This document discusses the diagnosis and management of ulcerative colitis and Crohn's disease. It defines the diseases, describes their classification systems and severity indices. It covers epidemiology, pathogenesis, diagnostic testing and differential diagnoses. Treatment strategies are outlined for induction and maintenance of remission for mild to severe ulcerative colitis. Management of Crohn's disease is discussed including medications such as aminosalicylates, corticosteroids, immunomodulators, biologics and their monitoring. Surgical options are also summarized.

1. Diagnosis and Management

2. Topics of Focus
 Ulcerative Colitis
 Disease Classification
 Management:
 Mild to moderate
 Severe, refractory disease
 Crohn’s
 Pathogenesis
 Diagnosis
 Management

3. UC Definition
 Chronic disease characterized by diffuse mucosal
inflammation limited to the colon
 Rectum involved in majority of cases
 Extends proximally and in a circumferential, continuous
fashion
 Hallmark symptoms: Bloody diarrhea, Urgency, Tenesmus
 Abdominal pain, fever, weight loss, extraintestinal
complications
 Potential Triggers:
 Smoking cessation
 Heavy NSAID use
 Isotretinoin

4. Epidemiology
 Cause unknown
 Hypothesis: Combination of genetic, immune, and
environmental factors thought to contribute
 Incidence higher in developed countries
 Men and women affected equally
 Peak age of onset between 15 and 30 years
 Second peak in between 50 and 70 years

5. UC Disease Classification
 Extensive:
Inflammation that extends beyond
splenic flexure and may involve the
entire colon (pancolitis)
 20-30% of pts
 Associated with higher incidence
of colectomy/cancer/mortality
 Left sided colitis
 Inflammation extends to splenic
flexure
 30-40% of pts
 Proctosigmoiditis
 Inflammation extends to
rectosigmoid colon
 30-40% of pts
 Ulcerative proctitis
 Inflammation confined to rectum
 40% of pts

7. Clinical Severity Index
Truelove and Witts Criteria
Sign/Symptom Mild Severe
Bowel movements
Rectal bleeding
Temperature (°F)
Pulse (beats/minute)
Hematocrit (%)
Sedimentation rate
<4/d
Intermittent
Normal
<90
Normal
<30
>6/d
Frequent
>37.5° C
>90
<75% normal
>30
Truelove SC, Witts LJ. Br Med J. 1955;2:1041-1048.

8. Severe Ulcerative Colitis
 15% of UC patients develop a severe flare
 May occur as the initial presentation of UC
 Mortality:
 1950s (pre-tx era) 25-60%
 1960s 7%
 Present 1%

9. Endoscopic Severity Index
Modified Sutherland Scale
Mild Moderate Severe
Edema, loss of
vascular pattern,
granular
Friable, coarsely
granular, pinpoint
ulcerations
Ulcerations,
spontaneous
hemorrhage
Modified from Sutherland LR, et al. Gastroenterology. 1987;92:1894-1898.

10. DDx of IBD
 Infectious
 E. coli O157: H7
 C diff
 Syphilis
 TB
 Chlamydia
 Schistosomiasis
 Amebiasis
 HSV/CMV
 Ischemia
 Radiation injury
 NSAID
 Celiac dz/microscopic colitis
 Acute self limited colitis
 Irritable bowel syndrome

11. Goals of Therapy
 Induction of remission of symptoms
 Maintenance of remission of symptoms
 Reduction in need for long term steroids
 Mucosal healing
 Prevention of surgery
 Prevention and treatment of extraintestinal
complications

12. Ulcerative Colitis
Induction Therapies
 Mild disease
 5-ASA
 Topical (distal)
 Oral (extensive)
 Combination
 Severe disease
 IV steroids
 Cyclosporine
 Infliximab/Adalimumab
• Moderate disease
– 5-ASA
• Topical (distal)
• Oral (distal)
– Steroid
• Topical (distal)
• Oral (distal/extensive)

