Inflammatory bowel disease

Learning objectives

Inflammatory bowel disease (IBD) is a term for two conditions (Crohn’s disease and ulcerative colitis) that are characterized by chronic inflammation of the gastrointestinal (GI) tract
Prolonged inflammation results in damage to the GI tract
Caused by an interaction of environmental and genetic factors leading to immune responses and inflammation in the intestine → autoimmune disease

IBD	Crohn’s disease	Ulcerative colitis
Affected location	Can affect any part of the GI tract (from mouth to anus), most often affects the portion of the small intestine before the large intestine (i.e., ileocecal region)	Restricted to the large intestine (colon) and rectum
Damaged areas	Damaged areas appear in patches that are next to areas of healthy tissue	Damaged areas are continuous (not patchy), usually starting at the rectum and spreading further into the colon
Inflammation	Inflammation may reach through the multiple layers of the walls of the GI tract → transmural inflammation leading to abscesses or granulomatous disease	Inflammation is present only in the innermost layer of the lining of the colon (i.e., mucosa) → loss of colonic mucosa

Both conditions

Anemia (due to prolonged GI bleeding, often iron and/or vitamin B12 deficiency)
Colorectal cancer
Skin, eye, and joint inflammation (e.g., iritis/uveitis, ankylosing spondylitis)
Medication side effects (e.g., infections, corticosteroids are associated with a risk of osteoporosis and hypertension)
Primary sclerosing cholangitis
Blood clots (i.e., venous thromboembolism [VTE])
Severe dehydration

Crohn’s disease

Ulcerative colitis

Age
- Most people are diagnosed before 30 years of age
- Some people do not develop the disease until their 50-60s
White ethnicity
Family history
Smoking
NSAIDs medications (e.g., ibuprofen, naproxen sodium, diclofenac sodium)

Combination of endoscopy (for Crohn’s disease) or colonoscopy (for ulcerative colitis) and imaging studies

Antidiarrheal medications (i.e., psyllium powder, methylcellulose, loperamide)
Anti-inflammatory drugs (i.e., glucocorticoids, 5-aminosalicylic acids)
Immunosuppressants (i.e., cyclosporine, azathioprine, mercaptopurine, methotrexate)
Antibiotics (i.e., ciprofloxacin, metronidazole)
Biologics (i.e., TNF-α inhibitor infliximab)
Nutritional support
Surgery to remove damaged parts of the GI tract

IBD medication management during the perioperative period

Drug	Recommendation
Glucocorticoids	Continue; administer stress dose (see next table)
5-aminosalicylic acid	Discontinue on day of surgery and resume 3 days after surgery if normal renal function
Azathioprine, 6-mercaptopurine	Discontinue on day of surgery and resume 3 days after surgery if normal renal function
Methotrexate	Continue unless previous poor wound healing or postoperative infections
Cyclosporine	Continue but carefully monitor for infectious complications
Infliximab	Continue without interruption

Glucocorticoid management during the perioperative period

Axis suppression	Minor surgical stress	Moderate surgical stress	Major surgical stress
No Prednisone < 5 mg/d Glucocorticoids < 3 weeks Negative corticotropin test	Daily dose No supplementation	Daily dose No supplementation	Daily dose No supplementation
Documented or suspected Prednisone > 10 mg/d for > 3 weeks Positive corticotropin test	Daily dose No supplementation	Hydrocortisone 50 mg IV (induction) 25 mg IV every 8 hours for 24-48 hours	Hydrocortisone 100 mg IV (induction) 50 mg IV every 8 hours for 24 hours 25 mg IV every 8 hours for 24-48 hours
Unknown Prednisone 5-10 mg ≥ 3 weeks	Daily dose No supplementation	Positive corticotropin test Hydrocortisone 50 mg IV (induction) 25 mg IV every 8 hours for 24-48 hours	Hydrocortisone 100 mg IV (induction) 50 mg IV every 8 hours for 24 hours 25 mg IV every 8 hours for 24-48 hours