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Inflammatory Bowel Disease
By C. Andrew Kistler, MD, PharmD, RPh
A 38-year-old man with a remote history of inflammatory bowel disease (IBD) presents to the hospital with a several month long history of abdominal pain, nausea, vomiting, bloody and mucoid diarrhea, 20 lb weight loss, and subjective fevers. He says he cannot remember when he was diagnosed and has missed several appointments with his gastroenterologist. He reports that he is taking oral prednisone and mesalamine at home but cannot remember the doses or frequencies. Over the last month, the patient decided to increase the oral prednisone dose secondary to what he thought was a “flare”, but it only helped minimally.
On examination, his vital signs were stable with no fever, tachycardia, or hypotension. He appears to be thin but not cachectic, and his mucus membranes are mildly dry. His heart and lung examinations are benign. The abdominal examination is significant for tenderness to palpation in the left lower quadrant, but no rebounding or guarding is present. He has good peripheral pulses, and his skin appears to have decreased turgor.
During the preliminary workup of his symptoms, the patient is asked when his last colonoscopy took place, but he cannot remember.
Submit your diagnosis to see full explanation.
In the patient case discussed above, colorectal cancer (CRC) should be included in the differential diagnosis; however, other causes need to be ruled out first. This patient was initially treated as having an ulcerative colitis (UC) flare after reviewing his previous records and admission labs. He was started on intravenous steroids and empiric treatment with antibiotics. After infectious etiologies were ruled out and his symptoms showed some subjective improvement, the decision to perform a colonoscopy was made.
Patients with IBD have an increased risk of CRC that is dependent on the extent, duration, and degree of inflammation present on biopsy. The risk of CRC in patients with IBD has been shown to increase anywhere from 8 to 10 years after initial diagnosis. IBD patients are about five to six times more likely to develop CRC compared
with non-IBD patients.1 In UC patients with pancolitis, the cumulative incidence is approximately 5% to 10% after 20 years and increases up to 20% after 30 years.2,3 When patients with IBD are diagnosed with CRC, they also have a higher risk of mortality compared to patients who do not have IBD. Between 10% to 15% of IBD patient deaths are attributable to CRC.4
Due to the lack of consistent epidemiologic data, a universal surveillance schedule remains to be determined. Depending on the gastroenterological society, the recommendations vary. According to the American College of Gastroenterology (ACG), yearly surveillance colonoscopies should begin about 8 to 10 years after diagnosis of IBD, and several biopsies should be taken regularly during these colonoscopies.5 The American Gastroenterological Association (AGA) calls for surveillance colonoscopies starting 8 years after diagnosis, but they can be delayed until 15 years in patients with isolated left sided colitis.6 Furthermore, AGA recommends repeat colonoscopies every 1 to 2 years, depending on the physician’s clinical judgment and colonoscopy results. Several other GI societies, such as the American Society for Gastrointestinal Endoscopy and British Society of Gastroenterology, also provide recommendations; however, the regimens above appear to be the ones most commonly followed.
There is some data on the role of NSAIDs and other anti-inflammatory medications in preventing CRC. However, there are not many well-controlled studies specifically including IBD patients. The limited data that we do have in IBD patients shows some trending towards decreased risk, but additional studies are needed in order
to further clarify prevention strategies in patients with IBD.7 In addition to NSAIDs and other anti-inflammatory agents, folic acid and ursodeoxycholic acid are also being studied in the prevention of CRC in IBD patients.8
References
1. Mattar MC, Lough D, Pishvaian MJ, Charabaty A. Current management of inflammatory bowel disease and colorectal cancer. Gastrointest Cancer Res. 2011;4(2):53-61.
2. Gyde SN, Prior P, Allan RN, et al. Colorectal cancer in ulcerative colitis: a cohort study of primary referrals from three centres. Gut. 1988;29(2):206-217.
3. Collins RH Jr, Feldman M, Fordtran JS. Colon cancer, dysplasia, and surveillance in
patients with ulcerative colitis. A critical review. N Enl J Med. 1987;316(26):1654-1658.
4. Munkholm P. Review article: the incidence and prevalence of
colorectal cancer in inflammatory bowel disease. Aliment Pharmacol Ther. 2003;18(suppl 2):1-5.
5. Kornbluth A, Sachar DB. Ulcerative colitis practice guidelines in adults. American Journal of Gastroenterology, Practice Parameters Committee. Am J Gastroenterol. 1997;92(2):204-211.
6. Farraye FA, Odze RD, Eaden J, Itzkowitz SH. AGA technical review on the diagnosis and management of colorectal neoplasia in inflammatory bowel disease. Gastroenterology. 2010;138(2):746-774, 774.e1-e4; quiz e12-e13.
7. Velayos FS, Loftus EV Jr, Jess T, et al. Predictive and protective factors associated with colorectal cancer in ulcerative colitis: A case-control study. Gastroenterology. 2006;130(7):1941-1949.
8. Tung BY, Emond MJ, Haggitt RC, et al. Ursodiol use is associated with lower prevalence of colonic neoplasia in patients with ulcerative colitis and primary sclerosing cholangitis. Ann Intern Med. 2001;134(2):89-95.
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