgeon for complicating obstruction, hemorrhage, perforation, abscess or fistulaformation, toxic megacolon, or perianal disease.
Consider surgical intervention for patients in whom medical therapy fails. The 2 most commonchoices today (for ulcerative colitis) are proctocolectomy with ileostomy and total colectomy
with ileoanal anastomosis. Elective surgery can sometimes be performed laparoscopically. For
fulminant colitis, the surgical procedure of choice consists of a subtotal colectomy with end
ileostomy and creation of a Hartman pouch.
In Crohn's disease, surgically resect only as much bowel as necessary to correct the problembecause the recurrence rate after surgery approaches 100%.
Patients with toxic megacolon initially require nasogastric suction and IV steroids. Failure toimprove within 48 hours is an indication for total colectomy.
Extracolonic manifestations (ie, uveitis, arthritis, dermatitis, sclerosing cholangitis) are bestmanaged with the aid of specialty consultation.
Medication
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Therapy for Crohn's disease generally is less effective than that for ulcerative colitis. In addition
to the therapies outlined herein, intravenous cyclosporine is helpful in refractory ulcerative
colitis. Zileuton, a 5-lipoxygenase inhibitor, has shown some efficacy in treating Crohn's disease.
Hyperbaric oxygen therapy may be helpful in the treatment of inflammatory bowel disease (IBD)
that is unresponsive to other therapies. Its therapeutic efficacy appears to result from decreasedgeneration of prostaglandin E2. Previous work has linked mucosal prostaglandin E2 to the
intestinal damage associated with IBD.8
Agents for symptomatic treatment include loperamide and the combination of diphenoxylate and
atropine, which are useful in mild disease to reduce the number of bowel movements and to
relieve rectal urgency. Cholestyramine, a resin that binds bile salts, is useful for reducingdiarrhea in patients with Crohn's disease who have had ileal resections. The anticholinergic agent
dicyclomine may help relieve intestinal spasms. Antidiarrheal and anticholinergic medications
must be avoided in acute severe disease because they may precipitate toxic megacolon. Avoid
the long-term use of narcotics for pain. An iron supplement should be added when significant
rectal bleeding is present.
Antidiarrheal agents
These agents inhibit peristalsis in the GI tract.
Loperamide (Imodium)
Acts in intestinal muscles to inhibit peristalsis and to slow intestinal motility. Prolongs
movement of electrolytes and fluid through bowel; increases viscosity and loss of fluids andelectrolytes.
Dosing Interactions Contraindications Precautions
Adult
Initial dose: 4 mg POMaintenance: 2 mg PO after each loose stool; not to exceed 16 mg/d
Pediatric
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2 mg bid
8-12 years: 2 mg PO tid initially; followed by 0.1 mg/kg PO after each loose stool; not to exceed
2 mg tid>12 years: Administer as in adults
Chronic diarrhea: 0.08-0.24 mg/kg/d PO divided bid/tid; not to exceed 2 mg/dose
Dosing Interactions Contraindications Precautions
Phenothiazines, tricyclic antidepressants, and CNS depressants may increase toxicity
Dosing Interactions Contraindications Precautions
Documented hypersensitivity; diarrhea resulting from infection; pseudomembranous colitis
Dosing Interactions Contraindications Precautions
Pregnancy
B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals
Precautions
Discontinue use if no clinical improvement is noted in 48 h; because metabolized primarily in
liver, monitor for CNS toxicity in patients with hepatic insufficiency; do not use if high fever orblood in stool coincides with diarrhea
Diphenoxylate and Atropine (Lomotil)
Drug combination that consists of diphenoxylate, a constipating meperidine congener, and
subtherapeutic amount of atropine to discourage abuse. Inhibits excessive GI propulsion and
motility.
Dosing Interactions Contraindications Precautions
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Adult
15-20 mg/d PO tid/qid; followed by 5-15 mg/d
Pediatric
2 years: 0.3-0.4 mg/kg/d PO divided qid2-5 years: 2 mg PO tid
5-8 years: 2 mg PO qid
8-12 years: 2 mg PO 5 times/d>12 years: Administer as in adults
Dosing Interactions Contraindications
Precautions
May delay metabolism of drugs by liver; CNS depressants, MAOIs, and antimuscarinic agentsmay increase toxicity
Dosing Interactions Contraindications Precautions
Documented hypersensitivity; narrow-angle glaucoma; hepatic insufficiency
Dosing Interactions Contraindications Precautions
Pregnancy
C - Fetal risk revealed in studies in animals but not established or not studied in humans; mayuse if benefits outweigh risk to fetus
Precautions
Dehydration may influence variability of response in young children, predisposing them to
delayed diphenoxylate intoxication; caution in patients with UC; decrease in intestinal motilitymay be detrimental to patients with diarrhea resulting from Shigella and Salmonella species and
toxigenic strains ofEscherichia coli
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Cholestyramine (Questran)
Useful in treating diarrhea associated with pseudomembranous colitis. Inhibits enterohepaticreuptake of intestinal bile salts by forming nonabsorbable complex with bile acids in intestine.
