Overview
What is inflammatory bowel disease (IBD)?
What are the symptoms of inflammatory bowel disease (IBD)?
Which physical findings are related to the severity of inflammatory bowel disease (IBD)?
What is the role of lab testing in the diagnosis and management of inflammatory bowel disease (IBD)?
What is the role of imaging in the evaluation of inflammatory bowel disease (IBD)?
What is the medical approach to treatment of inflammatory bowel disease (IBD)?
Which medications are used in the treatment of inflammatory bowel disease (IBD)?
What is the role of surgery in the management of inflammatory bowel disease (IBD)?
What are the surgical options for treatment of inflammatory bowel disease (IBD)?
What is inflammatory bowel disease (IBD)?
What is the overlap in extraintestinal symptoms of ulcerative colitis (UC) and Crohn disease (CD)?
What is the role of inflammation in the manifestation of inflammatory bowel disease (IBD)?
When is surgical intervention curative for inflammatory bowel disease (IBD)?
What is the pathophysiology of Crohn disease (CD)?
What is the role of genetics in the pathogenesis of inflammatory bowel disease (IBD)?
What is the role of inflammatory mediators in the pathogenesis of inflammatory bowel disease (IBD)?
How is inflammatory bowel disease (IBD) studied in animals?
How do the characteristics of inflammation vary between ulcerative colitis (UC) and Crohn disease?
What is the pathophysiology of ulcerative colitis (UC)?
How is the rectum involvement in Crohn disease (CD)?
Why is the incidence of gallstones and kidney stones increased in Crohn disease (CD)?
Which characteristics define the etiology of inflammatory bowel disease (IBD)?
What is the primary cause of inflammatory bowel disease (IBD)?
What are the environmental risk factors of inflammatory bowel disease (IBD)?
What are the genic risks of inflammatory bowel disease (IBD)?
Which genes are associated with inflammatory bowel disease (IBD)?
Which genetic loci are involved in the etiology of Crohn disease (CD)?
What is the role of the interlectin gene (ITLN1) in the etiology of Crohn disease (CD)?
Where are inflammatory bowel disease (IBD)-susceptibility genes?
What is the genetic predisposition for ulcerative colitis (UC)?
Where have susceptibility genetic loci been found for ulcerative colitis (UC)?
How much do genetic influences increase the risk for ulcerative colitis (UC)?
What is the role of smoking in the etiology of inflammatory bowel disease (IBD)?
How does the incidence of ulcerative colitis compare to Crohn disease?
What is the prevalence of inflammatory bowel disease (IBD) in the US?
What are the racial predilections for inflammatory bowel disease (IBD) in the US?
How does the prevalence of inflammatory bowel disease (IBD) vary by sex?
How does the incidence of inflammatory bowel disease (IBD) vary by age?
What is the global prevalence of inflammatory bowel disease (IBD)?
What are the extraintestinal complications of inflammatory bowel disease (IBD)?
What is the mortality rate for inflammatory bowel disease (IBD)?
What is the likelihood of malignancy in patients with inflammatory bowel disease (IBD)?
Where can more information on malignancy in inflammatory bowel disease (IBD) be found?
What are the morbidities associated with inflammatory bowel disease (IBD)?
What is the incidence of inflammatory bowel disease (IBD) in patients with asthma or COPD?
What are the risk factors for psychologic morbidity in inflammatory bowel disease (IBD)?
What is the recurrence rate of ulcerative colitis (UC)?
What is the probability of progression of ulcerative colitis (UC)?
What treatment is considered curative for ulcerative colitis (UC)?
What is the risk of colorectal cancer in patients with ulcerative colitis (UC)?
What is the clinical course of Crohn disease (CD)?
What is the rate of remission in patients with Crohn disease (CD)?
When is surgery indicated for Crohn disease (CD)?
What is the likelihood of recurrence of perianal fistulas in Crohn disease (CD)?
What are the intestinal complications of inflammatory bowel disease (IBD)?
What are the extraintestinal complications of inflammatory bowel disease (IBD) in Swiss patients?
What are the benefits of patient education about inflammatory bowel disease (IBD)?
Presentation
What are the clinical manifestations of inflammatory bowel disease (IBD)?
What are the systemic symptoms associated with inflammatory bowel disease (IBD)?
How are symptoms of inflammatory bowel disease (IBD) associated with inflammatory damage?
What are the physical findings characteristic of inflammatory bowel disease (IBD)?
