Diagnosis and Management

Topics of Focus

Ulcerative Colitis

Disease Classification

Management:

Mild to moderate

Severe, refractory disease

Crohn’s

Pathogenesis

Diagnosis

Management

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

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

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 splenicflexure

30-40% of pts

Proctosigmoiditis

Inflammation extends to rectosigmoid colon

30-40% of pts

Ulcerative proctitis

Inflammation confined to rectum

40% of pts

Clinical Severity IndexTruelove 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.

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%

Endoscopic Severity IndexModified 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.

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

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

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)

Maintenance of Remission

Azathioprine/6-mercaptopurine Immunomodulators inhibit proliferation of T and B

lymphocytes, leading to decreased production of cytotoxicT 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

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.

Exit Strategies for Severe Steroid Refractory

UC in Hospital…

Cyclosporine

Infliximab

Surgery

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%

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

Infliximab for UC: ACT I and II

Clinical Response

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

IPAA for Ulcerative Colitis

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

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…

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

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

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

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

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

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

To make a diagnosis of IBD…

History

Clinical symptoms

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 ×

To make a diagnosis of IBD…

History

Clinical symptoms

What to check if suspicious for

IBD? CBC

CMP Vitamin D, Vitamin B12

ESR/CRP

Stool cultures

Fecal calprotectin/ lactoferrin

To make a diagnosis of IBD…

History

Clinical symptoms

CD- Endoscopic AppearanceNormal Aphthous ulcers

Serpiginous ulcers Cobblestoning of mucosa

CT Findings

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

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

Cumulative Probability of Surgical

Intervention in CD

Munkholm P, et al. Gastroenterology. 1993;105:1716.

Years

Pro

bab

ilit

y (

%)

0

20

40

60

80

100

0 2 5 8 11 14 17 20

±2 SD

D

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 3650

100

80

60

40

20

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: Months2002 552 229 95 37n=

Penetrating

StricturingInflammatory

70%

18%

Over a 20-year period, 88% risk of developing stricturing (18%) or penetrating (70%) disease

Vermiere et al, Aliment Pharmacol Ther 2006; 25: 3

Response

Continue Txand observe

Response

Taper & stop Tx Observation

Relapse within 1yr?

Steroids + AZA or MTX or Biologic

No response

AZA /MTX/Biologic ? Surgery

Relapse

Biologic vscombination therapy

No response

No response

Colonic(± small intestine)

Small intestine

Smoking cessation5-ASA/Sulfasalazine ± antibiotics

Smoking cessationBudesonide / corticosteroids

Patient Mild presentation Inflammatory disease No perianal disease No extraintestinal manifestations Non-smoking

Disease Management: Low risk of

progression

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 cessationSteroids+ 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

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

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

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)

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

Anti-TNF Quick Review…

Infliximab

Certolizumab pegol

Adalimumab

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

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

Primary End Point

Secondary End Point

A 37 yo M is evaluated for a 1 month history of stool leakage. In the past week he has developed perianalpain 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

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

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

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

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

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

Skin manifestations of IBD: oral lesions

Aphthous Ulcer

Skin manifestations of IBD

Courtesy of J-F Colombel, MD.

Erythema nodosum

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 IBDImportant 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

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

Skin manifestations of IBD

Pyoderma gangrenosum

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

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

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

Skin manifestations of IBD

Sweet’s syndrome

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

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

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

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

EIM of IBD: axial involvement Axial involvement varies from asymptomatic

sacroiliitis to inflammatory LBP to ankylosingspondylitis (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

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

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)

PhysiotherapyReview 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

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…