eMedicine Specialties > Emergency Medicine > Gastrointestinal

Inflammatory Bowel Disease: Follow-up

Author: Sarvotham Kini, MD, Associate Professor of Emergency Medicine, Medical University of South Carolina, Charleston.
Contributor Information and Disclosures

Updated: Nov 20, 2009

Follow-up

Further Outpatient Care

  • Nutritional support in Crohn's disease includes supplementation with trace metals, fat-soluble vitamins, 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 the Crohn'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.
    • The mortality rate is 50% if perforation occurs.
    • 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 diagnosing toxic megacolon is 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.
    • Fistula types include enterovesical (leading to recurrent urinary tract infections and pneumaturia), enteroenteric, enteromesenteric, enterocutaneous, rectovaginal, and perianal.
    • Additional problems include stenosis and obstruction.
    • Perianal complications occur in 90% of patients with Crohn's disease.
    • 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:
    • Ulcerative colitis carries a 10- to 30-fold increase in development of carcinoma of the colon.
    • Risk increases with extent and duration of the disease.
    • Cumulative risks of cancer after 15, 20, and 25 years are 8%, 12%, and 25%, respectively.
    • 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.
    • The risk of cancer in Crohn's disease may be equal to that of ulcerative colitis if the entire 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 inflamed area, 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 bowel disease (IBD). In some cases, they may be more problematic than the bowel disease itself.
    • Arthritic
      • Peripheral arthritis, usually migratory and monoarticular, tends to parallel disease activity but may antedate it.
      • Ankylosing spondylitis is associated with human leukocyte antigen-B27 (HLA-B27).
    • Ocular
      • Episcleritis manifests with burning eyes and scleral injection (see Media file 3) 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.

      • Inflammatory bowel disease. Episcleritis. Courtes...

        Inflammatory bowel disease. Episcleritis. Courtesy of Dr David Sevel.

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        Inflammatory bowel disease. Episcleritis. Courtes...

        Inflammatory bowel disease. Episcleritis. Courtesy of Dr David Sevel.

      • Iritis, which manifests as an acute painful red eye with photophobia and conjunctival injection, often runs a course independent of intestinal disease. It can progress to blindness. Treatment is with topical or systemic steroids.
      • Cataracts are associated with long-term steroid use. Patients taking long-term steroids should have an annual slit-lamp examination.
    • Dermatologic
      • Erythema nodosum is characterized by painful, tender, raised red or violaceous subcutaneous nodules, usually found over the extensor aspects of the arms and the legs, especially the anterior tibia. Activity usually follows that of the intestinal disease and often heralds onset of increased bowel activity.
      • Pyoderma gangrenosum is characterized by ulcerating relatively painless lesions that correlate with bowel activity in about 50% of patients (see Media file 4). Although ulcers may exhibit purulent drainage, culture to the present time, the treatment of pyoderma gangrenosum has involved the use of corticosteroids and cyclosporine. Reports have indicated that not only does the condition respond to infliximab13 but this drug should probably be considered the drug of choice against pyoderma gangrenosum.

      • Inflammatory bowel disease. Pyoderma gangrenosum....

        Inflammatory bowel disease. Pyoderma gangrenosum. Courtesy of Dr Gene Izuno.

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        Inflammatory bowel disease. Pyoderma gangrenosum....

        Inflammatory bowel disease. Pyoderma gangrenosum. Courtesy of Dr Gene Izuno.

