Blackwell Clinical Handbook

Edward V. Loftus, Jr, MD, is a Consultant in the Division of Gastroenterology and Hepatology at Mayo Clinic and Foundation, and Associate Professor of Medicine at Mayo Medical School in Rochester, Minnesota. After receiving his medical degree from the University of Pennsylvania, he completed a residency in Internal Medicine at Temple University Health Sciences Center in Philadelphia. He subsequently completed a fellowship in Gastroenterology at Mayo Graduate School of Medicine in Rochester, Minnesota. Dr. Loftus is a member of the American Gastroenterological Association, the American Society for Gastrointestinal Endoscopy, the American College of Gastroenterology, and the Crohn's and Colitis Foundation of America. He is a Fellow of the American College of Physicians and the American College of Gastroenterology. He is an Associate Editor of the American Journal of Gastroenterology. He is also on the Editorial Board of Gastroenterology and Inflammatory Bowel Diseases, a medical journal sponsored by the CCFA. He also serves the CCFA as the Chair of the Medical Advisory Committee of the Minnesota-Dakotas Chapter, and as the Co-Chair of the Patient Education Committee at the national level. Dr. Loftus has lectured widely on the epidemiology, natural history, and medical management of inflammatory bowel disease. He has received a number of research grants, his interest centering on epidemiologic and outcomes research in inflammatory bowel disease. In addition, he has authored numerous articles, abstracts, and book chapters.

1. Introduction and definitions * Purpose of book * Brief description of IBD subtypes and their classification by extent (e.g., proctitis, left-sided, pancolitis; ileitis, colitis, ileocolitis) * Burden of disease in USA, Canada, UK, Europe, Australia/N.Z., Japan 2. Epidemiology and genetics * Descriptive epi (incidence, prevalence, mortality) * Risk factors (smoking, appendectomy, NSAIDs, antibiotics, infections, dietary, etc) * Family risks, phenotype of familial IBD * Genetic epi (NOD2/CARD15, others), both molecular and population level * Include brief section on microscopic colitis epi 3. Pathophysiology * Brief overview of mucosal immunology * Interactions between gut microbes, epithelial cells, and lymphocytes * Lymphocyte trafficking, adhesion molecules, etc * Physiological consequences of intestinal inflammation, how it produces symptoms 4. Clinical features, clinical course, and natural history of Crohn's disease * Symptoms, signs, endoscopic features * Disease activity assessment * Non-malignant intestinal complications * Clinical course/natural history in regards to remission/relapse, need for surgery * Quality of life 5. Clinical features, clinical course, and natural history of ulcerative colitis * Symptoms, signs, endoscopic features * Disease activity assessment * Risk of progression of extent * Non-malignant intestinal complications (toxic megacolon, hemorrhage, stricture) * Clinical course/natural history in terms of relapse, need for surgery * Quality of life 6. Clinical features, clinical course, and natural history of related conditions (pouchitis, microscopic colitis, separate section for each) * Symptoms and signs * Diagnosis * Long-term sequelae including risk of surgery and malignancy 7. Complications of inflammatory bowel disease * Classical extraintestinal manifestations (ocular, spondyloarthropathy, dermatologic, hepatobiliary) * Osteoporosis/osteopenia/fractures * Others (nephrolithiasis, cholelithiasis, hematologic, thromboembolism, pancreatitis, neurologic, cardiopulmonary, etc) * Cancer in IBD (colorectal, small bowel, lymphoma) 8. Diagnosis * Blood tests (C-reactive protein, ANCA/ASCA serologies) * Endoscopy * Histology * Barium radiography * Newer radiologic techniques (CT enterography, MR enterography, tagged WBC scanning, PET scanning) * Capsule endoscopy 9. Medical treatment of ulcerative colitis * Supportive therapies (anti-diarrheals, anti-spasmodics, analgesics) * 5-Aminosalicylates (sulfasalazine, mesalamine, balsalazide, olsalazine) * Corticosteroids * Topical therapy (5-ASA and steroids) for proctitis and left-sided disease * Antibiotics * Purine anti-metabolites (azathioprine, 6-mercaptopurine) * Methothrexate * Cyclosporine * Infliximab * Probiotics * Nicotine 10. Medical treatment of Crohn's disease * Supportive therapies * 5-Aminosalicylates * Conventional corticosteroids * Budesonide discussed separately * Antibiotics * Purine anti-metabolites * Methotrexate * Cyclosporine/tacrolimus * Mycophenolate * Infliximab (including a discussion of how to minimize antibody formation) * Other anti-tumor necrosis factor therapies (e.g., adalimumab) * Other biological therapies studied 11. Medical treatment of microscopic colitis and pouchitis * Pouchitis: antibiotics, probiotics * Microscopic colitis: anti-diarrheals, bismuth, budesonide, 5-aminosalicylates, conventional corticosteroids, purine analogs 12. Surgical indications and therapy in inflammatory bowel disease * Emergency indications for both (severe disease, toxic megacolon, bleeding, perforation, obstruction) * Non-emergent indications (refractory to medical therapy, or adverse events from medical therapy) * Neoplastic indications * Types of surgery for each * UC: proctocolectomy with ileostomy, or with ileal pouch-anal anastomosis * CD: ileal/ileocolonic resection, stricturoplasty, gastrojejunostomy for gastroduodenal disease, proctocolectomy with ileostomy for colonic, perianal procedures * Complications of surgery including pouch dysfunction (exclude pouchitis) 13. Nutritional/dietary treatment of IBD * Malnutrition as consequence of IBD * Adjunctive treatment of malnutrition * Primary therapy for IBD (some evidence for CD, none for UC) * IBD patients with short bowel syndrome 14. Integrated management of specific clinical scenarios in IBD * Proctitis/left-sided UC * Pancolitis (induction, maintenance) * Steroid-dependent UC * AZA-refractory UC * Severe UC (in hospital) * Mild to moderate Crohn's (induction, maintenance) * Severe Crohn's * Fistulizing Crohn's * Steroid-dependent Crohn's