Sections

DDx

Diagnostic Considerations

Approximately 90% of patients with Crohn disease have involvement of the terminal ileum and/or right colon. Pediatric patients are more likely (about 20%) to present with disease limited to the small intestine, although very young children often present with purely colonic disease. Occasionally, gastric or duodenal Crohn disease manifests as seemingly refractory peptic ulcer disease.

Consider anorexia and bulimia in patients with suspected inflammatory bowel disease (IBD) and irritable bowel syndrome (IBS), because not only are abdominal pain, weight loss, and vomiting consistent in these four conditions, but IBD is frequently diagnosed in late-teen and young-adult patients, which are also the peak years for anorexia and bulimia.

Due to the nonspecific gastrointestinal symptoms of Crohn disease and ulcerative colitis, several other diagnoses (see below) must be considered before establishing a diagnosis of Crohn disease or ulcerative colitis, particularly in the absence of typical endoscopic findings and in populations at higher risk for other diagnoses.

Note that historically—and especially when a preoperative computed tomography (CT) scanning has not been done—Crohn disease is frequently diagnosed at the time of laparotomy for presumed appendicitis. Another disease in the differential diagnosis is salmonellosis, which can present as bloody diarrhea.

Diarrhea

Consider the following conditions in patients with diarrhea as a dominant symptom:

Celiac disease
Microscopic (lymphocytic, collagenous) colitis
Irritable bowel syndrome
Lactose intolerance
Functional diarrhea
Gastrointestinal infections (eg, intestinal tuberculosis,^[56] amebiasis,^[56]chronic Yersinia infection,^[56]and antibiotic-associated colitis/Clostridium difficile infection)
Behcet disease^[56]
AIDS
C1 esterase deficiency, hereditary angioedema
Colorectal malignancy (eg, adenocarcinoma, lymphoma)

Abdominal pain, gastrointestinal bleeding, and/or intestinal ulceration

In patients with predominant abdominal pain, gastrointestinal bleeding, and/or intestinal ulceration, consider the following conditions in the differential diagnosis:

Ischemic colitis
Radiation-induced colitis
Arteriovenous malformations
Nonsteroidal anti-inflammatory drug (NSAID) enteropathy
Behcet disease
Intestinal tuberculosis
Colorectal malignancy