14. Maintenance of Remission
 Azathioprine/6-mercaptopurine
 Immunomodulators inhibit proliferation of T and B
lymphocytes, leading to decreased production of cytotoxic
T lymphocytes and plasma cells
 Infliximab/Adalimumab
 Anti-TNF agent neutralizes the biologic activity of TNF-alpha by
inhibiting binding to its receptors. This then leads to decreased
cytokine response
 Vedolizumab
 Humanized monoclonal antibody to a4b7 integrin blocks
interaction with MAdCAM-1 and inhibits lymphocyte
migration to inflamed tissue

15. Principles of Corticosteroid
Therapy
 Do not under- or overdose corticosteroids:
 No benefit with doses > 60 mg prednisone:
 Prednisone- 60 mg equivalents:
 Solumedrol 4:5 conversion  48 mg
 Hydrocortisone 4:1 conversion  240 mg
 Use for 3-5 days- if NO response, begin to
consider next step.

16. Exit Strategies for Severe Steroid Refractory
UC in Hospital…
 Cyclosporine
 Infliximab
 Surgery

17. Cyclosporine
 Lipophilic peptide produce by a soil fungus-
Tolypocladium inflatumgams
 Blocks production of IL-2 by T-helper lymphocytes
 Inhibits T-cell proliferation
 Blocks production of B-cell activating factors
Response/remission rates up to 80%

18. Cyclosporine:
What to check for and how to use it…
 Baseline Studies:
 Creatinine Clearance: >30% dec
GFR is CI
 Cholesterol (< 120 mg/dl is CI)
 Magnesium (>1.5 mg/dl)
 R/O active infection
 Therapy protocol:
 Continue IV steroids
 CsA IV 2 mg/kg/day
 Prophylactic TMP-SMZ
 Monitoring:
 CsA levels goal= 200-300 ng/ml
 Follow daily labs especially
electrolytes
 Vitals- may need to tx HTN
Am J Gastroenterol 1997;92:1424

19. Infliximab for UC: ACT I and II
Clinical Response

20. Infliximab
- What to check for and how to use it…
 Baseline studies
 Check for TB
 Check for Hepatitis B
 R/o superimposed infection (C
diff and CMV)
 Premedication:
 Diphenhydramine: 25-50 mg
PO/IV
 Acetaminophen: 650 mg po
 Induction dosing:
 5 mg/kg- round to closest 100 mg
 3 doses at 0,2, and 6 weeks and
every 8 wks thereafter

21. IPAA for Ulcerative Colitis

22. Putting it all together:
Initial Tx of Severe UC
 Daily KUB
 IV Solumedrol- 20 mg IV q 8 hrs
 NO narcotics, anti-cholinergics
 Be wary of superimposed infection:
 Stool culture & C. diff
 +/- flex sig with biopsy

23. Assess response clinically
at day 3-5
At least partial response NO response
Transition to po steroids
6-MP/biologic therapy as outpt
Flex Sig w/ bx
Blood for CMV DNA
Stool C. diff
Biologic therapy
Surgery
Cyclosporine
In the hospital…

24.  A 37 yo F presents to ED with 2 week history of acute onset
bloody diarrhea. Diarrhea has escalated to 15 times/day. She
has UC diagnosed 2 years ago and currently takes
Azathioprine.
 PE: appears ill T 38.9 BP 70/40 P 148 RR 35
 Abd: absent bowel sounds; distention, and diffuse marked
tenderness with mild palpation
 Labs WBC 16.8
 KUB as shown
 Which of the following is most appropriate management?
 CT scan
 Immediate surgery
 Start Infliximab
 Start IV Hydrocortisone

26. Toxic Megacolon
 Any inflammatory condition of the colon can
predispose to toxic megacolon
 Incidence in UC ranges from 8-17%:
 Most severe complication associated with UC!
 Increased mortality risk:
 Range of 19-45%
 40% mortality rate in pts undergoing emergent
colectomy after a perforation occurred
 Hemodynamic instability/progressive abdominal
distention/tenderness all indications for immediate
surgery

27. Diagnosis of Toxic Megacolon
 Diagnosis made on basis of clinical signs and
abdominal plain films
 Dilation of transverse or ascending colon > 6 cm
AND at least 1 of the following:
 Fever > 38.6° C
Pulse > 120
 WBC > 10.5
 Anemia

