eMedicine Specialties > Gastroenterology > Colon

Inflammatory Bowel Disease: Follow-up

Author: William A Rowe, MD, Consulting Staff, Gastroenterology, Gastroenterology Associates
Contributor Information and Disclosures

Updated: Apr 28, 2008

Follow-up

Further Inpatient Care

• Day of admission
  • Admit the patient to the hospital if surgical intervention is anticipated or if he or she does not respond to outpatient treatment, is dehydrated, or has uncontrolled pain or diarrhea.
  • Start intravenous hydration. If indicated, obtain an abdominal flat plate image to exclude obstruction or megacolon. If the patient is nauseated or vomiting or has evidence of obstruction or megacolon, nasogastric intubation is indicated. Consider consultation with a surgeon.
  • If the patient has colitis, send a stool sample for C difficile toxin titer testing; also send one for routine culture and sensitivity testing if the patient has a new diagnosis of IBD. Laboratory studies to be considered include CBC count with differential, albumin level, ESR, glucose value, calcium level, magnesium level, phosphate value, electrolyte status, BUN/creatinine values, and a pregnancy test in females of childbearing age.
  • Initiate treatment with an oral aminosalicylate, intravenous corticosteroids, and metronidazole or ciprofloxacin (if antibiotics are indicated). Electrolyte correction and, potentially, transfusion, can be performed if indicated based on laboratory findings.
  • Keep patients NPO, except for medications (Crohn disease only); patients with ulcerative colitis may maintain a regular diet unless megacolon is present or surgery is being contemplated. Consider additional consultations with a registered dietitian and a stoma nurse if indicated. Consider line placement of central venous access.
• Hospital day 1
  • If the abdominal flat plate findings were not diagnostic or if diagnostic concerns remain, order a barium study (small bowel series or barium enema). Although a colonoscopic evaluation also may be contemplated, consider the increased risk of perforation in persons with acute colitis.
  • Assess and correct the posthydration CBC count and electrolyte values, as indicated. Depending on the response to the initial interventions, advancement of the diet may be considered.
• Hospital days 2 and 3
  • By the second hospital day, most patients should be showing clear evidence of clinical improvement. Assess the electrolyte status if intravenous fluids are still being administered. Consider advancement of the diet.
  • The corticosteroid dose can be tapered. If the patient is not improving, consider other treatment options; these may include hyperalimentation, other medical therapies, surgical intervention, or transfer to a tertiary care facility. Consider skipping to interventions typically enacted on day 3 or 4 (or discharge).
  • Hospital day 3 is similar to day 2. The corticosteroid dose can be reduced, and a switch to oral forms of all medications can be contemplated. If home treatments are needed (eg, home hyperalimentation), initiate arrangements for these. The diet can be advanced as tolerated. Consider skipping to day 4 or 5 interventions.
• Hospital day 4
  • Continue to advance the diet, as tolerated. Continue the switch to oral medications. Many patients with a flare of Crohn disease or ulcerative colitis may be discharged by this time (occasionally even sooner); some may require another day of intravenous therapy.
  • If no progress has been made in the patient's condition since admission, additional treatments are necessary, including surgery or more aggressive medical treatments. Again, consider transfer to a tertiary care facility. If the patient has been unable to tolerate an oral diet, initiate hyperalimentation and/or reconsider surgical intervention.
• Day of discharge/hospital day 5
  • Most patients should be able to be discharged on or before the fifth hospital day. A regular diet should be tolerated, with some restrictions if strictures are present. An ESR may be obtained to assist in future disease assessment but is unlikely to alter current management.
  • Discharge the patient on oral medications, with appropriate follow-up as an outpatient, typically within a few weeks.

