Treatment of Non-specific and Infective Ileal Ulcers
For non-specific terminal ileal ulcers, observation without specific intervention is the recommended approach as there is no significant difference in clinical or endoscopic outcomes compared to mesalamine treatment. 1
Diagnostic Considerations
- Before initiating treatment, it's crucial to exclude specific etiologies of ileal ulcers such as Crohn's disease, intestinal tuberculosis, NSAID-induced ulcers, and eosinophilic enteritis 2
- Approximately 60% of symptomatic isolated terminal ileal ulcers have specific etiologies that require targeted treatment 2
- Diagnosis may require a combination of clinical, endoscopic, and histological findings to determine the underlying cause 2
Treatment Algorithm for Non-specific Ileal Ulcers
First-line Approach
- Observation without specific intervention is appropriate for confirmed non-specific ileal ulcers, as studies show high spontaneous remission rates (78% endoscopic remission at 12 months) 1
- Clinical symptoms often resolve without specific treatment (81.3% clinical remission at 12 months) 1
Alternative Approaches
- Short-term prednisone therapy may be considered for symptomatic patients, as case reports demonstrate rapid healing of solitary non-specific ileal ulcers 3
- For persistent symptoms despite observation, mesalamine 4g/day may provide earlier symptomatic relief (70.3% vs 43.8% clinical remission at 1 month) though long-term outcomes are similar to observation 1
Treatment for Infective Ileal Ulcers
- Targeted antimicrobial therapy based on the identified pathogen is the cornerstone of treatment 2
- For suspected intestinal tuberculosis, anti-tuberculosis therapy should be initiated following appropriate diagnostic workup 2
- Metronidazole (10-20 mg/kg/day) may be effective for certain infective causes, though potential side effects should be considered 4
Treatment for Specific Etiologies
Crohn's Disease
- For mild ileocolonic Crohn's disease, high-dose mesalazine (4 g/daily) may be sufficient initial therapy 4
- For moderate to severe disease, oral corticosteroids such as prednisolone 40 mg daily is appropriate 4
- Azathioprine (1.5-2.5 mg/kg/day) or mercaptopurine (0.75-1.5 mg/kg/day) may be used as adjunctive therapy and steroid-sparing agents 4
NSAID-induced Ulcers
- Discontinuation of the offending NSAID is the primary intervention 2
- Proton pump inhibitors or misoprostol may provide mucosal protection if NSAID therapy must be continued 2
Monitoring and Follow-up
- Regular clinical assessment is recommended to monitor symptom resolution 2
- Follow-up endoscopy should be considered within 3-6 months to assess mucosal healing, particularly for patients with persistent symptoms 2
- Patients with non-specific ulcers who remain symptomatic require close monitoring and re-evaluation, as they may later develop specific diagnoses requiring targeted treatment 2
Important Considerations and Pitfalls
- Non-specific ileal ulcers generally have a benign course without progression to serious complications over the short term 1
- Surgical intervention should be reserved for complications such as obstruction, perforation, or bleeding 5
- Misdiagnosis of irritable bowel syndrome is common in patients with solitary non-specific ileal ulcers, highlighting the importance of ileocolonoscopy in persistent unexplained gastrointestinal symptoms 3