28.  A 45 yo M is evaluated for a 1 week history of non-
bloody diarrhea that occurs ten times a day and is
accompanied by mild abdominal cramping. He has a
5 year history of ulcerative colitis for which he takes
mesalamine.
 PE T 37.9 C BP 110/80 P 100
 Abd: Hyperactive BS; mild diffuse tenderness; no
rebound/guarding
 WBC 23 H/H/Plt wnl Bun/Creat 15/1 CRP 32 K 2.9
 AAS: normal
 Which of the following is the most appropriate
diagnostic test to perform next?
 Abdominal CT
 Colonoscopy
 RUQ u/s
 Stool for C diff

30. Crohn’s Disease
 Focal, asymmetrical, transmural, and occasionally
granulomatous inflammation primarily affecting the
GI tract
 Most commonly affects 2nd and 3rd decades
 Incidence 5/100,000 and on the rise
 Prevalence 50/100,000 and on the rise
 Disease of “Westernized” countries
 Incidence increasing in Asian countries
 Neither medically nor surgically curable
 Cost of medical and surgical tx= $2 billion annually

31. Inflammatory Cascade
 Widely accepted theory: Overly aggressive immune
response to bacterial antigens in genetically
predisposed individuals
 Intestinal microbiota activate immune cells leading to
dysregulated cytokine production leading to intestinal
inflammation
 Additional proposed mechanism
 Increased cytokines may modulate composition of
commensal flora or alter gene expression in specific
bacterial subgroups causing increased growth rates and
virulence leading to inflammation

32. To make a diagnosis of IBD…
History
Clinical
symptoms

33. IBD not to be confused with
IBS…
Symptom IBD IBS
Abdominal pain × ×
Diarrhea × ×
Bloating × ×
Constipation × ×
Mucus in stools × ×
Rectal bleeding/urgency ×
Weight loss ×
Nocturnal symptoms ×
Anemia ×
Elevated inflammatory markers ×
Extraintestinal manifestations ×

34. To make a diagnosis of IBD…
History
Clinical
symptoms

35. What to check if suspicious for
IBD?
 CBC
 CMP
 Vitamin D, Vitamin B12
 ESR/CRP
 Stool cultures
 Fecal calprotectin/ lactoferrin

36. To make a diagnosis of IBD…
History
Clinical
symptoms

37. CD- Endoscopic Appearance
Normal Aphthous ulcers
Serpiginous ulcers Cobblestoning of mucosa

38. CT Findings

39. Current Serologic Markers for Crohn’s
Disease
 IBD-7 serology
 ASCA (anti-Saccaromyces cerevisae)
 Anti-OmpC (outer membrane porin type C of E. coli)
 CBir1
 p-ANCA
 ASCA thought to be associated with a more aggressive
disease phenotype and a risk for surgery

40. Disease Phenotype
 Inflammatory vs Stricturing vs Fistulizing
 Location
 Ileocolonic= most common location
 Ileal
 Colonic
 Perianal
 Upper GI (jejunoileitis) -> most commonly seen in
children
 Extraintestinal manifestations
 Smoker

41. Cumulative Probability of Surgical
Intervention in CD
Munkholm P, et al. Gastroenterology. 1993;105:1716.
Years
Probability(%)
0
20
40
60
80
100
0 2 5 8 11 14 17 20
±2 SD
D

42. Cumulative incidence of surgical resection over 1
yr in Crohn's disease pts starting corticosteroids
Faubion et al, Gastroenterology 2001; 121: 255
38% of patients required surgery within 12 mos
Predictors: TI, stricturing/penetrating dz, age <40.
n=77 Days
Cumulative probability (%)
30 60 90 182 365
0
100
80
60
40
20

