Inflammatory Bowel Disease

Crohn's Disease

  • Any part of GI tract from the mouth to the rectum
  • Transmural involvement
  • Endoscopy: Skip lesions, cobblestoning, ulcerations, strictures
  • Histology: Neutrophilic inflammation, noncaseating granulomas, Paneth cell metaplasia, and intestinal villi blunting

Ulcerative Colitis

  • Continuous lesions starting in rectum (generally only in colon)
  • Mucosa and submucosal involvement only
  • Endoscopy: Pseudopolyps, continuous areas of inflammation

General Overview


  • Peak incidence 15-40yo with possible second peak 50-80yo
  • Abdominal pain
  • Diarrhea
  • Fatigue
  • Fever
  • GI bleeding
  • Unintentional weight loss

Risk factors for IBD

  • Smoker in CD, but may be **protective for the development UC**
  • Ashkenazi Jewish, White (compared to Black, Hispanic)
  • Sedentary lifestyle, Obesity
  • "Western" diet (processed, fried, sugar)
  • Acute gastroenteritis, recent antibiotic use
  • NSAID use
  • Family history of IBD

Extraintestinal manifestations of IBD (CD and UC)

  • Arthritis
    • Peripheral arthritis
    • Ankylosing Spondylitis (UC)
    • Sacroileitis
  • Dermatological
    • Aphthous stomatitis
    • Erythema nodosum
    • Pyoderma gangrenosum
  • Ocular
    • Episcleritis and Scleritis (CD)
    • Uveitis
  • Primary sclerosing cholangitis (UC)

DDx of IBD

  • Infectious colitis
  • Ischemic colitis
  • Radiation-induced colitis
  • Diverticulitis
  • Appendicitis
  • Colorectal malignancy (obstructing/perforating), lymphoma
  • Celiac
  • IBS

Initial testing

  • CBC
  • BUN
  • Creatinine
  • Liver enzymes
  • CRP and ESR
  • Consider stool Cx and C. diff toxin PCR
  • Consider fecal calprotectin if IBS vs. IBD

Subsequent testing

  • Iron profile
  • Vitamin B12, Folate
  • Albumin, prealbumin
  • Vitamin D, calcium

Diagnostic Tests

  • Colonoscopy with ileoscopy and biopsy
  • Capsule endoscopy (avoid in strictures)
  • CT enterography
  • MR enterography
  • Small bowel follow-through
  • Esophagogastroduodenoscopy recommended if upper GI symptoms, unexplained iron deficiency anemia, active Crohn's disease with normal colonoscopy

Preventive measures

  • Smoking cessation
  • Consider avoid NSAIDs (may exacerbate disease)
  • Avoid pregnancy in women of childbearing age
    • Conflicting data about OCP and IBD, may have small risk of association
  • Ensure routine immunizations
    • Tetanus and diphtheria, Polio, MMR, Varicella, Meningitis
    • HPV
    • Herpes zoster
    • Influenza
    • Pneumococcal
    • Hepatitis A and B
    • Prior to starting anti-TNF agents, obtain PPD testing and CXR (rule out TB), and update immunizations including Hep B
  • Anxiety/depression
  • Osteoporosis
    • Screening/prevention if on chronic systemic steroids
  • Colorectal Cancer
    • Screening for colorectal cancer based on extent of disease
    • Usually begin 8y after onset, q1-2 years (with random biopsies)
  • Cervical Cancer
    • Consider more frequent screening if on immunosuppressive therapy

Induction of Remission

  • 5-ASA (sulfasalazine, mesalamine)
    • Pentasa total 4g daily divided QID or BID
      • If achieve remission, maintain dose or reduce to 3g daily
      • Creat at 6w, 3mo, 6mo, 12mo, then yearly
  • Glucorticoids (Topical Ileal release budesonide (Entocort EC), prednisone)
    • Prednisone 40 mg PO x 1 week and then taper 5mg weekly for total duration of 8 weeks


  • 5-ASA (sulfasalazine, mesalamine)
  • Immunomodulators (azathioprine and 6-mercaptopurine, methotrexate)
  • Anti-TNF agents (infliximab, adalimumab)
  • Consider Probiotics Lactobacillus GG and Escherichia coli Nissle 1917


  • Loperamide if no systemic (fever, tachycardia)
  • Avoid opioids as may mask acute abdomen
  • Consider avoid NSAIDs (limited data may worsen disease)