Canadian IBD Today

The Role Of Upfront Surgery in the Management of Ileal Crohn’s Disease

Paulo Gustavo Kotze, MD — Wed, 11 Sep 2024 00:00:00 +0000

Crohn's disease (CD) is a chronic inflammatory disorder characterized by transmural inflammation that can affect any part of the gastrointestinal tract. Among the various phenotypes of CD, involvement of the terminal ileum, known as ileal CD, poses unique challenges in management due to its potential for complications such as strictures, fistulas, and abscesses. While medical therapy remains a cornerstone in the management of CD, the role of surgery, particularly upfront surgical intervention (early resection), has garnered increasing attention in recent years.

The decision to pursue surgical intervention at the outset of disease management, rather than relying solely on medical therapy, is a subject of ongoing debate in the field. Upfront surgery (prior to advanced medical therapies) may offer benefits such as rapid resolution of symptoms, avoidance of long-term immunosuppressive therapy and prevention of disease progression. However, concerns regarding the postoperative morbidity and potential for recurrence associated with surgical intervention warrant careful consideration.

Acute Severe Ulcerative Colitis: Review of Management and Emerging Treatments

Natasha Klemm, MD, Yvette Leung, MD — Wed, 11 Sep 2024 00:00:00 +0000

Acute severe ulcerative colitis (ASUC) is a medical emergency, with an overall mortality rate of 1%. Patients with ulcerative colitis (UC) have a 20–25% rate of severe exacerbation requiring hospitalization for urgent medical treatment and surgical consideration. The rate of re-hospitalization for recurrent ASUC is 34.4%, and it typically occurs within 24 months of the index admission. Treatment requires a patient-centred multidisciplinary approach that includes gastroenterology, colorectal surgery, and nutrition support, with the goal of minimizing disease complications, adverse events of treatment, and healthcare costs.6 Clinicians and patients have an increasing number of treatment options and additional safety issues to consider. We review the current approach to management and summarize emerging data on the use of novel agents to treat ASUC.

Treatment Related Adverse Events and Monitoring of Patients Receiving Biologic or Small Molecule Therapy for Inflammatory Bowel Disease

Michael Stewart, MD, FRCPC — Wed, 11 Sep 2024 00:00:00 +0000

The management of Inflammatory Bowel Disease (IBD) has evolved with the emergence of new treatment paradigms and the introduction of novel advanced therapies, including monoclonal antibodies (mAbs) and small molecules. These advanced therapies have improved disease control, but they necessitate careful pre-treatment assessment and ongoing monitoring to manage potential adverse effects and optimize patient outcomes. This review focuses on practical approaches to treatment-specific monitoring of currently available advanced therapies.

Medical Management of Inflammatory Bowel Disease in the Elderly

Farhad Peerani, MD — Wed, 11 Sep 2024 00:00:00 +0000

The optimal management of inflammatory bowel disease (IBD) can be challenging at the best of times; however, this notion becomes more salient when treating the niche population of elderly IBD. The prevalence of IBD in elderly Canadians has almost doubled in a span of 5 years, increasing from 1/160 in 2018 to 1/88 in 2023. While the majority of IBD patients are diagnosed between 20-40 years of age, 10-15% are diagnosed at >60 years of age. Elderly-onset ulcerative colitis (UC) patients more commonly have left-sided colitis with less disease extension whereas elderly-onset Crohn’s disease (CD) patients typically exhibit an inflammatory colonic phenotype. Although elderly-onset IBD patients typically demonstrate a less aggressive natural history overall, they have a similar risk of surgery compared to their adult-onset IBD counterparts with the majority being treated with non-advanced therapies. A lack of physician knowledge and comfort level in treating elderly IBD likely contribute to patients being maintained inappropriately on long-term steroids and/or 5-aminosalicylates.

The existing literature on elderly IBD often fails to differentiate between aging pediatric or adult-onset IBD patients and elderly-onset IBD patients; therefore, this article will discuss the management of both groups together. Nevertheless, it is important to note that these two groups likely have different underlying pathophysiological mechanisms driving their respective diseases which can have implications for therapeutic decisions. Unfortunately, the majority of evidence to help guide decision-making in elderly IBD is derived from retrospective analyses of real-world data or health administrative datasets, as well as post-hoc analyses of randomized controlled trials (RCTs). Drug efficacy aside, nuanced care of the elderly IBD patient involves an appreciation of frailty and comorbidity to help contextualize the risks of immunosuppressive therapy. Not only is the safety of therapies contingent upon the intrinsic immunosuppressive properties of the drug, but in addition, drug efficacy needs to be considered with respect to the effectiveness in controlling disease activity and achieving corticosteroid-free remission.

Ophthalmic Complications in Inflammatory Bowel Disease

Marie-Lyne Bélair, MD, FRCSC, Evangelina Esposito, MD, ChM — Wed, 11 Sep 2024 00:00:00 +0000

The prevalence of inflammatory bowel disease (IBD), estimated at 843 per 100,000 people (95% PI 828-859) (i.e., 0.843% of the population) in 2023 is increasing in Canada and is expected to reach 1.1% of the Canadian population by 2035. Consequently, extraintestinal manifestations and complications will also increase. Up to 50% of patients suffering from IBD will develop an extraintestinal manifestation (EIM) during the course of their disease, patients with Crohn’s disease (CD) being more often affected then those with ulcerative colitis (UC). Ocular manifestations are the third most common EIM after articular and dermatological involvements. Ocular complaints in patients with IBD can represent an EIM, a complication of systemic treatment or an unrelated affection. All patients presenting with a red eye, light sensitivity, loss of vision or any acute ocular symptom(s) should be promptly evaluated by an eye specialist. Early detection of ophthalmologic diseases and appropriate management require collaboration between specialists and are of utmost importance to avoid permanent visual loss.

The most common ocular manifestations reported in IBD patients are episcleritis (2-5%) and anterior uveitis (0.5-3.5%). Other less common manifestations include scleritis, intermediate and posterior uveitis, retinal vasculitis, retinal vascular occlusions, orbital inflammatory syndrome, and optic neuritis. Ocular manifestations can also be associated with malabsorption syndromes encountered in some patients with IBD. Secondary vitamin A deficiency can result in night blindness and keratoconjunctivitis sicca.