43. Cosnes et al. Inflamm Bowel Dis 2002;8:244
The Evolution of Crohn's Disease:
Inflammation Leads to Structural Damage
24022821620419218016815614413212010896847260483624120
0
20
40
60
80
100
Cumulative probability (%)
Patients at risk: Months
2002 552 229 95 37n=
Penetrating
Stricturing
Inflammatory
70%
18%
Over a 20-year period, 88% risk of developing stricturing (18%) or penetrating (70%) disease

44. Vermiere et al, Aliment Pharmacol Ther 2006; 25: 3
Response
Continue Tx
and observe
Response
Taper & stop Tx
Observation
Relapse within 1yr?
Steroids + AZA
or MTX or Biologic
No response
AZA /MTX/Biologic
? Surgery
Relapse
Biologic vs
combination therapy
No response
No
response
Colonic
(± small intestine) Small intestine
Smoking cessation
5-ASA/Sulfasalazine ± antibiotics
Smoking cessation
Budesonide / corticosteroids
Patient
 Mild presentation
 Inflammatory disease
 No perianal disease
 No extraintestinal manifestations
 Non-smoking
Disease Management: Low risk of
progression

45. Vermiere et al, Aliment Pharmacol Ther 2006; 25: 3
Patient
 Young age at onset (<18 yr)
 Non-inflammatory disease behavior
 Extensive disease (small/large bowel)
 Early steroid need
 Extraintestinal manifestations
 Active smoker
Response
Taper and stop steroids
and continue
immunosuppressants
Smoking cessation
Steroids+ AZA or MTX or Biologic therapy
No response
Anti-TNF or combination
therapy
Response
Maintenance
No response
Switch therapies
Surgery
Disease Management:
Intermittent to High Risk of Progression

46. Azathioprine/6-MP
Metabolism
AZA 6-MP
6-MMP
6-TGN
HPRT
6-MMPR
6-TIMP
TPMTTPMT
IMPDH/GMPS
Dosing of 6-MP: 1.5 mg/kg
Dosing of Azathioprine: 2.5 mg/kg
Two Methods of Starting Therapy: Dose escalation to target weight
calculated dose vs starting immediately at weight calculated dose
Check TPMT Enzyme Activity prior to starting therapy

47. Lab monitoring while on therapy
 CBC
 Q week for 1 month
 Q 2 wks for 1 month
 Q 1 month for 3 months
 Q 3 months
 May need to adjust
monitoring parameters
if dose escalate
 LFTs
 Q 3 months
 Leukopenias
 Pancreatitis
 Nausea/vomiting
 If occurs with 6-MP, can
switch to AZN or vice
versa
 Allergic reactions
 Infections
 Hepatotoxicity
 Malignancy

48. Methotrexate
 Induction: 25 mg IM/SQ weekly
 Maintenance: 15 mg/week
 Daily Folic acid supplementation
 Adverse reactions:
 Nausea/vomiting
 Infections
 Interstitial or hypersensitivity pneumonitis
 Check baseline CXR
 Potential for myelosuppression and hepatotoxicity
 Monitor CBC and especially LFTs closely (Q 1-3 months)

49.  A 19 yo woman is evaluated for a 3 month history of
progressively worsening diarrhea, abdominal pain, and weight
loss. Her brother was diagnosed with Crohn’s disease at age
16.
 PE: T 37.4 BP 110/65 RR 20 P 90
 Abd Exam: RLQ tenderness; no rebound/guarding. Rectal
exam: normal
 C-scope: moderately to severely active CD involving TI with
diagnosis confirmed histologically.
 MRE: active inflammation involving the distal 20 cm w/o
abscess/phlegmon/obstruction
 Which of the following is the most effective maintenance
treatment:
 Ciprofloxacin + Metronidazole
 Infliximab
 Mesalamine
 Prednisone
 Surgical Resection

50. Anti-TNF Quick Review…
 Infliximab
 Certolizumab pegol
 Adalimumab

52. Anti-TNF agents
 Check PPD, CXR and Hep B surf antigen prior to initiating
therapy
 Immunogenicity
 Infusion/ Injection site reactions
 Class Effect:
 Delayed hypersensitivity reactions
 Infections
 Non-Hodgkin’s lymphoma (including hepatosplenic T-cell
lymphoma in children receiving infliximab + azathioprine)
 Other malignancies
 Drug-induced lupus
 Demyelinating disease
 Worsening Heart failure