Further Outpatient Care

• Outpatient medical care follows the approach outlined earlier in the article (see Medical Care) using the medications described (see Medication).
• Most outpatients' disease is in remission and requires little or no medication other than aminosalicylates (perhaps). Flares of IBD can generally be managed in an outpatient setting, primarily by stepping up the medication as described in the step-wise approach (see Medication).
• The biggest concern for outpatients is the duration and dosing of oral corticosteroids. This author uses a dose that is adequate to suppress inflammation (and thus symptoms), typically in the range of 20-40 mg of prednisone per day. Once symptoms are controlled, a rapid taper of the steroid follows. Patients in whom flares are frequent (>1-2 times/y), in whom the duration of steroid use is long (more than a few weeks each year), in whom reduction of the steroid dose causes recurrence of symptoms, or in whom steroids do not appear to be working are candidates for more intensive therapy. This higher step would include immune-modifying agents, infliximab, or experimental agents.
• One health maintenance issue of particular importance to patients with IBD is a reduction in bone density, either from decreased calcium absorption (because of the underlying disease process) or because of corticosteroid use. Crippling osteoporosis can be a very serious complication for patients with IBD. The threshold for obtaining bone density studies should be low, and treatment (with bisphosphonates and calcium supplements) can be initiated in patients with significantly low bone density.

Inpatient & Outpatient Medications

• If a step-wise approach is observed, the least amount of medication that is effective can be used (see Medication). A general rule of thumb is that once remission is achieved, the medications used to achieve remission (except for steroids, which should be tapered off) are continued. Despite the widespread availability of home infusion, intravenous corticosteroids are still used only in hospital settings because of potential problems and the dosing schedule.
• Home infusion of intravenous hyperalimentation is increasingly available for rare patients with Crohn disease in whom prolonged bowel rest is necessary. The short bowel may require prolonged hyperalimentation. Home intravenous antibiotics can also be arranged in this setting, if necessary.

Transfer

• The decision to transfer care of a patient (inpatient or outpatient) depends on the expertise and comfort level of the treating physician. Outpatient requests for a tertiary opinion should occur when patients have disease that is difficult to control with aminosalicylates and occasional brief courses of corticosteroids.
• Relatively infrequent use and the monitoring necessary for azathioprine, 6-MP, and infliximab prompt some physicians to choose to refer patients to tertiary care centers when the need for these agents becomes apparent; others are comfortable handling these agents themselves.
• For patients with refractory disease or those in whom corticosteroids cannot be weaned, referral for a second opinion generally is wise. Transfer inpatients for a tertiary opinion if the patient is not responding to intravenous steroids within a few days of admission; alternatively, strongly consider surgical intervention.

Deterrence/Prevention

• No known dietary or lifestyle changes prevent IBD.
• Dietary manipulation may help symptoms in persons with ulcerative colitis, and it actually may help reduce inflammation in persons with Crohn disease (see Diet). However, no evidence indicates that consuming or avoiding any particular food item causes or avoids flares of IBD.
• Smoking cessation is the only lifestyle change that may benefit patients with Crohn disease. Smoking has been linked to increases in the number and severity of flares of Crohn disease. Smoking cessation is occasionally sufficient to achieve remission in a patient with refractory Crohn disease.

Complications

• See the subtopics in Clinical for the various complications that occur with IBD.