What are the physical findings characteristic of Crohn disease (CD)?
What should be included in the physical exam of patients with inflammatory bowel disease (IBD)?
DDX
What is the involvement of the small intestine in inflammatory bowel disease (IBD)?
When is Crohn disease (CD) frequently diagnosed?
What are the differential diagnoses for Inflammatory Bowel Disease?
Workup
What is the role of lab studies in the evaluation of inflammatory bowel disease (IBD)?
What is the role of CBC count in the diagnosis of inflammatory bowel disease (IBD)?
What is the diagnostic significance of anemia in the evaluation of inflammatory bowel disease (IBD)?
What is the role of serum iron studies in the evaluation of inflammatory bowel disease (IBD)?
When are folate supplements indicated in the management of inflammatory bowel disease (IBD)?
How is nutritional status assessed in patients with inflammatory bowel disease (IBD)?
What is the role of fecal calprotectin levels in the diagnosis of inflammatory bowel disease (IBD)?
What is the role of stool culture in the diagnosis of inflammatory bowel disease (IBD)?
What is the most common cause of acute terminal ileitis in inflammatory bowel disease (IBD)?
What is the role of radiography in the diagnosis of inflammatory bowel disease (IBD)?
What is toxic megacolon in inflammatory bowel disease (IBD)?
What is the role of barium enema imaging for the diagnosis of inflammatory bowel disease (IBD)?
How are abnormalities of inflammatory bowel disease (IBD) described on barium studies?
What are findings of barium enema suggestive of inflammatory bowel disease (IBD)?
What radiographs findings are characteristic of inflammatory bowel disease (IBD)?
When is a small bowel radiography series used for the diagnosis of inflammatory bowel disease (IBD)?
What is the role of small bowel enteroclysis in the diagnosis of inflammatory bowel disease (IBD)?
What is the role of fistulographic studies in the diagnosis of inflammatory bowel disease (IBD)?
What is the role of ultrasonography in the diagnosis of inflammatory bowel disease (IBD)?
What is the role of CT scanning in the diagnosis of inflammatory bowel disease (IBD)?
When is CT scanning used in the diagnosis of inflammatory bowel disease (IBD)?
What is the role of MRI in the diagnosis of inflammatory bowel disease (IBD)?
What is the role of CT enterography in the diagnosis of inflammatory bowel disease (IBD)?
What is the role of a colonoscopy in the diagnosis of inflammatory bowel disease (IBD)?
What is the accuracy of a colonoscopy with ileoscopy in the assessment of Crohn disease (CD)?
What is the role of colonoscopy in the treatment of inflammatory bowel disease (IBD)?
What is the role of colonoscopy in the surveillance of inflammatory bowel disease (IBD)?
What is the role of flexible sigmoidoscopy in the diagnosis of inflammatory bowel disease (IBD)?
How is capsule enteroscopy used for the diagnosis of inflammatory bowel disease (IBD)?
Where is inflammation seen in ulcerative colitis (UC)?
What are the histologic characteristics of ulcerative colitis (UC)?
What is involved in the inflammation of the colon in inflammatory bowel disease (IBD)?
What are the typical histologic findings of ulcerative colitis (UC)?
What is the histology of Crohn disease (CD)?
What are the histologic findings characteristic of Crohn disease (CD)?
Treatment
What are the goals of therapy for inflammatory bowel disease (IBD)?
What are the treatment options for inflammatory bowel disease (IBD)?
What are the benefits of deep mucosal healing in the treatment of inflammatory bowel disease (IBD)?
What is included in the symptomatic therapy of inflammatory bowel disease (IBD)?
How should corticosteroid therapy for inflammatory bowel disease (IBD) flares be administered?
What are the treatment options for low bone density in inflammatory bowel disease (IBD)?
When is inpatient treatment indicated for inflammatory bowel disease (IBD)?
How is suspected bowel obstruction managed in inflammatory bowel disease (IBD)?
What are the discharge requirements for patients with inflammatory bowel disease (IBD)?
When should step-down therapy be considered in the management of inflammatory bowel disease (IBD)?
What are the treatment options for refractory inflammatory bowel disease (IBD)?
How does smoking cessation affect patients with inflammatory bowel disease (IBD)?
What is included in the top-down approach to the treatment of inflammatory bowel disease (IBD)?
What are common comorbidities in older patients with inflammatory bowel disease (IBD)?