53. Sonic Trial!
 Randomized, double-blind trial evaluating the
efficacy of monotherapy vs combined
immunosuppression therapy
 508 pts w/ CD immunosuppressive therapy naïve
randomized to:
 Infliximab + placebo capsule
 Azathioprine + placebo infusion
 Infliximab + Azathioprine
 Received medications till week 30 and were given the
option to continue in a blinded study extension through
week 50
 Primary End point:
 Steroid free remission at week 26
Colombel et al. NEJM ‘10

54. Primary End Point

55. Secondary End Point

56.  A 37 yo M is evaluated for a 1 month history of stool
leakage. In the past week he has developed perianal
pain and low-grade fevers. He was diagnosed 4 years
ago with Crohn’s disease involving the small bowel and
colon. He is on 6-MP.
 PE VSS; normal abdominal exam
 Rectal: 2 fistula orifices right anterolateral to the anus
with expression of white material with gentle palpation. A
fluctuant, tender region that is 1.5 cm diameter is noted
left posterolateral to the anus.
 In addition to EUA and surgical debridement of abscess
cavities and fistula tracts, which is the most appropriate
management?
 Ciprofloxacin
 Corticosteroids
 Infliximab
 Metronidazole

57. Perianal fistula
 Adequate evaluation of patients with perianal
fistula includes
 endoscopy to assess extent of rectal disease and
presence of proximal disease
 pelvic floor imaging with magnetic resonance imaging
or anal endoscopic ultrasound
 examination under anesthesia
 Anti-TNF agents are useful in treating non-
complicated peri-anal fistula
 Don’t wait too long, call the colorectal surgeon

58.  A 29 yo F is evaluated for painful red spots on her shins and a recent
increase in the frequency of loose stools with some bleeding. She
has no other symptoms and was diagnosed with ulcerative colitis 4
years ago. Her only medication is mesalamine.
 Exam: few tender, erythematous subcutaneous nodules, each
measuring about 1 to 3 cm in diameter, are noted on the anterior
surfaces of the legs.
 Labs: WBC 9200
 Which of the following is the most appropriate therapy for the skin
lesions?
 Broad spectrum antibiotics
 Intensified therapy for UC
 NSAIDs
 Topical steroid cream

59. Common Extraintestinal manifestations
of IBD
 Joints
 Peripheral arthritis
 Ankylosing spondylitis and sacroileitis
 Skin
 Pyoderma gangrenosum
 Erythema nodosum
 Eyes
 Episcleritis
 Iritis
 Uveitis
 Hepato-biliary
 Primary sclerosing cholangitis
 Gallstones
 Other
 Hypercoagulable state
 Renal stones
 Aphthous stomatitis

60. EIMs of IBD: The Facts
 EIMs are most commonly associated with
colonic disease, extensive disease and family
history1
 Although virtually every organ system can be
involved the most commonly involved organs
are skin, eyes, joints and biliary tract
 Studies have reported ranges of 6-40% of
patients with IBD have at least one EIM2,3
 1-6% of patients have more than one EIM
1Extracolonic diagnosis in UC: an epidemiological study. Monsen AU, Am J Gastroent, 1990; 85(6): 711-6
2The prevalence of EID in IBD: population-based study. Bernstein A, Gastro, 2001: 96(4): 1116-22
3Autoimmune disorders and EIM in 1st degree familial and sporadic IBD: case-controlled study. Ricart A, IBD. 2004: 10(3):
207-14

61. EIMs of IBD: more Facts
 EIMs may precede, parallel, or be independent of
intestinal disease activity
 Musculoskeletal diseases are the most common
EIMs found in patients with IBD
 Cutaneous disorders associated with IBD occur in
about 15% of patients
Rare extraintestinal manifestations of IBD. Hoffman R, Inflamm Bowel Dis, 2004; 10: 140-147