Dosing
Interactions Contraindications Precautions
Adult
4 g PO qd/bid; not to exceed 24 g/d or 6 doses/d
Pediatric
240 mg/kg/d PO divided tid
Dosing Interactions Contraindications Precautions
Inhibits absorption of numerous drugs, including warfarin, thyroid hormone, amiodarone,
NSAIDs, methotrexate, digitalis glycosides, glipizide, phenytoin, imipramine, niacin,
methyldopa, tetracyclines, clofibrate, hydrocortisone, and penicillin G
Dosing
Interactions Contraindications Precautions
Documented hypersensitivity
Dosing Interactions Contraindications Precautions
Pregnancy
C - Fetal risk revealed in studies in animals but not established or not studied in humans; mayuse if benefits outweigh risk to fetus
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Precautions
Caution in constipation and phenylketonuria
Antispasmodic agents
These agents are used to treat functional disturbances of GI motility.
Dicyclomine (Bentyl)
Useful in treating GI motility disturbances; blocks action of acetylcholine at parasympathetic
sites in secretory glands, smooth muscle, and CNS.
Dosing
Interactions Contraindications Precautions
Adult
80 mg/d PO divided qid initially, then increase to 160 mg/d
Pediatric
10 mg/dose PO tid/qid
Dosing Interactions Contraindications Precautions
Effects are weakened when administered with anti-Parkinson drugs, haloperidol, and
phenothiazines; toxicity increases when administered concurrently with amantadine,
antihistamines, type I antiarrhythmics, phenothiazines, TCAs, or narcotic analgesics
Dosing Interactions Contraindications Precautions
Documented hypersensitivity; myasthenia gravis; narrow-angle glaucoma
Dosing Interactions
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Contraindications Precautions
Pregnancy
B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals
Precautions
Caution when administering to patients with hepatic or renal insufficiency, cardiovasculardisease, urinary tract obstruction, UC, GI obstruction, hyperthyroidism, or hypertension
Aminosalicylates
These agents are effective for treating acute ulcerative colitis (UC) and for maintaining its
remission; they are also beneficial in mildly to moderately active Crohn's disease (CD) when the
colon is involved. Sulfasalazine has not been clearly shown to maintain remission in CD.Furthermore, there is some question as to its effectiveness versus small bowel disease.
Newer aminosalicylate preparations without sulfapyridine (eg, 5-aminosalicylic acid [5-ASA])
were developed because tolerance of sulfasalazine has been limited by the sulfa-containing
moiety. Because free 5-ASA is absorbed rapidly from the proximal GI tract, it has been modifiedin the newer formulations. Olsalazine consists of two 5-ASA molecules linked together by an
azo bond. Intestinal bacteria cleave the bond, which enables olsalazine to work, primarily in the
colon.
Additional formulations of 5-ASA (mesalamine) are Asacol, Pentasa, Rowasa, and Balsalazide.
Asacol is composed of 5-ASA coated in a pH-dependent acrylic resin, which allows delayedrelease of 5-ASA in the distal ileum and the right colon. Pentasa consists of 5-ASA encapsulated
into microgranules of ethylcellulose and released continuously throughout the GI tract.
Therefore, it is useful in patients with CD involvement of the small bowel and the colon. Rowasa
contains 5-ASA in suppository or enema formulations, which are useful for treating andmaintaining remissions in ulcerative proctitis and proctosigmoiditis. Balsalazide is mesalamine
linked to an inert carrier molecule. In the colon, bacteria cleave the bond and release free
mesalamine.
Because oral aminosalicylates interfere with folate absorption, folic acid supplementation (1
mg/d) should be given.