Prognosis

• Prognosis is discussed in Mortality/Morbidity. The typical course of IBD (for the vast majority of patients) includes periods of remission interspersed with occasional flares.
• Ulcerative colitis
  • The average patient with ulcerative colitis has a 50% probability of having another flare during the next 2 years. However, the range of experiences is very broad; some patients may only have one flare over 25 years (as many as 10%), and others may have almost constant flares (much less common).
  • Patients with ulcerative colitis limited to the rectum and sigmoid at the time of diagnosis have a greater than 50% chance of progressing to more extensive disease and a 12% rate of colectomy over 25 years. More than 70% of patients presenting with proctitis alone continue to have disease limited to the rectum over 20 years. Most patients who develop more extensive disease do so within 5 years of diagnosis. Of patients with ulcerative colitis involving the entire colon, 60% eventually require colectomy, whereas very few of those with proctitis require colectomy. Of interest, most surgical interventions are required in the first year of disease; the annual colectomy rate after the first year is 1% for all patients.
  • Surgical resection for ulcerative colitis is considered curative for that disease, although postoperative pouchitis may occur in some patients. Of note, pouchitis is far more common in patients who have had a colectomy for ulcerative colitis than in those who have had a colectomy for other reasons (eg, familial adenomatous polyposis).
• Crohn disease
  • The clinical course of Crohn disease is much more variable than that of ulcerative colitis. The clinical activity of Crohn disease is independent of the anatomic location and extent of disease. A patient in remission has a 42% likelihood of being free of relapse for 2 years and only a 12% likelihood of being free of relapse for 10 years. Over a 4-year period, approximately one quarter of patients remain in remission, one quarter have frequent flares, and one half have a course that fluctuates between periods of flares and remissions.
  • Surgery for Crohn disease is generally performed for complications (eg, stricture, stenosis, obstruction, fistula, bleeding) rather than for the inflammatory disease itself. After operation, the frequency of recurrence of Crohn disease is high, generally in a pattern mimicking the original disease pattern, often on one or both sides of the surgical anastomosis. Approximately one third of patients with Crohn disease who require surgery require surgery again within 5 years, and two thirds require surgery again within 15 years. Endoscopic evidence of recurrent inflammation is present in 93% of patients 1 year after surgery for Crohn disease. Surgery is an important treatment option for Crohn disease, but patients should be aware that it is not curative and that disease recurrence after surgery is the rule.

Patient Education

• Patients with IBD benefit tremendously from education about their disease. As a chronic, often life-long disease that is frequently diagnosed in young adulthood, increasing patient knowledge improves medical compliance and assists in the management of symptoms.
• The Crohn's & Colitis Foundation of America is the most prominent organization in the United States that can directly provide educational materials for patients. This organization also supplies physicians with educational brochures at no cost upon request.
• For excellent patient education resources, visit eMedicine's Crohn Disease Center and Esophagus, Stomach, and Intestine Center. Also, see eMedicine's patient education articles Inflammatory Bowel Disease, Crohn Disease, Crohn Disease FAQs, and Irritable Bowel Syndrome.

Miscellaneous

Medicolegal Pitfalls

• Physicians may be at risk in certain areas of the treatment of patients with IBD. In general, these may be easily avoided by documenting appropriate education of the patient in the patient's medical record.
• Patients with IBD are more prone to the development of malignancy. Persons with Crohn disease have a higher rate of small bowel malignancy. Because no effective screening protocol is available, this should not be an issue. Patients with pancolitis, particularly ulcerative colitis, are at a higher risk of developing colonic malignancy after 8-10 years of disease. The current standard of practice is to screen these patients with colonoscopy at 2-year intervals once they have had the disease for that duration. If a patient refuses appropriate screening, document it in the medical record.
• Use of corticosteroids may lead to debilitating illness, particularly after long-term use. Warn patients who refuse to try more aggressive therapies and insist on continuing to take corticosteroids of the potential for long-term harm with these drugs, and take care to document these warnings and the alternatives offered in the medical record. Recommend to any patient who requires more than the rare short course of steroids that a yearly ophthalmologic examination is warranted because of the risk of cataract development.
• Patients with IBD who are undergoing endoscopic procedures have higher complication rates than the general population; the informed consent obtained for endoscopic procedures should always mention bleeding and perforation as potential complications. The single factor cited in most lawsuits involving endoscopy is failure to obtain adequate informed consent; missed malignancy and perforation are secondary.
• Ulcerative colitis is a surgically curable disease. Keep this in mind in patients who are having significant difficulty with their disease or are having significant adverse effects from medications (particularly those related to long-term steroid use). This author makes certain to mention this (and document it) when first meeting any patient with ulcerative colitis.
• If a decision is made to use or to continue immunosuppressant agents (ie, azathioprine, 6-MP) in a pregnant patient with IBD, the physician should be aware of the latest literature⁹ and should document the discussion of such with the patient, particularly given that these agents are still rated pregnancy class D by the US FDA.

