Monitoring

Treatments and their complications should be closely monitored.

In patients in symptomatic remission, the American Gastroenterological Association (AGA) recommends a monitoring strategy which includes both symptoms and biomarkers.[138]​ Interval biomarker monitoring may be performed every 6-12 months. Faecal biomarkers (faecal calprotectin or faecal lactoferrin) may be particularly useful for monitoring.[29]​ It should be noted however, that the diagnostic performance of these tests in a low pre-test probability setting may result in high rates of false results.[138]

In patients in symptomatic remission, the AGA recommends utilising normal levels of faecal biomarkers or normal C-reactive protein (CRP) to rule out active inflammation and reduce the need for endoscopic assessment.[138]​ In patients with elevated faecal biomarkers or CRP, endoscopic assessment of disease rather than empirical treatment adjustment is recommended.[138]

In patients with mild symptoms and normal stool or serum markers of inflammation (faecal calprotectin, faecal lactoferrin or CRP) the AGA suggests endoscopic assessment of disease rather than empirical treatment adjustment.[138]

Patients with long-standing UC are at increased risk for development of dysplasia.[139]​​ The risk of colorectal cancer increases with longer duration and extensive severe colitis, family history of colorectal cancer, young age at onset of disease, presence of backwash ileitis, and personal history of primary sclerosing cholangitis.

Patients with UC should undergo surveillance colonoscopy beginning 8 to 10 years after disease onset.[33][140]​​​ [ Cochrane Clinical Answers logo ] ​ Surveillance intervals vary depending on patient risk factors. Patients with high-risk features (stricture or dysplasia detected within the past 5 years, primary sclerosing cholangitis, extensive colitis with severe active inflammation, family history of colorectal cancer in first degree relative <50 years) should be scheduled for their next surveillance colonoscopy in 1 year.[27][140]​​​​ Patients with intermediate risk factors (extensive colitis with mild-to-moderate active inflammation, post-inflammatory polyps, family history of colorectal cancer in first degree relative >50 years) should undergo surveillance colonoscopy at 3 years.[140]​ All other patients should have their next surveillance colonoscopy scheduled for 5 years.[27] British guidelines recommend less frequent surveillance in those with low-risk disease.[140]​​

Pan-colonic methylene blue or indigo carmine chromoendoscopy should be performed during surveillance colonoscopy with targeted biopsies of visible lesions.[23]

If sufficient expertise in chromoendoscopy is not available, biopsy specimens of the colon in patients with documented pancolitis should be obtained in all four quadrants every 10 cm from the caecum to the rectum, to obtain a minimum of 32 biopsy samples.[27] Diagnosis of dysplasia should be confirmed by a second gastrointestinal pathologist. The management of dysplastic polypoid lesions is evolving.

Expert-consensus guidelines recommend surveillance colonoscopy over colectomy following complete removal of endoscopically resectable polypoid and non-polypoid dysplastic lesions.[141] In patients with invisible low- or high-grade dysplasia, referral to an endoscopist with expertise in irritable bowel disease surveillance and image-enhanced examination using chromoendoscopy with high-definition endoscopy is recommended in order to better inform subsequent decisions regarding surveillance colonoscopy or colectomy.[141] If a visible dysplastic lesion is identified in the same region of the colon as the invisible dysplasia, and the lesion can be resected endoscopically, then these patients may remain in a surveillance programme. If, however, a dysplastic lesion is not discovered, management should be individualised after discussion with the patient of the risks and benefits of surveillance colonoscopy and colectomy.[141]

Concomitant or underlying infection should always be ruled out at times of exacerbations.

Patients should be monitored and educated regarding the risk of osteoporosis.[46][142]​​​

  • All patients should receive education on the importance of lifestyle changes (e.g., engaging in regular weight-bearing exercise, stopping smoking, avoiding excessive alcohol intake), as well as vitamin D and calcium supplementation.[7]

  • Dual energy x-ray absorptiometry scans should be selectively ordered based on a thorough risk-factor assessment.[7]

  • In patients found to be osteoporotic or to have a low-trauma fracture, screening for other causes of low bone density should be performed through a full blood count, total serum alkaline phosphatase level, calcium level, creatinine level, 25-(OH) vitamin D level, protein electrophoresis, and testosterone level (in males).

  • Corticosteroid dosing in inflammatory bowel disease should be kept to a minimum, and other immunomodulatory agents should be considered to help withdraw patients from corticosteroids once corticosteroid dependence becomes evident.

  • Vitamin D and calcium supplementation should be given to those deemed to be at high risk for osteoporosis or with confirmed osteoporosis.[7]

  • Younger men and premenopausal women require 1000 mg/day of elemental calcium, whereas men and women >50 years of age require up to 1500 mg/day.

  • Vitamin D 400 to 800 IU/day is usually an adequate replacement dose in healthy people; it can be obtained from many multivitamin preparations.

  • Bisphosphonate therapy is approved for the prevention and treatment of osteoporosis in patients with known osteoporosis, patients with atraumatic fractures, and patients who cannot withdraw from corticosteroids after 3 months of use.

Patients with primary sclerosing cholangitis should be surveyed for:[143]

  • Cholangiocarcinoma every 6 to 12 months with ultrasound, computed tomography, or magnetic resonance imaging, with or without serum carbohydrate antigen 19-9

  • Gallbladder adenocarcinoma every 12 months with ultrasound.

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