Refresher Course: Inflammatory Bowel Disease

Pooja Amy Shah, MD
Volume 53 - Issue 10 - October 2013

A 31-year-old mother of two presented after several months of runny diarrhea. How do you respond to the patient? Jason Domagalski, MD, FAAFP, opened the session by encouraging the audience to share their diagnostic questions, which ranged from finding out details about travel and medication to questions about joint pain, systemic symptoms, and abdominal pain.  

Dr Domagalski narrowed the options to Crohn’s disease (CD) or ulcerative colitis (UC). CD is an inflammatory bowel disease that affects any part of the digestive track, from anus to mouth. It presents in the teens or 20s, and often includes perianal findings during a physical examination. It has an incidence rate of 5/100,000 and a prevalence rate of 50/100,000. 

In comparison, UC—mucousal inflammation limited only to the colon—has an incidence rate of 9-12/100,000 and a prevalence of 205-240/100,000. The cardinal symptom is bloody diarrhea and it is less associated with systemic symptoms. It is less debilitating than CD. 

Diagnosis

The first step is clinical suspicion, which is then confirmed by endoscopic and histological findings. Radiological and stool studies can also be conducted. 

Treatment

Therapy involves a multidisciplinary approach based on the disease type and involves treatment for flares versus maintenance. In some cases, surgical intervention may be necessary. 

There are several pharmacologic treatment options, which include:

  • Steroids. These are usually the primary care physician’s first choice and help inhibit the immune response. Steroids are recommended for acute flares in UC and CD. It is not recommended as a maintenance therapy; the risks of chronic use include increased infections, bone mineral losses, and diabetes.
  • Antibiotics. These are generally targeted to modify gut flora. While the pooled analysis seems promising, the individual tests show that these are not an effective class of agents except in reducing fistula drainage in CD.
  • 5-ASA. There is strong evidence for use in cases of UC—for both active flares and to maintain remission. They do have anti-inflammatory properties and can be used both orally or as an enema in distal disease. Rare side effects include pancreatitis, interstitial nephritis, and hepatitis.
  • Immunosuppressants. Methotrexate is not recommended in cases of UC but is effective for active and maintenance of CD. Thiopurines is not recommended in active UC or CD, but is effective in the maintenance of UC and CD. Finally, calcineurin inhibitors can be helpful in severe active UC.
  • Biologics. Anti TNF α antibodies are effective for active UC and CD, maintenance in CD, and cessation of fistula drainage. There is a risk of opportunistic infection and an associated risk of lymphoma. 

Non-adherence to treatment remains between 43% and 60%; non-adherent patients are 5.5 times more likely to flare up. Barriers are age-specific (adolescents want to be normal, young adults have multiple responsibilities, and the elderly have cognitive decline). To improve adherence, focus on education, cognitive and behavioral interventions, and for the best impact, a multicomponent approach.