When are anti-TNF agents contraindicated in the treatment of inflammatory bowel disease (IBD)?
What is the role of surgery in the treatment of inflammatory bowel disease (IBD)?
When is colectomy indicated in the treatment of inflammatory bowel disease (IBD)?
What are the most common surgical options for the treatment of inflammatory bowel disease (IBD)?
What are the surgical options for fulminant colitis in inflammatory bowel disease (IBD)?
What are risk factors for postoperative complications in inflammatory bowel disease (IBD)?
What are the indications for surgical intervention in Crohn disease (CD)?
What are the limitations to surgical treatment of Crohn disease (CD)?
What is the role of segmental resection in the treatment of inflammatory bowel disease (IBD)?
How are symptomatic enteroenteric fistulas treated in inflammatory bowel disease (IBD)?
What are contraception options for women with inflammatory bowel disease (IBD)?
Which medications should be minimized prior to surgery for inflammatory bowel disease (IBD)?
Which dietary modifications may be beneficial in the management of inflammatory bowel disease (IBD)?
What is the role of vitamin supplementation in the management of inflammatory bowel disease (IBD)?
What is the role of activity modification in the management of inflammatory bowel disease (IBD)?
How is inflammatory bowel disease (IBD) managed during pregnancy?
How is fertility affected in women with inflammatory bowel disease (IBD)?
How does sulfasalazine affect the fertility of men with inflammatory bowel disease (IBD)?
How does parental inflammatory bowel disease (IBD) affect infant health?
Which treatments are considered safe for pregnant patients with inflammatory bowel disease (IBD)?
When is effective contraception required during the treatment of inflammatory bowel disease (IBD)?
When should women with inflammatory bowel disease (IBD) plan conception?
Which agents used to treat inflammatory bowel disease (IBD) can be detected in breast milk?
Which antibiotics are contraindicated in breast-feeding women with inflammatory bowel disease (IBD)?
What is the best approach for the treatment of mild to moderate inflammatory bowel disease (IBD?)
What is the first step in medication therapy for inflammatory bowel disease (IBD)?
What is the second step in medication therapy for inflammatory bowel disease (IBD)?
When are immune modifying agents indicated in the treatment of inflammatory bowel disease (IBD)?
When is a step-down approach used in the treatment of inflammatory bowel disease (IBD)?
Why is weaning off steroid therapy a priority in the treatment of inflammatory bowel disease (IBD)?
What is the role of oral aminosalicylates in the treatment of inflammatory bowel disease (IBD)?
Which probiotic agents are used in the diagnosis of inflammatory bowel disease (IBD)?
What are the most commonly used antibiotics in the treatment of inflammatory bowel disease (IBD)?
What is the role of antibiotics in the treatment of inflammatory bowel disease (IBD)?
When are corticosteroids indicated for treatment of inflammatory bowel disease (IBD)?
How are corticosteroids administered for the treatment of inflammatory bowel disease (IBD)?
When should patients be weaned off of corticosteroid therapy for inflammatory bowel disease (IBD)?
How often should bone mineral density be assessed in patients with inflammatory bowel disease (IBD)?
What is the role of IV corticosteroids in the treatment of inflammatory bowel disease (IBD)?
What is the role of budesonide in the treatment of inflammatory bowel disease (IBD)?
What is the role of topical corticosteroids in the treatment of inflammatory bowel disease (IBD)?
When are corticosteroid suppositories indicated the treatment of inflammatory bowel disease (IBD)?
What is the effectiveness of immune modifiers in the treatment of inflammatory bowel disease (IBD)?
What is the role of intramuscular MTX in the treatment of inflammatory bowel disease (IBD)?
What monitoring is needed during immune modifier therapy for inflammatory bowel disease (IBD)?
What is the role of infliximab (Remicade) in the treatment of inflammatory bowel disease (IBD)?
What is the role of infliximab in the treatment Crohn disease fistula?
What are the adverse effects of infliximab for the treatment of inflammatory bowel disease (IBD)?
Which anti-TNF-alpha agents are used in the treatment of inflammatory bowel disease (IBD)?
What is the role of natalizumab in the treatment of inflammatory bowel disease (IBD)?
What is the role of vedolizumab in the treatment of inflammatory bowel disease (IBD)?
Which experimental agents have shown efficacy in the treatment of inflammatory bowel disease (IBD)?
