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Northeast Florida Medicine
Vol. 66, No. 4 2015
73
Inflammatory Bowel Disease
Gallstones
Prevalence of gallstones in UC is approximately 10
percent, which is the same as the general population; nev-
ertheless, in CD, it varies from 13 percent to 34 percent.
45
Augmented lithogenicity in CD is due to a disruption of
the enterohepatic circulation of bile acids owed to gall-
bladder hyponesis
35
, extensive ileal involvement and/or
resection of the small bowel; presenting a 3X increased
risk of gallstones development.
46,47
Both cholesterol and
pigment stones can be found in CD.
Drug Induced Pancreatitis
Generally, drug exposure can cause acute pancreatitis in
up to two percent of the general population.
48
Azathioprine
(AZA) and 6-mercaptopurine (MP), immunosuppressors
commonly used to treat IBD, appear to be the most im-
portant cause of pancreatitis in CD. Moreover, Crohn’s
disease patients hold a higher risk of acute pancreatitis
than patients treated with these same drugs for other
causes, especially when they are female. A 3.1 percent
incidence rate of AP in patients treated with AZA/MP
has been described.
20
Drugs that follow the lead are mesalamine, cortico-
steroids,
49,50
and metronidazole.
51
Subsequent causes of
AP in IBD have an Idiopathic (20.7 percent) and biliary
(12.2 percent) etiology.
20
Pancreatic Cancer
Pancreatic cancer (PC) is the third leading cause of can-
cer deaths among men and women in the United States,
accounting for 7 percent of all cancer related deaths.
52
IBD patients, especially male with UC, seem to be at an
increased risk of developing this condition. This may be
due to the repeated episodes of inflammation, although
a cause-effect relationship is yet to be established.
53
UC patients hold a 4.85-fold risk of PC. While IBDmen
show a 6.22 times higher risk of developing this type of
cancer, IBD women do not seem to have an increased risk
of pancreatic malignancy, nor do patients with Crohn´s
disease. Altogether, IBD patients display a 3.36X higher
risk of developing pancreatic carcinoma.
54
Laboratory findings in pancreatic cancer are frequently
nonspecific. However, modern imaging scanning helps
diagnose this entity in clinically expressive patients. Im-
aging modalities include CT, endoscopic ultrasonography
(EUS), Magnetic resonance cholangiopancreatography
(MRCP), and endoscopic retrograde cholangiopancrea-
tography (ERCP).
EUS has a detection rate of 99-100 percent for all pan-
creatic malignancies, including those smaller than 3 cm.
55
Also, it is as precise as ERCP or MRCP for obstructive
jaundice’s etiology identification.
56
Management
The management of the binomial IBD-AP does not differ
from the conventional approach of patients with acute pan-
creatitis. Drugs with known pancreatic toxicity should be
excluded temporarily from treatment and/or replaced with a
safer therapeutic alternative. For example, 5-aminosalicilic acid
(5-ASA)mesalamine, canbe safely switched to 4-aminosalicilic
acid (4-ASA), awell-toleratednontoxic agent for thepancreas.
57
In active IBD, serum amylase should be assessed weekly as a
forecaster of the appearance of AP.
58
Prognosis of AP in IBD beyond the acute critical period
is mostly benign. Recurrence rate fluctuates between 13-21
percent
20,59
; however, AP is a severe disease with an overall
mortality of 5 percent. This rate reaches up to 30 percent
in necrotizing pancreatitis and infected necrosis.
20,59
The use of endoscopic delivered anastomotic stents,
formerly only possible through surgery, creates a valuable
conduit between two lumens, enabling drainage of large
fluid collections and bypass of blockages and strictures.
This less invasive procedure is a huge step forward in
the management of commonly present complications
associated to the IBD-pancreas binomial.
60,61
Finally, given inflammatory bowel disease’s chronicity
and disease-related complications, efforts to increase
patient awareness contribute to medical compliance and
improve the management of symptoms. Moreover, since
IBD patients are more prone to develop pancreatic cancer
after a certain period of time, it must be emphasized to
assess for malignancy periodically.
Conclusion
IBD includes Crohn’s disease, ulcerative colitis and
microscopic colitis, chronic diseases attributed to im-
munologic disturbances. Each requires a tailored medical
approach. It is evident that pancreatic involvement in IBD
is a tangible entity, and not uncommon. Therefore, to
improve IBD patients’ quality of life, physicians need to
be aware of the onset of pancreatic diseases and be able
to treat them appropriately.
v