From the Guidelines
Terminal ileitis, typically caused by Crohn's disease, should be treated with a step-up approach, starting with immunosuppressive therapies such as azathioprine, and progressing to biologics like infliximab or adalimumab if necessary, as outlined in the WSES-AAST guidelines for the management of inflammatory bowel disease in the emergency setting 1.
Diagnosis
The diagnosis of terminal ileitis involves a combination of clinical evaluation, laboratory tests, stool studies, and imaging. According to the WSES-AAST guidelines, diagnosis of IBD is generally made by assessment of symptoms, biochemical markers, and colonoscopy combined with radiology and histology 1. The guidelines also highlight the importance of differentiating between Crohn's disease and ulcerative colitis, as the treatment approaches may differ.
Treatment
Treatment of terminal ileitis depends on the underlying cause, with Crohn's disease being a common cause. The WSES-AAST guidelines recommend a tailored treatment approach, taking into account the type, distribution, and disease severity, as well as co-morbidity and patient preferences 1. For Crohn's disease-related ileitis, treatment may include:
- Immunomodulators such as azathioprine (2-3mg/kg/day) 1
- Biologics like infliximab, adalimumab, or vedolizumab, which have been shown to be effective in inducing and maintaining remission in patients with Crohn's disease 1
- JAK inhibitors like tofacitinib, which have been approved for the treatment of ulcerative colitis and may also be effective in Crohn's disease 1
Complications and Outcomes
Untreated terminal ileitis can lead to serious complications, including intestinal obstruction, perforation, fistula formation, or abscess development. The WSES-AAST guidelines highlight the importance of prompt diagnosis and treatment to prevent these outcomes 1. With proper treatment, patients with Crohn's disease can experience improved outcomes, including reduced hospitalization rates and decreased risk of surgery 1. However, patients with Crohn's disease still show progression towards a complicated phenotype, characterized by the formation of stenosis or abscess/fistula, emphasizing the need for ongoing monitoring and adjustment of treatment as needed 1.
From the Research
Diagnosis of Terminal Ileitis
- Terminal ileitis is an inflammatory condition of the terminal portion of the ileum that may occur acutely or exhibit chronic obstructive symptoms and bleeding 2
- The diagnosis of terminal ileitis requires a clinical, laboratory, endoscopic, and histopathological evaluation of the individuals 2, 3
- Terminal ileitis is commonly associated with Crohn's disease (CD), but it may also be associated with other conditions such as ulcerative colitis, non-steroidal anti-inflammatory drug (NSAID) intake, infectious diseases, eosinophilic enteritis, malignant diseases, spondyloarthropathies, vasculitides, ischemia, sarcoidosis, and amyloidosis 2, 3
Treatment of Terminal Ileitis
- Mesalamine in microgranular formulation seems to be equally as effective as a standard dosage of steroids in the treatment of the mild to moderate form of Crohn's ileitis 4
- Oral delayed-release mesalazine is an effective therapy for active disease (remission in up to 45% of patients) and for quiescent disease (relapse in 34% of recipients over a duration of up to 12 months) in patients with Crohn's disease 5
- Sulfasalazine is of proven efficacy as maintenance therapy in ulcerative colitis, but its use is limited in patients with ileitis alone 6
- Immunosuppressive agents such as azathioprine and 6-mercaptopurine may be especially helpful in Crohn's patients refractory to other drugs or dependent on high doses of steroids 6
- Metronidazole is as effective as sulfasalazine in Crohn's disease involving the colon and has an important role in severe perineal disease 6