What is the treatment for terminal ileitis?

Treatment of Terminal Ileitis

The treatment of terminal ileitis should be tailored to the underlying cause, with high-dose mesalazine (4g daily) being the first-line treatment for mild to moderate isolated terminal ileitis, while corticosteroids, immunomodulators, or biologics are indicated for more severe disease or cases associated with Crohn's disease. 1, 2

Diagnostic Considerations

Before initiating treatment, it's crucial to determine the underlying cause of terminal ileitis, as it's not always Crohn's disease:

• Common causes of terminal ileitis:

  • Crohn's disease (most common chronic cause)
  • Infectious ileitis (Yersinia, tuberculosis, etc.)
  • NSAID-induced ileitis
  • Lymphoid hyperplasia
  • Ischemic ileitis
  • Malignancies (lymphoma)
  • Spondyloarthropathies
  • Vasculitides 3, 4

• Key diagnostic tests:

  • Endoscopic evaluation with biopsies
  • Stool cultures and C. difficile testing
  • Inflammatory markers (CRP, ESR)
  • Cross-sectional imaging (CT or MRI)

Treatment Algorithm

1. Mild to Moderate Isolated Terminal Ileitis

• First-line therapy:

  • High-dose mesalazine (4g daily) 1, 2
  • Mesalazine in microgranular formulation has shown efficacy comparable to corticosteroids in treating mild to moderate terminal ileitis 2

• Alternative options:

  • Metronidazole (10-20 mg/kg/day) may be effective but has potential side effects 1
  • Ciprofloxacin (500 mg twice daily) for suspected infectious causes 1

2. Moderate to Severe Terminal Ileitis (Crohn's Disease)

• First-line therapy:

  • Oral corticosteroids: Prednisolone 40 mg/day with gradual taper over 8 weeks 1, 5
  • For severe disease: IV corticosteroids (hydrocortisone 400 mg/day or methylprednisolone 60 mg/day) 1

• Second-line/steroid-sparing options:

  • Azathioprine (1.5-2.5 mg/kg/day) or mercaptopurine (0.75-1.5 mg/kg/day) as adjunctive therapy 1
  • Anti-TNF agents (infliximab 5 mg/kg at weeks 0,2, and 6, then every 8 weeks) for refractory disease 1, 6

3. Fistulizing Disease

• Medical management:

  • Metronidazole 400 mg three times daily and/or ciprofloxacin 500 mg twice daily 1
  • Azathioprine/mercaptopurine for maintenance 1
  • Infliximab for refractory fistulas 1, 6

• Surgical management:

  • Seton placement for draining fistulas
  • Fistulectomy for persistent fistulas 1

4. Nutritional Support

• Elemental or polymeric diets as adjunctive therapy 1
• Total parenteral nutrition in complex, fistulating disease 1

Surgical Management

Surgery should be considered in the following scenarios:

• Failure of medical therapy
• Complications (strictures, obstruction, perforation, abscess)
• Limited ileal or ileocecal disease as primary therapy 1

Important considerations:

• Preserve maximum intestinal length
• Limit resection to macroscopically affected segments
• Avoid primary anastomosis in the presence of sepsis or malnutrition 5

Monitoring and Follow-up

• Regular assessment of clinical parameters (stool frequency, abdominal pain)
• Laboratory monitoring (CRP, albumin, CBC)
• Endoscopic evaluation to assess mucosal healing
• Fecal calprotectin for monitoring disease activity 5

Common Pitfalls to Avoid

1. Misdiagnosis: Terminal ileitis is not always Crohn's disease. Proper diagnostic workup is essential before initiating long-term immunosuppressive therapy 3, 4

2. Inappropriate appendectomy: Appendectomy of a normal appendix in the presence of terminal ileitis has an elevated risk of intra-abdominal septic complications and fistulas 1

3. Delayed treatment escalation: In non-responders to initial therapy, prompt escalation to more effective treatments is crucial 5

4. Prolonged steroid use: Implement steroid-sparing strategies early 5

5. Overlooking infectious causes: Rule out infectious etiologies before starting immunosuppressive therapy 5, 7

The management of terminal ileitis requires careful consideration of the underlying cause, disease severity, and patient-specific factors. While high-dose mesalazine is effective for mild to moderate isolated terminal ileitis, more aggressive therapy with immunomodulators or biologics may be necessary for severe or complicated disease.