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Northeast Florida Medicine
Vol. 66, No. 4 2015
45
Inflammatory Bowel Disease
being used to treat the underlying condition. These include
azathioprine, 5-ASA, Flagyl, and, occasionally, corticoste-
roids. Drug-induced pancreatitis typically resolves rapidly
after discontinuation of the drug. Autoantibodies directed
against pancreatic tissue have been described. There is a
suggestion that inflammation of the duodenum and papil-
la in CD may account for some drainage difficulties and
pancreatitis in these patients as well.
Thromboembolic Events
Venous and arterial thromboembolisms are disease specific
extraintestinal symptoms in patients with IBD that can cause
significant morbidity and mortality. It is thought that there
is a two to fourfold increase of venous thrombosis in patients
with IBD. Arterial embolism is much less frequent. In pa-
tients with IBD, coagulation and fibrinolysis are activated
due to acute and chronic inflammation.When patients with
IBD are in clinical remission, they still remain at risk for
thromboembolic events. Extensive colonic involvement has
been associated with these disorders. Genetic factors includ-
ing hypercoagulability, such as Factor V Leiden, Factor II
mutation, or theMTHFR genemutation, have been studied
in patients with IBD. Increased levels of homocysteine have
been detected in patients with IBD as compared to controls.
In addition, B12 deficiency and folate deficiency may in-
deed aggravate hyperhomocysteinemia. All hospitalized and
immobilized patients with IBD should be treated with low
dose heparin for prophylaxis.
12
Pulmonary Manifestations
Pulmonary manifestations in patients with IBD are rec-
ognized somewhat less frequently than other manifestations.
Several studies have shown empiric pulmonary function
with disturbance in diffusing capacity and up to 50 per-
cent of patients with IBD, even those without respiratory
symptoms.
13
These pulmonary features may include upper
airway disease, large and small airway manifestations, and
parenchymal disease, such as that seen with cryptogenic or-
ganizing pneumonia. One possible link between pulmonary
disease as an extraintestinal manifestation of IBD might be
the common embryologic of the GI and pulmonary epithe-
lium from the primitive foregut. In general, patients with
UC are at a higher risk of developing these manifestations
as compared to those with CD.
The most common pulmonary involvement with these
conditions is bronchiectasis, followed by chronic bronchitis.
Chest radiography is fairly nonspecific, but when high resolu-
tionCT is done, a physician commonly finds dilated airways
and bronchial wall thickening in these affected patients.
Upper airway disease may include subglottic stenosis and a
diffuse tracheitis.The bronchiolitis obliterans withorganizing
pneumonia (BOOP) is the most frequent manifestation of
parenchymal pulmonary disease. These patients have fever,
cough, and dyspnea. Radiographs reveal patchy opacities,
whereas CT will show scattered unilateral or bilateral foci
of consolidation and centrilobular nodules. Methotrexate
is used to treat inflammatory bowel disease, and a hyper-
sensitivity pneumonitis and occasional pulmonary fibrosis
may be seen. In addition, serositis presenting with pleural
effusions, pericarditis, pleural pericarditis or myocarditis can
develop as a result of drug therapy for IBD. Depending on
the type of pulmonary manifestation, any drugs that could
be remotely responsible must be withdrawn immediately.
Typically pulmonary symptoms either induced by the disease
or by its specific treatments, show good response to inhaled
corticosteroids. IV steroids may be necessary as well.
Some less common pulmonary features associated with
IBDcan include a chronic suppurative bronchitis, subglottic
stenosis, necrobiotic nodules within the lung parenchyma,
chronic bronchiolitis, and pulmonary infiltrates with eo-
sinophilia. In addition, it appears that some patients with
concomitant IBD may also have pulmonary sarcoidosis.
Both diseases have an association with HLA A3, B8, DR3.
Parenchymal lung disease in Crohn’s follows the onset of
bowel symptoms with a delay ranging anywhere from1 to 19
years.
13
However, pulmonary symptoms have been reported
to predate the intestinal manifestations of these diseases.
14
WithCrohn’s disease, fistulae can develop anywhere through-
out the GI tract, and these sinus tracts have been noted to
communicate with the airway and parenchyma from the
esophagus, ileum, or colon. This rare phenomenon should
be considered in any patient with active intestinal disease
who has recurrent pneumonia of unclear cause.
Part of the treatment plan for IBD may include mesa-
lamine products or 5-ASA. These compounds are used to
treat both ulcerative colitis and Crohn’s. An increase in
cough and exacerbation of asthma has been noted with
these drugs. Pharyngitis, sinusitis, and chest pain are also
more frequently seen in those taking these medications
compared to placebo. A very rare lymphocytic alveolitis has
been reported with the use of mesalamine. Mesalamine has
also been implicated in both acute and chronic eosinophilic
pneumonia. Infliximab, a monoclonal antibody directed
against anti-tumor necrosis factor alpha, has had a major
impact on the treatment of IBD. It is also used to treat
rheumatoid arthritis, and sarcoidosis. It has a dramatic effect
on granulomatous inflammation. However, it has also been
reported to predispose patients to life threatening infection,
the most widely publicized being reactivation of tuberculo-
sis.
3
Other opportunistic infections have also been reported