Complications in IBD

Table of Contents

Local Complications of IBD

  1. Local complications of CD
    1. Fistulas
    2. Abscesses
    3. Fissures
    4. Malabsorption
  2. Local Complications of UC
    1. Bowel perforation
    2. Fulminant Colitis
    3. Toxic Megacolon
    4. Colorectal Cancer
  3. Opportunistic Infections and IBD
  4. Pancreatitis and IBD
    1. Acute pancreatitis
    2. Chronic pancreatitis
  5. Thrombocytopenia and IBD

NOTE: MANY OF THESE COMPLICATIONS ARE CONSIDERED EXTRAINTESTINAL COMPLICATIONS OF IBD (SYSTEMIC) VS. LOCAL (GUT-SPECIFIC).  THIS IS THE REASON FOR SEPERATING “LOCAL” (GUT-SPECIFIC) COMPLICATIONS.

 

Local Complications of Inflammatory Bowel Disease

For people living with IBD, you may be aware or have experienced a number of potential complications that may occur over the course of either CD or UC.  These complications are generally categorized as being either a systemic complication or “extraintestinal” or a local complication meaning a specific complication of the GI tract.  To make matters even a bit more confusing, some complications can be both local and systemic complications of IBD.  For example, some infections are complications of IBD that can be both local and systemic. 

In this section, we will focus of local complications meaning those complications specific to the GI tract.  Extraintestinal complications of IBD are presented in a separate section.  To review the extraintestinal complications related to IBD please refer to the table of contents accompanying this site.

In both CD and UC, longer disease duration increases the risk of local complications.  Although local complications occur in both CD and UC, some local complications are more common to one form or the other.1 If you have been diagnosed with CD, complications are generally related to fistula formation and abscess.  A description of fistula follows in the next section.  On the other hand, if you have been diagnosed with UC, it is often accompanied by severe inflammation, perforation of the bowel, and potentially toxic megacolon (an abnormally enlarged colon).

 

1. Local Complications of Crohn’s Disease

Local complications of CD, meaning complications of the GI tract, include the following: (1) fistulas, (2) abscesses, (3) fissures, and (4) malabsorption.

 

Fistulas

A fistula typically develops from a deep sore or ulcer within the intestine that develops into a small tunnel between the intestine and the skin, usually near the anus but they can also cause tunnels between the intestine and the bladder.  In females, fistula can occur between the intestine and the vagina.[1,2] 

Fistulas are more common in CD than UC.  It is estimated that 3 out of every 10 patients diagnosed with CD will develop a fistula at some point.  The presence of fistula usually is a sign of a more aggressive course of CD.  Most fistulas are perianal meaning that they form around the anus. They can cause bleeding and/or discharge when passing stools and can be very painful.  Perianal fistulas are classified as being either simple or complex.  Simple fistulas are superficial and do not show signs of abscess or anorectal stricture.  Complex fistulas typically involve multiple tunnel openings with abscesses, rectovaginal fistula and anorectal stricture with inflammation.[2] 

Treatment goals are to reduce fistula secretion and/or to heal any fistulasThe treatment of fistulas requires the coordinated expertise of your gastroenterologist, along with a surgeon and a radiologist.  Treatment of fistula will likely involve surgery in combination with medical treatment, such as corticosteroids and/or a TNF inhibitor.[2]

Sources:

[1] Crohn’s & Colitis Foundation Fact Sheet: Intestinal Complication, January 2015. Available at: http://www.crohnscolitisfoundation.org/assets/pdfs/intestinalcomps.pdf

[2] Hvas CL, et al Diagnosing and treatment of fistualising Crohn’s disease. Dan Med Bull 2011;58:C4338. 

 

Abscesses

An abscess is a boil or localized pocket of pus caused by a bacterial infection.  They are more common in CD than in UC; however, people with UC can also develop them.[1,3] An abscess is often associated with a fistula and almost always occurs at the site of a prior surgery.  In CD, abscesses are typically found in the abdomen, the anal, and the rectal areas. In people with UC, abscesses generally develop in the colon.[3]

The treatment of choice for managing an abscess is percutaneous abscess drainage (PAD).  This procedure involves inserting a needle into the abscess and then putting in a tube to drain the abscess.  PAD is generally done under local anesthetic using imaging to accurately mark the site of the abscess.  The benefits of draining an abscess are delaying surgery to allow any inflammation associated with the infection to resolve and allowing time to optimize nutritional status.[3,4]

Sources

[1] Crohn’s & Colitis Foundation Fact Sheet: Intestinal Complication, January 2015. Available at: http://www.crohnscolitisfoundation.org/assets/pdfs/intestinalcomps.pdf

[3] Richards RJ. Management of abdominal and pelvic abscess in Crohn’s disease. World J Gastrointest Endosc 2011l3:209-212.