62. Skin manifestations of IBD: oral lesions
Aphthous Ulcer

63. Skin manifestations of IBD
Courtesy of J-F Colombel, MD.
Erythema nodosum

64. Erythema Nodosum
 Prevalence of EN in IBD 10-20%
 more common in women
 most commonly occurs on extensor surfaces -
usually on shins, but can appear on calves, trunk
and face
 usually associated with colonic involvement
 commonly associated with disease activity but
not necessarily severity or extent
 can rarely precede diagnosis of IBD
Important cutaneous manifestations of IBD. Trost L, Postgrad Med J 2005; 81:580-585
EIMs in IBD. Danese S, World Jl of Gastro 2005; 11 (46): 7227-7236

65. Erythema Nodosum
 characterized by sudden onset multiple, red, warm
and painful nodules
 systemic symptoms --fever, malaise and especially
peripheral joint involvement-- can occur
 self-limiting
 typical course lasts 3-6 weeks, but residual bruise-like
lesions (should not scar) and arthralgias can last for
months
 resolves with control of IBD and often recurs with
exacerbations

66. Skin manifestations of IBD
Pyoderma gangrenosum

67. Pyoderma gangrenosum (PG)
 PG occurs in 1-10% patients with IBD
 more common in UC than CD
 most common in young to middle aged adults
 more common in women than men
 can occur anywhere but most commonly found on
extensor surfaces of lower extremities
Relationship of Extraintestinal involvements in IBD. Das K, Dig Dis Sci; 1999 44(1): 1-13
Important cutaneous manifestations of IBD. Trost L, Postgrad Med J, 2005; 81:580-585
Rare extraintestinal manifestations of IBD. Hoffman R, Inflamm Bowel Dis, 2004; 10: 140-147
EIM of IBD. Kethu, S, J Clinical Gastro, 2006; 40(6): 467-475

68. Pyoderma gangrenosum (PG)
 Diagnosis usually made clinically
 biopsy of lesions can extend ulcers and lead to poor
wound healing
 Need to exclude underlying infectious etiology
 approx 50% patients with PG develop large ulcers in
response to minor trauma (pathergy)
 surgical trauma i.e. scar or adjacent to ileostomy can
be site of PG1
Relationship of Extraintestinal involvements in IBD. Das K, Dig Dis Sci; 1999 44(1): 1-13
Important cutaneous manifestations of IBD. Trost L, Postgrad Med J, 2005; 81:580-585
Rare extraintestinal manifestations of IBD. Hoffman R, Inflamm Bowel Dis, 2004; 10: 140-147
EIM of IBD. Kethu, S, J Clinical Gastro, 2006; 40(6): 467-475

69. Pyoderma gangrenosum (PG)
 can occur before, during, or after onset of IBD
and may or may not parallel disease activity
 PG has been reported years after
proctocolectomy2
 Treatment:
 usually with systemic steroids (high doses), but sulfa
drugs, CYA, tacrolimus, 6-MP and dapsone have been
used
 Remicade has been used successfully in refractory
PG
 preventing secondary infections is crucial
1Relationship of Extraintestinal involvements in IBD. Das K, Dig Dis Sci; 1999, 44(1): 1-13
2PG in IBD. Levitt MD, Br J Surg; 1991, 78(6): 676-78

70. Skin manifestations of IBD
Sweet’s syndrome

71. Sweet’s syndrome
 Described first in 1964; less than 40 cases
associated with IBD in literature
 associated with malignancies (leukemias), CTD
or post-URI
 Four cardinal features
 fever
 leukocytosis
 tender red plaques
 histologic findings of neutrophilic infiltrate with
leukocytoclasis
Rare extraintestinal manifestations of IBD. Hoffman R, Inflamm Bowel Dis, 2004; 10: 140-147
Sweet’s Syndrome – An EIM in IBD. Digestion, Ytting H, 2005; 72: 195-200
Acute febrile neutrophilic dermatosis