Differential Diagnoses

Workup

World Gastroenterology Organisation Global Guideline. Inflammatory bowel disease: a global perspective. Munich, Germany: World Gastroenterology Organisation (WGO); 2009.
American Gastroenterological Association medical position statement: perianal Crohn's disease. Gastroenterology. 2003 Nov. 125(5):1503-7. [QxMD MEDLINE Link].
Kornbluth A, Sachar DB. Ulcerative colitis practice guidelines in adults: American College of Gastroenterology, Practice Parameters Committee. Am J Gastroenterol. 2010 Mar. 105(3):501-23; quiz 524. [QxMD MEDLINE Link].
Kiran RP, Nisar PJ, Church JM, Fazio VW. The role of primary surgical procedure in maintaining intestinal continuity for patients with Crohn's colitis. Ann Surg. 2011 Jun. 253(6):1130-5. [QxMD MEDLINE Link].
Agrawal D, Rukkannagari S, Kethu S. Pathogenesis and clinical approach to extraintestinal manifestations of inflammatory bowel disease. Minerva Gastroenterol Dietol. 2007 Sep. 53(3):233-48. [QxMD MEDLINE Link].
Thoreson R, Cullen JJ. Pathophysiology of inflammatory bowel disease: an overview. Surg Clin North Am. 2007 Jun. 87(3):575-85. [QxMD MEDLINE Link].
Rioux JD, Xavier RJ, Taylor KD, et al. Genome-wide association study identifies new susceptibility loci for Crohn disease and implicates autophagy in disease pathogenesis. Nat Genet. 2007 May. 39(5):596-604. [QxMD MEDLINE Link]. [Full Text].
Tsianos EV, Katsanos KH, Tsianos VE. Role of genetics in the diagnosis and prognosis of Crohn's disease. World J Gastroenterol. 2012 Jan 14. 18(2):105-18. [QxMD MEDLINE Link]. [Full Text].
Lashner B. Inflammatory bowel disease. Carey WD, ed. Cleveland Clinic: Current Clinical Medicine -- 2009. Philadelphia, Pa: Saunders; 2009.
Wilkins T, Jarvis K, Patel J. Diagnosis and management of Crohn's disease. Am Fam Physician. 2011 Dec 15. 84(12):1365-75. [QxMD MEDLINE Link].
Trinchieri A, Lizzano R, Castelnuovo C, Zanetti G, Pisani E. Urinary patterns of patients with renal stones associated with chronic inflammatory bowel disease. Arch Ital Urol Androl. 2002 Jun. 74(2):61-4. [QxMD MEDLINE Link].
Amre DK, D'Souza S, Morgan K, et al. Imbalances in dietary consumption of fatty acids, vegetables, and fruits are associated with risk for Crohn's disease in children. Am J Gastroenterol. 2007 Sep. 102(9):2016-25. [QxMD MEDLINE Link].
Jantchou P, Morois S, Clavel-Chapelon F, Boutron-Ruault MC, Carbonnel F. Animal protein intake and risk of inflammatory bowel disease: The E3N prospective study. Am J Gastroenterol. 2010 Oct. 105(10):2195-201. [QxMD MEDLINE Link].
Bengtson MB, Solberg IC, Aamodt G, Jahnsen J, Moum B, Vatn MH. Relationships between inflammatory bowel disease and perinatal factors: both maternal and paternal disease are related to preterm birth of offspring. Inflamm Bowel Dis. 2010 May. 16(5):847-55. [QxMD MEDLINE Link].
Hampe J, Grebe J, Nikolaus S, et al. Association of NOD2 (CARD 15) genotype with clinical course of Crohn's disease: a cohort study. Lancet. 2002 May 11. 359(9318):1661-5. [QxMD MEDLINE Link].
Hugot JP, Chamaillard M, Zouali H, et al. Association of NOD2 leucine-rich repeat variants with susceptibility to Crohn's disease. Nature. 2001 May 31. 411(6837):599-603. [QxMD MEDLINE Link].
Duerr RH, Taylor KD, Brant SR, et al. A genome-wide association study identifies IL23R as an inflammatory bowel disease gene. Science. 2006 Dec 1. 314(5804):1461-3. [QxMD MEDLINE Link].
Glas J, Seiderer J, Wetzke M, et al. rs1004819 is the main disease-associated IL23R variant in German Crohn's disease patients: combined analysis of IL23R, CARD15, and OCTN1/2 variants. PLoS One. 2007 Sep 5. 2(9):e819. [QxMD MEDLINE Link]. [Full Text].
Van Limbergen J, Russell RK, Nimmo ER, et al. IL23R Arg381Gln is associated with childhood onset inflammatory bowel disease in Scotland. Gut. 2007 Aug. 56(8):1173-4. [QxMD MEDLINE Link]. [Full Text].
Barrett JC, Hansoul S, Nicolae DL, et al. Genome-wide association defines more than 30 distinct susceptibility loci for Crohn's disease. Nat Genet. 2008 Aug. 40(8):955-62. [QxMD MEDLINE Link]. [Full Text].
Hampe J, Franke A, Rosenstiel P, et al. A genome-wide association scan of nonsynonymous SNPs identifies a susceptibility variant for Crohn disease in ATG16L1. Nat Genet. 2007 Feb. 39(2):207-11. [QxMD MEDLINE Link].
Parkes M, Barrett JC, Prescott NJ, et al. Sequence variants in the autophagy gene IRGM and multiple other replicating loci contribute to Crohn's disease susceptibility. Nat Genet. 2007 Jul. 39(7):830-2. [QxMD MEDLINE Link]. [Full Text].
Libioulle C, Louis E, Hansoul S, et al. Novel Crohn disease locus identified by genome-wide association maps to a gene desert on 5p13.1 and modulates expression of PTGER4. PLoS Genet. 2007 Apr 20. 3(4):e58. [QxMD MEDLINE Link]. [Full Text].
Hedin C, Whelan K, Lindsay JO. Evidence for the use of probiotics and prebiotics in inflammatory bowel disease: a review of clinical trials. Proc Nutr Soc. 2007 Aug. 66(3):307-15. [QxMD MEDLINE Link].
Wellcome Trust Case Control Consortium. Genome-wide association study of 14,000 cases of seven common diseases and 3,000 shared controls. Nature. 2007 Jun 7. 447(7145):661-78. [QxMD MEDLINE Link]. [Full Text].
Fisher SA, Tremelling M, Anderson CA, et al. Genetic determinants of ulcerative colitis include the ECM1 locus and five loci implicated in Crohn's disease. Nat Genet. 2008 Jun. 40(6):710-2. [QxMD MEDLINE Link]. [Full Text].
Weersma RK, Zhernakova A, Nolte IM, et al. ATG16L1 and IL23R are associated with inflammatory bowel diseases but not with celiac disease in the Netherlands. Am J Gastroenterol. 2008 Mar. 103(3):621-7. [QxMD MEDLINE Link].
Silverberg MS, Cho JH, Rioux JD, et al. Ulcerative colitis-risk loci on chromosomes 1p36 and 12q15 found by genome-wide association study. Nat Genet. 2009 Feb. 41(2):216-20. [QxMD MEDLINE Link]. [Full Text].
Okada Y, Yamazaki K, Umeno J, et al. HLA-Cw*1202-B*5201-DRB1*1502 haplotype increases risk for ulcerative colitis but reduces risk for Crohn's disease. Gastroenterology. 2011 Sep. 141(3):864-871.e1-5. [QxMD MEDLINE Link].
Centers for Disease Control and Prevention. Inflammatory bowel disease (IBD). Available at http://www.cdc.gov/ibd/#epidIBD. Accessed: August 6, 2012.
Molodecky NA, Soon IS, Rabi DM, et al. Increasing incidence and prevalence of the inflammatory bowel diseases with time, based on systematic review. Gastroenterology. 2012 Jan. 142(1):46-54.e42; quiz e30. [QxMD MEDLINE Link].
