Inflammatory bowel disease

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15 Inflammatory bowel disease


A 28-year-old female presents with a 3-month history of diarrhoea, weight loss, fatigue, and right lower quadrant abdominal pain. She complains of six to eight non-bloody bowel movements daily with at least one at night that awakens her from sleep. She has lost 10 kg since her symptom onset. She has fevers to 38.5°C without chills. She also complains of perianal pain with purulent drainage. She has generalised joint aches with intermittent swelling of the knees and mouth sores. Her past medical history is otherwise unremarkable and she does not take any medications. She denies taking any non-steroidal anti-inflammatory drugs. She is an active smoker of one pack a day for the last 5 years. She has no family history of inflammatory bowel disease.

On examination, she is a normally developed, thin-appearing female in no distress. Her heart rate is 110 beats per minute, blood pressure is 90/40 mmHg and temperature 38°C. There are aphthous-type ulcerations in the buccal mucosa of the mouth. There is mild right knee effusion without erythema. Abdominal examination reveals soft diffuse tenderness with localisation to the right lower quadrant and a possible mass. There are no guarding and no rebound. Rectal exam finds a draining perianal fistula without fluctuance, and a mild anal stricture.

Pertinent admission studies of blood haematology and chemistry show the following: haemoglobin 9 g/dL, haematocrit 27, white blood cell count 24,000, blood urea nitrogen 30, creatinine 1.0, anion gap 12 and albumin 2.8 g/dL.

Abdominal and chest plain films are negative. CT enterography shows terminal ileal thickening with narrowing. There is mesenteric stranding with borderline enlarged lymph nodes.

Stool studies show Clostridium difficile toxin, ova and parasites; culture, Escherichia coli O157:H7 pending.

The patient was admitted. Intravenous hydration and antibiotics were administered. Intravenous methylprednisolone 50 mg daily was started for a presumptive diagnosis of Crohn’s disease. A tuberculosis skin test (PPD) was placed. On day 2 the patient was afebrile and underwent a colonoscopy, which showed ulceration of the terminal ileum and right colon and also in the lower rectum (biopsies subsequently showed findings consistent with Crohn’s disease). Patient shows some signs of clinical improvement on day 3 with better volume status and some decrease in diarrhoea. Stool studies and PPD were negative. Methylprednisolone was switched to oral prednisone. She was infused with infliximab and continued to show clinical improvement and was discharged on hospital day 5. Prednisone was tapered off over 4 weeks. She was seen after her second infliximab infusion 9 days later. Her diarrhoea had cleared, her energy improved and her mouth sores and joint symptoms resolved. Her perianal drainage, while still present, had decreased. Infliximab was continued for remission maintenance. At last follow-up 6 months later she was completely asymptomatic and her perianal fistula had closed.


Inflammatory bowel disease (IBD) is traditionally divided into ulcerative colitis (UC) and Crohn’s disease (CD). Unlike infectious colitis that is typically self-limited, IBD is a chronic illness that is punctuated by disease exacerbations and remissions. While some similarities exist, UC and CD are very different diseases with regard to their clinical presentation, pattern of bowel involvement, response to therapy and prognosis (Table 15.1 and Box 15.1). With current methods, proper diagnosis of CD or UC can be made, although 10–15% of patients are labelled indeterminate colitis. Incidence and prevalence rates for UC and CD vary throughout the world but are highest in developed countries of northern Europe and North America.

Table 15.1 Pathological features in inflammatory bowel disease

Ulcerative colitis Crohn’s disease

Macroscopic appearance   Microscopic appearance  

Preservation of crypt architecture suggests acute self-limited colitis.

Granulomas may occur in tuberculosis, schistosomiasis and syphilis.

Ulcerative Colitis

Clinical presentation

UC typically presents in the third or fourth decade of life. Clinical presentation is based on disease location and severity. Severity is classified as mild, severe or fulminant with moderate disease between mild and severe (Table 15.2). Diarrhoea, usually bloody with cramping typically awakening the patient from sleep, signifies mucosal inflammation. Mild disease may be accompanied by frequent diarrhoea but is not associated with significant life impairment. Moderate disease, between mild and severe, typically leads to significant symptoms including profound diarrhoea (usually bloody), dehydration, fatigue and weight loss. This may progress to severe disease, which may require hospitalisation. Fulminant disease is most severe often requiring intensive care or surgery.

UC may be associated with extraintestinal manifestations in some patients (Table 15.3) which may be associated with disease activity (Fig 15.1). Those not associated with disease activity may run a clinical course independent of the disease and persist after colectomy.

Mild to moderate disease

Oral mesalamine

The best option for patients with mild to moderate UC is mesalamine (5-aminosalicylate), orally or rectally. Response rates vary because of differences in dose, disease activity and definitions of outcomes but about two-thirds will respond. Sulfasalazine, the first of this class, is both an inexpensive and effective medication. It remains essentially unchanged until it reaches the colon where it is cleaved into the active moiety 5-aminosalicylate and sulfapyridine by bacteria. Sulfapyridine (a sulfa antibiotic) is responsible for most of the observed toxicity that includes allergic reaction or renal toxicity (Box 15.2). The remaining mesalamine formulations differ on their mechanism and site of drug delivery. Newer preparations release in the colon, require fewer tablets and can be dosed once or twice daily to improve compliance. These medications are well tolerated. Headache is the most common adverse effect and, rarely, renal toxicity occurs. A baseline serum creatinine should be determined prior to starting therapy. Pancreatitis has also been described with sulfasalazine due to its sulfa moiety but also with mesalamine, although the likelihood with mesalamine is extremely low.

Mesalamine is not useful in moderate to severe UC and in mild to moderate disease is often administered at too low a dose. In appropriate doses all are probably equally effective. Sulfasalazine is relatively inexpensive and once or twice daily preparations will enhance compliance. Olsalazine should be avoided if possible, because it can cause secretory diarrhoea. Common preparations with the usual doses to induce and maintain remission are outlined in Table 15.4.

Table 15.4 Oral mesalamine preparations for induction and maintenance of remission in mild to moderate ulcerative colitis

  Optimal daily dose for remission (g)
Drug Induction Maintenance
Oral mesalamine
Sulfasalazine 4–6 2–4
Eudragit S coated 3.6–4.8 2.4–3.6
Ethylcellulose coated 3–4 2–3
Balsalazide 6.75 3–4.5
Topical mesalamine
Mesalamine suppository 0.5–1 twice daily 1 daily
Mesalamine enema 4 nightly 4 nightly or every other night

From Kornbluth A, Sachar DB. Ulcerative colitis practice guidelines in adults. Am J Gastroenterol 2010; 105:501–523.