Medications
Which experimental treatments hold promise in the treatment of inflammatory bowel disease (IBD)?
What is the effectiveness of treatments for Crohn disease (CD)?
What is the stepwise approach to treating inflammatory bowel disease (IBD)?
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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.
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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.
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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.
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Inflammatory bowel disease. The table distinguishes features of Crohn disease (CD) and ulcerative colitis (UC).
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Inflammatory bowel disease. Toxic megacolon. Courtesy of Dr. Pauline Chu.
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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.
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Inflammatory bowel disease. Pyoderma gangrenosum. Courtesy of Dr. Gene Izuno.
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Inflammatory bowel disease. Severe advanced pyoderma gangrenosum of the medial aspect of the left ankle in a patient with inflammatory bowel disease.
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Inflammatory bowel disease. Crohn disease involving the terminal ileum. Note the "string sign" in the right lower quadrant (viewer's left).
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Inflammatory bowel disease. Increased postrectal space is a known feature of ulcerative colitis.
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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.
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Inflammatory bowel disease. Double-contrast barium enema study shows pseudopolyposis of the descending colon in a patient with ulcerative colitis.
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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.
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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.
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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.
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Inflammatory bowel disease. Inflamed colonic mucosa demonstrating pseudopolyps in a patient with ulcerative colitis.
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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.
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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.
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Inflammatory bowel disease. Chronic architectural changes in ulcerative colitis. Note the trifid crypt.
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Inflammatory bowel disease. Basal plasmacytosis in ulcerative colitis. Plasma cells separate the crypt bases from the muscularis mucosae.
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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.
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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.
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Inflammatory bowel disease. Another gross specimen illustrating ulcerative colitis.
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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.
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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.
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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.
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Inflammatory bowel disease. Computed tomography scan depicting Crohn disease in the fundus of the stomach.
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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.
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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.
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Inflammatory bowel disease. Crohn disease involving the terminal ileum. Note the "string sign" in the right lower quadrant (viewer's left).
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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.
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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).
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Inflammatory bowel disease. Computed tomography scan depicting Crohn disease in the fundus of the stomach.
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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.
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Inflammatory bowel disease. This laparoscopic view depicts creeping fat along the mesentery of the terminal ileum in a patient with Crohn disease.
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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.
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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.
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Inflammatory bowel disease. Colonic granuloma in a patient with Crohn disease (arrow). Hematoxylin-eosin staining. Courtesy of Dr E. Ruchelli.
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Inflammatory bowel disease. A deep knifelike, fissuring, transmural ulcer in Crohn disease is shown in this histologic image.
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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.
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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.
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Inflammatory bowel disease. A crypt abscess demonstrating active, neutrophilic inflammation in Crohn disease.
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Inflammatory bowel disease. Granuloma in the mucosa in a Crohn disease patient.
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Inflammatory bowel disease. Double-contrast barium enema study shows changes of ulcerative colitis disease. Note the granular mucosa.
Tables
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. |
|
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. |
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- Overview
- Presentation
- DDx
- Workup
- Treatment
- Approach Considerations
- Symptomatic Therapy/Supportive Care
- Overview of Therapy
- Aminosalicylates
- Antibiotics
- Corticosteroids
- Immunomodulators
- Clinical Trial Agents
- Inpatient Management
- Management of Refractory Disease
- Management in Remission
- Management of the Older IBD Patient
- Surgical Intervention
- Diet, Lifestyle Modifications, and Activity
- Reproduction and Pregnancy
- Consultations
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- Guidelines
- Guidelines Summary
- British Society of Gastroenterology Guidelines (BSG) (2019)
- European Crohn's and Colitis Organisation Guidelines on Medical Treatment (ECCO) (2019)
- European Crohn's and Colitis Organisation Guidelines on Surgical Management (ECCO) (2019)
- American Gastroenterological Association Guidelines (AGA) (2020)
- Resources
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- Medication
- Medication Summary
- 5-Aminosalicylic Acid Derivatives
- Antibiotics, Other
- Corticosteroids
- Immunosuppressants
- TNF Inhibitors
- Alpha 4 Integrin Inhibitors
- Histamine H2 Antagonists
- Proton Pump Inhibitors
- Antidiarrheals
- Anticholinergic, Antispasmodic Agents
- Monoclonal Antibodies
- Corticosteroids, Rectal
- DMARDs, JAK Inhibitors
- Bile Acid Sequestrants
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