[4] IBD relief: Percutaneous abscess drainage (PAD) for inflammatory bowel disease (IBD). Available at: https://www.ibdrelief.com/learn/treatment/surgery/percutaneous-abscess-drainage-for-ibd.

Fissures

Fissures are tears or cracks in the lining of the anus.  These fissures may be superficial or deep.  Unlike fistulas, fissures only appear in the anal area.  Fissures often result in mild-to-severe rectal pain and bleeding, especially during bowel movements.  They are conservatively treated with topical application of corticosteroids, local anesthetics and laxatives.[1,5,6]

Sources

[1] Crohn’s & Colitis Foundation Fact Sheet: Intestinal Complication, January 2015. Available at: http://www.crohnscolitisfoundation.org/assets/pdfs/intestinalcomps.pdf

[5] Vershenya S, et al. Combined approach to the treatment of chronic anal fissures. Updates Surg 2015;67:83-89.

[6] Stewart DB, et al. Clinical practice guidelines for the management of anal fissures. Dis Colon Rectum 2017;60:7-14.

Malabsorption

Malabsorption occurs when the small intestine cannot absorb enough nutrients and fluids.[7] It is a local complication of CD.  It typically does not develop unless the disease is extensive and of long duration.  Malabsorption leads to malnutrition, which is a major complication of IBD and primarily responsible for chronic weight loss.7 Treatment to replace nutrients is generally effective.[1]

 

Sources:

[1] Crohn’s & Colitis Foundation Fact Sheet: Intestinal Complication, January 2015. Available at: http://www.crohnscolitisfoundation.org/assets/pdfs/intestinalcomps.pdf

[7]Scaldaferri F, et al. Nutrition and IBD: malnutrition and/or sarcopenia? A practical guide. Gastroenterology Research and Practice 2017;ID 8646495.

 

2. Local Complications of UC

Local complications of UC include the following: (1) bowl perforation (rupture of the bowel), (2) fulminant colitis, (3) toxic megacolon, and (4) increased risk of cancer.

 

Bowel perforation

In people with CD, a perforated bowel is most often the result of a fistula and/or abscess.  A perforation in patients with UC is often due to a condition called toxic megacolon, which is an enlarged and extended colon.[8]  In both CD and UC, chronic inflammation can weaken the intestinal wall leading to hole and a potentially life-threatening condition called peritonitis. [1,8]

Sources

[1] Crohn’s & Colitis Foundation Fact Sheet: Intestinal Complication, January 2015. Available at: http://www.crohnscolitisfoundation.org/assets/pdfs/intestinalcomps.pdf

[8] Crohn’s & Colitis Foundation of America. Surgery for Crohn’s disease and ulcerative colitis. Available at: http://www.crohnscolitisfoundation.org/assets/pdfs/surgery_ brochure_final.pdf

 

Fulminant Colitis

Fulminant colitis is the most severe and rarest form of ulcerative colitis.  It occurs in less than 10% of patients with UC.  In patients with CD, the condition is referred to as toxic colitis.[1] 

In recent years, the descriptors “acute severe” and “severe” have replaced the terms fulminant and toxic colitis due to improved diagnostic criteria and reported outcomes.  However, the term “fulminant” is sometimes used to describe a critical form of severe colitis defined as more than 10 stools per day, daily continuous bleeding, fever, and the need for blood transfusion.[9]

            Fulminant colitis (severe colitis) in patients with UC is best managed through the combined efforts of a gastroenterologist and surgeon working with the patient.  Although medical therapy is the first-line treatment in most cases, if the patient has signs of heavy bleeding, perforation, or peritonitis, surgery is immediately indicated.   Laparoscopic colectomy and ileostomy are the surgical procedures of choice in most cases.[9]

 

Sources

[1] Crohn’s & Colitis Foundation Fact Sheet: Intestinal Complication, January 2015. Available at: http://www.crohnscolitisfoundation.org/assets/pdfs/intestinalcomps.pdf

[9] Strong SA. Management of acute colitis and toxic megacolon. Clin Colon Rectal Surg 2010;23:274-284.

 

Toxic Megacolon

Toxic megacolon is the most severe and potentially life-threatening complication of IBD.  Toxic megacolon is more commonly associated with UC.  It is uncommon in younger patients with IBD.[1, 9]

Sources

[1] Crohn’s & Colitis Foundation Fact Sheet: Intestinal Complication, January 2015. Available at: http://www.crohnscolitisfoundation.org/assets/pdfs/intestinalcomps.pdf

[1] Strong SA. Management of acute colitis and toxic megacolon. Clin Colon Rectal Surg 2010;23:274-284.

