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CI is the most common cause of mesenteric ischemia, and encompasses a wide clinical spectrum from mild, reversible disease to life-threatening colonic gangrene. While most commonly seen in elderly patients, younger patients are also at risk, especially if an underlying risk factor such as vasculitis, hyper-coagulability, or certain medication use such as oral contraceptives, pseudoephedrine, cocaine, or ergot, is present. Colonoscopic evaluation is critical in the evaluation of patients with CI, although it must be kept in mind that CI may mimic or be mimicked by other entities, such as IBD or carcinoma. Conservative management usually leads to a full clinical recovery, although several subsets of patients may require segmental resection. Clinicians should always consider CI in the differential diagnosis of acute colitis, especially in elderly patients. [ABSTRACT FROM AUTHOR]

Most women with IBD can expect an uneventful pregnancy. Evidence compiled over many years indicates the importance of controlling disease activity at the time of conception and during pregnancy to optimize the outcome for mother and baby. For this reason drug therapy is often required to treat flare-ups and maintain remission during this time. Where possible, women with IBD should plan a pregnancy to coincide with times when the disease is quiescent, and drug treatment minimal. In practice, however, many pregnancies are unexpected or occur in women with active disease that requires intensive medical therapy. Provided adequate information has been supplied in advance of conception, much of the apprehension that accompanies these events can be substantially reduced. Ongoing supervision by the clinician during pregnancy and the puerperium provides invaluable support, and enables maternal disease flare-ups to be identified and treated as expediently as possible. [ABSTRACT FROM AUTHOR]

NSAID injury can mimic IBC, can exacerbate IBD, and NSAID use may also be more common in the diarrheal syndrome of collagenous colitis, though there is no clear role in pathogenesis. [ABSTRACT FROM AUTHOR]

Although the therapy of CD is primarily medical, surgery still plays an important role in its management. The high incidence of postoperative CD recurrence is, however, a major drawback. We provide a clear and practical algorithm which will help the clinician to decide when and what kind of prophylactic treatment is indicated. Strategies to prevent recurrence start with a careful selection of patients to send for surgery, based on the known risk factors of recurrence. Current evidence suggests only a moderate effect of the known active agents in the prevention of postoperative CD recurrence. Only patients at higher risk for recurrence should continue on, or be treated with, immunosuppressives (6-MP or azathioprine) after surgery. All others can be followed clinically, or alternatively should undergo an ileocolonoscopy 3-12 months after surgery. If severe endoscopic recurrence is seen, therapy is indicated to prevent the imminent clinical symptoms, or eventually a new resection. Much is anticipated from newer biological agents potentially interacting with earlier steps in the pathogenesis of recurrent CD. [ABSTRACT FROM AUTHOR]

Surgery plays an important role in the management of CD, and likely will continue to do so until the etiology of CD is elucidated and more specific medical therapies are available. In most instances surgery leads to an improvement in quality of life and allows patients to regain normal physical well-being without experiencing the side-effects and dysutility of taking medication. Thus, the need for surgery should not be considered a failure of management. Instead, there is a role for both medical therapy and surgical therapy. Because of the variable patterns of disease seen in CD, as well as the individual concerns of patients, treatment may have to be individualized. Optimally, care should be given, using a team approach including gastroenterologists, surgeons and paramedical personnel such as nurses, enterostomal therapists, and psychiatrists. Care should also be provided as a continuum. In order, however, to achieve excellent results, patients require careful preoperative evaluation and management, and surgeons must be familiar with the various patterns of disease and the complications that they may encounter. [ABSTRACT FROM AUTHOR]

Pouchitis is an idiopathic inflammatory disease of the ileal reservoir in patients who have undergone IPAA. Approximately half of all UC patients who undergo this procedure will have at least one episode of pouchitis, with approximately 15% experiencing a chronic course. PSC and other EIM increase the likelihood of developing pouchitis while smoking is protective. Similar genetic and autoimmune mechanisms to UC appear to occur in an ileal reservoir that demonstrates increasingly colon-like adaptations with respect to bacterial content and mucosal characteristics. While most patients have a good response to antibiotic therapy, those with chronic disease become a therapeutic challenge with the specter of dysplasia looming in the foreground. [ABSTRACT FROM AUTHOR]

Initial treatment of mild to moderately active UC may be sulfasalazine, oral or rectal mesalamine, balsalazide, corticosteroid enemas, or oral corticosteroids. Patients with persistent mild to moderate symptoms of active UC in spite of these therapies (treatment-refractory) may require AZA/6-MP, and in some cases intravenous corticosteroid or transder-mal nicotine. Patients with severely active UC should be treated with intravenous conventional corticosteroids, and intravenous cyclosporine may be considered in those who do not respond. Remission should be maintained with sulfasalazine, oral or rectal mesalamine, olsalazine, or balsalazide, and in some cases with AZA/6-MP. [ABSTRACT FROM AUTHOR]

Over the past decade preliminary data regarding the pharmacoeconomics of inflammmatory bowel disease have emerged. The synthesis of this information has culminated in the first models which evaluate the marginal cost-utility of competing therapies. Since the validity of these comparisons is critically dependent upon accurate efficacy, natural history, cost and utility inputs investigators must identify areas where important data are lacking. Through this process, more sophisticated and valid models will be developed. Highly effective, yet costly, new treatments for IBD will soon be in widespread use. Because societal resources are limited, health-care providers must make intelligent choices regarding the introduction of new technologies. Consideration of data from cost-utility models is likely to become an important part of the decision-making process. [ABSTRACT FROM AUTHOR]

Colon biopsies are critical in helping to diagnose diarrhea, to distinguish different forms of colitis, to determine the extent of disease, and to determine if neoplasia has arisen in the setting of chronic colitis. Colon biopsies in some instances can be definitive, but this usually requires the appropriate clinical scenario. For instance, to appreciate that segmental granulomatous colitis is CD and not the much rarer colonic sarcoidosis requires ancillary clinical information. Often colon biopsies may definitively reveal an abnormality, but the findings may be non-specific in regard to a definitive diagnosis. Thus, to utilize colon biopsies most appropriately in patient management usually requires frequent clinician-pathologist interaction, often repeat endoscopy with biopsies at a different time, and the assessment of any prior biopsies or resections. Once a patient has a firm diagnosis of CD he/she rarely converts to a disease that is indistinguishable from UC, and typically continue to behave like CD. Conversely, it is not too uncommon for patients with UC to develop features that strongly suggest that CD is the real underlying disease. These patients also tend to behave like those with CD. The ileum should be intubated whenever possible in cases of undiagnosed diarrhea and in cases of colitis to help distinguish if CD might be present. Gastric biopsies may reveal a pattern of focally active gastritis and this may serve as a clue for CD when the diagnosis is unknown or in doubt. [ABSTRACT FROM AUTHOR]

The nature of UC has changed dramatically over the past five decades. Although the presentation of the disease has remained the same, the impact of the introduction of therapies such as corticosteroids and the aminosalicylates has changed the clinical course of the disease. The course of treated UC offers patients and physicians a much more optimistic out-look than that documented in earlier studies. The advances in medical therapy have been complemented by refinement of surgical techniques, which have improved the quality of life and gained patient acceptance. The new millennium will bring further promise to patients and to those of us who care for these patients. [ABSTRACT FROM AUTHOR]