Loftus EV Jr. Clinical epidemiology of inflammatory bowel disease: Incidence, prevalence, and environmental influences. Gastroenterology. 2004 May. 126(6):1504-17. [QxMD MEDLINE Link].
Loftus EV Jr, Silverstein MD, Sandborn WJ, Tremaine WJ, Harmsen WS, Zinsmeister AR. Ulcerative colitis in Olmsted County, Minnesota, 1940-1993: incidence, prevalence, and survival. Gut. 2000 Mar. 46(3):336-43. [QxMD MEDLINE Link]. [Full Text].
Loftus EV Jr, Silverstein MD, Sandborn WJ, Tremaine WJ, Harmsen WS, Zinsmeister AR. Crohn's disease in Olmsted County, Minnesota, 1940-1993: incidence, prevalence, and survival. Gastroenterology. 1998 Jun. 114(6):1161-8. [QxMD MEDLINE Link].
Roth MP, Petersen GM, McElree C, Feldman E, Rotter JI. Geographic origins of Jewish patients with inflammatory bowel disease. Gastroenterology. 1989 Oct. 97(4):900-4. [QxMD MEDLINE Link].
Sonnenberg A, McCarty DJ, Jacobsen SJ. Geographic variation of inflammatory bowel disease within the United States. Gastroenterology. 1991 Jan. 100(1):143-9. [QxMD MEDLINE Link].
Shivananda S, Lennard-Jones J, Logan R, et al. Incidence of inflammatory bowel disease across Europe: is there a difference between north and south? Results of the European Collaborative Study on Inflammatory Bowel Disease (EC-IBD). Gut. 1996 Nov. 39(5):690-7. [QxMD MEDLINE Link]. [Full Text].
Langholz E. Current trends in inflammatory bowel disease: the natural history. Therap Adv Gastroenterol. 2010 Mar. 3(2):77-86. [QxMD MEDLINE Link]. [Full Text].
Card T, Hubbard R, Logan RF. Mortality in inflammatory bowel disease: a population-based cohort study. Gastroenterology. 2003 Dec. 125(6):1583-90. [QxMD MEDLINE Link].
Jess T, Loftus EV Jr, Harmsen WS, et al. Survival and cause specific mortality in patients with inflammatory bowel disease: a long term outcome study in Olmsted County, Minnesota, 1940-2004. Gut. 2006 Sep. 55(9):1248-54. [QxMD MEDLINE Link]. [Full Text].
Hutfless SM, Weng X, Liu L, Allison J, Herrinton LJ. Mortality by medication use among patients with inflammatory bowel disease, 1996-2003. Gastroenterology. 2007 Dec. 133(6):1779-86. [QxMD MEDLINE Link].
Dorn SD, Sandler RS. Inflammatory bowel disease is not a risk factor for cardiovascular disease mortality: results from a systematic review and meta-analysis. Am J Gastroenterol. 2007 Mar. 102(3):662-7. [QxMD MEDLINE Link].
[Guideline] Farraye FA, Odze RD, Eaden J, et al. AGA medical position statement on the diagnosis and management of colorectal neoplasia in inflammatory bowel disease. Gastroenterology. 2010 Feb. 138(2):738-45. [QxMD MEDLINE Link].
AGA medical position statement on the diagnosis and management of colorectal neoplasia in inflammatory bowel disease. 2010. Available at http://www.gastrojournal.org/article/S0016-5085(09)02202-1/fulltext. Accessed: August 6, 2012.
Colonoscopic surveillance for prevention of colorectal cancer in people with ulcerative colitis, Crohn's disease or adenomas. London, UK: National Institute for Health and Clinical Excellence (NICE); 2011. Available at http://guideline.gov/content.aspx?id=34830. Accessed: August 6, 2012.
Barclay L. COPD, asthma may up risk for inflammatory bowel disease. Medscape Medical News by WebMD. November 20, 2014. Available at http://www.medscape.com/viewarticle/835213. Accessed: November 22, 2014.
Brassard P, Vutcovici M, Ernst P, et al. Increased incidence of inflammatory bowel disease in Québec residents with airway diseases. Eur Respir J. 2015 Apr. 45(4):962-8. [QxMD MEDLINE Link].
Brooks AJ, Rowse G, Ryder A, Peach EJ, Corfe BM, Lobo AJ. Systematic review: psychological morbidity in young people with inflammatory bowel disease - risk factors and impacts. Aliment Pharmacol Ther. 2016 Jul. 44(1):3-15. [QxMD MEDLINE Link]. [Full Text].
Meucci G, Vecchi M, Astegiano M, et al. The natural history of ulcerative proctitis: a multicenter, retrospective study. Gruppo di Studio per le Malattie Infiammatorie Intestinali (GSMII). Am J Gastroenterol. 2000 Feb. 95(2):469-73. [QxMD MEDLINE Link].
Henriksen M, Jahnsen J, Lygren I, et al. Ulcerative colitis and clinical course: results of a 5-year population-based follow-up study (the IBSEN study). Inflamm Bowel Dis. 2006 Jul. 12(7):543-50. [QxMD MEDLINE Link].
Solberg IC, Vatn MH, Hoie O, et al. Clinical course in Crohn's disease: results of a Norwegian population-based ten-year follow-up study. Clin Gastroenterol Hepatol. 2007 Dec. 5(12):1430-8. [QxMD MEDLINE Link].
Lichtenstein GR, Hanauer SB, Sandborn WJ. Management of Crohn's disease in adults. Am J Gastroenterol. 2009 Feb. 104(2):465-83; quiz 464, 484. [QxMD MEDLINE Link].
Buisson A, Chevaux JB, Allen PB, Bommelaer G, Peyrin-Biroulet L. Review article: the natural history of postoperative Crohn's disease recurrence. Aliment Pharmacol Ther. 2012 Mar. 35(6):625-33. [QxMD MEDLINE Link].
Larsen S, Bendtzen K, Nielsen OH. Extraintestinal manifestations of inflammatory bowel disease: epidemiology, diagnosis, and management. Ann Med. 2010 Mar. 42(2):97-114. [QxMD MEDLINE Link].
Vavricka SR, Brun L, Ballabeni P, et al. Frequency and risk factors for extraintestinal manifestations in the Swiss inflammatory bowel disease cohort. Am J Gastroenterol. 2011 Jan. 106(1):110-9. [QxMD MEDLINE Link].
[Guideline] Bernstein CN, Fried M, Krabshuis JH, et al. World Gastroenterology Organization Practice Guidelines for the diagnosis and management of IBD in 2010. Inflamm Bowel Dis. 2010 Jan. 16(1):112-24. [QxMD MEDLINE Link].
Gisbert JP, McNicholl AG. Questions and answers on the role of faecal calprotectin as a biological marker in inflammatory bowel disease. Dig Liver Dis. 2009 Jan. 41(1):56-66. [QxMD MEDLINE Link].
Reuters Health. Study backs wider use of fecal calprotectin in pediatric IBD workup. Medscape Medical News by WebMD. May 27, 2013. Available at http://www.medscape.com/viewarticle/804796. Accessed: June 1, 2013.
Henderson P, Anderson NH, Wilson DC. The diagnostic accuracy of fecal calprotectin during the investigation of suspected pediatric inflammatory bowel disease: a systematic review and meta-analysis. Am J Gastroenterol. 2014 May. 109(5):637-45. [QxMD MEDLINE Link].
