Inflammatory Bowel Disease

Abstract

Background: Inflammatory bowel diseases are common in Europe, with prevalences as high as 1 in 198 persons (ulcerative colitis) and 1 in 310 persons (Crohn's disease).

Methods: This review is based on pertinent articles retrieved by a search in PubMed and in German and European guidelines and Cochrane reviews of controlled trials.

Results: Typically, the main clinical features of inflammatory bowel diseases are diarrhea, abdominal pain, and, in the case of ulcerative colitis, peranal bleeding. These diseases are due to a complex immunological disturbance with both genetic and environmental causes. A defective mucosal barrier against commensal bowel flora plays a major role in their pathogenesis. The diagnosis is based on laboratory testing, ultrasonography, imaging studies, and, above all, gastrointestinal endoscopy. Most patients with Crohn's disease respond to budesonide or systemic steroids; aminosalicylates are less effective. Refractory exacerbations may be treated with antibodies against tumor necrosis factor (TNF) or, more recently, antibodies against integrin, a protein of the cell membrane. In ulcerative colitis, aminosalicylates are given first; if necessary, steroids or antibodies against TNF-α or integrin are added. Maintenance therapy to prevent further relapses often involves immunosuppression with thiopurines and/or antibodies. Once all conservative treatment options have been exhausted, surgery may be necessary.

Conclusion: The treatment of chronic inflammatory bowel diseases requires individually designed therapeutic strategies and the close interdisciplinary collaboration of internists and surgeons.

Figure 1

The mucosal barrier in health, in Crohn’s disease, and in ulcerative colitis. Modified from Stange E. (ed.): Entzündliche Darmerkrankungen, Stuttgart: Schattauer 2015; 26, 27, with the kind permisison of Schattauer Verlag.

Figure 2

Typical endoscopic and tomographic findings in chronic inflammatory bowel disease. a) Mild ulcerative colitis: edema and erythema, with broken light reflexes from the granulated colonic mucosa. b) Terminal ileitis in Crohn’s disease: partly aphthous (8 o’clock), partly confluent ulcerations (2 and 4 o’clock) of the small bowel mucosa. c) Contrast-enhanced computerized tomography (CT): massively dilated cecum with coprostasis and thickening of the wall of the ascending and transverse colon with loss of haustration in an acute, severe relapse of longstanding ulcerative colitis (kindly provided by PD Dr. C. Schraml, Department of Diagnostic and Interventional Radiology [Director, Prof. Dr. K. Nikolaou], Universitätsklinikum Tübingen). d) Contrast-enhanced magnetic resonance enteroclysis: Crohn’s disease, mixed inflammatory and fibrotic-stenotic changes in the terminal ileum (acknowledgement as above).

eFigure 1

Treatment algorithm for Crohn’s disease, developed by K.H. and E.F.S.

eFigure 2

Treatment algorithm for ulcerative colitis, developed by K.H. and E.F.S.