What treatment is required for chronic ileitis from an outpatient GI clinic and is a repeat EGD necessary?

Management of Chronic Ileitis: Diagnostic Approach and Treatment

For chronic ileitis, endoscopic assessment is necessary to guide appropriate treatment, and therapy should include mesalamine as first-line treatment with escalation to immunomodulators or biologics for refractory cases. 1

Diagnostic Approach

Initial Assessment

• Measure fecal calprotectin to confirm active inflammation
  • Values >150 μg/g strongly suggest active inflammation 1
  • Values >250 μg/g warrant urgent gastroenterology referral 1
• Obtain CRP to assess systemic inflammation
• Test for infectious causes (stool cultures, C. difficile)

Endoscopic Evaluation

• Repeat EGD is indicated when:
  • Symptoms persist despite treatment
  • Upper GI symptoms are present
  • Treatment decisions require confirmation of disease activity 1
• Ileocolonoscopy is essential to:
  • Assess disease extent and severity
  • Obtain biopsies from inflamed and normal-appearing areas
  • Multiple biopsies (minimum two samples) should be taken from each segment 1

Biopsy Protocol

• Terminal ileum: Multiple biopsies (at least 2 representative samples)
• Colon: Biopsies from all segments (ascending, transverse, descending, sigmoid, rectum)
• Upper GI: If symptoms present or to differentiate between Crohn's disease and other causes 1

Treatment Algorithm

First-Line Treatment

• Mesalamine (5-ASA) oral therapy:
  • Initial dosing: 2.4-4.8 g/day in divided doses 2
  • Monitor renal function before and during therapy
  • Continue for 8-12 weeks before assessing response

For Moderate Disease or Inadequate Response

• Add immunomodulators:
  • Azathioprine (2-2.5 mg/kg/day) or
  • 6-mercaptopurine (1-1.5 mg/kg/day)
• Consider budesonide (9 mg daily) for 8 weeks with taper

For Severe or Refractory Disease

• Biologic therapy:
  • Anti-TNF agents (infliximab, adalimumab, certolizumab)
  • Anti-integrin therapy (vedolizumab)
  • Anti-IL-12/23 (ustekinumab)

Follow-up and Monitoring

Disease Activity Monitoring

• Fecal calprotectin every 3-6 months
  • Values <150 μg/g suggest mucosal healing 1
  • Persistent elevation >150 μg/g warrants endoscopic reassessment
• CRP monitoring, especially if elevated at baseline

Endoscopic Reassessment

• Indicated for:
  • Persistent symptoms despite therapy
  • Elevated inflammatory markers
  • Consideration of treatment escalation or de-escalation 1
• Not routinely needed if in clinical remission with normalized biomarkers 1

Important Considerations

Differential Diagnosis

• Chronic ileitis is not always Crohn's disease 3
• Consider other causes:
  • NSAID-induced enteropathy
  • Infectious ileitis (tuberculosis, Yersinia)
  • Lymphoid hyperplasia
  • Eosinophilic enteritis 4
  • Medication-related inflammation

Treatment Pitfalls

• Monitor for mesalamine-induced acute intolerance syndrome (occurs in ~3% of patients) 2
  • Symptoms: cramping, acute abdominal pain, bloody diarrhea
  • May mimic disease flare
  • Discontinue mesalamine if suspected
• Watch for renal impairment with mesalamine therapy 2
  • Evaluate renal function before and during treatment
  • Discontinue if renal function deteriorates

When to Consider Treatment Escalation

• Persistent symptoms after 8-12 weeks of mesalamine therapy
• Elevated inflammatory markers despite treatment
• Endoscopic evidence of ongoing inflammation
• Development of complications (strictures, fistulae)

By following this structured approach to diagnosis and treatment, chronic ileitis can be effectively managed in the outpatient GI clinic setting, with the goal of achieving mucosal healing and preventing disease progression.