What is the treatment approach for ileitis (inflammation of the ileum)?

Treatment Approach for Ileitis

The treatment of ileitis should be tailored to its underlying cause, with Crohn's disease being the most common etiology requiring a step-up approach starting with aminosalicylates for mild disease and progressing to corticosteroids, immunomodulators, and biologics for more severe cases.

Understanding Ileitis

Ileitis refers to inflammation of the ileum (the terminal portion of the small intestine). While commonly associated with Crohn's disease, ileitis can result from various other conditions that require different treatment approaches:

Differential Diagnosis of Ileitis

• Inflammatory bowel disease (primarily Crohn's disease)
• Infectious causes (bacterial, viral, parasitic)
• Medication-induced (particularly NSAIDs)
• Spondyloarthropathies
• Vasculitides
• Ischemic conditions
• Neoplasms
• Eosinophilic enteritis
• Backwash ileitis in ulcerative colitis
• Sarcoidosis
• Amyloidosis
• Endometriosis 1, 2, 3

Treatment Algorithm for Ileitis

1. Crohn's Disease-Related Ileitis

Mild to Moderate Active Disease:

• First-line therapy: High-dose mesalazine (4 g/day) for mild ileocolonic disease 4
• Second-line therapy: Oral corticosteroids (prednisolone 40 mg daily) for patients who fail to respond to mesalazine 4
• Alternative for isolated ileo-cecal disease: Budesonide 9 mg daily (slightly less effective than prednisolone but with fewer side effects) 4

Moderate to Severe Disease:

• Corticosteroids: Prednisolone 40 mg daily with gradual tapering over 8 weeks 4
• For severe disease: Intravenous steroids (hydrocortisone 400 mg/day or methylprednisolone 60 mg/day) 4
• Adjunctive therapy: Consider elemental or polymeric diets 4

Maintenance Therapy:

• Aminosalicylates, azathioprine (1.5-2.5 mg/kg/day), or mercaptopurine (0.75-1.5 mg/kg/day) 4

Refractory Disease:

• Biologics: Infliximab 5 mg/kg at weeks 0,2, and 6, then every 8 weeks 4, 5
• Surgery: Consider for patients who have failed medical therapy, especially those with limited ileal disease 4

2. Fistulating Ileitis (Crohn's Disease)

• First-line: Metronidazole 400 mg three times daily and/or ciprofloxacin 500 mg twice daily 4
• Second-line: Azathioprine or mercaptopurine 4
• Refractory cases: Infliximab (three infusions of 5 mg/kg at 0,2, and 6 weeks) 4, 5
• Adjunctive therapy: Surgical intervention (Seton drainage, fistulectomy) combined with medical treatment 4

3. Pouchitis with Ileitis

• First-line: Metronidazole 400 mg three times daily or ciprofloxacin 250 mg twice daily for 2 weeks 4
• Second-line: Mesalazine or corticosteroids if antibiotics are ineffective 4
• Chronic pouchitis: Long-term, low-dose metronidazole or ciprofloxacin 4
• Refractory cases: Consider infliximab 6

4. Infectious Ileitis

• Targeted antimicrobial therapy based on identified pathogen
• Supportive care until resolution for self-limited cases

5. NSAID-Induced Ileitis

• Discontinuation of the offending medication
• Supportive care until resolution

Monitoring and Follow-up

• Regular clinical assessment of symptoms
• Laboratory monitoring (CRP, ESR, CBC)
• Endoscopic evaluation to assess mucosal healing in IBD-related ileitis
• Imaging studies as needed (MRI enterography, CT enterography)

Special Considerations

Pregnancy

• Maintaining disease control during pregnancy is essential for both maternal and fetal health 4
• Most IBD medications can be continued during pregnancy with the exception of methotrexate

Nutritional Support

• Consider nutritional support for patients with malnutrition
• Total parenteral nutrition may be appropriate adjunctive therapy in complex, fistulating disease 4

Surgical Indications

• Failed medical therapy
• Complications (obstruction, perforation, abscess)
• Limited ileal disease where surgery may be curative 4

Treatment Efficacy

A randomized trial comparing mesalamine formulations with methylprednisolone in mild to moderate Crohn's ileitis found comparable efficacy between microgranular mesalamine (79% remission) and steroids (61% remission), suggesting that targeted mesalamine delivery to the ileum can be effective in selected patients 7.

For chronic refractory pouchitis with ileitis, infliximab has shown promising results with clinical remission achieved in 90% of patients in one small study 6.