[Guideline] Lichtenstein GR, Abreu MT, Cohen R, Tremaine W. American Gastroenterological Association Institute medical position statement on corticosteroids, immunomodulators, and infliximab in inflammatory bowel disease. Gastroenterology. 2006 Mar. 130(3):935-9. [QxMD MEDLINE Link]. [Full Text].
Prideaux L, De Cruz P, Ng SC, Kamm MA. Serological antibodies in inflammatory bowel disease: a systematic review. Inflamm Bowel Dis. 2012 Jul. 18(7):1340-55. [QxMD MEDLINE Link].
D'Inca R, Dal Pont E, Di Leo V, et al. Calprotectin and lactoferrin in the assessment of intestinal inflammation and organic disease. Int J Colorectal Dis. 2007 Apr. 22(4):429-37. [QxMD MEDLINE Link].
Panes J, Bouzas R, Chaparro M, et al. Systematic review: the use of ultrasonography, computed tomography and magnetic resonance imaging for the diagnosis, assessment of activity and abdominal complications of Crohn's disease. Aliment Pharmacol Ther. 2011 Jul. 34(2):125-45. [QxMD MEDLINE Link].
Rimola J, Ordas I, Rodriguez S, et al. Magnetic resonance imaging for evaluation of Crohn's disease: validation of parameters of severity and quantitative index of activity. Inflamm Bowel Dis. 2011 Aug. 17(8):1759-68. [QxMD MEDLINE Link].
Paulsen SR, Huprich JE, Fletcher JG, et al. CT enterography as a diagnostic tool in evaluating small bowel disorders: review of clinical experience with over 700 cases. Radiographics. 2006 May-Jun. 26(3):641-57; discussion 657-62. [QxMD MEDLINE Link].
Guimaraes LS, Fidler JL, Fletcher JG, et al. Assessment of appropriateness of indications for CT enterography in younger patients. Inflamm Bowel Dis. 2010 Feb. 16(2):226-32. [QxMD MEDLINE Link].
Solem CA, Loftus EV Jr, Fletcher JG, et al. Small-bowel imaging in Crohn's disease: a prospective, blinded, 4-way comparison trial. Gastrointest Endosc. 2008 Aug. 68(2):255-66. [QxMD MEDLINE Link].
Wilkins T, Jarvis K, Patel J. Diagnosis and management of Crohn's disease. Am Fam Physician. 2011 Dec 15. 84(12):1365-75. [QxMD MEDLINE Link].
Baumgart DC. Endoscopic surveillance in Crohn's disease and ulcerative colitis: who needs what and when?. Dig Dis. 2011. 29 Suppl 1:32-5. [QxMD MEDLINE Link].
Leighton JA, Shen B, Baron TH, et al. ASGE guideline: endoscopy in the diagnosis and treatment of inflammatory bowel disease. Gastrointest Endosc. 2006 Apr. 63(4):558-65. [QxMD MEDLINE Link]. [Full Text].
Li CY, Zhang BL, Chen CX, Li YM. OMOM capsule endoscopy in diagnosis of small bowel disease. J Zhejiang Univ Sci B. 2008 Nov. 9(11):857-62. [QxMD MEDLINE Link]. [Full Text].
Yamamoto H, Kita H, Sunada K, et al. Clinical outcomes of double-balloon endoscopy for the diagnosis and treatment of small-intestinal diseases. Clin Gastroenterol Hepatol. 2004 Nov. 2(11):1010-6. [QxMD MEDLINE Link].
Moschler O, May A, Muller MK, Ell C. Complications in and performance of double-balloon enteroscopy (DBE): results from a large prospective DBE database in Germany. Endoscopy. 2011 Jun. 43(6):484-9. [QxMD MEDLINE Link].
Gross SA, Stark ME. Initial experience with double-balloon enteroscopy at a U.S. center. Gastrointest Endosc. 2008 May. 67(6):890-7. [QxMD MEDLINE Link].
Gerson LB, Flodin JT, Miyabayashi K. Balloon-assisted enteroscopy: technology and troubleshooting. Gastrointest Endosc. 2008 Dec. 68(6):1158-67. [QxMD MEDLINE Link].
Amezaga AJ, Van Assche G. Practical approaches to "top-down" therapies for Crohn's disease. Curr Gastroenterol Rep. 2016 Jul. 18(7):35. [QxMD MEDLINE Link].
Froslie KF, Jahnsen J, Moum BA, Vatn MH. Mucosal healing in inflammatory bowel disease: results from a Norwegian population-based cohort. Gastroenterology. 2007 Aug. 133(2):412-22. [QxMD MEDLINE Link].
Schnitzler F, Fidder H, Ferrante M, et al. Mucosal healing predicts long-term outcome of maintenance therapy with infliximab in Crohn's disease. Inflamm Bowel Dis. 2009 Sep. 15(9):1295-301. [QxMD MEDLINE Link].
Baert F, Moortgat L, Van Assche G, et al. Mucosal healing predicts sustained clinical remission in patients with early-stage Crohn's disease. Gastroenterology. 2010 Feb. 138(2):463-8; quiz e10-1. [QxMD MEDLINE Link].
Colombel JF, Sandborn WJ, Reinisch W, et al. Infliximab, azathioprine, or combination therapy for Crohn's disease. N Engl J Med. 2010 Apr 15. 362(15):1383-95. [QxMD MEDLINE Link].
Ha C, Kornbluth A. Mucosal healing in inflammatory bowel disease: where do we stand?. Curr Gastroenterol Rep. 2010 Dec. 12(6):471-8. [QxMD MEDLINE Link].
Feagan BG, Lemann M, Befrits R, et al. Recommendations for the treatment of Crohn's disease with tumor necrosis factor antagonists: an expert consensus report. Inflamm Bowel Dis. 2012 Jan. 18(1):152-60. [QxMD MEDLINE Link].
Hanauer SB. Crohn's disease: step up or top down therapy. Best Pract Res Clin Gastroenterol. 2003 Feb. 17(1):131-7. [QxMD MEDLINE Link].
Ashton JJ, Gavin J, Beattie RM. Exclusive enteral nutrition in Crohn's disease: evidence and practicalities. Clin Nutr. 2019 Feb. 38(1):80-9. [QxMD MEDLINE Link].
Ford AC, Bernstein CN, Khan KJ, et al. Glucocorticosteroid therapy in inflammatory bowel disease: systematic review and meta-analysis. Am J Gastroenterol. 2011 Apr. 106(4):590-9; quiz 600. [QxMD MEDLINE Link].
Ardizzone S, Cassinotti A, Duca P, et al. Mucosal healing predicts late outcomes after the first course of corticosteroids for newly diagnosed ulcerative colitis. Clin Gastroenterol Hepatol. 2011 Jun. 9(6):483-489.e3. [QxMD MEDLINE Link].
Gordon M, Naidoo K, Thomas AG, Akobeng AK. Oral 5-aminosalicylic acid for maintenance of surgically-induced remission in Crohn's disease. Cochrane Database Syst Rev. 2011. (1):CD008414. [QxMD MEDLINE Link].
Sandborn WJ, Regula J, Feagan BG, et al. Delayed-release oral mesalamine 4.8 g/day (800-mg tablet) is effective for patients with moderately active ulcerative colitis. Gastroenterology. 2009 Dec. 137(6):1934-43.e1-3. [QxMD MEDLINE Link].
Tursi A, Brandimarte G, Papa A, et al. Treatment of relapsing mild-to-moderate ulcerative colitis with the probiotic VSL#3 as adjunctive to a standard pharmaceutical treatment: a double-blind, randomized, placebo-controlled study. Am J Gastroenterol. 2010 Oct. 105(10):2218-27. [QxMD MEDLINE Link].
Mach T. Clinical usefulness of probiotics in inflammatory bowel diseases. J Physiol Pharmacol. 2006 Nov. 57 Suppl 9:23-33. [QxMD MEDLINE Link].
Khan KJ, Ullman TA, Ford AC, et al. Antibiotic therapy in inflammatory bowel disease: a systematic review and meta-analysis. Am J Gastroenterol. 2011 Apr. 106(4):661-73. [QxMD MEDLINE Link].