Sulfasalazine (Azulfidine)
Combination of 5-ASA or mesalamine and sulfapyridine. Taken PO, remains intact until itreaches terminal ileum and colon, where it is split by bacteria into its 2 moieties. Active portion
appears to be 5-ASA, which inhibits prostaglandin synthesis; sulfa portion is absorbed and
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causes most adverse reactions. Abdominal discomfort common. Folate deficiency may result
from competition between folate and sulfasalazine for absorption.
Dosing Interactions Contraindications Precautions
Adult
3-4 g PO qd in divided doses
Pediatric
2 years: 30 mg/kg PO divided qid
Dosing Interactions Contraindications Precautions
Decreases effects of iron, digoxin, and folic acid; increases effects of PO anticoagulants, PO
hypoglycemic agents, and methotrexate
Dosing Interactions Contraindications Precautions
Documented hypersensitivity; GI or GU obstruction
Dosing Interactions Contraindications Precautions
Pregnancy
B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals
D - Fetal risk shown in humans; use only if benefits outweigh risk to fetus
Precautions
Caution in patients with renal or hepatic impairment, blood dyscrasias, or urinary obstruction
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Olsalazine (Dipentum)
Alternate treatment for patients who do not tolerate sulfasalazine. Useful in maintaining
remission in UC; exerts anti-inflammatory activity in UC.
Dosing Interactions Contraindications Precautions
Adult
500 mg PO bid
Pediatric
Not established
Dosing Interactions Contraindications Precautions
None reported
Dosing Interactions Contraindications Precautions
Documented hypersensitivity
Dosing Interactions Contraindications Precautions
Pregnancy
C - Fetal risk revealed in studies in animals but not established or not studied in humans; mayuse if benefits outweigh risk to fetus
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Precautions
Relatively high incidence of diarrhea may be dose related (unclear whether other underlyingcauses may contribute)
Mesalamine (Asacol, Pentasa, Rowasa, Canasa)
Treats mildly to moderately active UC.Usual course of therapy in adults is 3-6 wk. Some patients may need concurrent PR and PO
therapy.
Dosing Interactions Contraindications Precautions
Adult
Cap: 1 g PO qidTab: 800 mg PO tidRectal supp: Insert 1 PR bid
Pediatric
Not established
Dosing Interactions Contraindications Precautions
Decreases effects of iron, digoxin, and folic acid; mesalamine increases effect of POanticoagulants, methotrexate, and PO hypoglycemic agents
Dosing Interactions Contraindications Precautions
Documented hypersensitivity
Dosing Interactions Contraindications Precautions
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Pregnancy
B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals
Precautions
Elderly patients may have difficulty administering and retaining rectal suppositories; caution in
renal or hepatic impairment
Corticosteroids
These agents are the treatments of choice for an acute inflammatory bowel disease (IBD) attack;
administer IV in severe disease. Give increased or stress doses to patients already on steroids. Do
not use steroids for maintaining remission because of their lack of efficacy9
and potentialcomplications, including avascular necrosis, osteoporosis, cataracts, emotional lability,
hypertension, diabetes mellitus, cushingoid features, acne, and facial hair. Cortenema,
Cortifoam, and Anusol-HC suppositories are useful in treating distal disease (proctitis andproctosigmoiditis).
Budesonide (Entocort EC), a synthetic corticosteroid, is available for Crohn's disease (CD) withileal or ileocecal involvement.
10It is indicated for PO treatment to induce remissions of attacks
of mild-to-moderate severity involving the ileum and/or ascending colon.9
The drug contains
budesonide granules in an ethylcellulose matrix coated with a methacrylic acid polymer. Thecoating, which requires a pH more than 5.5 to dissolve, prevents release of the drug in the
stomach. The ethylcellulose matrix delays release further until the drug reaches the ileum and
ascending colon. A potential advantage is that fewer adverse effects occur than with the use of
systemic corticosteroids. However, some absorption occurs and may slow growth in adolescents.
Prednisone (Sterapred)
Used as immunosuppressant in treatment of autoimmune disorders; may decrease inflammationby reversing increased capillary permeability and suppressing PMN activity.
