Inflammatory Bowel Diseases

Ashwin N. Ananthakrishnan MD, MPH, Assistant Professor of Medicine, Harvard Medical School; Director, Crohn’s and Colitis Center, Massachusetts General Hospital, Boston, MA, USA. Ramnik J. Xavier MD, Kurt Isselbacher Professor of Medicine, Harvard Medical School; Chief of Gastroenterology, Massachusetts General Hospital; Institute Member, Broad Institute of MIT and Harvard, Boston, MA, USA. Daniel K. Podolsky MD, President, University of Texas Southwestern Medical Center; Professor of Internal Medicine, University of Texas Southwestern Medical School, Dallas, TX, USA.

Preface ix

Section I Pathogenesis and Clinical Features 1

1 Epidemiology and Pathogenesis 3

Clinical Take Home Messages 3

Epidemiology 3

Pathogenesis 6

Genetics 6

Microbiome 8

Environmental Triggers 9

Case Studies and Multiple Choice Questions 12

References 13

Answers to Questions 15

2 Clinical Features and Diagnosis of Crohn’s Disease 17

Clinical Take Home Messages 17

Clinical Features 19

Disease Course and Natural History 20

Diagnosis 21

History and Physical Examination 21

Laboratory Investigations 22

Serologic Markers 23

Endoscopy 23

Histology 25

Imaging Studies 25

Case Studies and Multiple Choice Questions 27

References 28

Answers to Questions 31

3 Clinical Features and Diagnosis of Ulcerative Colitis 33

Clinical Take Home Messages 33

Clinical Features 34

Disease Course and Natural History 35

Diagnosis 35

History and Physical Examination 36

Laboratory Investigations 36

Serologic Markers 37

Endoscopy 37

Histology 39

Imaging Studies 40

Differential Diagnosis (UC and CD) 40

Case Studies and Multiple Choice Questions 44

References 45

Answers to Questions 47

4 Extraintestinal Manifestations of Inflammatory Bowel Diseases 49

Clinical Take Home Messages 49

Arthritis and Arthropathy 50

Metabolic Bone Disease 51

Cutaneous Manifestations 52

Hepatobiliary Manifestations 53

Ophthalmologic Manifestations 55

Renal Complications 55

Thromboembolic and Cardiovascular Complications 56

Case Studies and Multiple Choice Questions 57

References 58

Answers to Questions 61

Section II Therapeutic Agents 63

5 Aminosalicylates 65

Clinical Take Home Messages 65

Efficacy in Ulcerative Colitis 66

Efficacy in Crohn’s Disease 68

Safety 68

Multiple Choice Questions 70

References 71

Answers to Questions 73

6 Corticosteroids 75

Clinical Take Home Messages 75

Efficacy in Ulcerative Colitis 76

Efficacy in Crohn’s Disease 77

Safety 78

Case Studies and Multiple Choice Questions 80

References 81

Answers to Questions 83

7 Immunomodulators 85

Clinical Take Home Messages 85

Thiopurines 85

Efficacy in Ulcerative Colitis 87

Efficacy in Crohn’s Disease 88

Safety 89

Methotrexate 90

Efficacy in Ulcerative Colitis 90

Efficacy in Crohn’s Disease 91

Safety 91

Calcineurin Inhibitors 91

Efficacy in Ulcerative Colitis 91

Efficacy in Crohn’s Disease 93

Case Studies and Multiple Choice Questions 94

References 95

Answers to Questions 99

8 Biologic Therapies 101

Clinical Take Home Messages 101

Infliximab 102

Efficacy in Ulcerative Colitis 102

Efficacy in Crohn’s Disease 105

Safety 108

Adalimumab 110

Efficacy in Ulcerative Colitis 110

Efficacy in Crohn’s Disease 111

Certolizumab Pegol 112

Efficacy in Crohn’s Disease 113

Newer Therapies 115

Case Studies and Multiple Choice Questions 116

References 117

Answers to Questions 121

9 Antibiotics 123

Clinical Take Home Messages 123

Efficacy in Ulcerative Colitis 123

Efficacy in Crohn’s Disease 124

Other Microbial Modification Methods – Probiotics and Fecal Microbiota Transplantation 125

Multiple Choice Questions 126

References 127

Answers to Questions 129

Section III Management 131

10 Medical Management of Ulcerative Colitis 133

Clinical Take Home Messages 133

Assessment of Extent, Activity, and Severity 133

Limited Colitis – Proctitis, Proctosigmoiditis, and Left‐sided Colitis 135

Pancolitis 136

Mild to Moderate Disease 137

Moderate to Severe Disease 138

Severe Disease 140

Case Studies and Multiple Choice Questions 142

References 144

Answers to Questions 146

11 Medical Management of Crohn’s Disease 149

Clinical Take Home Messages 149

Mild to Moderate Disease 150

Moderate to Severe Disease 151

Case Studies and Multiple Choice Questions 154

References 156

Answers to Questions 157

12 Surgical Management of Inflammatory Bowel Diseases 159

Clinical Take Home Messages 159

Surgery for Ulcerative Colitis 159

Pouch‐related Complications in Ulcerative Colitis 161

Surgery for Crohn’s Disease 163

Prophylaxis for Prevention of Postoperative Recurrence in Crohn’s Disease 164

Case Studies and Multiple Choice Questions 167

References 168

Recommended Reading 169

Answers to Questions 170

13 Complications of Inflammatory Bowel Diseases 171

Clinical Take Home Messages 171

Complications of Ulcerative Colitis 172

Toxic Megacolon and Perforation 172

Colonic Strictures 173

Clostridium difficile and Cytomegalovirus Colitis 173

Colorectal Dysplasia and Cancer 174

Magnitude and Risk Factors 174

Surveillance for Dysplasia and Cancer 175

Management of Dysplasia 175

Chemoprevention 176

Complications of Crohn’s Disease 176

Fibrostenosis and Strictures 176

Abscesses 177

Fistulizing Crohn’s Disease 178

Small‐bowel Cancer 181

Case Studies and Multiple Choice Questions 182

References 184

Answers to Questions 187

Section IV Special Considerations 189

14 Nutrition in Inflammatory Bowel Diseases 191

Clinical Take Home Messages 191

Malnutrition and Micronutrient Deficiencies 191

Dietary Therapies for Inflammatory Bowel Diseases 193

Case Studies and Multiple Choice Questions 194

References 195

Answers to Questions 197

15 Pregnancy, Conception, and Childbirth 199

Clinical Take Home Messages 199

Fertility 199

Effect of Pregnancy on Disease 200

Effect of Disease on Pregnancy 200

Maternal Medication Use During Pregnancy 201

Paternal Medication Use 203

Inheritance 203

Case Studies and Multiple Choice Questions 204

References 205

Answers to Questions 207

16 Inflammatory Bowel Disease During Childhood and Adolescence 209

Clinical Take Home Messages 209

Epidemiology and Clinical Features 209

Treatment of Pediatric Inflammatory Bowel Disease 210

Very Early‐onset Inflammatory Bowel Disease 211

Transition of Care in Pediatric Crohn’s Disease 211

Case Studies and Multiple Choice Questions 213

References 214

Answers to Questions 216

Index 217