      • Aphthous ulcers are more common in patients with IBD than in the general population.
    • Other
      • Additional extraintestinal manifestations include pericholangitis, chronic active hepatitis, cirrhosis, primary sclerosing cholangitis, and bile duct carcinoma. Pericholangitis is the most common hepatic complication of IBD and is usually asymptomatic. Look for elevations of the alkaline phosphatase, less often bilirubin. Primary sclerosing cholangitis can progress to cirrhosis, in which case liver transplantation is the treatment of choice. However, it can recur in the transplanted liver.
      • Gallstones occur in about one third of patients with Crohn's disease, resulting from increased lithogenicity of the bile due to impaired ileal absorption of bile acids.
      • A hypercoagulable state can occur, leading to deep venous thromboses, pulmonary embolism, and arterial thromboses. Additionally, portal or hepatic vein thrombosis, stokes, retinal venous thrombosis, gonadal vein thrombosis, and mesenteric venous thrombosis have been reported. The incidence of thrombotic complications may be as high as 39%. The hypercoagulable state correlates with the activity of the disease. Its cause is unclear, but it may be related to increased levels of plasminogen activator inhibitor, factors V and VIII and fibrinogen or to decreased levels of factor V Leiden, antithrombin III, and proteins C and S.

Prognosis

  • Ulcerative colitis
    • A small percentage of patients have a single attack and no recurrence. Typically, however, remissions and exacerbations are characteristic of ulcerative colitis (UC), with acute attacks lasting weeks to months.
    • Twenty percent of patients require colectomy, which is curative.
    • Long-term morbidity primarily results from complications of medical therapy, especially long-term steroids.
  • Crohn's disease
    • Prognosis depends on the site and extent of disease.
    • Periodic remissions and exacerbations are the rule.
    • Approximately 50% of patients require surgical intervention; 50% of patients undergoing surgery require a second operation; of these patients, 50% have a third operation.
    • Rate of recurrence is 25-50% within 1 year for patients who have responded to medical management. This rate is higher for patients who require surgery.
    • Overall, the quality of life with Crohn's disease generally is lower than with ulcerative colitis. Death usually occurs as a consequence of surgery, pulmonary embolus, or sepsis.
    • Intestinal cancer may become a more important long-term complication in patients with Crohn's disease because of longer survival.

Patient Education

Miscellaneous

Medicolegal Pitfalls

  • Failure to obtain early surgical consultation for suspected obstruction, peritonitis, or fulminant disease
  • Failure to consider diagnosis of inflammatory bowel disease (IBD), especially Crohn's disease (CD), in patients presenting with perianal disease: Look for fistulous openings, induration, redness, or tenderness near the anus.
  • Failure to recognize unusual presentations, such as sciatica resulting from a terminal ileal abscess with right iliopsoas extension
  • Failure to recognize that steroids may mask the clinical severity of illness: The febrile patient on steroids may be harboring a serious bacterial infection or abscess.
  • Failure to consider concomitant enteric infection (eg, C difficile) as the cause of an exacerbation
  • Use of antidiarrheals, anticholinergics, and narcotics in fulminant disease, which should be avoided
  • Overzealous use of steroids in the presence of an undrained abscess or when symptoms are due to a stricture or fibrotic process, rather than active inflammation
  • Failure to perform endoscopic examination: Remember that all patients with new-onset rectal bleeding should undergo an endoscopic evaluation of the colon, unless an infectious etiology seems likely. For a young patient with apparent distal rectal bleeding (red blood on toilet paper and coating the stool), a flexible sigmoidoscopy may suffice.
  • Prescribing NSAIDs: Beware of prescribing NSAIDs because they can lead to disruption of GI mucosal integrity and cause a flare of IBD.
  • Failure to consider the diagnosis of Crohn disease in a patient with seemingly refractory gastric or duodenal ulcer disease.