Sandborn WJ, Travis S, Moro L, et al. Once-daily budesonide MMX® extended-release tablets induce remission in patients with mild to moderate ulcerative colitis: results from the CORE I study. Gastroenterology. 2012 Nov. 143(5):1218-26.e2. [QxMD MEDLINE Link].
Silverman J, Otley A. Budesonide in the treatment of inflammatory bowel disease. Expert Rev Clin Immunol. 2011 Jul. 7(4):419-28. [QxMD MEDLINE Link].
Chande N, Wang Y, MacDonald JK, McDonald JW. Methotrexate for induction of remission in ulcerative colitis. Cochrane Database Syst Rev. 2014 Aug 27. CD006618. [QxMD MEDLINE Link]. [Full Text].
Khan KJ, Dubinsky MC, Ford AC, Ullman TA, Talley NJ, Moayyedi P. Efficacy of immunosuppressive therapy for inflammatory bowel disease: a systematic review and meta-analysis. Am J Gastroenterol. 2011 Apr. 106(4):630-42. [QxMD MEDLINE Link].
Kotlyar DS, Lewis JD, Beaugerie L, et al. Risk of lymphoma in patients with inflammatory bowel disease treated with azathioprine and 6-mercaptopurine: a meta-analysis. Clin Gastroenterol Hepatol. 2015 May. 13(5):847-58.e4; quiz e48-50. [QxMD MEDLINE Link]. [Full Text].
Vande Casteele N, Ferrante M, Van Assche G, et al. Trough concentrations of infliximab guide dosing for patients with inflammatory bowel disease. Gastroenterology. 2015 Jun. 148(7):1320-9.e3. [QxMD MEDLINE Link].
Ford AC, Sandborn WJ, Khan KJ, et al. Efficacy of biological therapies in inflammatory bowel disease: systematic review and meta-analysis. Am J Gastroenterol. 2011 Apr. 106(4):644-59, quiz 660. [QxMD MEDLINE Link].
Rubin DT, Panaccione R, Chao J, Robinson AM. A practical, evidence-based guide to the use of adalimumab in Crohn's disease. Curr Med Res Opin. 2011 Sep. 27(9):1803-13. [QxMD MEDLINE Link].
Louis E, Mary JY, Vernier-Massouille G, et al. Maintenance of remission among patients with Crohn's disease on antimetabolite therapy after infliximab therapy is stopped. Gastroenterology. 2012 Jan. 142(1):63-70.e5; quiz e31. [QxMD MEDLINE Link].
Rubin DT, Panaccione R, Chao J, Robinson AM. A practical, evidence-based guide to the use of adalimumab in Crohn's disease. Curr Med Res Opin. 2011 Sep. 27(9):1803-13. [QxMD MEDLINE Link].
US Food and Drug Administration. FDA drug safety communication: new risk factor for progressive multifocal leukoencephalopathy (PML) associated with Tysabri (natalizumab). Available at http://www.fda.gov/drugs/drugsafety/ucm288186.htm. Accessed: July 11, 2012.
Brown T. FDA OKs vedolizumab (Entyvio) for ulcerative colitis, Crohn’s. Medscape Medical News from WebMD. May 20, 2014. Available at http://www.medscape.com/viewarticle/825449. Accessed: June 1, 2014.
Sandborn WJ, Feagan BG, Fedorak RN, et al, for the Ustekinumab Crohn's Disease Study Group. A randomized trial of Ustekinumab, a human interleukin-12/23 monoclonal antibody, in patients with moderate-to-severe Crohn's disease. Gastroenterology. 2008 Oct. 135(4):1130-41. [QxMD MEDLINE Link].
Sandborn, WJ, Sands BE, Gasink C, et al. Reduced rates of Crohn's- related surgeries, hospitalizations and alternate biologic initiation with ustekinumab in the IM-UNITI study through 2 years. Gastroenterology. 2018 May. 154(6) Suppl 1:S-377-8.
Chen JH, Andrews JM, Kariyawasam V, et al, for the IBD Sydney Organisation and the Australian Inflammatory Bowel Diseases Consensus Working Group. Review article: acute severe ulcerative colitis - evidence-based consensus statements. Aliment Pharmacol Ther. 2016 Jul. 44(2):127-44. [QxMD MEDLINE Link].
Peyrin-Biroulet L. Anti-TNF therapy in inflammatory bowel diseases: a huge review. Minerva Gastroenterol Dietol. 2010 Jun. 56(2):233-43. [QxMD MEDLINE Link].
FDA. Drug labels for the Tumor Necrosis Factor-alpha (TNFα) blockers now include warnings about infection with Legionella and Listeria bacteria. US Food and Drug Administration. September 7, 2011. Available at https://www.fda.gov/drugs/drugsafety/ucm270849.htm. Accessed: April 5, 2012.
Mokrowiecka A, Daniel P, Slomka M, Majak P, Malecka-Panas E. Clinical utility of serological markers in inflammatory bowel disease. Hepatogastroenterology. 2009 Jan-Feb. 56(89):162-6. [QxMD MEDLINE Link].
Kefalakes H, Stylianides TJ, Amanakis G, Kolios G. Exacerbation of inflammatory bowel diseases associated with the use of nonsteroidal anti-inflammatory drugs: myth or reality?. Eur J Clin Pharmacol. 2009 Oct. 65(10):963-70. [QxMD MEDLINE Link].
de Silva S, Ma C, Proulx MC, et al. Postoperative complications and mortality following colectomy for ulcerative colitis. Clin Gastroenterol Hepatol. 2011 Nov. 9(11):972-80. [QxMD MEDLINE Link].
Lazarev M, Ullman T, Schraut WH, Kip KE, Saul M, Regueiro M. Small bowel resection rates in Crohn's disease and the indication for surgery over time: experience from a large tertiary care center. Inflamm Bowel Dis. 2010 May. 16(5):830-5. [QxMD MEDLINE Link].
Faculty of Sexual and Reproductive Healthcare Clinical Effectiveness Unit. Sexual and reproductive health for individuals with inflammatory bowel disease. London (UK): Faculty of Sexual and Reproductive Healthcare (FSRH); 2009.
Yamamoto T, Nakahigashi M, Umegae S, Matsumoto K. Prospective clinical trial: enteral nutrition during maintenance infliximab in Crohn's disease. J Gastroenterol. 2010. 45(1):24-9. [QxMD MEDLINE Link].
Helwick C. Low vitamin D exacerbates inflammatory bowel disease. Medscape Medical News from WebMD. May 21, 2013. Available at http://www.medscape.com/viewarticle/804509. Accessed: June 1, 2013.
Ananthakrishnan AN, Cagan A, Gainer VS, et al. Normalization of vitamin D status is associated with reduced risk of surgery and hospitalization in inflammatory bowel disease: a prospective study. Gastroenterology. 2013 May. 144(5 Suppl 1):S-1.
Raftery TC, Healy M, Cox G, et al. Vitamin D supplementation improves muscle strength, fatigue and quality of life in patients with Crohn's disease in remission: results of a randomized double-blind placebo-controlled study. Gastroenterology. 2013 May. 144(5 Suppl 1):S-227.
Johannesson E, Simren M, Strid H, Bajor A, Sadik R. Physical activity improves symptoms in irritable bowel syndrome: a randomized controlled trial. Am J Gastroenterol. 2011 May. 106(5):915-22. [QxMD MEDLINE Link].