Dosing Interactions Contraindications
Precautions
Adult
5-60 mg/d PO qd or divided bid/qid
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Pediatric
4-5 mg/m2/d PO; alternatively, 1-2 mg/kg PO qd; not to exceed 60 mg/d; taper over 2 wk as
symptoms resolve
Dosing
Interactions Contraindications Precautions
Estrogens may decrease clearance; concurrent digoxin may cause digitalis toxicity secondary to
hypokalemia; phenobarbital, phenytoin, and rifampin may increase metabolism (consider
increasing maintenance dose); monitor for hypokalemia with coadministration of diuretics
Dosing Interactions Contraindications Precautions
Documented hypersensitivity; viral, fungal, or tubercular skin infections
Dosing Interactions Contraindications Precautions
Pregnancy
B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals
Precautions
Abrupt discontinuation may cause adrenal crisis; hyperglycemia, edema, osteonecrosis,
myopathy, peptic ulcer disease, hypokalemia, osteoporosis, euphoria, psychosis, myasthenia
gravis, growth suppression, and infections may occur
Methylprednisolone (Adlone, Medrol, Solu-Medrol)
Decreases inflammation by suppressing migration of polymorphonuclear leukocytes and
increasing permeability or capillaries.
Dosing Interactions Contraindications Precautions
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Adult
125-250 mg IV loading dose, followed by maintenance dose of 0.5-1 mg/kg/dose IV q6h for upto 5 d
Pediatric
2 mg/kg IV loading dose, followed by maintenance dose of 0.5-1 mg/kg/dose IV q6h for up to 5d
Dosing Interactions Contraindications Precautions
Coadministration with digoxin may increase digitalis toxicity secondary to hypokalemia;
estrogens may increase levels; phenobarbital, phenytoin, and rifampin may decrease levels(adjust dose); monitor patients for hypokalemia when taking concurrently with diuretics
Dosing Interactions Contraindications Precautions
Documented hypersensitivity; viral, fungal, or tubercular skin infections
Dosing Interactions Contraindications Precautions
Pregnancy
C - Fetal risk revealed in studies in animals but not established or not studied in humans; may
use if benefits outweigh risk to fetus
Precautions
Hyperglycemia, edema, osteonecrosis, peptic ulcer disease, hypokalemia, osteoporosis, euphoria,psychosis, growth suppression, myopathy, and infections are possible complications
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Hydrocortisone (Anusol-HC, Anuprep HC)
Decreases inflammation by suppressing migration of polymorphonuclear leukocytes andreversing increased capillary permeability.
Dosing
Interactions Contraindications Precautions
Adult
10-100 mg PR qd/bid for 2-3 wk
Pediatric
Not established
Dosing Interactions Contraindications Precautions
Clearance may decrease with estrogens; may increase digitalis toxicity secondary to
hypokalemia
Dosing
Interactions Contraindications Precautions
Documented hypersensitivity; viral, fungal, or tubercular skin infections
Dosing Interactions Contraindications Precautions
Pregnancy
C - Fetal risk revealed in studies in animals but not established or not studied in humans; mayuse if benefits outweigh risk to fetus
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Precautions
Caution in hyperthyroidism, osteoporosis, peptic ulcer, cirrhosis, nonspecific UC, diabetesmellitus, and myasthenia gravis
Immunosuppressants
These agents are useful as steroid-sparing agents, in healing fistulas, or when the patient hasserious contraindications to surgery.
9They are used in patients refractory to or unable to tolerate
steroids. Some agents, including azathioprine and its metabolite, 6-mercaptopurine, have been
useful in Crohn's disease (CD) complicated by recurrent rectal fistulas or perianal disease;response can take up to 6 months. Methotrexate has also been tried.
Azathioprine (Imuran)
Inhibits mitosis and cellular metabolism by antagonizing purine metabolism and inhibitingsynthesis of DNA, RNA, and proteins; these effects may decrease proliferation of immune cells
and result in lower autoimmune activity.
Dosing Interactions Contraindications Precautions
Adult
1 mg/kg/d PO for 6-8 wk; increase by 0.5 mg/kg PO q4wk until response noted; not to exceed2.5 mg/kg/d
Pediatric
Initial dose: 2-5 mg/kg/d PO/IV
Maintenance dose: 1-2 mg/kg/d PO
Dosing Interactions
Contraindications Precautions
Allopurinol increases toxicity; ACE inhibitors may induce severe leukopenia; may increase
levels of methotrexate metabolites and decrease effects of anticoagulants, neuromuscular
blockers, and cyclosporine
Dosing
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Interactions Contraindications Precautions
Documented hypersensitivity
Dosing Interactions Contraindications Precautions
Pregnancy
C - Fetal risk revealed in studies in animals but not established or not studied in humans; may
use if benefits outweigh risk to fetus
Precautions
Increases risk of neoplasia; caution with liver disease and renal impairment; hematologic toxiceffects may occur; check TPMT level before therapy and monitor liver, renal, and hematologic
functions; pancreatitis is rarely associated
Antibiotics
Institute parenteral antibiotics active against coliforms and anaerobes for fulminant disease,including toxic megacolon. Agents may include metronidazole or ampicillin or a cephalosporin
and an aminoglycoside.
