Pulmonary manifestations of inflammatory bowel disease

Abstract

Bronchopulmonary signs and symptoms are examples of variable extraintestinal manifestations of the inflammatory bowel diseases (IBD). These complications of Crohn's disease (CD) and ulcerative colitis (UC) seem to be underrecognized by both pulmonary physicians and gastroenterologists. The objective of the present review was to gather and summarize information on this particular matter, on the basis of available up-to-date literature. Tracheobronchial involvement is the most prevalent respiratory presentation, whereas IBD-related interstitial lung disease is less frequent. Latent and asymptomatic pulmonary involvement is not unusual. Differential diagnosis should always consider infections (mainly tuberculosis) and drug-induced lung pathology. The common link between intestinal disease and lung pathology is unknown, but many hypotheses have been proposed. It is speculated that environmental pollution, common immunological mechanisms and predisposing genetic factors may play a role.

Keywords: Crohn's disease; inflammatory bowel disease; interstitial lung disease; tracheobronchitis; ulcerative colitis.

Figure 1

Chest X-ray of a 19-year-old woman with long standing CD treated with mesalazine. Pulmonary infiltrations and right sided pleural effusion are visible. Due to the presence of fever, dry cough and pleural chest pain, pleuropneumonia was diagnosed and antibiotics were introduced. Because of lack of response to antimicrobial treatment she was referred to a pulmonary physician, who recommended withdrawal of mesalazine. After initial improvement, the general and radiological symptoms relapsed (see Figure 2), suggesting the possibility of IBD-related pathology

Figure 2

Computed tomography of the same patient performed a few weeks after the presented chest X-ray (Figure 1). Subpleural nodes and nodules are visible. Video-assisted thoracoscopic examination was performed and lung biopsy revealed organizing pneumonia. Clinical and radiological symptoms responded very well to oral steroids and did not relapse until renewed introduction of mesalazine

Figure 3

Chest X-ray of a young woman treated for CD with infliximab, showing consolidation in the left lower lobe (A) and a CT scan showing bilateral opacities predominantly in the left basal segments (B). She presented with productive cough and fever, non-responsive to empirical antibiotic treatment. The radiological picture and clinical context suggested IBD-related lung disease. Transbronchial lung biopsy was non-diagnostic and the patient refused surgical biopsy. Steroids were introduced but were withdrawn shortly after the bronchoalveolar aspirate appeared positive for Mycobacterium tuberculosis. Note the atypical location of TB lung infiltrations