Special Concerns

  • Children
    • Approximately 15-30% of patients with inflammatory bowel disease (IBD) are younger than 20 years.
    • Presentation can include growth failure from malnutrition and delayed sexual maturation. Many of these children also have depression.
    • Sulfasalazine may be used as in adults, but administer steroids on an alternate day regimen, if possible, to diminish adverse effects.
    • Although immunosuppressives have been used in children, concern for adverse reactions is high; the possibility of malignancy exists in view of potential for longer exposure.
  • Pregnancy
    • Outlook generally is favorable; however, inflammatory bowel disease (IBD) is associated with an increased frequency of adverse pregnancy outcomes, especially if the disease is active at the time of conception.
    • Fertility in women with IBD is normal or only minimally impaired. The incidence of prematurity, stillbirth, and developmental defects in IBD are similar to those of the general population.
    • If the IBD is inactive at time of conception, it is likely to remain inactive during pregnancy. If IBD is active at the time of conception, ulcerative colitis tends to worsen. In two thirds of patients who have active Crohn's disease at the time of conception, the degree of activity remains the same; in the other third, some have improvement and others have deterioration.
    • Sulfasalazine and steroids may be administered during pregnancy. Sulfasalazine can be taken throughout pregnancy; however, it interferes with folate absorption, and pregnant women have an increased requirement for folic acid. Hence, women taking sulfasalazine should also take 1 mg of folate twice a day. The use of steroids during pregnancy has not been associated with an increased rate of activity; thus, the risks of treatment with sulfasalazine or corticosteroids in pregnant women with IBD are less significant than the risks of allowing disease activity to go untreated.
 
Acknowledgments

The authors and editors of eMedicine gratefully acknowledge the contributions of previous author, William Shapiro, MD, to the development and writing of this article.



More on Inflammatory Bowel Disease

Overview: Inflammatory Bowel Disease
Differential Diagnoses & Workup: Inflammatory Bowel Disease
Treatment & Medication: Inflammatory Bowel Disease
Follow-up: Inflammatory Bowel Disease
Multimedia: Inflammatory Bowel Disease
References
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Further Reading

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Keywords

IBD, inflammatory bowel disease, IBD symptoms, IBD diagnosis, IBD treatment, ulcerative colitis, Crohns, Crohn disease, Crohn's disease, regional enteritis, terminal ileitis, granulomatous ileocolitis, inflammation of the colon, colitis, irritable bowel syndrome, mucous colitis, spastic colon

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Contributor Information and Disclosures

Author

Sarvotham Kini, MD, Associate Professor of Emergency Medicine, Medical University of South Carolina, Charleston.
Sarvotham Kini, MD is a member of the following medical societies: American College of Emergency Physicians, American College of Surgeons, and South Carolina Medical Association
Disclosure: Nothing to disclose.

Medical Editor

William K Chiang, MD, Associate Professor, Department of Emergency Medicine, New York University School of Medicine; Chief of Service, Department of Emergency Medicine, Bellevue Hospital Center
William K Chiang, MD is a member of the following medical societies: American Academy of Clinical Toxicology, American College of Medical Toxicology, and Society for Academic Emergency Medicine
Disclosure: Nothing to disclose.

Pharmacy Editor

Francisco Talavera, PharmD, PhD, Senior Pharmacy Editor, eMedicine
Disclosure: eMedicine Salary Employment

Managing Editor

Eugene Hardin, MD, FAAEM, FACEP, Former Chair and Associate Professor, Department of Emergency Medicine, Charles Drew University of Medicine and Science; Former Chair, Department of Emergency Medicine, Martin Luther King Jr/Drew Medical Center
Disclosure: Nothing to disclose.

CME Editor

John D Halamka, MD, MS, Associate Professor of Medicine, Harvard Medical School, Beth Israel Deaconess Medical Center; Chief Information Officer, CareGroup Healthcare System and Harvard Medical School; Attending Physician, Division of Emergency Medicine, Beth Israel Deaconess Medical Center
John D Halamka, MD, MS is a member of the following medical societies: American College of Emergency Physicians, American Medical Informatics Association, Phi Beta Kappa, and Society for Academic Emergency Medicine
Disclosure: Nothing to disclose.

Chief Editor

Steven C Dronen, MD, FAAEM, Director of Emergency Services, Director of Chest Pain Center, Department of Emergency Medicine, Ft Sanders Sevier Medical Center
Steven C Dronen, MD, FAAEM is a member of the following medical societies: American Academy of Emergency Medicine and Society for Academic Emergency Medicine
Disclosure: Nothing to disclose.

 
 
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