Metronidazole (Flagyl)
Useful in treating fulminant disease; used successfully in CD complicated by perianal ulcers andperirectal abscesses and fistulas; unclear whether drug is active because of its antibacterial
properties or through some other mechanism.
Dosing Interactions Contraindications Precautions
Adult
20 mg/kg/d PO in divided doses
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Pediatric
Not established
Dosing
Interactions Contraindications Precautions
May increase toxicity of anticoagulants, lithium, and phenytoin; cimetidine may increasetoxicity; disulfiram reaction may occur with orally ingested ethanol
Dosing Interactions Contraindications Precautions
Documented hypersensitivity
Dosing Interactions Contraindications Precautions
Pregnancy
B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals
Precautions
Adverse reactions include peripheral neuropathy, possible carcinogenesis, and mutagenesis;
adjust dose in patients with severe hepatic disease (may metabolize metronidazole slowly);monitor patients for seizures and development of peripheral neuropathy
Tumor necrosis inhibitors
Infliximab (Remicade), given intravenously, consists of monoclonal antibodies to TNF-alpha.
Infliximab is approved by the FDA for use in IBD.11
Infliximab is somewhat more effective
against CD than UC. The drug appears to promote mucosal healing, which not even prednisonedoes. Furthermore, it heals perianal and enterocutaneous fistulae and has been shown to reduce
signs and symptoms, achieve clinical remission and mucosal healing, and eliminate
corticosteroid use.12
Infliximab is indicated for patients who have experienced inadequateresponse to conventional therapy.
9
Etanercept (Enbrel) is a TNF receptor fusion protein that binds to TNF-alpha and TNF-beta,
blocking their interaction with TNF receptors. Although it is approved for the treatment of
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moderate-to-severe rheumatoid arthritis, it has also been used investigationally for CD, although
such use is not yet approved. Etanercept can cause an increased risk of infections, which can be
serious and life threatening.
Certolizumab pegol (Cimzia)
Pegylated anti-TNFalpha blocker, which results in disruption of the inflammatory process.Indicated for moderate-to-severe Crohn disease in individuals who have not responded to
conventional therapies.
Dosing Interactions Contraindications Precautions
Adult
400 mg SC initially; repeat at weeks 2 and 4; if favorable response occurs, initiate maintenance
dose of 400 mg SC q4wk
Administer as 2 separate 200-mg SC injections at 2 separate sites in abdomen or thigh
Pediatric
Not established
Dosing Interactions Contraindications Precautions
May interfere with immune response to live-virus vaccines (eg, MMR) and may reduce efficacy;
coadministration with anakinra (an interleukin-1 antagonist that also blocks TNF) may cause
additive adverse effects, particularly development of serious infections; may interfere withactivated partial thromboplastin time tests
Dosing Interactions Contraindications Precautions
Documented hypersensitivity
Dosing Interactions Contraindications
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PrecautionsPregnancy
B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals
Precautions
Common adverse effects include headache, upper respiratory tract infections, abdominal pain,injection site reactions, and nausea; increases risk of serious infections, including infections that
may result in hospitalization or death; may increase risk of opportunistic infections (eg,
tuberculosis, invasive fungal), so test for latent tuberculosis, and, if positive, initiate tuberculosistreatment prior to starting certolizumab; if infection occurs, patients should contact their
physician immediately; may cause reactivation of hepatitis B virus; may increase risk of
lymphoma and other malignancies because of immune suppression; anaphylaxis or serious
allergic reactions, demyelinating disease, cytopenias, pancytopenia, heart failure, and lupuslike
syndrome have been reported with TNF blockers
Infliximab (Remicade)
Neutralizes cytokine TNF-alpha and inhibits binding to TNF-alpha receptor.
Dosing Interactions Contraindications Precautions
Adult
5 mg/kg IV as single infusion
When long-term administration is needed, an induction dose of 5 mg/kg IV infusion at 0, 2, and
6 wk is administered, then 5 mg/kg q8wk for maintenance
IV infusion must be administered over at least 2 h; must use infusion set with in-line, sterile,nonpyrogenic, low-protein-binding filter (pore size
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Author: Sarvotham Kini, MD, Associate Professor of Emergency Medicine, Medical
University of South Carolina, Charleston.