 

Colorectal Cancer

The risk of colorectal cancer in patients with IBD increases with disease duration and severity.  In patients with UC, the rate of colorectal cancer is 5 to 8% after 20 years.  In patients with CD, the risk is strongest when there is major involvement of the colon.[1, 10]   Current screening and surveillance guidelines recommend the following: (1) a screening colonoscopy should be performed when a patient is in clinical remission, (2) surveillance should begin 8-10 years after the onset of symptoms for patients with left sided or extensive colitis, (3) surveillance schedules need to be consistently followed, and (4) two to four biopsies should be taken every 10 cm along the entire colon, with additional samples taken in suspected areas.[10]

 

Sources

[1] Crohn’s & Colitis Foundation Fact Sheet: Intestinal Complication, January 2015. Available

At: http://www.crohnscolitisfoundation.org/assets/pdfs/intestinalcomps.pdf

[10] Kim ER and Chang SY. Colorectal cancer in inflammatory bowel disease: The risk, pathogenesis, prevention and diagnosis. Word J Gastroenterol 2014;20:9872-9881.

 

3. Opportunistic Infections and IBD

NOTE: OPPORTUNSITIC INFECTIONS ARE RARE IN PEDIATIC IBD.  ALSO, VARIOUS OPPORTUNISTIC INFECTIONS MAY BE CLASSIFIED AS EITHER EXTRAINTESTINAL (SYSTEMIC) OR LOCAL (GUT-SPECIFIC) OR BOTH.  MY RECOMMEDNATION IS THAT IF YOU INCLUDE THIS SECTION, MAKE IT A SEPERATE SECTION.  KEEP IN MIND, YOU HAVE COVERED OPPORTUNSITC INFECTIONS IN THE AVERESE EVENTS RELATED TO THE VARIOUS MEDICAL THERAPIES.

 

Opportunistic infections (OIs) are caused by microorganisms that take advantage of a weakened immune system when they ordinarily would cause mild illness or no illness at all in healthy people.[11,12] In patients with IBD, the use of biological agents and immunosuppressants has resulted in improved outcomes but at the same time has increased the risk of infectious complications, especially in older patients with IBD. Patients with IBD on corticosteroids, immunosuppressants, and biological agents are considered immunocompromised and are at risk for opportunistic infections.[11-13]

Some of the risk factors for opportunistic infections include: malnutrition, older age, chronic diseases, corticosteroids, immunosuppressive agents, and biologics. Opportunistic infections include viral infections (herpes viruses, human papillomavirus, influenza virus, and JC virus), bacterial infections (tuberculosis, pneumococcal infection, listeriosis), and fungal infections (histoplasmosis, cryptococcosis, aspergillosis, candidiasis).11   While these OIs can result in serious illness and even death, only a minority of patients with IBD develop opportunistic infections.11 In pediatric patients with IBD, OIs are usually mild.

Recommendations to prevent OIs in people with IBD are to:

  • Evaluate and correct nutritional status[13]
  • Update immunizations before starting immunosuppressive therapies[13]
  • Get immunized against Herpes Zoster Virus (HZV)[13]
  • Get screened for tuberculosis before starting biologicals[13]
  • Get a yearly flu shot[13]
  • If you do a lot of traveling, carry a complete list of your immunization information and medications that you are taking[13]

If you are receiving immunosuppressive therapies, it is important to report any new or unusual symptoms to your gastroenterologist right away.  Also, if you are planning to travel outside the United States, it is a good idea to carry a card listing the medications that you are taking as this can be presented if there is a need to go to a hospital emergency room or urgent care center.[12]

Sources:

[11]Dave M, et al. Opportunistic Infections due to inflammatory bowel disease therapy. Inflamm Bowel Dis 2014;1:196-212.

[12]Kucharzil T and Maser C. Infections and chronic inflammatory bowel disease. Viszeralmedzin 2014;30:326-332.

[13]Veerman-Waters G, et al. Risk of infections and prevention in pediatric patients with IBDL ESPGHAN IB Porto Group Commentary, JPGN 2012;54:830-837.

 

Pancreatitis and IBD

NOTE: PANCREATITIS IS AN EXTRAINTESTINAL OR SYSTEMIC COMPLICATION OF IBD.  LOCAL COMPLICATIONS ARE GUT-SPECIFIC.  THE SECTION ON PANCREATITIS SHOULD BE IN THE SECTION EXTRAINTESTINAL COMPLICATIONS. HOWEVER, YOU ALREADY HAVE EXTRAINTESTINAL SECTION ALREADY ON YOUR SITE – SO WHAT IS MY RECOMMENDATION?  MAKES THIS A SEPERATE SECTION.  ALSO, BEAR IN MIND THAT PANCREATITIS RARELY OCCURS IN YOUNGER PATIENTS WITH IBD.  THIS FACT MAKES ME QUESTION THE VALUE OF INCLUDING THIS INFORMATION.