Special Concerns

• Because patients with IBD are often diagnosed in the peak of childbearing years, issues related to fertility, pregnancy, and childbearing are always a concern with the disease and its treatment.
• Reproduction  
  • In women, fertility is normal or only minimally impaired. Women considering pregnancy should not take immune modifiers (ie, 6-MP, azathioprine). Although some case reports and small series show no adverse outcomes of pregnancies in patients with IBD who are taking immune modifiers, birth defects are also reported. If a patient is taking an immune modifier and becomes pregnant, stopping the immune modifier and using steroids, as needed, is advisable in most instances. Vigilance for birth defects is appropriate.
  • For men with IBD, the major concern is the medications needed for treatment. Sulfasalazine can decrease sperm counts and sperm motility, causing a functional azoospermia; the other aminosalicylates do not seem to have this effect. The sperm effects are reversible by discontinuing the sulfasalazine. No firm evidence indicates that the use of immune modifiers in the father leads to more birth defects, although this has been suggested.
• Pregnancy  
  • Most infants are born healthy. The prevalence of prematurity, stillbirth, and birth defects is similar to that of the general population. The prevalence of spontaneous abortion is slightly higher in patients with IBD (12.2% vs 9.9% in the general population). Prior proctocolectomy or ileostomy is not an impediment to successful pregnancy.
  • In general, the aminosalicylates, including sulfasalazine, are safe during pregnancy. Folate supplements should be taken. Corticosteroids are also safe, but if high doses are needed near the end of the pregnancy, monitor the infant for signs of adrenal suppression. The literature suggests that continuation of immune modifiers (ie, azathioprine, 6-MP) may be safe in pregnancy. Metronidazole (Flagyl) and ciprofloxacin (Cipro) are safe in pregnancy. The topical agents are generally safe in pregnancy.
• Breastfeeding  
  • Mothers who require medication to control of their IBD should strongly consider bottle feeding their infants. Sulfasalazine metabolites can be detected in breast milk; exercise caution. Low concentrations of mesalamine and higher concentrations of its metabolites can be detected in breast milk. The significance of this is unknown. Corticosteroids can also be detected in breast milk. Immune modifiers are excreted in breast milk; either the immune modifier should be discontinued or the infant should be bottle fed. Metronidazole (Flagyl) and ciprofloxacin (Cipro) are excreted in breast milk; discontinue breastfeeding or discontinue the drugs.
  • Although small amounts of the topical agents are absorbed, and thus may be excreted in breast milk, the concentrations are much lower than with the oral forms of the same medications. These medications are probably reasonably safe in breastfeeding.
• Medications, safety in pregnancy 
  • All of the aminosalicylates and the corticosteroids appear to be safe in women in all phases of fertility, pregnancy, and lactation. Men should avoid sulfasalazine (Azulfidine) during periods when they and their mates are attempting to become pregnant.
  • The antibiotics (ie, metronidazole, ciprofloxacin) should generally be avoided during lactation; they are probably safe for fertility and during pregnancy.
  • The immune-modifying agents (ie, 6-MP, azathioprine) should be considered only on a case-by-case basis.
• Aspirin and nonsteroidal anti-inflammatory agents in IBD  
  • Substantial controversy has been raised in the medical/IBD community regarding the effects of aspirin or nonsteroidal anti-inflammatory drugs (NSAIDs) on IBD. Published data and recommendations indicate that aspirin and NSAIDs cause a number of flares of IBD and, thus, should be avoided in all patients with IBD. On the other hand, studies also indicate that only a very minor link exists between the use of aspirin or NSAIDs and flares of IBD.
  • This author's practice is to administer aspirin or NSAIDs judiciously when indicated (eg, with arthritis and/or arthralgias associated with IBD), with the caveat that the patient is warned of the possibility that the medication may cause a flare of the IBD. If, shortly after starting the NSAID, a flare occurs, then the NSAID should be discontinued. If the patient's disease remains in remission, the patient can be maintained on the NSAID as necessary.

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