IBD

Epidemiology of IBD in Europe

2.5-3 million inhabitants; annual cost 4.6-5.6 billion €

Age group most often diagnosed with IBD

15-20 % are children

Main anatomical difference between Crohn's and ulcerative colitis

Crohn: affects any GI segment, transmural; UC: colon only, mucosal/submucosal involvement

Endoscopic finding in Crohn's disease

"Segmental (""skip"") lesions, cobblestoning, deep ulcerations"

Endoscopic finding in ulcerative colitis

Continuous inflammation starting at rectum, superficial ulcerations

Histologic hallmark of Crohn's disease

Transmural inflammation, granulomas

Histologic hallmark of ulcerative colitis

Crypt abscesses, continuous mucosal inflammation, no granulomas

Extra-intestinal manifestations of IBD

Arthritis, ankylosing spondylitis, erythema nodosum, pyoderma gangrenosum, uveitis, primary sclerosing cholangitis

Definition of IBD-U (unclassified IBD)

Colonic disease where differentiation between UC and Crohn's not possible; 10-15 % of cases

Main diagnostic tools for IBD

Clinical history, endoscopy, imaging (US/CT/MR), histology

Definition of indeterminate colitis

Continuous disease with rectal sparing, uncertain histology after colectomy

Severity index for ulcerative colitis

Truelove-Witts index

Severity assessment for Crohn's disease

Based on clinical symptoms, imaging, CRP, complications

Therapeutic goals in IBD

Induce remission, maintain remission, prevent progression, achieve mucosal healing

Induction therapy principle

Used during flare-up; based on severity and location

Maintenance therapy principle

Used in remission; monitor disease activity and side effects

First-line drugs in ulcerative colitis

Mesalazine (5-ASA) - local/oral; induction and maintenance

Role of 5-ASA in Crohn's

Generally not effective (except possibly sulfasalazine in colonic Crohn's)

Corticosteroid for mild ileocecal Crohn's

Budesonide (topical effect, high first-pass hepatic metabolism)

Systemic corticosteroids - indication and caution

Used for induction only; not for maintenance due to adverse effects

Definition of steroid-resistant IBD

No response after 14 days of 40-60 mg prednisolone equivalent

Definition of steroid-dependent IBD

Relapse within 3-6 months or failure to taper steroids

Immunosuppressant commonly used in IBD

Azathioprine (2-2.5 mg/kg/day)

Azathioprine monitoring requirements

Screen for myelosuppression; pancreatitis possible (no screening needed)

Biologic therapies for IBD

Anti-TNF (infliximab, adalimumab), ustekinumab, vedolizumab

Small-molecule therapies for IBD

JAK inhibitors (tofacitinib, upadacitinib)

Therapy for stricturing Crohn's disease (B2)

Surgical (Heineke-Mikulicz or Finney stricturoplasty); treat inflammation if active

Therapy for penetrating Crohn's disease (B3)

Medical (anti-TNF) ± surgery for abscess/fistula

Best target for inflammatory-type Crohn's

Mucosal healing to prevent progression

Diagnosis of perianal Crohn's lesions

Pelvic MRI, rectal ultrasound, or surgical exam under anesthesia

Treatment of simple perianal fistula in Crohn's

Antibiotics, fistulotomy if feasible

Treatment of complex perianal fistula in Crohn's

Anti-TNF + seton placement; surgery if needed

Drugs avoided in perianal Crohn's

Systemic corticosteroids (GCS)

Emergency surgery indications in UC

Toxic megacolon, perforation, severe bleeding

Medical therapy ladder for ulcerative colitis

1️⃣ Mesalazine 2️⃣ Budesonide/local steroids 3️⃣ Systemic steroids 4️⃣ Azathioprine 5️⃣ Biologic or JAK inhibitor

Local therapy for distal UC

Suppositories, enemas, foam with mesalazine or budesonide

Maintenance therapy for UC

Mesalazine or azathioprine; biologics if refractory