Contributor Information and Disclosures
Updated: Nov 20, 2009
Print This Email This
Overview Differential Diagnoses & Workup Treatment & Medication Follow-up Multimedia References Keywords
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Bacterial RTIs: View S pneumoniae resistance mapClick on your state Consider the growing problem
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Follow-up
Further Outpatient Care
Nutritional support in Crohn's disease includes supplementation with trace metals, fat-solublevitamins, and medium-chain triglycerides.
A low-oxalate diet with citrate supplementation helps reduce the risk of nephrolithiasis. Oral calcium or cholestyramine may serve as an intestinal oxalate binder. Encourage the patient to join an IBD support group, such as theCrohn's and Colitis Foundation
of America(386 Park Avenue South, 17th Floor; New York, NY 10016; 1-800-932-2423).
Complications
Perforation and toxic megacolon are the most dreaded complications of ulcerative colitis (UC).Perforation can occur in the presence of fulminating disease, even in the absence of toxic
megacolon.
o The mortality rate is 50% if perforation occurs.o Suspect toxic megacolon in a patient with fulminant ulcerative colitis, especially if the
number of daily stools has declined sharply without a corresponding improvement in
symptoms. The abdomen is typically distended, tender, and tympanitic. Toxic
megacolon can be precipitated by antidiarrheal agents, hypokalemia, narcotics,
cathartics, and enemas, including barium enemas. The best method of diagnosingtoxic
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megacolonis through the use of plain radiography. Toxic megacolon occurs
predominantly in the transverse colon, probably because air collects there in the supine
position. The transverse colon is dilated, usually more than 8 cm. Dilation more than 6
cm is considered to be abnormal. A colectomy is required if no improvement occurs
within 24-48 hours.
Strictures usually are benign but can lead to obstruction. Fistulas and abscesses are much more common in Crohn's disease, but they are observed in
about 20% of patients with ulcerative colitis.
o Fistula types include enterovesical (leading to recurrent urinary tract infections andpneumaturia), enteroenteric, enteromesenteric, enterocutaneous, rectovaginal, and
perianal.
o Additional problems include stenosis and obstruction.o Perianal complications occur in 90% of patients with Crohn's disease.o In Crohn's disease, obstructive hydronephrosis may result from a right lower quadrant
inflammatory mass, leading to external compression of the right ureter.
Massive hemorrhage occurs in fewer than 1% of patients. Cancer concerns are as follows:
o Ulcerative colitis carries a 10- to 30-fold increase in development of carcinoma of thecolon.
o Risk increases with extent and duration of the disease.o Cumulative risks of cancer after 15, 20, and 25 years are 8%, 12%, and 25%, respectively.o Perform periodic colonoscopies with biopsies, especially in patients with pancolitis.
Most authors recommend beginning surveillance approximately 10 years after onset of
disease and repeating surveillance at 1- to 2-year intervals. Evidence currently does not
support the need for cancer surveillance in Crohn's disease.
o The risk of cancer in Crohn's disease may be equal to that of ulcerative colitis if theentire colon is involved. Hence, screening may be beneficial for patients with Crohn's
disease who have pancolitis. The risk of small intestinal malignancy in Crohn's disease is
increased. However, the malignancy is as likely to arise in a normal as in an inflamedarea, and no screening protocol has ever been demonstrated to be effective against
small bowel Crohn's disease.
Extraintestinal complications occur in approximately 20% of patients with inflammatory boweldisease (IBD). In some cases, they may be more problematic than the bowel disease itself.
o Arthritic Peripheral arthritis, usually migratory and monoarticular, tends to parallel
disease activity but may antedate it.
Ankylosing spondylitisis associated with human leukocyte antigen-B27 (HLA-B27).
o Ocular Episcleritis, shown in the image below, manifests with burning eyes and scleral
injection and is observed in 3-4% of IBD cases. Episcleritis parallels the course of
the disease and resolves with treatment of the IBD. Topical steroids may be
administered.
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Inflammatory bowel disease. Episcleritis. Courtesy of Dr David Sevel.
[CLOSE WINDOW]
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Inflammatory bowel disease. Episcleritis. Courtesy of Dr David Sevel.
Iritis, which manifests as an acute painful red ey