72. Sweet’s syndrome
 More common in women (one study cited 86%)1
Cutaneous lesions involve arms, legs,
trunk, hands & face
 Associated with
 arthralgias/arthritis (>60%)
 fever (50-80%)
 eye involvement (conjunctivitis or iridocyclitis in 40%)
1Sweet’s syndrome: A clinicopathologic review of 29 cases. Kemmett D, J Am Acad Derm, 1990; 23:503-507
Rare extraintestinal manifestations of IBD. Hoffman R, Inflamm Bowel Dis, 2004; 10: 140-147
Sweet’s Syndrome – An EIM in IBD. Digestion, Ytting H, 2005; 72: 195-200

73. Sweet’s syndrome
 Usually parallels IBD disease activity, but there have
been cases where it precedes IBD or occurs later in
its course
 Treatment based on uncontrolled non-randomized
studies
 most cases have responded to systemic steroids
 in a review of 29 cases, oral prednisone for average of 6
weeks resolved skin lesions
 other options for refractory lesions include dapsone,
colchicine, potassium iodide, cyclosporine
Sweet’s syndrome: A clinicopathologic review of 29 cases. Kemmett D, J Am Acad Derm, 1990; 23:503-507
Rare extraintestinal manifestations of IBD. Hoffman R, Inflamm Bowel Dis, 2004; 10: 140-147

74. EIM of IBD: peripheral
arthropathy
 Joint complications were seen in 16% UC and 33%
CD patients
 Several studies have shown that peripheral arthritis
is more common in extensive UC and colonic CD
 Most patients developed the joint complications after
diagnosis of IBD, but in a modest group of patients it
either predated the diagnosis of IBD or was present
at time of diagnosis
Peripheral arthropathies in IBD: articular distribution and natural history. Orchard T, Gut, 1998: 42: 387-391

75. EIM of IBD: axial involvement
 Axial involvement varies from asymptomatic
sacroiliitis to inflammatory LBP to ankylosing
spondylitis (AS)
 Sacroiliitis is hallmark of AS but under-reported
due to insidious onset and asymptomatic nature
(ranging from 10-52% in various studies)
 radiographic evidence present in 20-25% patients
 Diagnosis of inflammatory LBP includes
presence of pain during night and at rest which
improves with movement
Peripheral arthropathies in IBD: articular distribution and natural history. Orchard T, Gut, 1998: 42: 387-391
Review article: joint involvement in IBD. Devos M, Aliment Pharmacol Thera, 2004; 20(4) 36-42
Arthritis or vasculitis as presenting symptoms of CD. Mader R, Rheumatol Int, 2005: 25: 401-405

76. Ankylosing Spondylitis
 AS is present in 3-10% IBD patients
 Diagnosis of AS made using modified NY criteria
(combines clinical parameters with radiological
sacroiliitis)
 LBP and morning stiffness for >3 mos,
improves with exercise
 Associated decreased mobility of lumbar
spine and limitation in chest expansion and
radiological criteria
 Sacroiliitis of at least grade 2 bilaterally or
grade 3 unilaterally
Review article: joint involvement in IBD. Devos M, Aliment Pharmacol Thera, 2004; 20(4) 36-42

77. Treatment of IBD-arthropathies
 NSAIDS or COX-2 inhibitors
 Intra-articular/systemic steroids
 sulfasalazine (greater benefit with peripheral
arthropathy)
 mesalamine (two small studies in AS patients
showed improvement)
 MTX (scarce data , but benefit with peripheral
arthropathy)
 Infliximab (great success with both GI and joint -axial
and peripheral- symptoms in several studies)
 Physiotherapy
Review article: joint involvement in IBD. Devos M, Aliment Pharmacol Thera, 2004; 20(4) 36-42
Arthritis or vasculitis as presenting symptoms of CD. Mader R, Rheumatol Int, 2005: 25: 401-405
EIMs of CD. Juillerat P, Digeston, 2005; 71: 31-36

78. EIM Take home points….
 EIMs may precede, parallel, or be independent of
intestinal disease activity
 in most cases, erythema nodosum, aphthous
stomatitis, peripheral arthritis and episcleritis parallel
activity of intestinal disease
 Most commonly involved organs are joints, skin,
eyes, and biliary tract
 EIMs can occur after proctocolectomy in UC patients
so be aware…