What does the pancreas have to do with IBD?  To begin to answer the question, we need to understand what is the pancreas and what it does.  The pancreas is an organ within the abdomen located behind the stomach.  It is approximately six inches long.  It has two main functions: (1) producing enzymes to aid in digestion and (2) secreting insulin to help control blood sugar levels.

Pancreatitis is an inflammation of the pancreas.  The two most common forms of pancreatitis are acute and chronic.[14-16] Acute pancreatitis is commonly associated with IBD, with the most common cause being gallstones.  In adults, the incidence of acute pancreatitis is 1.2% for UC and 3.1% for CD. [15] Although IBD is one of the five most important causes of acute pancreatitis in children, it is still considered to be a rare condition.[15, 16] Acute pancreatitis can extend to regional tissues and/or distant organs.  A bout of acute pancreatitis is usually followed by full resolution of clinical and histological abnormalities.[14]

It is important to note that IBD therapy can be a cause of acute pancreatitis.[14-16] IBD treatment-induced acute pancreatitis is typically uncomplicated after stopping treatment.  Thiopurines, 5-aminosalycilyates (5-ASA), metronidazole and steroids have been reported to cause drug-induced acute pancreatitis.[14-16]

Regarding treatment of acute pancreatitis, most cases tend to be mild and easily managed.  Management of acute pancreatitis involves fluid and electrolyte replacement as well as nutritional support.[14-16]

Chronic pancreatitis occurs when irreversible scar tissue forms in the pancreas due to chronic inflammation.[14-16]Chronic pancreatitis can lead to impaired digestion and diabetes.  IBD-associated chronic pancreatitis is an extremely rare condition in children with IBD.[16] Excessive use of alcohol accounts for 70 percent of cases of chronic pancreatitis, while 20 percent are of unknown origin.[17] Treatment of chronic pancreatitis includes administering pancreatic enzymes and insulin to supplement what is not being secreted or released by the pancreas.[17]

[14]Roque Ramos L, et al. Inflammatory bowel disease and pancreatitis: a review. Journal of Crohn’s and Colitis 2016;1:95-104.

[15]Antonini F, et al. Pancreatic disorders in inflammatory bowel disease. World J. Gastrointest Pathophysiol 2016;7:276-282.

[16]Martin-de-Carpi J, et al. Pancreatic involvement in pediatric inflammatory bowel disease. Frontiers in Pediatrics 2007;5:1-5

[17]Cleveland Clinic. Pancreatitis Acute & Chronic Overview. Available at: https://

my.clevelandclinic.org/health/diseases/17319-pancreatitis-acute--chronic-overview

 

5. Thrombocytopenia and IBD

If you have been diagnosed with thrombocytopenia then you do not have enough platelets in your blood.  Platelets help your blood to clot.  Signs and symptoms of thrombocytopenia may include any of the following: red, purple, or brown bruises called “purpura”, a rash with small red or purple dots called “petechiae”, nosebleeds, bleeding gums, heavy menstrual bleeding, bleeding from your rectum, blood in stools, and blood in your urine.

Thrombocytopenia in patients with IBD can occur as a side effect of therapy.  Immune thrombocytopenia is rarely reported.[18-21] In the case of immune thrombocytopenic purpura (ITP), a person's own immune system creates antibodies that mark healthy platelets as "foreign substances" and then mistakenly attack and destroy them. While some cases of ITP are caused by drugs used to treat IBD, others are associated with infection, pregnancy, or immune disorders such as IBD itself. About half of all cases are classified as "idiopathic," meaning the cause is unknown.[22]

Various treatments have been used in patients having both IBD and ITP.  The best treatment strategy is yet to be identified.  Short courses of corticosteroids have been used successfully to induce remission in both diseases.[21] In more difficult cases, thrombocytopenia has been treated with high-dose corticosteroids and there are a few reports of the usefulness TNF inhibitors.[18-20]

 

 

 

Sources:

[18] Crespo Madrid N, et al. Coexistence of Crohn’s disease and primary immune thrombocytopenia and its implications for treatment. An Pediatri (Barc) 2015;83:433-435.

[19]Papadatou B, et al. Ulcerative colitis and acute thrombocytopenia in a pediatric patient: a case report and review of the literature. Health 2014;6:1497-1502.

[20]Shizuma T. Concomitant immune thrombocytopenia purpura and Crohn’s disease. Journal of Blood Disorders and Transfusion 2015;6:4.

[21]Boyne MS and Dye KR. Crohn’s colitis and idiopathic thrombocytopenic purpura. Postgrad Med J 2000;76:299-306.

[22]ITP Foundation. Helping children with thrombocytopenic purpura, are rare bleeding disorder. Available at: http://www.itpfoundation.org/itpdefined.htm