Gisbert JP. Safety of immunomodulators and biologics for the treatment of inflammatory bowel disease during pregnancy and breast-feeding. Inflamm Bowel Dis. 2010 May. 16(5):881-95. [QxMD MEDLINE Link].
FactTank - News in the numbers: Baby boomers retire. Pew Research Center. December 29, 2010. Available at http://pewresearch.org/databank/dailynumber/?NumberID=1150. Accessed: August 3, 2012.
Schnitzler F, Fidder H, Ferrante M, et al. Outcome of pregnancy in women with inflammatory bowel disease treated with antitumor necrosis factor therapy. Inflamm Bowel Dis. 2011 Sep. 17(9):1846-54. [QxMD MEDLINE Link].
Zelinkova Z, de Haar C, de Ridder L, et al. High intra-uterine exposure to infliximab following maternal anti-TNF treatment during pregnancy. Aliment Pharmacol Ther. 2011 May. 33(9):1053-8. [QxMD MEDLINE Link].
Roux CH, Brocq O, Breuil V, Albert C, Euller-Ziegler L. Pregnancy in rheumatology patients exposed to anti-tumour necrosis factor (TNF)-alpha therapy. Rheumatology (Oxford). 2007 Apr. 46(4):695-8. [QxMD MEDLINE Link].
O'Donnell S, O'Morain C. Review article: use of antitumour necrosis factor therapy in inflammatory bowel disease during pregnancy and conception. Aliment Pharmacol Ther. 2008 May. 27(10):885-94. [QxMD MEDLINE Link].
Casanova MJ, Chaparro M, Domenech E, et al. Safety of thiopurines and anti-TNF-a drugs during pregnancy in patients with inflammatory bowel disease. Am J Gastroenterol. 2013 Mar. 108(3):433-40. [QxMD MEDLINE Link].
Rajaratnam SG, Eglinton TW, Hider P, Fearnhead NS. Impact of ileal pouch-anal anastomosis on female fertility: meta-analysis and systematic review. Int J Colorectal Dis. 2011 Nov. 26(11):1365-74. [QxMD MEDLINE Link].
Bartels SA, DʼHoore A, Cuesta MA, Bensdorp AJ, Lucas C, Bemelman WA. Significantly increased pregnancy rates after laparoscopic restorative proctocolectomy: a cross-sectional study. Ann Surg. 2012 Dec. 256(6):1045-8. [QxMD MEDLINE Link].
Beyer-Berjot L, Maggiori L, Birnbaum D, Lefevre JH, Berdah S, Panis Y. A total laparoscopic approach reduces the infertility rate after ileal pouch-anal anastomosis: a 2-center study. Ann Surg. 2013 Aug. 258(2):275-82. [QxMD MEDLINE Link].
[Guideline] Lamb CA, Kennedy NA, Raine T, et al. British Society of Gastroenterology consensus guidelines on the management of inflammatory bowel disease in adults. Gut. 2019 Dec. 68(Suppl 3):s1-s106. [QxMD MEDLINE Link]. [Full Text].
[Guideline] Torres J, Bonovas S, Doherty G, et al. ECCO guidelines on therapeutics in Crohn's disease: medical treatment. J Crohns Colitis. 2020 Jan 1. 14 (1):4-22. [QxMD MEDLINE Link]. [Full Text].
[Guideline] Adamina M, Bonovas S, Raine T, et al. ECCO guidelines on therapeutics in Crohn's disease: surgical treatment. J Crohns Colitis. 2020 Feb 10. 14 (2):155-68. [QxMD MEDLINE Link]. [Full Text].
[Guideline] Feuerstein JD, Isaacs KL, Schneider Y, et al, for the AGA Institute Clinical Guidelines Committee. AGA clinical practice guidelines on the management of moderate to severe ulcerative colitis. Gastroenterology. 2020 Apr. 158(5):1450-61. [QxMD MEDLINE Link]. [Full Text].
Brooklyn TN, Dunnill MG, Shetty A, et al. Infliximab for the treatment of pyoderma gangrenosum: a randomised, double blind, placebo controlled trial. Gut. 2006 Apr. 55(4):505-9. [QxMD MEDLINE Link]. [Full Text].
Oren R, Arber N, Odes S, et al. Methotrexate in chronic active ulcerative colitis: a double-blind, randomized, Israeli multicenter trial. Gastroenterology. 1996 May. 110(5):1416-21. [QxMD MEDLINE Link].
Akbari M, Shah S, Velayos FS, Mahadevan U, Cheifetz AS. Systematic review and meta-analysis on the effects of thiopurines on birth outcomes from female and male patients with inflammatory bowel disease. Inflamm Bowel Dis. 2013 Jan. 19(1):15-22. [QxMD MEDLINE Link].
Francella A, Dyan A, Bodian C, Rubin P, Chapman M, Present DH. The safety of 6-mercaptopurine for childbearing patients with inflammatory bowel disease: a retrospective cohort study. Gastroenterology. 2003 Jan. 124(1):9-17. [QxMD MEDLINE Link].
Garcia-Erce JA, Gomollon F, Munoz M. Blood transfusion for the treatment of acute anaemia in inflammatory bowel disease and other digestive diseases. World J Gastroenterol. 2009 Oct 7. 15(37):4686-94. [QxMD MEDLINE Link]. [Full Text].
Granlund AB, Beisvag V, Torp SH, et al. Activation of REG family proteins in colitis. Scand J Gastroenterol. 2011 Nov. 46(11):1316-23. [QxMD MEDLINE Link]. [Full Text].
Kennedy NA, Rhatigan E, Arnott ID, et al. A trial of mercaptopurine is a safe strategy in patients with inflammatory bowel disease intolerant to azathioprine: an observational study, systematic review and meta-analysis. Aliment Pharmacol Ther. Nov 2013. 38(10):1255-66. [QxMD MEDLINE Link].
Kristensen SL, Ahlehoff O, Lindhardsen J, et al. Prognosis after first-time myocardial infarction in patients with inflammatory bowel disease according to disease activity: nationwide cohort study. Circ Cardiovasc Qual Outcomes. 2014 Nov. 7(6):857-62. [QxMD MEDLINE Link].
Stiles S. Ulcerative colitis, Crohn’s flares may raise post-MI risk: registry study. Heartwire News from Medscape by WebMD. October 17, 2014. Available at http://www.medscape.com/viewarticle/833424. Accessed: October 23, 2014.
[Guideline] Howdle P, Atkin W, Rutter M, et al. Colonoscopic surveillance for prevention of colorectal cancer in people with ulcerative colitis, Crohn's disease or adenomas: clinical guideline 118. National Institute for Health and Care Excellence (NICE). March, 2011. Available at https://www.nice.org.uk/guidance/cg118. Accessed: April 7, 2011.
Bryant RV, Brain O, Travis SP. Conventional drug therapy for inflammatory bowel disease. Scand J Gastroenterol. 2015 Jan. 50(1):90-112. [QxMD MEDLINE Link].
Garg SK, Loftus EV Jr. Risk of cancer in inflammatory bowel disease: going up, going down, or still the same?. Curr Opin Gastroenterol. 2016 Jul. 32(4):274-81. [QxMD MEDLINE Link].
Schaefer JS. MicroRNAs: how many in inflammatory bowel disease?. Curr Opin Gastroenterol. 2016 Jul. 32(4):258-66. [QxMD MEDLINE Link].
Bernstein CN. Does everyone with inflammatory bowel disease need to be treated with combination therapy?. Curr Opin Gastroenterol. 2016 Jul. 32(4):287-93. [QxMD MEDLINE Link].
Atreya R, Neurath MF. From bench to bedside: molecular imaging in inflammatory bowel diseases. Curr Opin Gastroenterol. 2016 Jul. 32(4):245-50. [QxMD MEDLINE Link].

