A 22-year-old woman presents to the clinic with a 3-year history of bloody diarrhea, abdominal pain, and anorectal fistulas. Her father had similar symptoms during his 20's and has had multiple abdominal surgeries. What is the percentage of patients with this disease who have family members with the same disease?
Family history may play a role in inflammatory bowel disease as 10 to 30% of patients with inflammatory bowel disease report a family member with the same disease.
A 25-year-old man is undergoing workup to determine if he has ulcerative colitis, Crohn disease, or indeterminate colitis. What diagnostic findings would indicate that he has Crohn disease?
Ulcerative colitis is a mucosal process in which the colonic mucosa and submucosa are infiltrated with inflammatory cells. The mucosa may be atrophic, and crypt abscesses are common. Endoscopically, the mucosa is frequently friable and may possess multiple inflammatory pseudopolyps. In longstanding ulcerative colitis, the colon may be foreshortened and the mucosa replaced by scar. A key feature of ulcerative colitis is the continuous involvement of the rectum and colon; rectal sparing or skip lesions suggest a diagnosis of Crohn disease. Crohn disease is a transmural inflammatory process that can affect any part of the gastrointestinal tract from mouth to anus. Mucosal ulcerations, an inflammatory cell infiltrate, and noncaseating granulomas are characteristic pathologic findings. Chronic inflammation may ultimately result in fibrosis, strictures, and fistulas in either the colon or small intestine. The endoscopic appearance of Crohn colitis is characterized by deep serpiginous ulcers and a "cobblestone" appearance.
What structures are most likely to be site of extracolonic disease in inflammatory bowel disease?
The liver is a common site of extracolonic disease in inflammatory bowel disease. Fatty infiltration of the liver is present in 40 to 50% of patients, and cirrhosis is found in 2 to 5%. Primary sclerosing cholangitis is a progressive disease characterized by intra- and extrahepatic bile duct strictures. Forty to 60% of patients with primary sclerosing cholangitis have ulcerative colitis. Pericholangitis is also associated with inflammatory bowel disease and may be diagnosed with a liver biopsy. Bile duct carcinoma is a rare complication of long-standing inflammatory bowel disease. Arthritis also is a common extracolonic manifestation of inflammatory bowel disease, and the incidence is 20 times greater than in the general population. Erythema nodosum is seen in 5 to 15% of patients with inflammatory bowel disease and usually coincides with clinical disease activity. Pyoderma gangrenosum is an uncommon but serious condition that occurs almost exclusively in patients with inflammatory bowel disease. Up to 10% of patients with inflammatory bowel disease will develop ocular lesions. These include uveitis, iritis, episcleritis, and conjunctivitis.
An 18-year-old woman is undergoing workup to determine if she has ulcerative colitis, Crohn disease, or indeterminate colitis. What diagnostic findings would indicate that she has ulcerative colitis?
The goals of medical therapy for inflammatory bowel disease are to decrease inflammation and alleviate symptoms. Mild to moderate flares are treated in the clinic and more severe symptoms may require hospitalization. What is the first -line therapy for inflammatory bowel disease in the outpatient setting?
Sulfasalazine (Azulfidine), 5-acetyl salicylic acid (5-ASA), and related compounds are first-line agents in the medical treatment of mild to moderate inflammatory bowel disease. These compounds decrease inflammation by inhibition of cyclooxygenase and 5-lipoxygenase in the gut mucosa. They require direct contact with affected mucosa for efficacy. Multiple preparations are available for administration to different sites in the small intestine and colon. Antibiotics are often used to decrease the intraluminal bacterial load in Crohn disease. Metronidazole has been reported to improve Crohn colitis and perianal disease, but the evidence is weak. Fluoroquinolones may also be effective in some cases. In the absence of fulminant colitis or toxic megacolon, antibiotics are not used to treat ulcerative colitis. Corticosteroids (either oral or parenteral) are a key component of treatment for an acute exacerbation of either ulcerative colitis or Crohn disease.
Corticosteroids are nonspecific inhibitors of the immune system, and 75 to 90% of patients will improve with the administration of these drugs. Azathioprine and 6-mercatopurine (6-MP) are antimetabolite drugs that interfere with nucleic acid synthesis and thus decrease proliferation of inflammatory cells. These agents are useful for treating ulcerative colitis and Crohn disease in patients who have failed salicylate therapy or who are dependent on, or refractory to, corticosteroids.