Media Gallery

Inflammatory bowel disease. Severe colitis noted during colonoscopy in a patient with inflammatory bowel disease. The mucosa is grossly denuded, with active bleeding noted. The patient had her colon resected very shortly after this view was obtained.
Inflammatory bowel disease. Stricture in the terminal ileum noted during colonoscopy in a patient with inflammatory bowel disease. This image depicts a narrowed segment visible upon intubation of the terminal ileum with the colonoscope. Relatively little active inflammation is present, indicating that this is a cicatrix stricture.
Inflammatory bowel disease. Enteroenteric fistula noted on a small bowel series of x-ray films in a patient with inflammatory bowel disease. The narrow-appearing segments filled out relatively normally on subsequent films. Note that barium is just starting to enter the cecum in the right lower quadrant (viewer's left), but the barium has also started to enter the sigmoid colon toward the bottom of the picture, thus indicating the presence of a fistula from the small bowel to the sigmoid colon.
Inflammatory bowel disease. The table distinguishes features of Crohn disease (CD) and ulcerative colitis (UC).
Inflammatory bowel disease. Toxic megacolon. Courtesy of Dr. Pauline Chu.
Inflammatory bowel disease. Early pyoderma gangrenosum, before skin breakdown. Medial aspect of the right ankle in a patient with inflammatory bowel disease. Same day and same patient as in the next image.
Inflammatory bowel disease. Pyoderma gangrenosum. Courtesy of Dr. Gene Izuno.
Inflammatory bowel disease. Severe advanced pyoderma gangrenosum of the medial aspect of the left ankle in a patient with inflammatory bowel disease.
Inflammatory bowel disease. Crohn disease involving the terminal ileum. Note the "string sign" in the right lower quadrant (viewer's left).
Inflammatory bowel disease. Increased postrectal space is a known feature of ulcerative colitis.
Inflammatory bowel disease. Plain abdominal radiograph of a patient with known ulcerative colitis who presented with an acute exacerbation of his symptoms. This image shows thumbprinting in the region of the splenic flexure of the colon.
Inflammatory bowel disease. Double-contrast barium enema study shows pseudopolyposis of the descending colon in a patient with ulcerative colitis.
Inflammatory bowel disease. Plain abdominal radiograph in a 26-year-old with a 10-year history of ulcerative colitis shows a long stricture/spasm of the ascending colon/cecum (<i>arrow</i>). Note the pseudopolyposis in the descending colon.
Inflammatory bowel disease. This single-contrast enema study in a patient with total colitis shows mucosal ulcers with a variety of shapes, including collar-button ulcers, in which undermining of the ulcers occurs, and double-tracking ulcers, in which the ulcers are longitudinally oriented.
Inflammatory bowel disease. This double-contrast barium enema study shows total colitis. Note the granular mucosa in the cecum/ascending colon and multiple strictures in the transverse and descending colon in a patient with a more than a 20-year history of ulcerative colitis.
Inflammatory bowel disease. Inflamed colonic mucosa demonstrating pseudopolyps in a patient with ulcerative colitis.
Inflammatory bowel disease. Chronic architectural changes in ulcerative colitis. Note the crypt branching and irregularity of size and shape, with an increase in chronic inflammatory cells in the lamina propria.
Inflammatory bowel disease. High-power view of a crypt abscess in ulcerative colitis shows the crypt to be dilated and filled with neutrophils and debris.
Inflammatory bowel disease. Chronic architectural changes in ulcerative colitis. Note the trifid crypt.
Inflammatory bowel disease. Basal plasmacytosis in ulcerative colitis. Plasma cells separate the crypt bases from the muscularis mucosae.
Inflammatory bowel disease. Low-power image of a colon biopsy specimen in a patient with ulcerative colitis illustrates changes limited to the mucosa. These changes include chronic alterations of the crypt architecture and an increase in chronic inflammatory cells in the lamina propria.
Inflammatory bowel disease. Bowel-wall thickening and foreshortening are apparent in this specimen from a colectomy for ulcerative colitis. In addition, the mucosa is hyperemic, with focal nodularity and ulceration.
Inflammatory bowel disease. Another gross specimen illustrating ulcerative colitis.
Inflammatory bowel disease. This is an example of low-grade glandular dysplasia in a patient with longstanding ulcerative colitis. Note the loss of mucin, nuclear hyperchromasia, and nuclear pseudostratification. See the next image.
Inflammatory bowel disease. High-grade dysplasia in the same patient as the previous image. There is significant cytologic atypia, with rounding of the nuclei and a greater degree of pseudostratification.
Inflammatory bowel disease. Histologic section from another location in the same patient as described in the previous image. This field shows glands that are suspicious for invasive carcinoma.
Inflammatory bowel disease. Computed tomography scan depicting Crohn disease in the fundus of the stomach.
Inflammatory bowel disease. Double-contrast barium enema study demonstrates marked ulceration, inflammatory changes, and narrowing of the right colon in a patient with Crohn colitis.
Inflammatory bowel disease. Cobblestoning in Crohn disease. Spot views of the terminal ileum from a small bowel follow-through study demonstrates linear longitudinal and transverse ulcerations that create a cobblestone appearance. Also, note the relatively greater involvement of the mesenteric side of the terminal ileum and the displacement of the involved loop away from the normal small bowel secondary to mesenteric inflammation and fibrofatty proliferation.
Inflammatory bowel disease. Crohn disease involving the terminal ileum. Note the "string sign" in the right lower quadrant (viewer's left).
Inflammatory bowel disease. This computed tomography scan from a patient with terminal ileal Crohn disease shows an enteroenteral fistula (arrow) between loops of diseased small intestine.
Inflammatory bowel disease. A teenage patient with Crohn disease underwent a contrast-enhanced upper gastrointestinal computed tomography study with small-bowel follow-through. Several loops of small bowel are in the pelvis. Note there is a loop of distal bowel with a thickened wall (solid arrow), which is contrasted with a less involved loop of bowel in which the intestinal wall is not thickened at all (dotted arrow).
Inflammatory bowel disease. Computed tomography scan depicting Crohn disease in the fundus of the stomach.
Inflammatory bowel disease. This colonoscopic image of a large ulcer and inflammation of the descending colon in a 12-year-old boy with Crohn disease.
Inflammatory bowel disease. This laparoscopic view depicts creeping fat along the mesentery of the terminal ileum in a patient with Crohn disease.
Inflammatory bowel disease. Cobblestone change of the mucosa of the terminal ileum in a patient with Crohn disease. Communicating fissures and crevices in the mucosa separate islands of more intact, edematous epithelium.
Inflammatory bowel disease. Fat wrapping on the serosal surface of the terminal ileum in Crohn disease. Fat wrapping often correlates directly with underlying strictures, stenosis, or areas of previous transmural inflammation.
Inflammatory bowel disease. Colonic granuloma in a patient with Crohn disease (arrow). Hematoxylin-eosin staining. Courtesy of Dr E. Ruchelli.
Inflammatory bowel disease. A deep knifelike, fissuring, transmural ulcer in Crohn disease is shown in this histologic image.
Inflammatory bowel disease. Another example of a deep, fissuring ulcer in a patient with Crohn disease. Note the increase in submucosal inflammation and scattered lymphoid aggregates.
Inflammatory bowel disease. Prominent lymphoid aggregates and granuloma in the muscularis propria and pericolic fat of patient with Crohn disease. The inflammation extends through the full thickness of the bowel wall.
Inflammatory bowel disease. A crypt abscess demonstrating active, neutrophilic inflammation in Crohn disease.
Inflammatory bowel disease. Granuloma in the mucosa in a Crohn disease patient.
Inflammatory bowel disease. Double-contrast barium enema study shows changes of ulcerative colitis disease. Note the granular mucosa.

of 44

Table 1. Common Extraintestinal Complications of IBD in US and Europe ^[54]

Complication	Prevalence
Scleritis	18%
Anterior uveitis	17%
Gall stones (particularly in Crohn disease)	13%-34%
Inflammatory arthritis	10%-35%
Anemia	9%-74%
Aphthous stomatitis	4%-20%
Osteoporosis	2%-20%
Erythema nodosum	2%-20%
Source: Larson S, Bendtzen K, Nielsen OH. Extraintestinal manifestations of inflammatory bowel disease: epidemiology, diagnosis and management. Ann Med. 2010;42:97-114.

Table 2. Extraintestinal Complications of IBD in Swiss Patients ^[55]

Complication	Crohn Disease	Ulcerative Colitis
Arthritis	33%	4%
Aphthous stomatitis	10%	4%
Uveitis	6%	3%
Erythema nodosum	6%	3%
Ankylosing spondylitis	6%	2%
Psoriasis	2%	1%
Pyoderma gangrenosum	2%	2%
Primary sclerosing cholangitis	1%	4%
Source: Vavricka SR, Brun L, Ballabeni P, et al. Frequency and risk factors for extraintestinal manifestations in the Swiss inflammatory bowel disease cohort. Am J Gastroenterol. 2011;106:110-9.

Back to List

Author

William A Rowe, MD President, Gastroenterology Associates of Central Pennsylvania, PC; Manager, Endoscopy Center of Central Pennsylvania, LLC; Clinical Associate Professor of Surgery, Division of Colon and Rectal Surgery, Milton S Hershey Medical Center, Pennsylvania State University College of Medicine

William A Rowe, MD is a member of the following medical societies: American Gastroenterological Association, American Society for Gastrointestinal Endoscopy

Disclosure: Nothing to disclose.

Coauthor(s)

Gary R Lichtenstein, MD Professor of Medicine, Director, Center for Inflammatory Bowel Disease, Department of Medicine, Division of Gastroenterology, Perelman School of Medicine at the University of Pennsylvania

Gary R Lichtenstein, MD is a member of the following medical societies: American College of Gastroenterology, American College of Physicians, American Gastroenterological Association, American Society for Gastrointestinal Endoscopy

Disclosure: Serve(d) as a director, officer, partner, employee, advisor, consultant or trustee for: Abbott Corp/Abbvie; Actavis; Alaven; CellCeutrix; Celgene; Ferring; Gilead; Hospira; Janssen Orthobiotech; Luitpold/American Regent; Pfizer Pharm; Prometheus Labs; Romark; Salix Pharma/Valeant; Santarus/Receptos/Celgene; Shire Pharma; Takeda; UCB<br/>Received research grant from: Salix Pharm/Valeant; Santarus/Receptos/Celgene; Shire Pharm; UCB<br/>Received author or editor honorarium or book royalty from for: Clinical Advances in Gastroenterology; Gastroenterology and Hepatology; Gastro-Hep Communications; Ironwood; Luitpold/American Regent; Merck; McMahon Publishing; Romark; SLACK Inc; Springer Science and Business Media; Up-To-Date.

Specialty Editor Board

Francisco Talavera, PharmD, PhD Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Received salary from Medscape for employment. for: Medscape.

Chief Editor

BS Anand, MD Professor, Department of Internal Medicine, Division of Gastroenterology, Baylor College of Medicine

BS Anand, MD is a member of the following medical societies: American Association for the Study of Liver Diseases, American College of Gastroenterology, American Gastroenterological Association, American Society for Gastrointestinal Endoscopy

Disclosure: Nothing to disclose.

Acknowledgements

Mounir Bashour, MD, CM, FRCS(C), PhD, FACS Assistant Professor of Ophthalmology, McGill University; Clinical Assistant Professor of Ophthalmology, Sherbrooke University; Medical Director, Cornea Laser and Lasik MD

Mounir Bashour, MD, CM, FRCS(C), PhD, FACS is a member of the following medical societies: American Academy of Ophthalmology, American Association for Pediatric Ophthalmology and Strabismus, American College of International Physicians, American College of Surgeons, American Medical Association, American Society of Cataract and Refractive Surgery, American Society of Mechanical Engineers, American Society of Ophthalmic Plastic and Reconstructive Surgery, Biomedical Engineering Society, Canadian Medical Association,Canadian Ophthalmological Society, Contact Lens Association of Ophthalmologists, International College of Surgeons US Section, Ontario Medical Association, Quebec Medical Association, and Royal College of Physicians and Surgeons of Canada

Disclosure: Nothing to disclose.

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.

Andrew A Dahl, MD Director of Ophthalmology Teaching, Mid-Hudson Family Practice Institute, The Institute for Family Health; Assistant Professor of Surgery (Ophthalmology), New York College of Medicine

Andrew A Dahl, MD is a member of the following medical societies: Alpha Omega Alpha, American Academy of Ophthalmology, American College of Surgeons, American Medical Association, American Society of Cataract and Refractive Surgery, and Wilderness Medical Society

Disclosure: Nothing to disclose.

Steven C Dronen, MD, FAAEM Chair, Department of Emergency Medicine, LeConte 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.

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.

Sarvotham Kini, MD Assistant Professor of Emergency Medicine, Emory University School of Medicine, Atlanta, GA

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.

Alex J Mechaber, MD, FACP Senior Associate Dean for Undergraduate Medical Education, Associate Professor of Medicine, University of Miami Miller School of Medicine

Alex J Mechaber, MD, FACP is a member of the following medical societies: Alpha Omega Alpha, American College of Physicians-American Society of Internal Medicine, and Society of General Internal Medicine

Disclosure: Nothing to disclose.

Hampton Roy Sr, MD Associate Clinical Professor, Department of Ophthalmology, University of Arkansas for Medical Sciences

Hampton Roy Sr, MD is a member of the following medical societies: American Academy of Ophthalmology, American College of Surgeons, and Pan-American Association of Ophthalmology

Disclosure: Nothing to disclose.

William Shapiro, MD Consulting Staff, Department of Urgent Care and Emergency Medicine, Scripps Clinic and Research Foundation

Disclosure: Nothing to disclose.

Francisco Talavera, PharmD, PhD Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Medscape Salary Employment

Rajeev Vasudeva, MD, FACG Clinical Professor of Medicine, Consultants in Gastroenterology, University of South Carolina School of Medicine

Rajeev Vasudeva, MD, FACG is a member of the following medical societies: American College of Gastroenterology, American Gastroenterological Association, American Society for Gastrointestinal Endoscopy, Columbia Medical Society, South Carolina Gastroenterology Association, and South Carolina Medical Association

Disclosure: Pricara Honoraria Speaking and teaching; UCB Consulting fee Consulting

R Christopher Walton, MD Professor, Director of Uveitis and Ocular Inflammatory Disease Service, Department of Ophthalmology, Assistant Dean for Graduate Medical Education, University of Tennessee College of Medicine; Consulting Staff, Regional Medical Center, Memphis Veterans Affairs Medical Center, St Jude Children's Research Hospital

R Christopher Walton, MD is a member of the following medical societies: American Academy of Ophthalmology, American College of Healthcare Executives, American Uveitis Society, Association for Research in Vision and Ophthalmology, and Retina Society

Disclosure: Nothing to disclose.